Scolaris Content Display Scolaris Content Display

Study flow diagram for previous version of the review (Bain 2015)
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Figure 1

Study flow diagram for previous version of the review (Bain 2015)

Update study flow diagram.
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Figure 2

Update study flow diagram.

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included trials.
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Figure 3

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included trials.

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included trial.
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Figure 4

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included trial.

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.1 Gestational diabetes.
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Figure 5

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.1 Gestational diabetes.

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.4 Caesarean section.
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Figure 6

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.4 Caesarean section.

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.6 Large‐for‐gestational age.
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Figure 7

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.6 Large‐for‐gestational age.

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.13 Gestational weight gain (kg).
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Figure 8

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.13 Gestational weight gain (kg).

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.16 Gestational weight gain (above IOM recommendations).
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Figure 9

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.16 Gestational weight gain (above IOM recommendations).

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.31 Gestational age at birth (weeks).
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Figure 10

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.31 Gestational age at birth (weeks).

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.33 Preterm birth.
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Figure 11

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.33 Preterm birth.

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.35 Macrosomia.
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Figure 12

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.35 Macrosomia.

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.37 Birthweight (g).
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Figure 13

Funnel plot of comparison: 1 Diet and exercise interventions versus control, outcome: 1.37 Birthweight (g).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 1 Gestational diabetes.
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Analysis 1.1

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 1 Gestational diabetes.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 2 Pre‐eclampsia.
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Analysis 1.2

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 2 Pre‐eclampsia.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 3 Pregnancy‐induced hypertension and/or hypertension.
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Analysis 1.3

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 3 Pregnancy‐induced hypertension and/or hypertension.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 4 Caesarean section.
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Analysis 1.4

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 4 Caesarean section.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 5 Perinatal mortality.
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Analysis 1.5

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 5 Perinatal mortality.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 6 Large‐for‐gestational age.
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Analysis 1.6

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 6 Large‐for‐gestational age.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 7 Operative vaginal birth.
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Analysis 1.7

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 7 Operative vaginal birth.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 8 Induction of labour.
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Analysis 1.8

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 8 Induction of labour.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 9 Perineal trauma.
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Analysis 1.9

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 9 Perineal trauma.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 10 Placental abruption.
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Analysis 1.10

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 10 Placental abruption.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 11 Postpartum haemorrhage.
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Analysis 1.11

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 11 Postpartum haemorrhage.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 12 Postpartum infection.
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Analysis 1.12

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 12 Postpartum infection.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 13 Gestational weight gain (kg).
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Analysis 1.13

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 13 Gestational weight gain (kg).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 14 Gestational weight gain (various times reported) (kg).
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Analysis 1.14

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 14 Gestational weight gain (various times reported) (kg).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 15 Gestational weight gain (kg/week).
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Analysis 1.15

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 15 Gestational weight gain (kg/week).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 16 Gestational weight gain (above IOM recommendations).
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Analysis 1.16

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 16 Gestational weight gain (above IOM recommendations).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 17 Gestational weight gain (within IOM recommendations).
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Analysis 1.17

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 17 Gestational weight gain (within IOM recommendations).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 18 Gestational weight gain (below IOM recommendations).
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Analysis 1.18

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 18 Gestational weight gain (below IOM recommendations).

Study

Diet

Exercise

Benefit in favour of intervention

Benefit in favour of control

Bruno 2016

Higher proportion of women in intervention group, compared with the control group, with Food Frequency Questionnaire score ≥ 2 at 36th week (P = 0.028). No clear difference between groups in ≥ 2 servings of vegetables/day (P = 0.400) or ≤ 3 times/week of food rich in saturated fat; higher proportion of women in intervention group, compared with the control group, having ≤ 30 g sugar/day (P = 0.026).

No clear difference between groups in number of steps/day or duration of physical activity in minutes at the 20th week. Women in the intervention group, compared with the control group, were less active at the 36th week (fewer steps/day (P = 0.016) and had a shorter duration of physical activity (P = 0.039)).

Some (diet)

Some (exercise)

Dodd 2014

Macronutrient consumption and food groups
No clear differences between groups (from trial entry, to 28 weeks, 36 weeks, 4 months) for total energy (kJ) (P = 0.09), bread and cereals (servings/day) (P = 0.27), dairy (servings/day) (P > 0.09 after trial entry), meat and legumes (servings/day) (P = 0.14), non‐core group foods (servings/day) (P > 0.10), alcohol (g) (P = 0.20), carbohydrates (g) (P = 0.06), percentage energy from carbohydrates (P = 0.39), protein (g) (P = 0.14), percentage energy from protein (P > 0.11 after trial entry), total fat (g) (P = 0.48), percentage energy from total fat (P = 0.06), saturated fat (g) (P = 0.71), monounsaturated fat (g) (P = 0.62), polyunsaturated fat (g) (P = 0.23). Women in the intervention group, compared with women in the control group, increased their consumption of fruit (servings/day) (P = 0.002), vegetables (servings/day) after trial entry (P < 0.003), dietary fibre (P = 0.002) and percentage energy from saturated fats (P = 0.04) overall.

Micronutrient consumption
No clear differences between groups (from trial entry, to 28 weeks, 36 weeks, 4 months) for caffeine (mg) (P = 0.57), sodium (mg) (P = 0.10), iron (mg) (P = 0.08), zinc (mg) (P = 0.11), magnesium (mg) (P = 0.06), phosphorus (mg) (P = 0.16), iodine (μg) (P = 0.38), retinol (μg) (P = 0.33), vitamin B1 (mg) (P = 0.07), niacin (mg) (P = 0.09) or vitamin E (mg) (P = 0.17). Women in the intervention group had greater intake of calcium (mg) (28 week P value = 0.04), potassium (mg) (28 week P value = 0.004; 36 week P value = 0.01), vitamin B2 (mg) (28 week P value = 0.05) (not maintained at 4 months postpartum); and increased consumption of vitamin A active equivalent (μg) (P = 0.003), vitamin C (mg) (P = 0.02), folate (μg) (P = 0.03) and folate food (μg) (P = 0.02) overall.

Healthy Eating Index (HEI)
Women in the intervention group, compared with the control group, had improvements in diet quality (HEI) at 28 and 36 weeks (both P < 0.0001); not sustained at 4 months postpartum (P = 0.41). Specifically, women in the intervention group, compared with the control group, increased consumption of total fruit (28 week P value = 0.0001; 36 week P value < 0.0001; 4 month P value = 0.07), whole fruit (28 week P value = 0.0003; 36 week P value < 0.0001; 4 month P value = 0.30), milk (28 week P value = 0.04; 36 week P value = 0.45; 4 month P value = 0.28) and dark‐green and orange vegetables and legumes (overall P value = 0.0006). No clear differences between groups in consumption of total vegetables (P = 012), total grains (P = 0.55), whole grains (P = 0.14), meat and beans (P = 0.67), oils (P = 0.15), saturated fat (P = 0.07), sodium (P = 0.34), or calories from solid fat, alcohol and added sugar (P = 0.56).

Glycaemic index and glycaemic load

No clear difference between groups (from trial entry to 28 weeks, 36 weeks, 4 months) in glycaemic load (P = 0.15) or glycaemic index (P = 0.10).

Changes in diet and knowledge of healthy food choices

"women receiving lifestyle advice were more likely to indicate that the approach to participate in the trial prompted changes to... their diet [... p < 0.0001]... Women who received the intervention indicated greater knowledge about healthy food choices [... p < 0.0001]... compared with women who received Standard Care."

Physical activity

Women in the intervention group, compared with the control group (from trial entry, to 28 weeks, 36 weeks, 4 months) had an increase in total activity (P = 0.01); and specifically an increase in household activity (P = 0.01). No clear differences between groups for commuting activity (P = 0.55), leisure activity (P = 0.06) or work activity (P = 0.52).

Changes in lifestyle and knowledge of healthy exercise during pregnancy

"women receiving lifestyle advice were more likely to indicate that the approach to participate in the trial prompted changes to... their lifestyle [...p < 0.0001]. Women who received the intervention indicated greater knowledge about... exercise during pregnancy [... p < 0.0001] compared with women who received Standard Care."

Some (diet and exercise)

No

Harrison 2013

Not reported

The intervention group had higher steps/day at 28 weeks gestation compared with the control group (P < 0.05); no clear difference between groups in MET minutes‐1/day estimated by the The International Physical Activity Questionnaire (P value not reported).

No clear difference between groups at 6 weeks postpartum in physical activity (steps/day) (P = 0.6).

Some (exercise)

No

Hawkins 2014

No clear differences between groups in change from baseline to mid‐pregnancy and baseline to postpartum for total caloric intake (P = 0.78; P = 0.44), calories from fat (%) (P = 0.66; P = 0.14), and fibre (g) (P = 0.20; P = 0.23).

No clear differences between groups in change from baseline to mid‐pregnancy and baseline to postpartum for moderate‐intensity (P = 0.17; P = 0.78), moderate and vigorous‐intensity (P = 0.80; P = 0.82), or sports/exercise (P = 0.72; P = 0.63) physical activity; though significant increase in vigorous‐intensity physical activity in the intervention compared with control group (P = 0.04; P = 0.046) (MET hours/week).

No (diet)

Some (exercise)

No

Hui 2012

At 2 months after enrolment, the intervention group, compared with the control group, had lower daily intakes of total calories (P = 0.002*), carbohydrate (g) (P = 0.04), fat (g) (P = 0.0001*), saturated fat (g) (P = 0.00004*), cholesterol (mg) (P = P = 0.001*) and fat ratio (%) (P = 0.001*); and higher carbohydrate ratio (%) (P = 0.02) and protein ratio (%) (P = 0.04); no clear differences between groups for intakes of protein (g) (P = 0.11), and fibre (g) (P = 0.63). At 2 months after enrolment, the intervention group, compared with the control group, had lower daily servings of medium‐fat meat (P = 0.01), 1‐2% fat milk (P = 0.02) and oil and fats (P = 0.02), and higher daily servings of skim milk (P = 0.02); no clear differences between groups for starch (P = 0.66), very lean meat (P = 0.66), lean meat (P = 0.17), high‐fat meat (P = 0.50), vegetables (P = 0.43), fruits (P = 0.39), or whole fat milk (P = 0.15).

*P values with statistical significance after Bonferroni
correction.

At 2 months after enrolment, the physical activity index was higher in the intervention group compared with the control group (P = 0.00002).

Some (diet)

Yes (exercise)

No

Hui 2014

Pre‐pregnancy BMI < 25

At 2 months after the onset of the intervention, women in the intervention group compared with the control group had lower intakes of total calorie (P = 0.01), carbohydrate (g) (P = 0.03), total fat (g) (P = 0.008), saturated fat (g) (P = 0.008), and cholesterol (mg) (P = 0.02); no clear difference between groups for intake of protein (g) (P = 0.36).

Pre‐pregnancy BMI ≥ 25

At 2 months after the onset of the intervention, women in the intervention group compared with the control group had lower intakes of total calorie (P = 0.05), total fat (g) (P = 0.02), saturated fat (g) (P = 0.01), and cholesterol (mg) (P = 0.03); no clear differences between groups for intakes of carbohydrate (g) (P = 0.44) or protein (g) (P = 0.17).

Pre‐pregnancy BMI < 25

At 2 months after the onset of the intervention, women in the intervention group compared with the control group had higher physical activity index (units) (P < 0.01).

Pre‐pregnancy BMI ≥ 25

At 2 months after the onset of the intervention, no clear difference between groups for physical activity index (units) (P value not reported)

Some (diet and exercise)

No

Jing 2015

No clear differences between groups at 20‐24 weeks gestation for intake of carbohydrate (g) (P = 0.058), fat (g) (P = 0.216), meat (g) (P = 0.235), vegetables (g) (P = 0.637), eggs (g) (P = 0.962), milk (g) (P = 0.060), beans (g) (P = 0.982). Higher intake of energy (kcal) (P = 0.024), protein (g) (P = 0.003), grain (g) (P = 0.013), fruit (g) (P = 0.048), seafood (P = 0.031), and nuts (P = 0.036) for women in intervention group compared with control group.

No clear difference between groups at 20‐24 weeks for time spent (hours/day) doing moderate activity (P = 0.824) [and no clear difference between groups for time spent (hours/day) on intensities A, B, C, E, F, G, H]. Less time spent resting (P = 0.033) and more time doing mild activity (P = 0.016) among women in the intervention group compared with control group [and more time spent (hours/day) on intensity D].

Some (diet and exercise)

No

Koivusalo 2016

The dietary index score improved more among women in the intervention group, compared with the control group (P = 0.16 unadjusted, P = 0.037 adjusted). No clear differences between groups in changes in food intake from the first to second trimester for low‐fat milk (times/day) (P = 0.726), whole‐grain cereal (times/day) (P = 0.182), fruits and berries (times/day) (P = 0.865), vegetables and legumes (times/day) (P = 0.419), animal protein (times/day) (P = 0.658), snacks (times/week) (P = 0.112), sugar sweetened beverages (times/week) (P = 0.750), fast food (times/week) (P = 0.731), spread fat (score) (P = 0.103), cooking fat (score) (P = 0.937). Intakes of low‐fat cheese (P = 0.040) and fish (P = 0.011) increased in the intervention group compared with the control group.

Women in the intervention group increased their median weekly leisure time physical activity while the physical activities of women in the control group remained unchanged (P = 0.17 unadjusted, P = 0.029 adjusted).

No clear difference between groups in proportion of women meeting the physical activity goal (150 minutes/week in the second trimester).

Some (diet and exercise)

No

Luoto 2011

Dietary changes

Compared with the control group, from baseline to 26‐28 weeks, the intervention group reduced their intake of saccharose (E%) (P = 0.04), and saturated fatty acids (E%) (P = 0.005); no clear differences between groups seen for intakes of total energy (MJ/day) (P = 0.97), total energy (kcal/day) (P = 0.97), protein (E%) (P = 0.094), carbohydrates (E%) (P = 0.76), dietary fibre (g/day) (P = 0.44), total fat (E%) (P = 0.15), trans fatty acids (E%) (P = 0.65), mono saturated fatty acids (E%) (P = 0.99), or polyunsaturated fatty acids (E%) (P = 0.21). Compared with the control group, from baseline to 36‐37 weeks, the intervention group reduced their intake of saccharose (E%) (P = 0.023) and saturated fatty acids (E%) (P = 0.01) and increased their intake of dietary fibre (g/day) (P = 0.019) and polyunsaturated fatty acids (E%) (P < 0.001); no clear differences between groups seen for intakes of total energy (MJ/day) (P = 0.90), total energy (kcal/day) (P = 0.90), protein (E%) (P = 0.29), carbohydrates (E%) (P = 0.60), total fat (E%) (P = 0.86), trans fatty acids (E%) (P = 0.30), or mono saturated fatty acids (E%) (P = 0.51).

