Casson, Karen

Hillyard, Medbh

Murphy, Marie H

Sinclair, Marlene

English

BackgroundThe public health guidance for physical activity (PA) levels in pregnancy recommends at least 150 minutes of moderate intensity PA weekly. The aim of this study was to understand how PA and sedentary behaviour levels of pregnant women with GDM in the UK have been affected by COVID-19. MethodsAn online survey exploring PA and sedentary behaviour levels of pregnant women with GDM during COVID-19 was carried out. SampleWomen who had been pregnant with GDM during the COVID pandemic were recruited through various social media platforms.EthicsEthical approval was granted by the Ulster University Nursing and Health Research Ethics Filter Committee. ResultsA total of 724 women accessed the survey, 553 of these met the eligibility criteria. Sedentary time increased for 79% of the women during the pandemic. Almost half of the women (47%) were meeting the PA guidelines pre COVID during their pregnancy, dropping to 23% during the COVID pandemic. Fear of leaving the house due to COVID was the most commonly reported reason for the decline DiscussionThese results show the large impact of COVID-19 on PA and sedentary behaviour levels and highlights the need for targeted public health initiatives. Women with GDM need to know how it is safe and beneficial to them to engage in PA and ways to do this from their own homes if fear of leaving the house due to COVID is a barrier for them. Investment of targeted online PA classes provided by certified trainers in PA for pregnant women is a worthy investment. The challenge is how best to do this with reduced face to face appointments and extra pressure on resources.<br/

