This document discusses the use of exercise and technology in managing gestational diabetes mellitus (GDM). It summarizes a systematic review finding that exercise improves glycemic control in GDM by lowering postprandial blood glucose, fasting blood glucose, and HbA1c. The document also evaluates several studies on using telemedicine, SMS reminders, and telemonitoring to support GDM management, finding benefits like reduced clinic visits but mixed results on outcomes. Exercise combined with standard care is effective for GDM, while remote monitoring shows promise but requires more research on clinical outcomes and cost-effectiveness.

1. GDM:
EXERCISE
& TECH
IRIS THIELE ISIP TAN MD, MSC
Director, UP Manila Interactive Learning Center
Chief, UP Medical Informatics Unit
Professor, UP College of Medicine
@endocrine_witch

2. NOTHING TO DISCLOSE

3. EXERCISE
TELECARE
SMS
POSTPARTUM

4. EXERCISE
TELECARE
SMS
POSTPARTUM

5. Several international guidelines
recommend exercise in GDM
management
No supporting evidence
from a systematic review
Harrison et al Journal of Physiotherapy 2016; 62:188-196

6. Exercise improves glycemic control in women diagnosed with gestational diabetes
mellitus: a systematic review. Harrison et al Journal of Physiotherapy 2016; 62:188-196.
EXERCISE AND GLYCEMIC CONTROL GDM
P Pregnant women with GDM
I Exercise performed more
than once a week, sufficient to
achieve an aerobic effect or
changes in muscle metabolism
O Postprandial blood
glucose, FBS, HbA1c,
requirement for insulin,
adverse events, adherence
M Systematic review (8 RCTs
qualitative n=588, 7 RCTS
quantitative n=544)

7. Harrison et al Journal of
Physiotherapy 2016; 62:188-196
Can adjunctive exercise improve acute postprandial blood
glucose in women with GDM vs standard care?
Does adjunctive exercise improve FBS and HbA1c?
What kind of exercise programs are effective in lowering
postprandial blood glucose levels? What variables affect
adherence?

8. Circuit type resistance
training n=2
Upright cycle ergometer
n=2 (one trial combined with walking)
Recumbent cycle
ergometer n=1
Arm ergometer n=1
Brisk walking n=1
Yoga n=1
Image from hammer-fitnes.ch
Image from runningonhungry.com
EXERCISE
Harrison et al Journal of
Physiotherapy 2016; 62:188-196

9. Harrison et al Journal of
Physiotherapy 2016; 62:188-196
Frequency
3-7 sessions per week
Intensity
Variable
Predicted HR max 50-70%
Between “moderate” and “somewhat hard”
Duration
20-45 min
Including short warm-up and
cool down periods
6 weeks or until 38 wks AOG
or to end of pregnancy
EXERCISE
Delivery
Individual session
Center-based with direct supervision
Home-based with direct, indirect
supervision (phone) or unsupervised
Both center- and home-based

10. Harrison et al Journal of Physiotherapy 2016; 62:188-196
POSTPRANDIAL BLOOD GLUCOSE

11. Harrison et al Journal of Physiotherapy 2016; 62:188-196
FASTING BLOOD GLUCOSE

12. HBA1C
Harrison et al Journal of Physiotherapy 2016; 62:188-196

13. INSULIN REQUIREMENT
Harrison et al Journal of Physiotherapy 2016; 62:188-196

14. Harrison et al Journal of
Physiotherapy 2016; 62:188-196
Can adjunctive exercise improve acute postprandial blood
glucose in women with GDM vs standard care? YES
Does adjunctive exercise improve FBS and HbA1c? YES

15. Harrison et al Journal of
Physiotherapy 2016; 62:188-196
What kind of exercise programs are effective in lowering
postprandial blood glucose levels?
Moderate intensity, minimum of 3x a week
What variables affect adherence?
Not reported by the trials

16. Harrison et al Journal of Physiotherapy 2016; 62:188-196
Adding exercise to usual
care of GDM reduces
postprandial BG, FBG and
HbA1c.
Exercise is safe.