Food habits related to the objectives of dietary counselling

From baseline to 26‐28 weeks, the intervention group, compared with the control group, increased their proportion of high‐fibre bread (% of all bread) (P = 0.001) and vegetable fats (% of all dietary fat) (P = 0.001), while the control group decreased their proportion of low‐fat cheeses (% of all cheese) (P = 0.001), and increased intake of snacks high in sugar and/or fat (g/day) (P = 0.022); no clear differences between groups in intake of vegetables, fruits and berries (g/day) (P = 0.117), fat‐free or low‐fat milk (% of all milk) (P = 0.093), frequency of eating fish (per week) (P = 0.120), or high‐fat foods (g/day) (0.664). From baseline to 36‐37 weeks, the intervention group, compared with the control group, increased their intake of vegetables, fruits and berries (g/day) (P = 0.001), proportion of high‐fibre bread (% of all bread) (P = 0.003) and vegetable fats (% of all dietary fat) (P = 0.003), while the control group decreased their proportion of low‐fat cheeses (% of all cheese) (P = 0.009); no clear differences between groups in proportion of fat‐free or low‐fat milk (% of all milk) (P = 0.630), frequency of eating fish (per week) (P = 0.068), intake of high‐fat foods (g/day) (0.108), or snacks high in sugar and/or fat (g/day) (P = 0.551).

Consumption of the main food groups and foods

From baseline to 26‐28 weeks gestation, the intervention group, compared with the control group, increased total intake of milk (P = 0.025), fish (P = 0.041), vegetable oils (P = 0.002) and oil based salad dressings (P = 0.002); while the control group, compared with the intervention group, increased consumption of porridge and breakfast cereals (P = 0.003) and candies and chocolates (P = 0.008) (all g/day); no clear differences between groups for intake of fruits and berries (P = 0.575), cooked potato or in dishes (P = 0.686), french fries, chips and other fatty potato products (P = 0.995), total bread (P = 0.459), rice and pasta (P = 0.118), total cheese (P = 0.318), red meat and game (P = 0.851), poultry (P = 0.252), sausages (P = 0.896), vegetable spreads (P = 0.071), butter and butter mixtures (P = 0.128), solid baking margarines (P = 0.194), sweet pastries and other sugary food items (P = 0.055), pizza and hamburgers (P = 0.703), tea (P = 0.464), coffee (P = 0.976), sugary soft drinks (P = 0.088) or juice (P = 0.096) (all g/day).

From baseline to 36‐37 weeks gestation, the intervention group, compared with the control group, increased total intake of fish (P = 0.044), vegetable oils (P = 0.002) and oil based salad dressings (P = 0.010); while the control group, compared with the intervention group, decreased consumption of vegetables (P = 0.005); no clear differences between groups for intake of fruits and berries (P = 0.134), cooked potato or in dishes (P = 0.157), french fries, chips and other fatty potato products (P = 0.388), total bread (P = 0.175), porridge and breakfast cereals (P = 0.811), rice and pasta (P = 0.187), total milk (P = 0.878), total cheese (P = 0.364), red meat and game (P = 0.806), poultry (P = 0.482), sausages (P = 0.444), vegetable spreads (P = 0.215), butter and butter mixtures (P = 0.417), solid baking margarines (P = 0.208), candies and chocolates (P = 0.133), sweet pastries and other sugary food items (P = 0.104), pizza and hamburgers (P = 0.755), tea (P = 0.235), coffee (P = 0.481), sugary soft drinks (P = 0.730) or juice (P = 0.094) (all g/day).

Physical activity changes

No clear differences between baseline to 26‐28 weeks or baseline to 36‐37 weeks for total MET minutes/week (P = 0.36; P = 0.63), MET minutes/week for at least moderate activity (P = 0.17; P = 0.82), MET minutes/week for light activity (P = 0.57; P = 0.17), or ≥ 800 MET minutes/week (%) (P = 0.27; P = 0.51). At 26‐28 weeks, the decreases in total leisure‐time physical activity (LTPA) (days/week) and moderate‐to‐vigorous LTPA (days/week) were smaller in the intervention group compared with the control group (P = 0.040; P = 0.016); though no clear differences between group/days in total LTPA (minutes/week) (P = 0.58), moderate‐to‐vigorous LTPA (minutes/week) (P = 0.11), light LTPA (days/week) (P = 0.80), light LTPA (minutes/week) (P = 0.65), or meeting physical activity recommendations for health (%) (P = 0.060) were observed.

No clear differences between groups from baseline to 36‐37 weeks in total LTPA (days/week: P = 0.80; minutes/week: P = 0.60), moderate‐to‐vigorous LTPA (days/week: P = 0.16; minutes/week: P = 0.96), or light LTPA (days/week: P = 0.21; minutes/week: P = 0.75), or meeting physical activity recommendations for health (%: P = 0.70).

"From 26‐28 weeks’ gestation to 36‐37 weeks’ gestation the number of weekly days with light‐intensity LTPA decreased significantly less in INT than in UC (0.1 vs. 0.6 days, p = 0.05, not shown in Table 4)."

Some (diet and exercise)

No

Petrella 2013

"Significant changes in eating habits occurred in the Therapeutic Lifestyle Changes group, increasing the number of snacks/day, the consumption of vegetables and fruits. Moreover, intervention also decreased the consumption of sugar. No differences in the number of daily spoons of oil, red meat and complex carbohydrates intake were found."

"The step numbers for each walking session was constant during pregnancy (3267 ± 1683 at 36th week and 3755 ± 1816 at 28th week)."

Not applicable (only reported for intervention group)

Not applicable (only reported for intervention group)

Phelan 2011

"No significant treatment... interaction effects over time were observed... for dietary factors." Repeated‐measures ANOVA of time (early pregnancy, late pregnancy, 6 months postpartum, 12 months postpartum) x treatment group interactions for dietary changes in calorie intake, percentage of calories from fat, percentage of calories from carbohydrate, percentage of calories from protein, percentage of calories from sweets, daily calories from soft drinks, daily saturated fat (g), daily servings of vegetables, daily servings of fruit and fruit juices, daily servings of bread, cereals, rice, pasta, daily servings of milk, yogurt, cheese, daily frequency of fats and oils, sweets, sodas, weekly fast food, daily iron from food (mg), daily calcium from food (mg), total daily dietary fibre (g), daily vitamin D from food (IU), daily folate from food (μg): P values all "NS."

"A trend was observed for an effect of the intervention on physical activity... which suggested a small intervention‐related increase in calories expended in physical activity during the postpartum period." Repeated‐measures ANOVA of time (early pregnancy, late pregnancy, 6 months postpartum, 12 months postpartum) x treatment group interaction for kcal (F = 2.5, P = 0.06, hp2 = 0.02).

No (diet)

Yes (exercise)

No

Polley 2002

"All groups decreased their fat consumption from these foods from baseline to 30 weeks, except normal‐weight women in the control condition. There was no effect of treatment on changes in fat intake from these foods from recruitment to 30 weeks (P>0.2)."

"Changes in exercise level from recruitment to 30 weeks (P>0.8) were not related to treatment condition."

No

No

Poston 2013

At 28 weeks gestation, the intervention group had lower intakes of total energy (MJ/day) (P = 0.016), dietary glycaemic load (g/day) (P = < 0.001), glycaemic load (%E) (P = 0.013), total fat (%E) (P = 0.010) and saturated fatty acids (%E) (P = 0.015), and higher protein (%E) (P = 0.034), and fibre (non‐starch polysaccharides) (g) (P = 0.040) compared with the control group; no clear differences between groups for dietary glycaemic index (%) (P = 0.054), carbohydrate (%E) (P = 0.207), protein (g) (P = 0.204), monounsaturated fatty acids (%E) (P = 0.088), polyunsaturated fatty acids (%E) (P = 0.075), or polyunsaturated fatty acid, saturated fatty acid ratio (P = 0.075).

"A principal component analysis (PCA) of Food Frequency Questionnaire (FFQ) data from the UPBEAT pilot study database was performed to derive three diet patterns: two with high coefficients for high‐sugar and/or highfat food groups defined as ‘Western’ and ‘Healthy‐unhealthy choices’ and a ‘traditional’ African or African‐Caribbean diet pattern…. The ‘Western’ and ‘Healthy‐unhealthy choices’ patterns scores were reduced in those who received the intervention."

At 28 weeks gestation, no clear differences between groups for physical activity, as measured by accelerometer (minutes/day of sedentary, active, light, moderate to vigorous activity) (P values not reported; mean differences with 95% confidence intervals indicate no clear differences), and Recent Physical Activity Questionnaire (minutes/day of sedentary, activity, light activity); self‐reported moderate to vigorous activity (minutes/day) was higher in the intervention group compared with the control group (P value not reported; mean difference with 95% confidence interval indicates difference), and women in the intervention group self‐reported walking (minutes/day) for leisure more than those in the control group (P = 0.003).

Some (diet and exercise)

No

Poston 2015

At 27‐28 weeks and 6 days, women in the intervention group, compared with the control group, had lower mean total energy (MJ/day) (P < 0.0001), glycaemic index (0‐100) (P < 0.0001), glycaemic load per day (P < 0.0001), and intake carbohydrate (% energy) (P = 0.0011), total fat (% energy) (P = 0.0011), saturated fat (g/day) (P < 0.0001) and saturated fat (% energy) (P < 0.0001); and higher intake of protein (% energy) (P < 0.0001), and fibre (g/day) (P = 0.013).

At 6 months postpartum, women in the intervention group, compared with the control group, had lower glycaemic load per day (P < 0.001), glycaemic index (0‐100) (P < 0.001), intakes of total energy (kcal per day) (P < 0.001), saturated fat (% energy) (P < 0.001), and total fat (% energy) (P < 0.001), and higher intake of protein (% energy) (P < 0.001); no clear differences between groups for intakes of carbohydrates (% energy) (P = 0.835) and fibre (g/day) (P = 0.873).

At 27‐28 weeks and 6 days, women in the intervention group, compared with the control group, were more physically active: MET (minutes/week) (P = 0.0015); attributed to more time spent walking (minutes/week) (P = 0.0018), with no clear difference seen between groups for moderate or vigorous activity (minutes/week) (P > 0.99).

At 6 months postpartum, no clear differences between groups for measures of physical activity: MET (minutes/week) (P = 0.607), moderate or vigorous activity (minutes/week) (P = 0.681), or walking (minutes/week) (P = 1.00).

Some (diet and exercise)

No

Rauh 2013

The intervention group had a lower change from baseline to 36‐38th week gestation energy intake compared with the control group (kcal/day) (P = 0.035).

No clear difference between groups in change from baseline to 36‐38th week gestation total activity (MET‐min/week) (P = 0.425).

Yes (diet)

No (exercise)

No

Sagedal 2017

At 36 weeks gestation the intervention group had a higher (more favourable) diet score compared with the control group (P = 0.013); dietary differences favouring the intervention group were identified in 7 domains: ‘drinking water when thirsty’ (P = 0.002), ‘vegetables with dinner’ (P = 0.027), ‘fruits and vegetables for between‐meal snacks’ (P = 0.023), ‘package size of unhealthy foods’ (P = 0.010), ‘added sugar' (P = 0.005), ‘eating beyond satiety’ (P = 0.009) and ‘food labels’ (P = 0.011); no clear differences between groups for 'meal regularity' (P = 0.176), 'eating sweets or snacks without appreciation' (P = 0.446), 'added salt' (P = 0.680).

At 36 weeks gestation the intervention group compared with the control group had higher weekly energy expenditure (MET‐minutes/week) (P = 0.009), and according to the International Physical Activity Questionnaire, fewer had 'low activity', and more had 'moderate activity' and 'high activity' (P = 0.013).

Some (diet)

Yes (exercise)

No

Vinter 2011

"When asked at 35 weeks’ gestation whether participation in the LiP study had resulted in more healthy eating habits, 85% of women in the intervention group responded affirmatively. In addition, 21% of women in the control group thought that their dietary habits in pregnancy were positively influenced by their participation."

At 35 weeks' gestation, women in the intervention group had higher self‐reported physical activity levels compared with those in the control group (physical activity ≥ 2 hours/week (P = 0.001); physical activity making them sweaty or short of breath ≥ 2 hours/week (P < 0.001)); no clear differences between groups at 6 months postpartum (physical activity ≥ 2 hours/week (P = 0.620); physical activity making them sweaty or short of breath ≥ 2 hours/week (P = 0.961)).

"Among women in the intervention group, 77.5% undertook leisure time sporting activities in addition to the aerobic classes. In addition, 65% of women in the control group engaged in some type of leisure time sporting activities during pregnancy (P = 0.016)."

At 35 weeks' gestation, women in the intervention group had improved eating habits compared with those in the control group (considered themselves as in the most healthy eating habit groups (P = 0.003)); no clear differences between groups at 6 months postpartum (considered themselves as in the most healthy eating habit groups (P = 0.609)).

Some (diet and exercise)

No

Figures and Tables -
Analysis 1.19

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 19 Behaviour changes associated with the intervention.

Study

Results

Benefit in favour of intervention

Benefit in favour of control

Hawkins 2014

No clear differences between groups in change in biomarkers of insulin resistance from baseline to mid‐pregnancy: glucose (mmol/L) (P = 0.63); insulin (pmol/L) (P = 0.39); leptin (pmol/L) (P = 0.73); adiponectin (nmol/L) (P = 0.51); resistin (nmol/L) (P = 0.19); tumour necrosis factor‐alpha (pmol/L) (P = 0.11); c‐reactive protein (nmol/L) (P = 0.19).

No

No

Koivusalo 2016

Women in the intervention group compared with the control group had a greater change (reduction) in fasting plasma glucose from baseline to the third trimester (P = 0.026 unadjusted; P = 0.011 adjusted). No clear difference between groups in change (increase) in 2‐hour glucose from baseline to second trimester (P = 0.92 unadjusted, P = 0.42 adjusted).

Some

No

Korpi‐Hyovalti 2011

No clear difference between groups in fasting glucose (mmol/L), OGTT 1‐hour glucose (mmol/L), OGTT 2‐hour glucose (mmol/L), or area under the curve (mmol/L/2 hour) (all reported to be P = NS) at weeks 26‐28.

No

No

Luoto 2011

There were no clear differences between groups in glucose intolerance measurements at 26‐28 weeks (glucose concentrations in 2‐hour OGTT (mg/L): fasting (P = 0.44), 1‐hour (P = 0.23), 2‐hour (P = 0.99); insulin (P = 0.10), or HOMA‐IR (P = 0.13)); or in the change from baseline (8‐12 weeks) to 26‐28 week values for insulin (P = 0.23), or HOMA‐IR (P = 0.24).