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Page 172Research and development | DPH Annual Report 2020The impact of COVID-19 on the physical activity and sedentary behaviour levels of pregnant women with gestational diabetes BackgroundThe public health guidance for physical activity (PA) recommends at least 150 minutes of moderate intensity PA weekly for the general population and during pregnancy.1 In Northern Ireland, it has been estimated that approximately 51% of non-pregnant females meet these guidelines.2 Despite the established benefits for mother and baby, levels of PA have been found to fall during pregnancy.3,4 The COVID-19 pandemic has had far-reaching consequences for all areas of society and has significant impacts for pregnant women. A recent review indicates that pregnant women with pre-existing comorbidities, high maternal age, and high body mass index who contract COVID-19 may be more likely to be admitted to an intensive care unit and preterm birth rates are higher in pregnant women with COVID-19 than in pregnant women without the virus.5 Pregnant women have also experienced changes in their maternity care, with a reduction in face-to-face appointments and restrictions on who can attend appointments with them. Women diagnosed with Gestational Diabetes Mellitus (GDM) are likely to have been further impacted with changing care pathways and testing procedures. GDM is a glucose intolerance with onset or first diagnosis during pregnancy.6 There is evidence to suggest the need for medication for women with GDM may be reduced through PA and PA can improve blood glucose control. 7,8 Current National Institute for Health and Care Excellence (NICE) guidelines recommend women diagnosed with GDM are told that possible treatment includes changes in diet, exercise and medication.9 Therefore, PA is particularly important for this group of women.  PA levels of the general population are known to have been impacted by COVID-19: for some lockdown has been positive with an increase in time for PA, for others working from home may have increased sedentary behaviour and reduced incidental PA associated with personal transport and general movement throughout the working day.10 The PA levels of pregnant women are also likely to have been affected, with frequently reported activities in pregnancy such as swimming, pregnancy yoga and Pilates not being possible during lockdown. 11 This research aimed to investigate the impact the COVID-19 pandemic had on the PA and sedentary behaviour levels of women with GDM in the UK.  ApproachA UK wide, online survey investigating the PA and sedentary behaviour levels of pregnant women diagnosed with GDM during COVID-19 was circulated through social media channels. Women who had been pregnant during the COVID-19 pandemic and had been diagnosed with GDM; were resident in the UK; were 18 years old or over and could understand written English were invited to participate. The questionnaire included: demographics, individual circumstances (eg living arrangements, access to Page 173Research and development | DPH Annual Report 2020space for PA), health and pregnancy, activity levels, sedentary behaviour, worry scores using the Brief Measure of Worry Severity Scale and level of agreement with COM-B statements relating to Capability (I had the ability to be physically active), Opportunity (I had the opportunity to be physically active) and Motivation (It was important to be physically active, I found exercise enjoyable and satisfying, I felt guilty when I don’t exercise) both before COVID-19 and during COVID-19. 12-15Ethical approval was granted by the Ulster University Nursing and Health Research Ethics Filter Committee on 3 July 2020.Findings• 553 responses to the survey. • Mean age of women was 32 years (SD 4.7), 93% were white, 59% had an undergraduate degree or higher and 62% were multiparous. • 13% of women were in their first trimester, 57% in their second trimester and 30% in their third trimester.• 47% of women were meeting the PA guidelines pre-COVID-19.• 23% met the PA guidelines during COVID-19.• Women in their first and third trimesters were less likely to meet the PA guidelines during COVID-19 than women in their second trimester (T1 13.1%, T2 28.2%, T3 18.2%, P=.008).• 60% of women reported decreased activity levels during COVID-19, 21% reported no change and 19% reported increased levels.• The most frequently cited reason for a decline in PA was fear of leaving the house due to COVID-19 (69%). • Level of education, having fitness equipment at home and knowledge of how to exercise safely in pregnancy were all positively associated with PA levels during COVID-19.• Women who reported they knew how to exercise safely in pregnancy were 1.8 times (OR 1.80, 95% CI 1.07, 3.02) more likely than those who did not know how to exercise safely in pregnancy to meet the PA guidelines during COVID-19 when controlling for level of education, fitness equipment ownership, space to exercise, key worker status, other children, maternity leave, employment status and working from home.• 76% of respondents agreed/strongly agreed they would take part in an online exercise class if it was available. • 92% of the women agreed/strongly agreed it would be useful to receive information on the PA guidelines in pregnancy. • 79% of the women had increased sedentary time during COVID-19.