The present study examines the effects of physical exercise on common anxiety symptoms in pregnant women with GDM. The BAI scores indicate normal or mild levels of anxiety symptoms pre- and post-intervention in all the pregnant women in the study. Interestingly, regardless of the intervention, no changes were detected in any group before and after the intervention. Nevertheless, we report a trend of regular self-paced walking to reduce the BAI scores, compared with the corresponding increases observed in women with no physical exercise (A) or in Mixed Exercise (M) programs.
In the present study, we report low levels of anxiety symptoms in all the participants independently of their physical exercise group. Interestingly, these low anxiety levels were observed in a high-risk population, as all participants were pregnant women diagnosed with GDM. This finding is in contrast with studies reporting an association between anxiety and GDM [18, 19] and a high prevalence of anxiety in women with GDM [22–25]. Several factors might explain the observed difference. First, routine medical care, counseling and support by the health care professionals in pregnant women with GDM play a protective role in anxiety symptoms in our study. All women had support from several experts, including a reproduction endocrinologist, a dietician, a psychologist, a specialized trainer, and a midwife. Psychosocial support interventions can have beneficial effects on anxiety, self-care, lifestyle behaviors, and physiological parameters [46]. Indeed, in our study, the women report that receiving support from health professionals has helped them accept GDM diagnosis, adhere to prescribed treatment, maintain optimal glycemic control, and contribute to adopting healthy behavior and lifestyle.
Second, several studies suggest a beneficial role of physical activity in anxiety and report a positive association of physical activity with lower levels of anxiety in various populations [37–39], including pregnant women and prenatal anxiety [26]. However, in the present study, the intervention did not have any effects on the BAI scores of any group, as no differences in BAI scores were found between the study groups pre- and post-intervention. Nevertheless, according to several studies, we expect that anxiety levels during pregnancy will increase in the third trimester [7]. As we have observed, BAI Scores were higher in all groups post-intervention, as we would expect related to third trimester higher anxiety levels as labor is close and concerns about the safety of the woman's and the newborn's health preoccupied the pregnant. Moreover, a trend of self-selected pace walking to reduce the BAI scores was detected, as the Walking groups had lower scores after the intervention in the third trimester, compared with Advice and Mixed Exercise groups that increased their BAI scores. However, this trend did not reach statistical significance. Maybe the women in the Walking group were less anxious as they were more active, more relaxed, and self-confident. This could be due to specific characteristics of physical activity behaviors and exercise, such as sedentary behavior and the type and intensity of exercise. Physical inactivity and sedentary behavior have been related to symptoms of depression and anxiety [40]. This association is important, especially for pregnant women, as this group tends not to meet the physical activity guidelines and has increased sedentary and/or inactivity behaviors [41, 42], while replacing sedentary behavior with moderate-to-vigorous physical activity could reduce anxiety [43]. However, sedentary behavior was not included in the study design. Moreover, aerobic exercise at a self-selected intensity may be a more effective way to reduce the symptoms of anxiety compared with resistance training [44], and high-intensity resistance training has been linked with increased levels of anxiety [45]. Indeed, our data indicate a tendency of aerobic self-paced walking to reduce anxiety symptoms, compared with mixed exercise. However, this tendency was not statistically significant.
Finally, other confounding factors, such as diet and marital satisfaction, that were not included in the study design might play a role in the association between anxiety and GDM. A recent study associates a proinflammatory diet with a higher incidence of anxiety disorders [47], emphasizing the role of diet in the association between anxiety and GDM. Moreover, recent reports suggest that marital satisfaction mediates anxiety symptoms in women with GDM and their partners. The anxiety symptoms of partners could also affect women with GDM [21].
The findings of the present study must be interpreted with caution considering some limitations. First, the small number of participants may have played a role in detecting an effect of physical exercise. However, recruitment challenges did not allow a larger group of participants due to the specific features of the study population (women with GDM) and the treatments involved (specific exercise and diet). Since the results revealed trends but not significance, future studies may benefit from a larger group of participants. Second, the duration of the treatment was limited (between 6–9 weeks), which might also interfere with the detection of significant effects, as the effect of exercise training may not have been adequate to induce a greater psychological impact on the women. Future studies will shed light on the effects of the different exercise characteristics on the relationship between anxiety and GDM. Finally, confounding factors, such as diet and sedentary behavior, should also be considered.
In conclusion, the present study adds new evidence on the role of physical exercise and its effects on the anxiety levels of women with GDM. Brisk walking (30–45 min) three times per week may create positive changes in the treatment plan and the anxiety state of pregnant women with GDM. To our knowledge, there is no study focusing on the effects of physical exercise on the symptoms of anxiety in women with GDM. Another novelty of the present study is the objective measure of physical exercise parameters, such as intensity, using wearable GPS devices and heart rate monitors in pregnant women with GDM. Exercise during pregnancy in women with GDM is safe when the required precautions are considered and should be prescribed according to international guidelines to achieve the maximum effect on psychosomatic adaptations.