No

No

Poston 2015

At 27‐28 weeks and 6 days gestation, no clear differences between groups in fasting blood glucose (mmol/L) (P = 0.49), 1‐hour blood glucose (mmol/L) (P = 0.43), 2‐hour blood glucose (mmol/L) (P = 0.81), plasma fasting insulin (mU/L) (P = 0.57), HOMA‐IR (units) (P = 0.60), plasma triglycerides (mmol/L) (P = 0.39), plasma LDL cholesterol (mmol/L) (P = 0.27), plasma HDL cholesterol (mmol/L) (0.93), plasma VLDL (mmol/L) (P = 0.39).

No

No

Vinter 2011

Glucose metabolism and insulin sensitivity

No clear differences between groups in fasting plasma glucose (mmol/L) at 28‐30 weeks (P = 0.060) or 34‐36 weeks (P = 0.431). No clear differences between groups in 2‐hour oral glucose tolerance test (mmol/L) at 28‐30 weeks (P = 0.459) or 34‐36 weeks (P = 0.723). No clear differences between groups in fasting insulin (mU/L) at 34‐36 weeks (P = 0.065) or change from baseline to 34‐36 weeks fasting insulin (P = 0.063); women in the intervention group had lower fasting insulin at 28‐30 weeks (P = 0.040), and lower change from baseline to 28‐30 weeks fasting insulin (P = 0.015). No clear differences between groups in HOMA‐IR at 34‐36 weeks (P = 0.062) or change from baseline to 34‐36 weeks fasting insulin (P = 0.079); women in the intervention group had lower fasting insulin at 28‐30 weeks (P = 0.032), and lower change from baseline to 28‐30 weeks fasting insulin (P = 0.022).
Lipid metabolism

No clear differences between groups at 28‐30 weeks or 34‐36 weeks for fasting cholesterol (mmol/L) (P = 0.332; P = 0.484), fasting HDL (mmol/L) (P = 0.781; P = 0.871), fasting LDL (mmol/L) (P = 0.148; P = 0.183), or fasting triglycerides (mmol/L) (P = 0.385; P = 0.399).

Some

No

Figures and Tables -
Analysis 1.20

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 20 Relevant biomarker changes associated with the intervention.

Study

Results

Benefits in favour of intervention

Benefits in favour of control

Dodd 2014

There were no clear differences between groups (from trial entry, to 28 weeks, 36 weeks and 4 months postpartum) in mean depressive scores (Edinburgh Postnatal Depression Scale (EPDS) mean scores) (adjusted P = 0.25), risk of depression (EPDS score > 12, %) (adjusted P = 0.95), symptoms of anxiety (Spielberger State‐Trait Anxiety Inventory (STAI) mean scores) (adjusted P = 0.51), or risk of high level anxiety (STAI score ≥ 15, %) (adjusted P = 0.31). There were no clear differences between groups for any of the domains assessing health related quality of life (from trial entry, to 28 weeks, 36 weeks and 4 months postpartum) (mean scores: physical functioning adjusted P = 0.53; physical role adjusted P = 0.59; bodily pain adjusted P = 0.27; general health adjusted P = 1.00; vitality adjusted P = 0.48; social functioning adjusted P = 0.52; emotional role adjusted P > 0.11; mental health adjusted P = 0.07; physical component adjusted P = 0.47; mental component adjusted P = 0.36). For emotional role and mental health domains there were significant interactions between treatment group and time point (P = 0.03; P = 0.007); although there were no significant differences between treatment groups at any individual time point, the pattern of change over pregnancy differed according to treatment group.

"All women reported a high degree of satisfaction with their pregnancy... p = 0.8722... and with birth... p = 0.9235... Most women agreed or strongly agreed that they felt in control during their pregnancy... p = 0.9945... and birth... p = 0.4510... and they liked their care providers... p = 0.1530... There were no differences with regard to the proportion of women who felt healthy during pregnancy... p = 0.3517... women who received the intervention were more likely to feel reassured about their own health... p = 0.0112... and that of their baby... p = 0.0143... In the postpartum period, most women felt healthy... p = 0.5942... and were not concerned about their future health... p = 0.9444... or the future health of their baby or child... p = 0.9467"

Some (reassurance about own health and health of baby)

No

Luoto 2011

No clear difference between groups from 8‐13 weeks to 36‐37 weeks in change in health related quality of life (15D questionnaire) (P = 0.24), or perceived health (VAS scale of 0–10 cm) (P = 0.061).

No

No

Phelan 2011

"The intervention group... had a significantly greater increase in scores on the Edinburgh Depression Scale during the postpartum period than did the standard‐care group (F = 23.2, P = 0.0001, hp2 = 0.094); however, multiple logistic regression analyses indicated no significant effects of the intervention compared with standard care on the prevalence of depression (defined as a score ≥13) at 30 wk of gestation (6.4% compared with 7.2%, respectively), 6 mo (3.4% compared with 3.6%, respectively), or 12 mo (5.2% compared with 6.3%, respectively) postpartum. Both groups reported very low depression scores overall... No significant treatment... interaction effects over time were observed for dietary disinhibition, stress or sleep."

Repeated‐measures ANOVA of time (early pregnancy, late pregnancy, 6 months postpartum, 12 months postpartum) x treatment group interactions for disinhibition, stress, and sleep score: P values all reported to be "NS."

No

Some (Edinburgh Depression Scale scores)

Poston 2013

At 28 weeks gestation, there was no clear difference between groups in the numbers of women reporting problems in each of the EuroQol quality of life (EQ‐5D) questionnaire domains: mobility, self‐care, usual activities, pain and discomfort, anxiety and depression; or in the time trade‐off health state rating and visual analogue scale of health related quality of life (0 to 100) (P values not reported, however treatment effects indicate no clear differences). At 28 weeks gestation there were also no clear differences between groups in Edinburgh Postnatal Depression Score total, total score > 9, and total score > 12 (P values not reported, however treatment effects indicate no clear differences).

No

No

Figures and Tables -
Analysis 1.21

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 21 Sense of well‐being and quality of life.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 22 Breastfeeding (exclusive).
Figures and Tables -
Analysis 1.22

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 22 Breastfeeding (exclusive).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 23 Breastfeeding (partial).
Figures and Tables -
Analysis 1.23

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 23 Breastfeeding (partial).

Study

Diet and exercise

Control

P value

Rauh 2013

Mean (SD not reported) (N = 148, unadjusted)

Exclusive breastfeeding duration (days): 130.7

Total breastfeeding duration (days): 232.1

Mean (SD not reported) (N = 65, unadjusted)

Exclusive breastfeeding duration (days): 116.3

Total breastfeeding duration (days): 219.4

P = 0.180

P = 0.465

Figures and Tables -
Analysis 1.24

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 24 Breastfeeding.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 25 Postnatal weight retention (latest time reported) (kg).
Figures and Tables -
Analysis 1.25

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 25 Postnatal weight retention (latest time reported) (kg).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 26 Return to pre‐pregnancy weight (latest time reported).
Figures and Tables -
Analysis 1.26

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 26 Return to pre‐pregnancy weight (latest time reported).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 27 Postnatal BMI (latest time reported).
Figures and Tables -
Analysis 1.27

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 27 Postnatal BMI (latest time reported).

Study

Intervention

Control

P value

Vinter 2011

6 months postpartum (median (IQR)) (N = 123)

Systolic blood pressure (mm Hg): 122 (116–129)

Diastolic blood pressure (mm Hg): 83.5 (78–88)

6 months postpartum (median (IQR)) (N = 115)

Systolic blood pressure (mm Hg): 122 (115–128)

Diastolic blood pressure (mm Hg): 82 (78–88)

0.770

0.733

Figures and Tables -
Analysis 1.28

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 28 Maternal cardiovascular health (latest time reported).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 29 Stillbirth.
Figures and Tables -
Analysis 1.29

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 29 Stillbirth.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 30 Neonatal mortality.
Figures and Tables -
Analysis 1.30

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 30 Neonatal mortality.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 31 Gestational age at birth (weeks).
Figures and Tables -
Analysis 1.31

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 31 Gestational age at birth (weeks).

Study

Intervention group

Control group

P value

Polley 2002

Mean (SD not reported)

Normal weight women (N = 30)

39.1 weeks

Overweight women (N = 27)

39.4 weeks

Mean (SD not reported)

Normal weight women (N = 31)

39.5 weeks

Overweight women (N = 22)

39.1 weeks

Not reported

Vinter 2011

Median (IQR)

(N = 150)

283 days (273‐290)

Median (IQR)

(n = 154)

283 days (274‐289)

0.952

Figures and Tables -
Analysis 1.32

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 32 Gestational age at birth (days or weeks).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 33 Preterm birth.
Figures and Tables -
Analysis 1.33

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 33 Preterm birth.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 34 Apgar score less than seven at five minutes.
Figures and Tables -
Analysis 1.34

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 34 Apgar score less than seven at five minutes.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 35 Macrosomia.
Figures and Tables -
Analysis 1.35

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 35 Macrosomia.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 36 Small‐for‐gestational age.
Figures and Tables -
Analysis 1.36

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 36 Small‐for‐gestational age.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 37 Birthweight (g).
Figures and Tables -
Analysis 1.37

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 37 Birthweight (g).

Study

Intervention group

Control group

P value

Herring 2016

Mean (SD not reported) (N = 27)

3147

Mean (SD not reported) (N = 29)

3361

Mean difference: ‐213 (95% CI: ‐431 to 3.7)

Polley 2002

Mean (SD not reported)

Born to normal weight women (N = 30)

3133.0

Born to overweight women (N = 27)

3282.8

Mean (SD not reported)

Born to normal weight women (N = 31)

3226.4

Born to overweight women (N = 22)

3349.0

Not reported

Vinter 2011

Median (IQR) (N = 150)

3742 (3464‐4070)

Median (IQR) (N = 154)

3593 (3335‐3930)

0.039

Figures and Tables -
Analysis 1.38

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 38 Birthweight (g).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 39 Birthweight z score.
Figures and Tables -
Analysis 1.39

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 39 Birthweight z score.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 40 Head circumference (cm).
Figures and Tables -
Analysis 1.40

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 40 Head circumference (cm).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 41 Head circumference z score.
Figures and Tables -
Analysis 1.41

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 41 Head circumference z score.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 42 Length (cm).
Figures and Tables -
Analysis 1.42

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 42 Length (cm).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 43 Length z score.
Figures and Tables -
Analysis 1.43

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 43 Length z score.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 44 Ponderal index (kg/m3).
Figures and Tables -
Analysis 1.44

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 44 Ponderal index (kg/m3).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 45 Adiposity (sum of skinfold thickness) (mm).
Figures and Tables -
Analysis 1.45

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 45 Adiposity (sum of skinfold thickness) (mm).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 46 Adiposity (abdominal circumference) (cm).
Figures and Tables -
Analysis 1.46

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 46 Adiposity (abdominal circumference) (cm).

Study

Intervention

Control

P value

Dodd 2014

Neonatal anthropometric measures

Mean (SD) (N = 488)

Chest circumference
(cm): 34.24 (1.92)

Arm circumference
(cm): 11.23 (1.01)

Biceps SFTM (mm): 4.37 (1.12)

Triceps SFTM (mm): 5.45 (1.30)

Subscapular SFTM (mm): 5.15 (1.30)

Suprailiac SFTM (mm): 5.76 (1.83)

Abdominal SFTM (mm): 3.85 (1.02)

Thigh SFTM (mm): 6.99 (1.85)

Abdominal circumference to length ratio: 0.65 (0.04)

Fat mass (g): 522.72 (180.70)

Fat‐free mass (g): 3026.64 (339.96)

Percentage body fat: 14.41 (3.39)

Percentage fat‐free mass: 85.59 (3.39)

(N = 215)

Fat‐free mass R0 (g): 3096.62 (320.97)

Percentage fat‐free mass R0: 88.98 (2.98)

Neonatal anthropometric measures

Mean (SD) (N = 482)

Chest circumference
(cm): 34.27 (2.08)

Arm circumference
(cm): 11.18 (1.12)

Biceps SFTM (mm): 4.31 (1.13)

Triceps SFTM (mm): 5.41 (1.44)

Subscapular SFTM (mm): 5.11 (1.21)

Suprailiac SFTM (mm): 5.75 (1.92)

Abdominal SFTM (mm): 3.82 (1.06)

Thigh SFTM (mm): 7.02 (1.90)

Abdominal circumference to length ratio: 0.65 (0.04)

Fat mass (g): 523.48 (189.05)

Fat‐free mass (g): 3030.07 (362.54)

Percentage body fat: 14.37 (3.44)

Percentage fat‐free mass: 85.63 (3.44)

(N = 179)

Fat‐free mass R0 (g): 3133.15 (348.92)

Percentage fat‐free mass R0: 89.10 (3.40)

"Average body circumferences, SFTM and calculated body fat measures were similar between the treatment groups, with no statistically significant differences identified... There were also no statistically significant differences identified between the two groups, with regard to fat‐free mass (R0) and percentage fat‐free mass (R0) obtained using bio‐impedance analysis"

(P value: 0.94; 0.60; 0.45; 0.85; 0.90; 0.97; 0.85; 0.74; 0.90; 0.94; 0.97; 0.91; 0.91; 0.56; 0.79)

Poston 2015

Mean (SD) (N = 249)

Triceps SFTM (mm): 5.3 (1.4)

(N = 244)

Subscapular SFTM (mm): 5.7 (1.4)

Mean (SD) (N = 268)

Triceps SFTM (mm): 5.3 (1.6)

(N = 258)

Subscapular SFTM (mm): 5.6 (1.4)

"Neonatal anthropometric measures were evaluated in a subgroup of infants and did not differ between groups"

(P values: 0.72; 0.66)

Figures and Tables -
Analysis 1.47

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 47 Adiposity.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 48 Shoulder dystocia.
Figures and Tables -
Analysis 1.48

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 48 Shoulder dystocia.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 49 Nerve palsy.
Figures and Tables -
Analysis 1.49

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 49 Nerve palsy.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 50 Bone fracture.
Figures and Tables -
Analysis 1.50

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 50 Bone fracture.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 51 Respiratory distress syndrome.
Figures and Tables -
Analysis 1.51

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 51 Respiratory distress syndrome.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 52 Hypoglycaemia.
Figures and Tables -
Analysis 1.52

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 52 Hypoglycaemia.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 53 Hyperbilirubinaemia.
Figures and Tables -
Analysis 1.53

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 53 Hyperbilirubinaemia.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 54 Childhood weight (latest time reported) (kg).
Figures and Tables -
Analysis 1.54

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 54 Childhood weight (latest time reported) (kg).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 55 Childhood weight z score (latest time reported).
Figures and Tables -
Analysis 1.55

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 55 Childhood weight z score (latest time reported).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 56 Childhood height (latest time reported) (cm).
Figures and Tables -
Analysis 1.56

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 56 Childhood height (latest time reported) (cm).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 57 Childhood height z score (latest time reported).
Figures and Tables -
Analysis 1.57

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 57 Childhood height z score (latest time reported).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 58 Childhood head circumference (latest time reported) (cm).
Figures and Tables -
Analysis 1.58

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 58 Childhood head circumference (latest time reported) (cm).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 59 Childhood adiposity (latest time reported) (BMI z score).
Figures and Tables -
Analysis 1.59

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 59 Childhood adiposity (latest time reported) (BMI z score).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 60 Childhood adiposity (latest time reported) (abdominal circumference) (cm).
Figures and Tables -
Analysis 1.60

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 60 Childhood adiposity (latest time reported) (abdominal circumference) (cm).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 61 Childhood adiposity (latest time reported) (subscapular skinfold thickness) (mm).
Figures and Tables -
Analysis 1.61

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 61 Childhood adiposity (latest time reported) (subscapular skinfold thickness) (mm).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 62 Childhood adiposity (latest time reported) (triceps skinfold thickness) (mm).
Figures and Tables -
Analysis 1.62

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 62 Childhood adiposity (latest time reported) (triceps skinfold thickness) (mm).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 63 Childhood adiposity (latest time reported) (total body fat) (%).
Figures and Tables -
Analysis 1.63

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 63 Childhood adiposity (latest time reported) (total body fat) (%).