• The percentage of women agreeing/strongly agreeing they had the ability to be physically active dropped from 87% before COVID-19 to 59% during COVID-19.• Reported opportunities to be physically active decreased from 88% before COVID-19 to 51% during COVID-19.• The mean worry score for the women was 12.15 (SD 6.65, range 0-24), 45% of the women had worry scores classified on the scale as ‘dysfunctional’ (A score of 12 or above). • Women with higher worry scores (over 12) were significantly less likely to meet the PA guidelines during COVID-19 than those with lower worry scores (OR 0.58, 95% CI 0.37, 0.92). However, there was no statistically significant association between worry scores and fear of leaving the house. Page 174Research and development | DPH Annual Report 2020Figure 1: Percentage of women meeting the PA guidelines before COVID-19 and during COVID-19 by country.  Figure 2: Agreement with COM-B statements before COVID-19 and during COVID-19.Page 175Research and development | DPH Annual Report 2020Implications for practice and policyThe findings highlight the need for focused interventions to address the decreased levels of PA and increased sedentary time for women with GDM as a result of the COVID-19 pandemic. The percentage of women meeting the PA guidelines during the COVID-19 pandemic dropped by 50%, with 69% of women who reported decreased PA levels during COVID-19 attributing the decline to fear of leaving the house due to COVID-19. Alternative PA options such as online exercise classes which can be completed in the women’s own home need to be made available for this group of women, thus removing the barrier of fear of leaving the house. Women who reported knowledge of how to exercise safely in pregnancy were 1.8 times more likely than those who did not have this knowledge to meet the PA guidelines during COVID-19. This highlights the importance of women receiving appropriate information on not only the PA guidelines for pregnancy but also examples of suitable and safe exercise they can carry out during pregnancy. While women in Northern Ireland are given ‘The Pregnancy book’ at their initial appointment which contains information on the PA guidelines, exercise tips, exercise to stop in pregnancy and stretching exercises, more information is required on types of appropriate exercise.16 For example, a bodyweight exercise circuit which could be carried out at home with little or no equipment would be helpful. The results of this study show the decline in both women’s perceived abilities and opportunities for PA during COVID-19. As the COVID-19 pandemic is likely to remain for some time and face-to-face group exercise classes have been suspended twice to date in Northern Ireland, considerable thought needs to be given to increasing the PA opportunities for this group of women within the current restrictions. The high level of worry experienced by this group of women is also cause for concern. Antenatal anxiety scores are associated with a greater risk of postnatal depression and women diagnosed with GDM are already at greater risk from postnatal depression.17,18 Evidence suggests physical activity in pregnancy can reduce the risk of both antenatal depression and postnatal depressive symptoms.19,20 ConclusionAction needs to be taken to reduce the decline in PA seen by the women in this study. PA in pregnancy with GDM has been found to have a number of positive benefits. A systematic literature review found that women who exercised were 47% less likely to need insulin compared to those in the control groups (OR 0.53, 95% CI 0.29, 0.97, P=0.04).7 It has also been found that women who use insulin during pregnancy are at higher risk for large for gestational age (LGA) infants (28.5% vs 13.1%, p<0.001) and caesarean sections (44.1% Vs 27.0%, p=0.001).21 PA has also been associated with lower birth weights and there is a lower risk of macrosomia in newborns of mothers who exercised during pregnancy.22,23 Women need to be fully informed that PA in pregnancy is not only safe but also beneficial. They need to be shown ways to be active from their own home and encouraged to remain active. Providing women with suitable examples of exercise routines and access to online exercise classes delivered by an instructor qualified in prenatal exercise are possible solutions to reduce the decline in PA during the COVID-19 pandemic and associated lockdown periods.  Page 176Research and development | DPH Annual Report 2020Recommendations are provided for policy makers, midwives and health service providers to assist them in understanding how best to support pregnant women with GDM through a second wave of COVID-19 or future lockdowns.Authors Medbh Hillyard, PhD Researcher, Ulster University Professor Marlene Sinclair Professor of Midwifery Research, Ulster UniversityProfessor Marie Murphy Dean of Postgraduate Research and Director of the Ulster Doctoral CollegeDr Karen Casson Lecturer in Health Promotion and Public Health, Ulster UniversityiReferences 1. Department of Health. UK Chief Medical Officers’ Physical Activity Guidelines 2019. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/832868/uk-chief-medical-officers-physical-activity-guidelines.pdf (Accessed 25 May 2020).2. Department of Health. Health Survey Northern Ireland: First Results 2017/2018. Health Survey NI Trend Tables. Available at: https://www.health-ni.gov.uk/publications/health-survey-northern-ireland-first-results-201718 (Accessed 24 September 2020). 3. Daly N, Mitchell C, Farren M, Kennelly MM, Hussey J, Turner MJ. Maternal obesity and physical activity and exercise levels as pregnancy advances: an observational study. Irish Journal of Medical Science 2016 May 1;185(2): 357-70.4. Currie S, Sinclair M, Liddle DS, Nevill A, Murphy MH. Application of objective physical activity measurement in an antenatal physical activity consultation intervention: a randomised controlled trial. BMC Public Health 2015 Dec;15(1):1-3.5. Allotey J, Stallings E, Bonet M, Yap M, Chatterjee S, Kew T, Debenham L, Llavall AC, Dixit A, Zhou D, Balaji R. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. BMJ 2020 1 Sept; 370.6. Metzger BE, Coustan DR, Organizing Committee. Summary and recommendations of the fourth international workshop-conference on gestational diabetes mellitus. Diabetes Care 1998 Aug 1;21:B161.7. Hillyard M, Casson K, Sinclair M, Murphy MH. Can physical activity and dietary interventions improve maternal and fetal outcomes in women with gestational diabetes mellitus? A systematic review and meta-analysis. Evidence Based Midwifery 2018 Sep 28;16(3):76-83.8. Harrison AL, Shields N, Taylor NF, Frawley HC. Exercise improves glycaemic control in women diagnosed with gestational diabetes mellitus: a systematic review. Journal of Physiotherapy 2016 Oct 1;62(4):188-96.Further information Medbh Hillyard, PhD Researcherhillyard-m@ulster.ac.ukiPage 177Research and development | DPH Annual Report 20209. National Institute for Health and Care Excellence (NICE). Diabetes in pregnancy: management from preconception to the postnatal period–NICE Guideline. Available at: https://www.nice.org.uk/guidance/ng3/chapter/1-Recommendations#gestational-diabetes-2 (Accessed 27 September 2020). 10. Sport Ireland. Impact of Covid-19 restrictions on sport and recreational walking. Available at: https://www.sportireland.ie/sites/default/files/media/document/2020-05/covid-and-sport-apr-2020-v2-22-may-2020.pdf (Accessed 28 September 2020).11. Nascimento SL, Surita FG, Godoy AC, Kasawara KT, Morais SS. Physical activity patterns and factors related to exercise during pregnancy: a cross sectional study. PloS One 2015 Jun 17;10(6):e0128953.12. Gladstone GL, Parker GB, Mitchell PB, Malhi GS, Wilhelm KA, Austin MP. A Brief Measure of Worry Severity (BMWS): Personality and clinical correlates of severe worriers. Journal of Anxiety Disorders 2005 Jan 1;19(8):877-92.13. Michie S, Van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation Science 2011 Dec 1;6(1):42.14. Sport England. COVID-19 Briefing. Exploring attitudes and behaviours in England during the COVID-19 pandemic. Available at: https://indd.adobe.com/view/793b48d5-bbcd-4de3-a50f-11d241a506b3 (Accessed 27 May 2020). 15. Active Pregnancy Foundation. Pregnancy and physical activity during the COVID-19 pandemic. Available at: https://www.activepregnancyfoundation.org/our-survey (Accessed 22 June 2020).16. Public Health Agency (PHA). The Pregnancy Book 2020. Available at: https://www.publichealth.hscni.net/publications/pregnancy-book-0 (Accessed 26 September 2020).17. Sinesi A, Maxwell M, O’Carroll R, Cheyne H. Anxiety scales used in pregnancy: systematic review. BJPsych Open 2019 Jan;5(1).18. Hinkle SN, Louis GM, Rawal S, Zhu Y, Albert PS, Zhang C. A longitudinal study of depression and gestational diabetes in pregnancy and the postpartum period. Diabetologia 2016 Dec 1;59(12):2594-602.19. Teychenne M, York R. Physical activity, sedentary behavior, and postnatal depressive symptoms: a review. American Journal of Preventive Medicine 2013 Aug 1;45(2):217-27.20. Nakamura A, van der Waerden J, Melchior M, Bolze C, El-Khoury F, Pryor L. Physical activity during pregnancy and postpartum depression: Systematic review and meta-analysis. Journal of Affective Disorders 2019 Mar 1;246:29-41.21. Benhalima K, Robyns K, Van Crombrugge P, Deprez N, Seynhave B, Devlieger R, Verhaeghe J, Mathieu C, Nobels F. Differences in pregnancy outcomes and characteristics between insulin-and diet-treated women with gestational diabetes. BMC Pregnancy and Childbirth 2015 Dec 1;15(1):271.22. Davenport MH, Meah VL, Ruchat SM, Davies GA, Skow RJ, Barrowman N, Adamo KB, Poitras VJ, Gray CE, Garcia AJ, Sobierajski F. Impact of prenatal exercise on neonatal and childhood outcomes: a systematic review and meta-analysis. British Journal of Sports Medicine 2018 Nov 1;52(21):1386-96.23. Barakat R, Pelaez M, Lopez C, Lucia A, Ruiz JR. Exercise during pregnancy and gestational diabetes-related adverse effects: a randomised controlled trial. British Journal of Sports Medicine 2013 Jul 1;47(10):630-6.

The impact of COVID-19 on the physical activity and sedentary behaviour levels of pregnant women with gestational diabetes

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The impact of COVID-19 on the physical activity and sedentary behaviour levels of pregnant women with gestational diabetes

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