Study

Intervention

Control

P value

Poston 2015

Anthropometric measures at 6 months

Mean (SD)

(N = 267)

Subscapular SFTM z score: 0.08 (1.37)

(N = 296)

Triceps SFTM z score: 0.10 (1.56)

(N = 267)

Sum of SFTM (mm): 17.08 (3.93)

(N = 267)

Subscapular triceps ratio: 0.83 (0.22)

(N = 315)

Waist length ratio: 0.64 (0.08)

(N = 314)

Weight for length z score: ‐0.08 (1.79)

(N = 329)

Mid upper arm circumference (cm): 15.30 (1.49)

Anthropometric measures at 6 months

Mean (SD)

(N = 280)

Subscapular SFTM z score: 0.36 (1.37)

(N = 298)

Triceps SFTM z score: 0.24 (1.43)

(N = 280)

Sum of SFTM (mm): 17.71 (3.97)

(N = 280)

Subscapular triceps ratio: 0.85 (0.23)

(N = 328)

Waist length ratio: 0.64 (0.10)

(N = 324)

Weight for length z score: 0.08 (1.63)

(N = 347)

Mid upper arm circumference (cm): 15.39 (2.08)

"There was no statistical difference in triceps skinfold thickness... but subscapular skinfold thickness z‐score was... lower in the intervention arm... The infant sum of skinfold thickness... did not reach statistical significance... There were no differences... in other anthropometric measures between the two arms"

(P values: 0.021; 0.246; 0.058; 0.423; 0.928; 0.184; 0.511)

Vinter 2011

Anthropometric measures at 2.8 years

Mean (95% CI) or N (%) (N = 82)

Overweight or obese: 9 (10.9%)

BMI (kg/m²): 16.4 (16.1; 16.7)

Hip (cm): 50.8 (50.1; 51.5)

Abdominal circumference/hip ratio: 0.97 (0.95; 0.97)

Dual Energy X‐ray scan results at 2.8 years

Mean (95% CI) (N = 37)

Total fat (g): 2463 (2147; 2779)

Lean body mass (g): 11,336 (10,942; 11,730)

Anthropometric measures at 2.8 years

Mean (95% CI) or N (%) (N = 75)

Overweight or obese: 5 (6.7%)

BMI (kg/m²): 16.1 (15.8; 16.4)

Hip (cm): 50.2 (49.4; 51.0)

Abdominal circumference/hip ratio: 0.96 (0.95; 0.97)

Dual Energy X‐ray scan results at 2.8 years

Mean (95% CI) (N = 30)

Total fat (g): 2442 (2189; 2696)

Lean body mass (g): 11,236 (10,797; 11,675)

"At a significance level of 0.05 (two‐sided), there were no statistically significant differences in any variables between the LiP intervention and control groups."

(Individual P values not reported)

Figures and Tables -
Analysis 1.64

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 64 Childhood adiposity (latest time reported).

Study

Intervention

Control

P value

Vinter 2011

Metabolic risk factors at 2.8 years

Mean (95% CI) or N (%)

(N = 63)

Systolic blood pressure (mm Hg): 98.3 (93.7–105.3)

Systolic blood pressure ≥ 90th percentile: 16 (25.4)

Diastolic blood pressure (mm Hg): 64.3 (61.0–67.3)

Diastolic blood pressure ≥ 90th percentile: 16 (25.4)

(N = 59)

Fasting plasma glucose (mmol/L): 5.2 (4.6 –5.6)

Fasting plasma glucose ≥ 5.6 mmol/L: 16 (20.8)

(N = 39)

Fasting insulin (pmol/L): 16 (8–33)

Fasting insulin ≥ 55 pmol/L: 3 (7.7)

Fasting HDL (mmol/L): 1.2 (1.1–1.4)

Fasting HDL ≥ 1.03 mmol/L: 6 (17.1)

Fasting triglycerides (mmol/L): 0.7 (0.6 –1.1)

Fasting triglycerides ≥ 1.7 mmol/L: 1 (2.9)

Metabolic syndrome (a high abdominal circumference plus 2 or more of the following: low HDL, high triglycerides, high fasting glucose, and high systolic and/or diastolic blood pressure): 0 (0)

Metabolic risk factors at 2.8 years

Mean (95% CI) or N (%)

(N = 54)

Systolic blood pressure (mm Hg): 97.3 (94.3–101.3)

Systolic blood pressure ≥ 90th percentile: 12 (22.0)

Diastolic blood pressure (mm Hg): 62.0 (60.3– 65.3)

Diastolic blood pressure ≥ 90th percentile: 12 (22.0)

(N = 59)

Fasting plasma glucose (mmol/L): 5.1 (4.7–5.5)

Fasting plasma glucose ≥ 5.6 mmol/L: 13 (18.1)

(N = 51)

Fasting insulin (pmol/L): 12 (8–18)

Fasting insulin ≥ 55 pmol/L: 3 (5.9)

Fasting HDL (mmol/L): 1.3 (1.1–1.5)

Fasting HDL ≥ 1.03 mmol/L: 6 (12.2)

Fasting triglycerides (mmol/L): 0.9 (0.6 –1.0)

Fasting triglycerides ≥ 1.7 mmol/L: 3 (6.1)

Metabolic syndrome (a high abdominal circumference plus 2 or more of the following: low HDL, high triglycerides, high fasting glucose, and high systolic and/or diastolic blood pressure): 0 (0)

"At a significance level of .05 (two‐sided), there were no statistically
significant differences in any variables between the LiPi and LiPc groups."

Figures and Tables -
Analysis 1.65

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 65 Childhood cardiovascular health (latest time reported).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 66 Antenatal visits.
Figures and Tables -
Analysis 1.66

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 66 Antenatal visits.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 67 Antenatal admissions.
Figures and Tables -
Analysis 1.67

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 67 Antenatal admissions.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 68 Length of antenatal stay (days).
Figures and Tables -
Analysis 1.68

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 68 Length of antenatal stay (days).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 69 Neonatal intensive care unit admission.
Figures and Tables -
Analysis 1.69

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 69 Neonatal intensive care unit admission.

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 70 Length of postnatal stay (mother) (days).
Figures and Tables -
Analysis 1.70

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 70 Length of postnatal stay (mother) (days).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 71 Length of postnatal stay (baby) (days).
Figures and Tables -
Analysis 1.71

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 71 Length of postnatal stay (baby) (days).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 72 Costs to families associated with the management provided (unit cost, €).
Figures and Tables -
Analysis 1.72

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 72 Costs to families associated with the management provided (unit cost, €).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 73 Costs associated with the intervention (unit cost, €).
Figures and Tables -
Analysis 1.73

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 73 Costs associated with the intervention (unit cost, €).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 74 Cost of maternal care (unit cost, €).
Figures and Tables -
Analysis 1.74

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 74 Cost of maternal care (unit cost, €).

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 75 Cost of infant care (unit cost, €).
Figures and Tables -
Analysis 1.75

Comparison 1 Combined diet and exercise interventions versus standard care, Outcome 75 Cost of infant care (unit cost, €).

Comparison 2 Combined diet and exercise interventions versus standard care: subgroups based on study design, Outcome 1 Gestational diabetes.
Figures and Tables -
Analysis 2.1

Comparison 2 Combined diet and exercise interventions versus standard care: subgroups based on study design, Outcome 1 Gestational diabetes.

Comparison 2 Combined diet and exercise interventions versus standard care: subgroups based on study design, Outcome 2 Pre‐eclampsia.
Figures and Tables -
Analysis 2.2

Comparison 2 Combined diet and exercise interventions versus standard care: subgroups based on study design, Outcome 2 Pre‐eclampsia.

Comparison 2 Combined diet and exercise interventions versus standard care: subgroups based on study design, Outcome 3 Caesarean section.
Figures and Tables -
Analysis 2.3

Comparison 2 Combined diet and exercise interventions versus standard care: subgroups based on study design, Outcome 3 Caesarean section.

Comparison 2 Combined diet and exercise interventions versus standard care: subgroups based on study design, Outcome 4 Large‐for‐gestational age.
Figures and Tables -
Analysis 2.4

Comparison 2 Combined diet and exercise interventions versus standard care: subgroups based on study design, Outcome 4 Large‐for‐gestational age.

Comparison 3 Combined diet and exercise interventions versus standard care: subgroups based on maternal BMI, Outcome 1 Gestational diabetes.
Figures and Tables -
Analysis 3.1

Comparison 3 Combined diet and exercise interventions versus standard care: subgroups based on maternal BMI, Outcome 1 Gestational diabetes.

Comparison 3 Combined diet and exercise interventions versus standard care: subgroups based on maternal BMI, Outcome 2 Pre‐eclampsia.
Figures and Tables -
Analysis 3.2

Comparison 3 Combined diet and exercise interventions versus standard care: subgroups based on maternal BMI, Outcome 2 Pre‐eclampsia.

Comparison 3 Combined diet and exercise interventions versus standard care: subgroups based on maternal BMI, Outcome 3 Pregnancy‐induced hypertension or hypertension.
Figures and Tables -
Analysis 3.3

Comparison 3 Combined diet and exercise interventions versus standard care: subgroups based on maternal BMI, Outcome 3 Pregnancy‐induced hypertension or hypertension.

Comparison 3 Combined diet and exercise interventions versus standard care: subgroups based on maternal BMI, Outcome 4 Caesarean section.
Figures and Tables -
Analysis 3.4

Comparison 3 Combined diet and exercise interventions versus standard care: subgroups based on maternal BMI, Outcome 4 Caesarean section.

Comparison 3 Combined diet and exercise interventions versus standard care: subgroups based on maternal BMI, Outcome 5 Perinatal mortality.
Figures and Tables -
Analysis 3.5

Comparison 3 Combined diet and exercise interventions versus standard care: subgroups based on maternal BMI, Outcome 5 Perinatal mortality.

Comparison 3 Combined diet and exercise interventions versus standard care: subgroups based on maternal BMI, Outcome 6 Large‐for‐gestational age.
Figures and Tables -
Analysis 3.6

Comparison 3 Combined diet and exercise interventions versus standard care: subgroups based on maternal BMI, Outcome 6 Large‐for‐gestational age.

Comparison 4 Combined diet and exercise interventions versus standard care: subgroups based on ethnicity, Outcome 1 Gestational diabetes.
Figures and Tables -
Analysis 4.1

Comparison 4 Combined diet and exercise interventions versus standard care: subgroups based on ethnicity, Outcome 1 Gestational diabetes.

Comparison 4 Combined diet and exercise interventions versus standard care: subgroups based on ethnicity, Outcome 2 Pre‐eclampsia.
Figures and Tables -
Analysis 4.2

Comparison 4 Combined diet and exercise interventions versus standard care: subgroups based on ethnicity, Outcome 2 Pre‐eclampsia.

Comparison 4 Combined diet and exercise interventions versus standard care: subgroups based on ethnicity, Outcome 3 Pregnancy‐induced hypertension or hypertension.
Figures and Tables -
Analysis 4.3

Comparison 4 Combined diet and exercise interventions versus standard care: subgroups based on ethnicity, Outcome 3 Pregnancy‐induced hypertension or hypertension.

Comparison 4 Combined diet and exercise interventions versus standard care: subgroups based on ethnicity, Outcome 4 Caesarean section.
Figures and Tables -
Analysis 4.4

Comparison 4 Combined diet and exercise interventions versus standard care: subgroups based on ethnicity, Outcome 4 Caesarean section.

Comparison 4 Combined diet and exercise interventions versus standard care: subgroups based on ethnicity, Outcome 5 Perinatal mortality.
Figures and Tables -
Analysis 4.5

Comparison 4 Combined diet and exercise interventions versus standard care: subgroups based on ethnicity, Outcome 5 Perinatal mortality.

Comparison 4 Combined diet and exercise interventions versus standard care: subgroups based on ethnicity, Outcome 6 Large‐for‐gestational age.
Figures and Tables -
Analysis 4.6

Comparison 4 Combined diet and exercise interventions versus standard care: subgroups based on ethnicity, Outcome 6 Large‐for‐gestational age.

Comparison 5 Combined diet and exercise interventions versus standard care: sensitivity analyses, Outcome 1 Gestational diabetes.
Figures and Tables -
Analysis 5.1

Comparison 5 Combined diet and exercise interventions versus standard care: sensitivity analyses, Outcome 1 Gestational diabetes.

Comparison 5 Combined diet and exercise interventions versus standard care: sensitivity analyses, Outcome 2 Pre‐eclampsia.
Figures and Tables -
Analysis 5.2

Comparison 5 Combined diet and exercise interventions versus standard care: sensitivity analyses, Outcome 2 Pre‐eclampsia.

Comparison 5 Combined diet and exercise interventions versus standard care: sensitivity analyses, Outcome 3 Pregnancy‐induced hypertension.
Figures and Tables -
Analysis 5.3

Comparison 5 Combined diet and exercise interventions versus standard care: sensitivity analyses, Outcome 3 Pregnancy‐induced hypertension.

Comparison 5 Combined diet and exercise interventions versus standard care: sensitivity analyses, Outcome 4 Caesarean section.
Figures and Tables -
Analysis 5.4

Comparison 5 Combined diet and exercise interventions versus standard care: sensitivity analyses, Outcome 4 Caesarean section.

Comparison 5 Combined diet and exercise interventions versus standard care: sensitivity analyses, Outcome 5 Perinatal mortality.
Figures and Tables -
Analysis 5.5

Comparison 5 Combined diet and exercise interventions versus standard care: sensitivity analyses, Outcome 5 Perinatal mortality.

Comparison 5 Combined diet and exercise interventions versus standard care: sensitivity analyses, Outcome 6 Large‐for‐gestational age.
Figures and Tables -
Analysis 5.6

Comparison 5 Combined diet and exercise interventions versus standard care: sensitivity analyses, Outcome 6 Large‐for‐gestational age.

Summary of findings for the main comparison. Combined diet and exercise interventions versus standard care (mother)

Combined diet and exercise interventions for preventing GDM

Population: pregnant women, excluding women already diagnosed with GDM, type 1 or type 2 diabetes

Setting: Australia (2 RCTs), Brazil (1 RCT), Canada (2 RCTs), China (2 RCTs), Denmark (1 RCT), Egypt (1 RCT), Finland (3 RCTs), Germany (1 RCT), Italy (2 RCTs), Norway (1 RCT), UK (2 RCTs), USA (5 RCTs)
Intervention: combined diet and exercise interventions
Comparison: standard care

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(RCTs)

Quality of the evidence
(GRADE)

Comments

Risk with control

Risk with diet and exercise interventions

GDM

Trial population

average RR 0.85

(0.71 to 1.01)

6633

(19 RCTs)

⊕⊕⊕⊝

MODERATE1,3

168 per 1000

143 per 1000

(119 to 170)

Hypertensive disorders of pregnancy (pre‐eclampsia)

Trial population

RR 0.98

(0.79 to 1.22)

5366

(8 RCTs)

⊕⊕⊝⊝

LOW2,4

Eclampsia was not reported by any trials (Sagedal 2017 reports combined severe pre‐eclampsia, HELLP and eclampsia)

57 per 1000

55 per 1000

(45 to 69)

Hypertensive disorders of pregnancy (pregnancy‐induced hypertension/hypertension)

Trial population

average RR 0.78
(0.47 to 1.27)

3073
(6 RCTs)

⊕⊝⊝⊝

VERY LOW2,5,6

103 per 1000

80 per 1000

(48 to 130)

Caesarean section

Trial population

RR 0.95

(0.88 to 1.02)

6089

(14 RCTs)

⊕⊕⊕⊝

MODERATE7

299 per 1000

284 per 1000

(263 to 305)

Perineal trauma

Trial population

RR 1.27

(0.78 to 2.05)

2733

(2 RCTs)

⊕⊕⊕⊝

MODERATE2

21 per 1000

27 per 1000

(17 to 44)

Gestational weight gain (kg)

Trial population

MD ‐ 0.89 (‐1.39 to ‐ 0.40)

5052
(16 RCTs)

⊕⊕⊕⊝

MODERATE8,9

The mean gestational weight gain in the intervention group was 0.89 kg less (1.39 kg less to 0.40 kg less)

Postnatal depression

Not estimable

(0 RCTs)

No data reported for postnatal depression in any of the included RCTs

Type 2 diabetes mellitus

Not estimable

(0 RCTs)

No data reported for type 2 diabetes mellitus in any of the included RCTs

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: confidence interval; GDM: gestational diabetes mellitus;HELLP: Haemolysis, Elevated Liver enzymes and Low Platelet count; kg: kilograms; MD: mean difference; RCT: randomised controlled trial; RR: risk ratio; UK: United Kingdom; USA: United States of America

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1Trial limitations (‐1): 19 RCTs, intervention unable to be blinded (not downgraded for this as outcome is objective); some RCTS with potentially serious design limitations (unclear randomisation, attrition bias)
2Imprecision (‐1): confidence interval crossing the line of no effect
3Inconsistency (0): I² = 42%, possibly largely due to one trial (Dodd 2014), not downgraded))
4Trial limitations (‐1): 8 RCTs, intervention unable to be blinded (not downgraded for this as outcome is objective); some RCTS with potentially serious design limitations (unclear randomisation, attrition bias) )
5Trial limitations: (‐1): 6 RCTs, intervention unable to be blinded (not downgraded for this as outcome is objective); some RCTs with potentially serious design limitations (unclear randomisation, attrition bias)
6Inconsistency (‐1): I² = 62%
7Trial limitations (‐1): 14 RCTs, intervention unable to be blinded (not downgraded for this as outcome is objective); some RCTs with potentially serious design limitations (unclear randomisation, attrition bias)
8Trial limitations (‐1): 16 RCTs, intervention unable to be blinded (not downgraded for this as outcome is objective); some RCTs with potentially serious design limitations
9Inconsistency (0): I² = 43% (not downgraded)

Figures and Tables -
Summary of findings for the main comparison. Combined diet and exercise interventions versus standard care (mother)
Summary of findings 2. Combined diet and exercise interventions versus standard care (child)

Combined diet and exercise interventions for preventing GDM

Population: pregnant women, excluding women already diagnosed with GDM, type 1 or type 2 diabetes

Setting: Australia (2 RCTs), Brazil (1 RCT), Canada (2 RCTs), China (2 RCTs), Denmark (1 RCT), Egypt (1 RCT), Finland (3 RCTs), Germany (1 RCT), Italy (2 RCTs), Norway (1 RCT), UK (2 RCTs), USA (5 RCTs)
Intervention: combined diet and exercise interventions
Comparison: standard care

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(RCTs)

Quality of the evidence
(GRADE)

Comments

Risk with control

Risk with diet and exercise interventions

Perinatal mortality

Trial population

RR 0.82

(0.42 to 1.63)

3757

(2 RCTs)

⊕⊕⊝⊝

LOW1

10 per 1000

8 per 1000

(4 to 16)

Large‐for‐gestational age

Trial population

RR 0.93

(0.81 to 1.07)

5353

(11 RCTs)

⊕⊕⊝⊝

LOW2,3

135 per 1000

126 per 1000

(109 to 144)

Mortality or morbidity composite

Not estimable

(0 RCTs)

No data reported for mortality or morbidity composite in any of the included RCTs

Neonatal hypoglycaemia

Trial population

average RR 1.42

(0.67 to 2.98)

3653

(2 RCTs)

⊕⊕⊝⊝

LOW3,4

63 per 1000

90 per 1000

(42 to 189)

Childhood adiposity (latest time reported) (BMI z score)

Trial population

MD 0.05

(‐0.29 to 0.40)

794

(2 RCTs)

⊕⊕⊝⊝

LOW3,5,6

Additional meta‐analyses presented in review for: abdominal circumference, subscapular skinfold thickness, triceps skinfold thickness and total body fat

The mean BMI z score in the intervention group was 0.05 higher (0.29 lower to 0.40 higher)

Type 2 diabetes mellitus

Not estimable

(0 RCTs)

No data reported for type 2 diabetes mellitus in any of the included RCTs

Neurosensory disability

Not estimable

(0 RCTs)

No data reported for neurosensory disability in any of the included RCTs

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; GDM: gestational diabetes mellitus; MD: mean difference; RCT: randomised controlled trial; RR: risk ratio; UK: United Kingdom; USA: United States of America

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1Imprecision (‐2): confidence interval crossing the line of no effect and few events
2Trial limitations (‐1): 12 RCTs, some with potentially serious or very serious design limitations (> 62% of weight from 1 RCT at low risk of bias overall)
3Imprecision (‐1): confidence interval crossing the line of no effect
4Inconsistency (‐1): I² = 77%
5Trial limitations (‐1): 2 RCTs with potentially serious or very serious design limitations (particularly in relation to attrition bias for long‐term follow‐up)
6Inconsistency (0): I² = 59% (not downgraded)

Figures and Tables -
Summary of findings 2. Combined diet and exercise interventions versus standard care (child)
Table 1. Maternal age (years)

Study ID

Diet and exercise intervention

Control

Asbee 2009

Mean (SD): 26.7 (6.0)

Mean (SD): 26.4 (5.0)

Bruno 2016

Mean (SD): 31.5 (5)

Mean (SD): 30.8 (5.5)

Dodd 2014

Mean (SD): 29.3 (5.4)

Mean (SD): 29.6 (5.6)

El Beltagy 2013

Not reported

Not reported

Harrison 2013

Mean (SD): 32.4 (4.6)

Mean (SD): 31.7 (4.5)

Hawkins 2014

N (%)
≤ 20 years: 6 (18.2)
21–24 years: 14 (42.4)
25–28 years: 5 (15.2)
≥ 29 years: 8 (24.2)

N (%)
≤ 20 years: 3 (8.6)
21–24 years: 14 (40.0)
25–28 years: 8 (22.9)
≥ 29 years: 10 (28.6)

Herring 2016

Mean (SD): 25.9 (4.9)

Mean (SD): 25.0 (5.7)

Hoirisch‐Clapauch 2016

Not reported

Not reported

Hui 2012

Mean (SD): 30.1 (5.2)

Mean (SD): 28.7 (5.9)

Hui 2014

Mean (SD)

BMI ≤ 24.9 kg/m²: 31 (3)

BMI ≥ 25 kg/m²: 31 (4)

Mean (SD)

BMI ≤ 24.9 kg/m²: 29 (6)

BMI ≥ 25 kg/m²: 32 (5)

Jing 2015

Mean (SD): 29.57 (4.13)

Mean (SD): 29.89 (3.86)

Koivusalo 2016

Mean (SD): 32.3 (4.9)

Mean (SD): 32.6 (4.5)

Korpi‐Hyovalti 2011

Mean (SD): 29.1 (5.4)

Mean (SD): 29.8 (5.4)

Luoto 2011

Mean (SD): 29.5 (4.8)

Mean (SD): 30.0 (4.7)

Petrella 2013

Mean (SD): 31.5 (4.2)

Mean (SD): 32.4 (5.9)

Phelan 2011

Mean (SD): 28.6 (5.2)

Mean (SD): 28.8 (5.2)

Polley 2002

Mean (SD): 25.5 (4.8)

Poston 2013

Mean (SD): 30.4 (5.7)

Mean (SD): 30.7 (4.9)

Poston 2015

Mean (SD): 30.5 (5.5)

Mean (SD): 30.4 (5.6)

Rauh 2013

Mean (SD): 32.2 (4.4)

Mean (SD): 30.8 (4.9)

Sagedal 2017

Mean (SD): 27.9 (4.2)

Mean (SD): 28.1 (4.5)

Vinter 2011

Median (IQR): 29 (27 ‐ 32)

Median (IQR): 29 (26 ‐ 31)

Wang 2015

Mean (SD): 31.0 (3.8)

Mean (SD): 30.27 (3.64)

Abbreviations: BMI: body mass index; IQR: interquartile range; N: number; SD: standard deviation

Figures and Tables -
Table 1. Maternal age (years)
Table 2. Maternal BMI (kg/m²)

Study ID

Diet and exercise intervention

Control

Asbee 2009

Mean (SD): 25.5 (6.0) [pre‐pregnancy]

Mean (SD): 25.6 (5.1) [pre‐pregnancy]

Bruno 2016

Mean (SD): 33.3 (6) [pre‐pregnancy]

Mean (SD): 34.5 (6.8) [baseline]

Mean (SD): 33.4 (5.5) [pre‐pregnancy]

Mean (SD): 33.9 (5.7) [baseline]

Dodd 2014

Median (IQR): 31.0 (28.1‐35.9) [baseline]

Median (IQR): 31.1 (27.7‐35.6) [baseline]

El Beltagy 2013

Not reported (all women were obese)

Not reported (all women were obese)

Harrison 2013

Mean (SD): 30.4 (5.6) [baseline]

Mean (SD): 30.3 (5.9) [baseline]

Hawkins 2014

N (%) [pre‐pregnancy]
25–30 kg/m²: 15 (45.5)
≥ 30 kg/m²: 18 (54.5)

N (%) [pre‐pregnancy]
25–30 kg/m²: 18 (51.4)
≥ 30 kg/m²: 17 (48.6)

Herring 2016

Mean (SD): 33.5 (5.8) [early pregnancy]

Mean (SD): 32.2 (5.4) [early pregnancy]

Hoirisch‐Clapauch 2016

Not reported

Not reported

Hui 2012

Mean (SD): 25.7 (5.1) [pre‐pregnancy]

Mean (SD): 24.9 (5.4) [pre‐pregnancy]

Hui 2014

Mean (SD) [pre‐pregnancy]

BMI ≤ 24.9 kg/m²: 21.6 (2.2)

BMI ≥ 25 kg/m²: 29.5 (5.1)

Mean (SD) [pre‐pregnancy]

BMI ≤ 24.9 kg/m²: 22.6 (1.9)

BMI ≥ 25 kg/m²: 29.7 (1.3)

Jing 2015

Mean (SD): 20.44 (2.54) [pre‐pregnancy]

Mean (SD): 20.44 (2.54); 20.74 (2.43) [pre‐pregnancy]

Koivusalo 2016

Mean (SD): 31.5 (6.0) [pre‐pregnancy]

Mean (SD): 32.2 (5.9) [baseline]

Mean (SD): 32.0 (5.5) [pre‐pregnancy]

Mean (SD): 32.3 (5.4) [baseline]

Korpi‐Hyovalti 2011

Mean (SD): 27.3 (6.0) [baseline]

Mean (SD): 25.5 (3.4) [baseline]

Luoto 2011

Mean (SD): 26.3 (4.9) [pre‐pregnancy]

Mean (SD): 26.4 (4.3) [pre‐pregnancy]

Petrella 2013

Mean (SD): 32.1 (5) [baseline]

Mean (SD): 32.9 (6.2) [baseline]

Phelan 2011

Mean (SD): 26.32 (5.6) [baseline]

Mean (SD): 26.48 (5.9) [baseline]

Polley 2002

Mean (SD) [pre‐pregnancy]

Normal weight: 22.8 (1.9)

Overweight: 31.4 (6.0)

Mean (SD) [pre‐pregnancy]

Normal weight: 22.5 (2.0)

Overweight: 34.1 (7.2)

Poston 2013

Mean (SD): 36.5 (4.7) [baseline]

Mean (SD): 36.1 (4.8) [baseline]

Poston 2015

Mean (SD): 36.3 (5.0) [baseline]

Mean (SD): 36.3 (4.6) [baseline]

Rauh 2013

Median (IQR): 21.7 (19.9 ‐ 23.7) [pre‐pregnancy]

Median (IQR): 22.2 (20.7 ‐ 24.3) [booking]

Median (IQR): 22.8 (20.6 ‐ 26.6) [pre‐pregnancy]

Median (IQR): 23.3 (21.2 ‐ 26.8) [booking]

Sagedal 2017

Mean (SD): 23.8 (4.1) [pre‐pregnancy]

Mean (SD): 23.5 (3.7) [pre‐pregnancy]

Vinter 2011

Median (IQR): 33.4 (31.7 ‐ 36.5)

Median (IQR): 33.3 (31.7 ‐ 36.9)

Wang 2015

Mean (SD): 22.95 (3.65) [pre‐pregnancy]

Mean (SD): 23.06 (3.63) [pre‐pregnancy]

Abbreviations: BMI: body mass index; IQR: interquartile range; N: number; SD: standard deviation

Figures and Tables -
Table 2. Maternal BMI (kg/m²)
Table 3. Maternal ethnicity

Study ID

Diet and exercise intervention

Control

Asbee 2009

N (%)
African American: 15 (26.3)
Asian: 3 (5.3)
White: 5 (8.8)
Hispanic: 33 (57.9)
Other: 1 (1.8)

N (%)
African American: 9 (21.4)
Asian: 1 (2.4)
White: 8 (19.0)
Hispanic: 23 (54.8)
Other: 1 (2.4)

Bruno 2016

N (%)

Caucasian: 79 (82.3)
African: 12 (12.6)
Others: 5 (5.2)

N (%)

Caucasian: 78 (82.1)
African: 13 (13.7)
Others: 4 (4.3)

Dodd 2014

N (%)
White: 995 (90.0)
Asian: 26 (2.4)
Indian: 40 (3.6)
Other: 44 (4.0)

N (%)

White: 998 (91.0)
Asian: 34 (3.1)
Indian: 35 (3.2)
Other: 30 (2.7)

El Beltagy 2013

Not reported (conducted in Egypt)

Not reported (conducted in Egypt)

Harrison 2013

Country of birth, N (%)
Australia: 36 (44)
Southeast Asia: 14 (16)
Southern/Central Asia: 36 (43)
Other: 14 (18)

Country of birth, N (%)
Australia: 38 (41)
Southeast Asia: 12 (13)
Southern/Central Asia: 36 (38)
Other: 14 (15)

Hawkins 2014

N (%)

Hispanic: 33 (100)

N (%)

Hispanic: 35 (100)

Herring 2016

N (%)

African American: 33 (100)

N (%)

African American: 33 (100)

Hoirisch‐Clapauch 2016

Not reported

Not reported

Hui 2012

N (%)
First Nations (Canadian Aboriginals with First
Nations status): 19 (17.4)

N (%)
First Nations (Canadian Aboriginals with First
Nations status): 22 (25.0)

Hui 2014

First Nations (Canadian Aboriginals with First Nations status), N (%)

BMI ≤ 24.9 kg/m²: 2 (6.7)

BMI ≥ 25 kg/m²: 3 (11.1)

First Nations (Canadian Aboriginals with First Nations status), N (%)

BMI ≤ 24.9 kg/m²: 1 (3.7)

BMI ≥ 25 kg/m²: 4 (13.8)

Jing 2015

Not reported (conducted in China)

Not reported (conducted in China)

Koivusalo 2016

Not reported (conducted in Finland)

Not reported (conducted in Finland)

Korpi‐Hyovalti 2011

Not reported (conducted in Norway)

Not reported (conducted in Norway)

Luoto 2011

Not reported (conducted in Finland)

Not reported (conducted in Finland)

Petrella 2013

N (%)

Caucasian: 28 (84.9)

Maghreb: 4 (12.1)

Other: 1 (3.0)

Caucasian: 20 (66.7)

Maghreb: 6 (20)

Other: 4 (13.3)

Phelan 2011

N (%)

Non‐Hispanic White: 138 (68.7)

Latina and Hispanic: 39 (19.6)

Non‐Hispanic African American: 14 (7.1)

Other: 9 (4.6)

N (%)
Non‐Hispanic White: 135 (67.5)

Latina and Hispanic: 39 (19.6)

Non‐Hispanic African American: 19 (9.6)

Other: 7 (3.3)

Polley 2002

N (%)

Black: 47 (39)

White 73 (61)

Poston 2013

N (%)

White: 52 (55)

Black: 38 (40)

Asian: 2 (2)

Other: 2 (2)

N (%)

White: 51 (57)

Black: 32 (26)

Asian: 1 (1)

Other: 5 (6)

Poston 2015

N (%)

White: 490 (63)

Black: 202 (26)

Asian: 47 (6)

Other: 44 (6)

N (%)
White: 483 (63)

Black: 200 (26)

Asian: 48 (6)

Other: 41 (5)

Rauh 2013

Country of birth, N (%)

Germany: 140 (83.8)

Others: 27 (16.2)

Country of birth, N (%)

Germany: 68 (81.9)

Others: 15 (18.1)

Sagedal 2017

Not reported (conducted in Norway)

Not reported (conducted in Norway)

Vinter 2011

N (%)
Caucasian: 150 (100)

N (%)

Caucasian: 154 (100)

Wang 2015

Not reported (conducted in China)

Not reported (conducted in China)

Abbreviations: N: number

Figures and Tables -
Table 3. Maternal ethnicity
Table 4. Maternal parity

Study ID

Diet and exercise intervention

Control

Asbee 2009

N (%)
0: 26 (45.6)
1 or more: 31 (54.4)

N (%)
0: 19 (44.2)
1 or more: 24 (55.8)

Bruno 2016

N (%)

0: 53 (55.2)

N (%)

0: 59 (62.1)

Dodd 2014

N (%)

0: 441 (40.2)

N (%)

0: 441 (40.2)

El Beltagy 2013

Not reported

Not reported

Harrison 2013

N (%)
First pregnancy: 42 (51)
Second pregnancy: 36 (43)
Third pregnancy or higher: 22 (27)

N (%)
First pregnancy: 43 (46) 42
Second pregnancy: 37 (40)
Third pregnancy or higher: 20 (21)

Hawkins 2014

N (%)
0: 6 (19.4)
1: 10 (32.3)
2: 7 (22.6)
≥ 3: 8 (25.8)

N (%)
0: 11 (31.4)
1: 10 (28.6)
2: 3 (8.6)
≥ 3: 11 (31.4)

Herring 2016

N (%):

0: 9 (27)

N (%):

0: 10 (30)

Hoirisch‐Clapauch 2016

Not reported

Not reported

Hui 2012

Not reported

Not reported

Hui 2014

Not reported

Not reported

Jing 2015

Not reported

Not reported

Koivusalo 2016

Previous deliveries, N (%)
0: 61 (42)
1: 42 (29)
2: 29 (20)
≥ 3: 12 (8)

Previous deliveries, N (%)
0: 52 (42)
1: 38 (30)
2: 24 (19)
≥ 3: 11 (9)

Korpi‐Hyovalti 2011

N (%)

0: 13 (50)

N (%)

0: 17 (63)

Luoto 2011

N (%)

0: 103 (47.0)

N (%)

0: 73 (40.6)

Petrella 2013

N (%)

0: 13 (39.4)

N (%)

0: 13 (43.3)

Phelan 2011

N (%)

0: 153 (76.3)

≥ 1: 48 (23.7)

N (%)

0: 153 (76.6)

≥ 1: 47 (23.4)

Polley 2002

N (%)

First pregnancy: 56 (47)

Second pregnancy: 36 (30)

Third pregnancy: 20 (17)

> third pregnancy: 7 (6)

Poston 2013

N (%)

0: 42 (45)

1: 29 (31)

≥ 2: 23 (24)

N (%)

0: 38 (43)

1: 36 (40)

≥ 2: 15 (17)

Poston 2015

N (%)

0: 336 (43)

≥ 1: 447 (57)

N (%)

0: 338 (44)

≥ 1: 434 (56)

Rauh 2013

N (%)

0: 110 (65.9)

1: 50 (29.9)

≥ 2: 7 (4.2)

N (%)

0: 53 (63.9)

1: 23 (27.7)

≥ 2: 7 (8.4)

Sagedal 2017

N (%)

0: 303 (100)

N (%)

0: 303 (100)

Vinter 2011

N (%)

0: 79 (52.7)

N (%)

0: 84 (54.6)

Wang 2015

Not reported

Not reported

Abbreviations: N: number

Figures and Tables -
Table 4. Maternal parity
Table 5. GDM diagnosis

Study ID

Timing

Screening/diagnosis test(s) and glucose threshold(s) used for diagnosis

Reference(s)

Notes

Asbee 2009

Not reported

Not reported

Not provided

Data not provided in format suitable for meta‐analysis

Bruno 2016

16th to 18th weeks; repeated in 24th to 28th weeks for women negative at first test

75 g 2‐hour OGTT

Thresholds: fasting ≥ 5.1 mmol/L and/or 1‐hour ≥ 10.0 mmol/L and/or 2‐hour ≥ 8.5 mmol/L

"IADPSG criteria" (no reference provided)

Dodd 2014

Not reported

"all women were encouraged to undergo screening"

75 g 2‐hour OGTT

Thresholds: fasting ≥ 5.5 mmol/L or 2‐hour ≥ 7.8 mmol/L

South Australian Perinatal Practice Guidelines 2013 (South Australian Perinatal Practice Guidelines: diabetes mellitus and abnormal glucose tolerance Government of Australia, SA Health, 2013. www.health.sa.gov.au/ppg/Default.
aspx?PageContentID=2118&tabid=100.)

El Beltagy 2013

24 to 28 weeks

"All women underwent routine GDM screening"

Not provided

Data not provided in format suitable for meta‐analysis

Harrison 2013

28 weeks

2‐hour OGTT

Thresholds: fasting ≥ 5.5 mmol/L and/or 2‐hour ≥ 8.0 mmol/L

OR

Thresholds: fasting ≥ 5.1 mmol/L and/or 1‐hour ≥ 10.0 mmol/L and/or 2‐hour ≥ 8.5 mmol/L

ADIPS 1998 (Hoffmann L, Nolan C, Wilson JD, Oats JJN, Simmons D. Gestational diabetes mellitus: management guidelines. MJA 1998;169:93–7.)

OR

IADPSG 2010 (Metzger BE, Gabbe SG, Persson B, et al. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycaemia in pregnancy. Diabetes Care 2010;33:676–82.)

Data in meta‐analysis according to IADPSG 2010 criteria [groups Ns not reported for ADIPS 1998 criteria]

Hawkins 2014

24 to 28 weeks gestation

50 g 1‐hour OGTT

Thresholds: 1‐hour > 7.493 mmol/L

100 g 3‐hour OGTT

Thresholds: not reported

American Diabetes Association 2012 (American Diabetes Association. Standards of medical care in diabetes–2012. Diabetes Care 2012; 35(Suppl. 1): S11–63.)

Data not provided in format suitable for meta‐analysis

Herring 2016

Not reported

Not reported

Not provided

Hoirisch‐Clapauch 2016

Not reported

Not reported

Not provided

Data not provided in format suitable for meta‐analysis

Hui 2012

Not reported

Not reported

Canadian Diabetes Association 2008 (Canadian Diabetes Association. 2008 Clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2008;32:S168–80.)

Hui 2014

Not reported

Not reported

Canadian Diabetes Association 2008 (Canadian Diabetes Association, Clinical Practice Guidelines Committee, Canadian Diabetes Association: 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes Care 2008, 32:S1:171.)

Jing 2015

Not reported

Not reported

Not provided

Koivusalo 2016

24 to 28 weeks

75 g 2‐hour OGTT

Thresholds: fasting ≥ 5.3 mmol/L and/or 1‐hour ≥ 10.0 mmol/L and/or 2‐hour ≥ 8.6 mmol/L

American Diabetes Association 2008 (Holcomb SS; American Diabetes Association. Update: standards of medical care in diabetes. Nurse Pract 2008;33:12–5.)

Korpi‐Hyovalti 2011

26 to 28 weeks

75 g 2‐hour OGTT

Thresholds: fasting ≥ 5.6 mmol/L or 2‐hour ≥ 7.8 mmol/L

Modified from the World Health Organization 1998 (Alberti KG, Zimmet PZ: Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus: provisional report of WHO consultation. Diabet Med 1998, 15:539‐53.)

All women also underwent 75 g 2 hour OGTT at 8 to 12 weeks; those diagnosed with GDM were excluded from the trial

Luoto 2011

26 to 28 weeks

2‐hour OGTT

Thresholds: fasting ≥ 5.3 mmol/L and/or 1‐hour > 10.0 mmol/L and/or 2‐hour > 8.6 mmol/L

OR

1) Any of the above thresholds or newborn birthweight ≥ 4500 g or use of insulin or other diabetic medication

2) Any of the above thresholds or newborn birthweight ≥ 4000 g or use of insulin or other diabetic medication

3) Any of the above thresholds or use of insulin or other diabetic medication

American Diabetes Association 2010 ((2010) Diagnosis and classification of diabetes mellitus. Diabetes Care 33: S62–9.)

Data in meta‐analysis according to American Diabetes Association 2010 criteria [use of data according to other criteria did not change results]

Petrella 2013

16th to 18th week or 24th to 28th week "as recommend"

75 g 2‐hour OGTT

Thresholds: not reported

American Diabetes Association 2011 (American Diabetes Association. Standards of medical care in diabetes‐2011. Diabetes Care 2011;34:S11–61.)

Phelan 2011

Not reported

Not reported

Not provided

Polley 2002

Not reported

Not reported

Not provided

Poston 2013

27 + 0 to 28 + 6 weeks

75 g 2‐hour OGTT

Thresholds: fasting ≥ 5.1 mmol/L and/or 1‐hour ≥ 10.0 mmol/L and/or 2‐hour ≥ 8.5 mmol/L

IADPSG 2010 (Metzger B, Gabbe SG, Persson B, Buchanan TA, Catalano PA, Damm P, Dyer AR, Leiva A, Hod M, Kitzmiler JL, Lowe LP, McIntyre HD, Oats JJ, Omori Y, Schmidt MI: International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycaemia in pregnancy. Diabetes Care 2010, 33:676–82.)

Poston 2015

27 + 0 to 28 + 6 weeks

75 g 2‐hour OGTT

Thresholds: fasting ≥ 5.1 mmol/L and/or 1‐hour ≥ 10.0 mmol/L and/or 2‐hour ≥ 8.5 mmol/L

IADPSG 2010 (Metzger BE, Gabbe SG, Persson B, et al. International Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and classification of hyperglycaemia in pregnancy. Diabetes Care 2010; 33: 676–82.)

Rauh 2013

24th to 28th week

2‐hour OGTT

Thresholds: not reported

German Society of Gynecology and Obstetrics 2010 (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe e.V.: Diagnostik und Therapie des Gestationsdiabetes. [http://www.dggg.de/leitlinien/].)

Sagedal 2017

30 weeks

75 g 2‐hour OGTT

Thresholds: 2‐hour ≥ 7.8 mmol/L

Norway national criteria 2008 (Tore HH, Torun C. Veileder i Fødselshjelp 2008 In) NGFNSfGaO, editor. Veileder i Fødselshjelp 2008; 2008. p. 112.); World Health Organization 2006 (World Health Organization. Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycaemia: Report of a WHO/IDF Consultation. Geneva, Switzerland: World Health Organization, 2006.)

Vinter 2011

28 to 30 weeks and 34 to 36 weeks

75 g 2‐hour OGTT

Thresholds: 2‐hour ≥ 9 mmol/L

OR

Thresholds: 2‐hour ≥ 8.5 mmol/L

"Danish national recommendations" (no reference provided)

OR

IADPSG 2010 (Metzger BE, Gabbe SG, Persson B, Buchanan TA, Catalano PA, Damm P et al. International Association of Diabetes and Pregnancy Study Group’s recommendations on the diagnosis and classification of hyperglycaemia in pregnancy. Diabetes Care 2010; 33: 676–82.)

All women also underwent an OGTT at baseline (12 to 15 weeks); those diagnosed with GDM were excluded from the trial

Data in meta‐analysis according to Danish national recommendations [use of data according to IADPSG 2010 criteria did not change results]

Wang 2015

24 to 28 weeks

75 g OGTT

"The International Association of Diabetes and Pregnancy Study Groups (IADPSG) criterion was used" (no reference provided)

Abbreviations: ADIPS: Australasian Diabetes in Pregnancy Society; g: gram; GDM: gestational diabetes mellitus; IADPSG: International Association of the Diabetes and Pregnancy Study Group; OGTT: oral glucose tolerance test;

Figures and Tables -
Table 5. GDM diagnosis
Comparison 1. Combined diet and exercise interventions versus standard care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Gestational diabetes Show forest plot

19

6633

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.71, 1.01]

2 Pre‐eclampsia Show forest plot

8

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Pre‐eclampsia

8

5366

Risk Ratio (M‐H, Fixed, 95% CI)

0.98 [0.79, 1.22]

2.2 Severe pre‐eclampsia/HELLP/eclampsia

2

2088

Risk Ratio (M‐H, Fixed, 95% CI)

0.72 [0.35, 1.46]

3 Pregnancy‐induced hypertension and/or hypertension Show forest plot

6

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

3.1 Pregnancy‐induced hypertension and/or hypertension

6

3073

Risk Ratio (M‐H, Random, 95% CI)

0.78 [0.47, 1.27]

3.2 Pregnancy‐induced hypertension

4

810

Risk Ratio (M‐H, Random, 95% CI)

0.46 [0.16, 1.29]

3.3 Hypertension

3

2532

Risk Ratio (M‐H, Random, 95% CI)

1.07 [0.84, 1.38]

4 Caesarean section Show forest plot

14

6089

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.88, 1.02]

5 Perinatal mortality Show forest plot

2

3757

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.42, 1.63]

6 Large‐for‐gestational age Show forest plot

11

5353

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.81, 1.07]

7 Operative vaginal birth Show forest plot

3

2164

Risk Ratio (M‐H, Fixed, 95% CI)

1.07 [0.86, 1.34]

8 Induction of labour Show forest plot

5

3907

Risk Ratio (M‐H, Random, 95% CI)

0.92 [0.79, 1.06]

9 Perineal trauma Show forest plot

2

2733

Risk Ratio (M‐H, Fixed, 95% CI)

1.27 [0.78, 2.05]

10 Placental abruption Show forest plot

1

1555

Risk Ratio (M‐H, Fixed, 95% CI)

2.96 [0.12, 72.50]

11 Postpartum haemorrhage Show forest plot

3

4235

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.89, 1.18]

12 Postpartum infection Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

12.1 Endometritis

1

2142

Risk Ratio (M‐H, Fixed, 95% CI)

1.19 [0.52, 2.74]

12.2 Wound infection

1

2142

Risk Ratio (M‐H, Fixed, 95% CI)

1.06 [0.65, 1.73]

12.3 Postpartum antibiotics

1

2142

Risk Ratio (M‐H, Fixed, 95% CI)

1.00 [0.77, 1.31]

12.4 Postpartum sepsis

1

1555

Risk Ratio (M‐H, Fixed, 95% CI)

0.33 [0.01, 8.06]

13 Gestational weight gain (kg) Show forest plot

16

5052

Mean Difference (IV, Random, 95% CI)

‐0.89 [‐1.39, ‐0.40]

14 Gestational weight gain (various times reported) (kg) Show forest plot

4

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

14.1 First trimester

1

272

Mean Difference (IV, Fixed, 95% CI)

‐0.03 [‐0.62, 0.56]

14.2 Second trimester

2

541

Mean Difference (IV, Fixed, 95% CI)

‐0.38 [‐0.77, 0.02]

14.3 Third trimester

1

269

Mean Difference (IV, Fixed, 95% CI)

‐0.10 [‐1.17, 0.97]

14.4 At 20‐24 weeks gestation

1

221

Mean Difference (IV, Fixed, 95% CI)

‐0.45 [‐1.48, 0.58]

14.5 At 26‐28 weeks gestation

1

203

Mean Difference (IV, Fixed, 95% CI)

‐0.90 [‐1.75, ‐0.05]

15 Gestational weight gain (kg/week) Show forest plot

4

2772

Mean Difference (IV, Random, 95% CI)

‐0.03 [‐0.06, ‐0.00]

16 Gestational weight gain (above IOM recommendations) Show forest plot

11

4556

Risk Ratio (M‐H, Random, 95% CI)

0.87 [0.79, 0.96]

17 Gestational weight gain (within IOM recommendations) Show forest plot

9

3730

Risk Ratio (M‐H, Fixed, 95% CI)

1.02 [0.93, 1.11]

18 Gestational weight gain (below IOM recommendations) Show forest plot

7

3499

Risk Ratio (M‐H, Fixed, 95% CI)

1.10 [0.98, 1.24]

19 Behaviour changes associated with the intervention Show forest plot

Other data

No numeric data

20 Relevant biomarker changes associated with the intervention Show forest plot

Other data

No numeric data

21 Sense of well‐being and quality of life Show forest plot

Other data

No numeric data

22 Breastfeeding (exclusive) Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

22.1 3 days postpartum

1

695

Risk Ratio (M‐H, Fixed, 95% CI)

1.02 [0.91, 1.15]

22.2 6 weeks postpartum

1

202

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.76, 1.13]

22.3 6 months postpartum

2

921

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.61, 1.36]

23 Breastfeeding (partial) Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

23.1 3 days postpartum

1

695

Risk Ratio (M‐H, Fixed, 95% CI)

0.51 [0.40, 0.66]

23.2 6 weeks postpartum

1

202

Risk Ratio (M‐H, Fixed, 95% CI)

1.44 [0.80, 2.60]

23.3 6 months postpartum

2

921

Risk Ratio (M‐H, Fixed, 95% CI)

0.98 [0.82, 1.18]

24 Breastfeeding Show forest plot

Other data

No numeric data

25 Postnatal weight retention (latest time reported) (kg) Show forest plot

6

1673

Mean Difference (IV, Fixed, 95% CI)

‐0.94 [‐1.52, ‐0.37]

26 Return to pre‐pregnancy weight (latest time reported) Show forest plot

3

960

Risk Ratio (M‐H, Fixed, 95% CI)

1.25 [1.08, 1.45]

27 Postnatal BMI (latest time reported) Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

27.1 BMI

2

902

Mean Difference (IV, Fixed, 95% CI)

‐0.15 [‐0.85, 0.55]

27.2 BMI change from baseline to 6 weeks postpartum

1

202

Mean Difference (IV, Fixed, 95% CI)

‐0.56 [‐1.12, ‐0.00]

28 Maternal cardiovascular health (latest time reported) Show forest plot

Other data

No numeric data

29 Stillbirth Show forest plot

5

4783

Risk Ratio (M‐H, Fixed, 95% CI)

0.69 [0.35, 1.36]

30 Neonatal mortality Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

30.1 Total

2

3756

Risk Ratio (M‐H, Fixed, 95% CI)

2.31 [0.60, 8.90]

30.2 No lethal anomalies

1

2202

Risk Ratio (M‐H, Fixed, 95% CI)

0.99 [0.06, 15.85]

30.3 Lethal anomalies

1

2202

Risk Ratio (M‐H, Fixed, 95% CI)

6.95 [0.36, 134.38]

31 Gestational age at birth (weeks) Show forest plot

11

5658

Mean Difference (IV, Fixed, 95% CI)

0.05 [‐0.05, 0.15]

32 Gestational age at birth (days or weeks) Show forest plot

Other data

No numeric data

33 Preterm birth Show forest plot

11

5398

Risk Ratio (M‐H, Fixed, 95% CI)

0.80 [0.65, 0.98]

34 Apgar score less than seven at five minutes Show forest plot

3

2864

Risk Ratio (M‐H, Fixed, 95% CI)

0.80 [0.48, 1.32]

35 Macrosomia Show forest plot

10

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

35.1 > 4000 g

9

5368

Risk Ratio (M‐H, Fixed, 95% CI)

0.89 [0.78, 1.01]

35.2 > 4500 g

4

3061

Risk Ratio (M‐H, Fixed, 95% CI)

0.63 [0.42, 0.94]

36 Small‐for‐gestational age Show forest plot

6

2434

Risk Ratio (M‐H, Fixed, 95% CI)

1.20 [0.95, 1.52]

37 Birthweight (g) Show forest plot

13

5763

Mean Difference (IV, Fixed, 95% CI)

‐17.67 [‐46.28, 10.94]

38 Birthweight (g) Show forest plot

Other data

No numeric data

39 Birthweight z score Show forest plot

4

2661

Mean Difference (IV, Fixed, 95% CI)

‐0.05 [‐0.13, 0.03]

40 Head circumference (cm) Show forest plot

4

4229

Mean Difference (IV, Fixed, 95% CI)

‐0.01 [‐0.11, 0.10]

41 Head circumference z score Show forest plot

1

2142

Mean Difference (IV, Fixed, 95% CI)

‐0.05 [‐0.14, 0.04]

42 Length (cm) Show forest plot

6

3303

Mean Difference (IV, Fixed, 95% CI)

‐0.09 [‐0.26, 0.09]

43 Length z score Show forest plot

2

2235

Mean Difference (IV, Fixed, 95% CI)

‐0.08 [‐0.15, ‐0.02]

44 Ponderal index (kg/m3) Show forest plot

3

2826

Mean Difference (IV, Fixed, 95% CI)

0.04 [‐0.16, 0.25]

45 Adiposity (sum of skinfold thickness) (mm) Show forest plot

2

1472

Mean Difference (IV, Fixed, 95% CI)

0.09 [‐0.33, 0.50]

45.1 Sum of biceps, triceps, subscapular, suprailiac, abdominal and thigh skinfold thickness

1

970

Mean Difference (IV, Fixed, 95% CI)

0.03 [‐0.86, 0.92]

45.2 Sum of triceps and subscapular skinfold thickness (mm)

1

502

Mean Difference (IV, Fixed, 95% CI)

0.10 [‐0.36, 0.56]

46 Adiposity (abdominal circumference) (cm) Show forest plot

2

1566

Mean Difference (IV, Fixed, 95% CI)

‐0.01 [‐0.23, 0.22]

47 Adiposity Show forest plot

Other data

No numeric data

48 Shoulder dystocia Show forest plot

2

2733

Risk Ratio (M‐H, Fixed, 95% CI)

1.20 [0.79, 1.83]

49 Nerve palsy Show forest plot

1

2142

Risk Ratio (M‐H, Fixed, 95% CI)

1.99 [0.36, 10.82]

50 Bone fracture Show forest plot

1

2142

Risk Ratio (M‐H, Fixed, 95% CI)

1.99 [0.36, 10.82]

51 Respiratory distress syndrome Show forest plot

2

2411

Risk Ratio (M‐H, Fixed, 95% CI)

0.56 [0.33, 0.97]

52 Hypoglycaemia Show forest plot

2

3653

Risk Ratio (M‐H, Random, 95% CI)

1.42 [0.67, 2.98]

53 Hyperbilirubinaemia Show forest plot

1

2142

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.61, 1.11]

54 Childhood weight (latest time reported) (kg) Show forest plot

3

882

Mean Difference (IV, Random, 95% CI)

‐0.05 [‐0.33, 0.22]

54.1 6 months

1

677

Mean Difference (IV, Random, 95% CI)

‐0.10 [‐0.26, 0.06]

54.2 10‐12 months

1

48

Mean Difference (IV, Random, 95% CI)

‐0.36 [‐0.96, 0.24]

54.3 2.8 years

1

157

Mean Difference (IV, Random, 95% CI)

0.30 [‐0.19, 0.79]

55 Childhood weight z score (latest time reported) Show forest plot

1

643

Mean Difference (IV, Fixed, 95% CI)

‐0.09 [‐0.26, 0.08]

56 Childhood height (latest time reported) (cm) Show forest plot

2

816

Mean Difference (IV, Fixed, 95% CI)

0.33 [‐0.58, 1.25]

56.1 6 months

1

659

Mean Difference (IV, Fixed, 95% CI)

1.04 [‐0.58, 2.66]

56.2 2.8 years

1

157

Mean Difference (IV, Fixed, 95% CI)

0.0 [‐1.11, 1.11]

57 Childhood height z score (latest time reported) Show forest plot

1

622

Mean Difference (IV, Fixed, 95% CI)

‐0.02 [‐0.31, 0.27]

58 Childhood head circumference (latest time reported) (cm) Show forest plot

1

670

Mean Difference (IV, Fixed, 95% CI)

‐0.12 [‐0.70, 0.46]

59 Childhood adiposity (latest time reported) (BMI z score) Show forest plot

2

794

Mean Difference (IV, Random, 95% CI)

0.05 [‐0.29, 0.40]

59.1 6 months

1

637

Mean Difference (IV, Random, 95% CI)

‐0.11 [‐0.39, 0.17]

59.2 2.8 years

1

157

Mean Difference (IV, Random, 95% CI)

0.24 [‐0.10, 0.58]

60 Childhood adiposity (latest time reported) (abdominal circumference) (cm) Show forest plot

2

833

Mean Difference (IV, Fixed, 95% CI)

0.26 [‐0.37, 0.90]

60.1 6 months

1

676

Mean Difference (IV, Fixed, 95% CI)

0.02 [‐0.81, 0.85]

60.2 2.8 years

1

157

Mean Difference (IV, Fixed, 95% CI)

0.60 [‐0.38, 1.58]

61 Childhood adiposity (latest time reported) (subscapular skinfold thickness) (mm) Show forest plot

2

705

Mean Difference (IV, Random, 95% CI)

‐0.17 [‐0.66, 0.32]

61.1 6 months

1

548

Mean Difference (IV, Random, 95% CI)

‐0.40 [‐0.73, ‐0.07]

61.2 2.8 years

1

157

Mean Difference (IV, Random, 95% CI)

0.10 [‐0.33, 0.53]

62 Childhood adiposity (latest time reported) (triceps skinfold thickness) (mm) Show forest plot

2

784

Mean Difference (IV, Fixed, 95% CI)

‐0.12 [‐0.48, 0.23]

62.1 6 months

1

627

Mean Difference (IV, Fixed, 95% CI)

‐0.18 [‐0.61, 0.25]

62.2 2.8 years

1

157

Mean Difference (IV, Fixed, 95% CI)

0.0 [‐0.63, 0.63]

63 Childhood adiposity (latest time reported) (total body fat) (%) Show forest plot

2

614

Mean Difference (IV, Fixed, 95% CI)

‐0.74 [‐1.56, 0.07]

63.1 6 months

1

547

Mean Difference (IV, Fixed, 95% CI)

‐0.80 [‐1.64, 0.04]

63.2 2.8 years

1

67

Mean Difference (IV, Fixed, 95% CI)

0.0 [‐3.03, 3.03]

64 Childhood adiposity (latest time reported) Show forest plot

Other data

No numeric data

65 Childhood cardiovascular health (latest time reported) Show forest plot

Other data

No numeric data

66 Antenatal visits Show forest plot

1

269

Mean Difference (IV, Fixed, 95% CI)

0.0 [‐0.36, 0.36]

67 Antenatal admissions Show forest plot

1

2153

Risk Ratio (M‐H, Fixed, 95% CI)

0.86 [0.71, 1.04]

68 Length of antenatal stay (days) Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

68.1 Antenatal stay (days)

1

2153

Mean Difference (IV, Fixed, 95% CI)

‐0.27 [‐0.49, ‐0.05]

68.2 Antenatal inpatient stay (nights), if admitted

1

139

Mean Difference (IV, Fixed, 95% CI)

0.0 [‐1.00, 1.00]

69 Neonatal intensive care unit admission Show forest plot

4

4549

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.93, 1.14]

70 Length of postnatal stay (mother) (days) Show forest plot

2

3511

Mean Difference (IV, Random, 95% CI)

0.01 [‐0.14, 0.17]

71 Length of postnatal stay (baby) (days) Show forest plot

2

3618

Mean Difference (IV, Fixed, 95% CI)

‐0.35 [‐0.90, 0.20]

72 Costs to families associated with the management provided (unit cost, €) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

72.1 Delivery cost to the patient

1

93

Mean Difference (IV, Fixed, 95% CI)

3.0 [‐10.82, 16.82]

72.2 Neonatal care cost to the patient

1

93

Mean Difference (IV, Fixed, 95% CI)

3.00 [‐13.67, 19.67]

73 Costs associated with the intervention (unit cost, €) Show forest plot

1

93

Mean Difference (IV, Fixed, 95% CI)

769.0 [‐1032.23, 2570.23]

73.1 Total costs

1

93

Mean Difference (IV, Fixed, 95% CI)

769.0 [‐1032.23, 2570.23]

74 Cost of maternal care (unit cost, €) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

74.1 Visits for primary health care

1

93

Mean Difference (IV, Fixed, 95% CI)

‐43.0 [‐127.61, 41.61]

74.2 Visits for specialist health care

1

93

Mean Difference (IV, Fixed, 95% CI)

‐47.0 [‐195.33, 101.33]

74.3 Visits to a diabetes nurse

1

93

Mean Difference (IV, Fixed, 95% CI)

6.00 [‐7.02, 19.02]

74.4 Visits to a dietitian

1

93

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

74.5 Use of insulin/other diabetes medication

1

93

Mean Difference (IV, Fixed, 95% CI)

‐1.0 [‐7.83, 5.83]

74.6 Hospital days before and after delivery

1

93

Mean Difference (IV, Fixed, 95% CI)

101.00 [‐206.71, 408.71]

74.7 Delivery cost to the municipality

1

93

Mean Difference (IV, Fixed, 95% CI)

22.0 [‐234.43, 278.43]

74.8 Absence from work

1

93

Mean Difference (IV, Fixed, 95% CI)

128.0 [‐1295.58, 1551.58]

75 Cost of infant care (unit cost, €) Show forest plot

1

93

Mean Difference (IV, Fixed, 95% CI)

453.0 [‐298.20, 1204.20]

75.1 Neonatal care cost to municipality

1

93

Mean Difference (IV, Fixed, 95% CI)

453.0 [‐298.20, 1204.20]

Figures and Tables -
Comparison 1. Combined diet and exercise interventions versus standard care
Comparison 2. Combined diet and exercise interventions versus standard care: subgroups based on study design

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Gestational diabetes Show forest plot

19

6633

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.71, 1.01]

1.1 Individually‐randomised

17

6492

Risk Ratio (M‐H, Random, 95% CI)

0.84 [0.70, 1.01]

1.2 Cluster‐randomised

2

141

Risk Ratio (M‐H, Random, 95% CI)

1.05 [0.42, 2.60]

2 Pre‐eclampsia Show forest plot

8

5366

Risk Ratio (M‐H, Fixed, 95% CI)

0.98 [0.79, 1.22]

2.1 Individually‐randomised

7

5273

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.78, 1.21]

2.2 Cluster‐randomised

1

93

Risk Ratio (M‐H, Fixed, 95% CI)

1.24 [0.22, 7.05]

3 Caesarean section Show forest plot

14

6089

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.88, 1.02]

3.1 Individually‐randomised

13

6038

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.88, 1.02]

3.2 Cluster‐randomised

1

51

Risk Ratio (M‐H, Fixed, 95% CI)

0.71 [0.33, 1.54]

4 Large‐for‐gestational age Show forest plot

11

5353

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.81, 1.07]

4.1 Individually‐randomised

9

5209

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.82, 1.08]

4.2 Cluster‐randomised

2

144

Risk Ratio (M‐H, Fixed, 95% CI)

0.59 [0.25, 1.40]

Figures and Tables -
Comparison 2. Combined diet and exercise interventions versus standard care: subgroups based on study design
Comparison 3. Combined diet and exercise interventions versus standard care: subgroups based on maternal BMI

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Gestational diabetes Show forest plot

19

6633

Risk Ratio (M‐H, Random, 95% CI)

0.86 [0.72, 1.02]

1.1 Normal weight women (BMI < 25 kg/m²)

3

300

Risk Ratio (M‐H, Random, 95% CI)

0.91 [0.19, 4.24]

1.2 Overweight or obese women (BMI ≥ 25kg/m²)

8

2901

Risk Ratio (M‐H, Random, 95% CI)

0.77 [0.50, 1.20]

1.3 Obese women (BMI ≥ 30kg/m²)

3

1738

Risk Ratio (M‐H, Random, 95% CI)

0.96 [0.81, 1.13]

1.4 Any women

8

1694

Risk Ratio (M‐H, Random, 95% CI)

0.80 [0.63, 1.03]

2 Pre‐eclampsia Show forest plot

8

5366

Risk Ratio (M‐H, Fixed, 95% CI)

0.98 [0.79, 1.21]

2.1 Normal weight women (BMI < 25 kg/m²)

2

243

Risk Ratio (M‐H, Fixed, 95% CI)

0.34 [0.10, 1.22]

2.2 Overweight or obese women (BMI ≥ 25kg/m²)

3

2369

Risk Ratio (M‐H, Fixed, 95% CI)

1.12 [0.82, 1.54]

2.3 Obese women (BMI ≥ 30kg/m²)

2

1809

Risk Ratio (M‐H, Fixed, 95% CI)

0.92 [0.64, 1.32]

2.4 Any women

3

945

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.51, 1.73]

3 Pregnancy‐induced hypertension or hypertension Show forest plot

6

3073

Risk Ratio (M‐H, Random, 95% CI)

0.71 [0.41, 1.25]

3.1 Underweight women

1

110

Risk Ratio (M‐H, Random, 95% CI)

0.70 [0.26, 1.88]

3.2 Normal weight women (BMI < 25 kg/m²)

1

182

Risk Ratio (M‐H, Random, 95% CI)

0.28 [0.08, 0.97]

3.3 Overweight or obese women (BMI ≥ 25kg/m²)

5

2781

Risk Ratio (M‐H, Random, 95% CI)

0.82 [0.43, 1.58]

4 Caesarean section Show forest plot

14

6089

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.88, 1.02]

4.1 Normal weight women (BMI < 25 kg/m²)

3

300

Risk Ratio (M‐H, Fixed, 95% CI)

0.92 [0.58, 1.45]

4.2 Overweight or obese women (BMI ≥ 25kg/m²)

7

2662

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.83, 1.01]

4.3 Obese women (BMI ≥ 30kg/m²)

2

1826

Risk Ratio (M‐H, Fixed, 95% CI)

0.99 [0.87, 1.12]

4.4 Any women

5

1301

Risk Ratio (M‐H, Fixed, 95% CI)

0.98 [0.75, 1.28]

5 Perinatal mortality Show forest plot

2

3757

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.42, 1.63]

5.1 Overweight or obese women (BMI ≥ 25kg/m²)

1

2202

Risk Ratio (M‐H, Fixed, 95% CI)

0.99 [0.32, 3.07]

5.2 Obese women (BMI ≥ 30 kg/m²)

1

1555

Risk Ratio (M‐H, Fixed, 95% CI)

0.74 [0.31, 1.74]

6 Large‐for‐gestational age Show forest plot

11

5353

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.81, 1.07]

6.1 Normal weight women (BMI < 25 kg/m²)

1

57

Risk Ratio (M‐H, Fixed, 95% CI)

0.6 [0.11, 3.32]

6.2 Overweight or obese women (BMI ≥ 25kg/m²)

4

2385

Risk Ratio (M‐H, Fixed, 95% CI)

0.89 [0.76, 1.06]

6.3 Obese women (BMI ≥ 30kg/m²)

3

1986

Risk Ratio (M‐H, Fixed, 95% CI)

1.17 [0.89, 1.54]

6.4 Any women

4

925

Risk Ratio (M‐H, Fixed, 95% CI)

0.64 [0.40, 1.03]

Figures and Tables -
Comparison 3. Combined diet and exercise interventions versus standard care: subgroups based on maternal BMI
Comparison 4. Combined diet and exercise interventions versus standard care: subgroups based on ethnicity

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Gestational diabetes Show forest plot

19

6633

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.71, 1.01]

1.1 Majority 'low risk' ethnicities

5

2998

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.50, 1.43]

1.2 Majority 'high risk' ethnicities

1

56

Risk Ratio (M‐H, Random, 95% CI)

1.07 [0.07, 16.33]

1.3 Mixed ethnicities

7

2123

Risk Ratio (M‐H, Random, 95% CI)

0.89 [0.76, 1.05]

1.4 Unclear

6

1456

Risk Ratio (M‐H, Random, 95% CI)

0.83 [0.61, 1.12]

2 Pre‐eclampsia Show forest plot

8

5366

Risk Ratio (M‐H, Fixed, 95% CI)

0.98 [0.79, 1.22]

2.1 Majority 'low risk' ethnicities

3

2806

Risk Ratio (M‐H, Fixed, 95% CI)

0.99 [0.76, 1.29]

2.2 Mixed ethnicities

2

1615

Risk Ratio (M‐H, Fixed, 95% CI)

0.96 [0.58, 1.58]

2.3 Unclear

3

945

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.51, 1.73]

3 Pregnancy‐induced hypertension or hypertension Show forest plot

6

3073

Risk Ratio (M‐H, Random, 95% CI)

0.78 [0.47, 1.27]

3.1 Majority 'low risk' ethnicities

5

2804

Risk Ratio (M‐H, Random, 95% CI)

0.64 [0.34, 1.17]

3.2 Unclear

1

269

Risk Ratio (M‐H, Random, 95% CI)

1.37 [0.70, 2.72]

4 Caesarean section Show forest plot

14

6089

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.88, 1.02]

4.1 Majority 'low risk' ethnicities

5

2987

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.84, 1.03]

4.2 Majority 'high risk' ethnicities

2

156

Risk Ratio (M‐H, Fixed, 95% CI)

0.87 [0.54, 1.42]

4.3 Mixed ethnicities

5

1986

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.82, 1.07]

4.4 Unclear

2

960

Risk Ratio (M‐H, Fixed, 95% CI)

1.15 [0.84, 1.56]

5 Perinatal mortality Show forest plot

2

3757

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.42, 1.63]

5.1 Majority 'low risk' ethnicities

1

2202

Risk Ratio (M‐H, Fixed, 95% CI)

0.99 [0.32, 3.07]

5.2 Mixed ethnicities

1

1555

Risk Ratio (M‐H, Fixed, 95% CI)

0.74 [0.31, 1.74]

6 Large‐for‐gestational age Show forest plot

11

5353

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.81, 1.07]

6.1 Majority 'low risk' ethnicities

3

2577

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.77, 1.07]

6.2 Majority 'high risk' ethnicities

1

56

Risk Ratio (M‐H, Fixed, 95% CI)

3.21 [0.14, 75.68]

6.3 Mixed ethnicities

5

2036

Risk Ratio (M‐H, Fixed, 95% CI)

1.05 [0.80, 1.38]

6.4 Unclear

2

684

Risk Ratio (M‐H, Fixed, 95% CI)

0.63 [0.32, 1.23]

Figures and Tables -
Comparison 4. Combined diet and exercise interventions versus standard care: subgroups based on ethnicity
Comparison 5. Combined diet and exercise interventions versus standard care: sensitivity analyses

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Gestational diabetes Show forest plot

11

5019

Risk Ratio (M‐H, Random, 95% CI)

0.86 [0.68, 1.09]

2 Pre‐eclampsia Show forest plot

4

4311

Risk Ratio (M‐H, Fixed, 95% CI)

0.99 [0.78, 1.26]

3 Pregnancy‐induced hypertension Show forest plot

4

2694

Risk Ratio (M‐H, Random, 95% CI)

0.58 [0.27, 1.25]

4 Caesarean section Show forest plot

10

4968

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.87, 1.02]

5 Perinatal mortality Show forest plot

2

3757

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.42, 1.63]

6 Large‐for‐gestational age Show forest plot

8

4618

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.83, 1.09]

Figures and Tables -
Comparison 5. Combined diet and exercise interventions versus standard care: sensitivity analyses