17. EXERCISE
TELECARE
SMS
POSTPARTUM

18. Diabetes Res Clin Pract (2015), http://dx.doi.org/10.1016/j.diabres.2015.07.007
Included 3 RCTs only
Convenience of reducing face-to-face and unscheduled consultations
More trials that include cost evaluation are required

19. TELECARE APPROACH TO GDM
Perez-Ferre et al Int J Endocrinol 2010
P 100 pregnant women with GDM
I Telemedicine system for
transmission of capillary glucose
data and SMS with weekly
professional feedback
C Traditional face-to-face
outpatient clinic visits
O Percentage of women with
HbA1c <5.8%, normal vaginal
delivery and LGA infants
M Randomized parallel group

20. Perez-Ferre et al Int J Endocrinol 2010
VISIT 1 VISIT 2 VISIT 3 VISIT 4
Before 28
wks AOG
32-34 wks
AOG
36-38 wks
AOG
39-40 wks
AOG
BODY WEIGHT, BP, HBA1C, URALB/CREA, CBG LOG, INSULIN REQUIREMENT
TELEMEDICINE group
BOTH groups
Image from accu-chek.com
Image from gsmarena.com
App to transmit CBG to
central database via SMS
IR transmission of CBG
from glucometer to phone
Patient sends CBGs once a week
Endocrinologist & nurse
educator evaluate CBG data
Two- way communication via SMS
Unscheduled visits allowed

21. 62% reduction in clinic
visits for telemedicine group
82% reduction in clinic visits for
insulin-treated women p<0.03
More contacts (15.05 vs 9.11) taking
less time (3.8 vs 4.6 h)
Perez-Ferre et al Int J Endocrinol 2010
NS difference in
HbA1c, vaginal
delivery, LGA infants

22. Perez-Ferre et al Int J Endocrinol 2010
Reduction in number of clinic
visits saves time for both
patient & health professional
Telemedicine connection
increases accessibility to
health team, at convenience
Reduces transportation,
clinic waiting times
Minimizes intereference
with woman’s work schedule
Particularly useful for
insulin-treated who
require more contacts to
adjust insulin dose

23. INTERNET-BASED TELEMEDICINE FOR
UNDERSERVED WOMEN WITH GDM
Homko et al Diabetes Tech & Ther 2007
P Pregnant women with GDM
I Internet group (n=32);
provided computers & internet
access for communication via
website
C Control group n =25;
maintained paper logbooks
reviewed at each visit
O Use of system, self-efficacy,
maternal glucose control, pregnancy
and neonatal outcomes
M Randomized trial

24. Homko et al Diabetes Tech & Ther 2007

25. Homko et al Diabetes Tech & Ther 2007
7 women (22%) never
accessed the system
3 women (20%) required a
second visit for additional
training and/or to correct
technical problems
Women in intervention
group had higher feelings of
diabetes psychosocial
self-efficacy
NS difference in glucose control, pregnancy and neonatal outcomes

26. Women sent
average of 3 wks
data in 8-wk
follow-up
Daily responsibility of poor
young single mothers with small
children limited applicability of
telemedicine approach
Logistics of providing, installing &
maintaining hardware was labor-intensive
Homko et al Diabetes Tech & Ther 2007

27. TELEMEDICINE SYSTEM WITH AUTOMATED
REMINDERS FOR WOMEN WITH GDM
Homko et al Diabetes Tech & Ther 2012
P Pregnant women with GDM
I Telemedicine group (n=40);
Interactive Voice Response
telephone system
C Control group n =40;
maintained paper logbooks
reviewed at each visit
O Maternal glucose control and
infant birth weight
M Randomized trial

28. Homko et al Diabetes Tech & Ther 2012
IVR system can be accessed from any phone
Asynchronous
phone messaging
between clinicians
and patients
Automated
reminders for
patients to transmit
data

29. Homko et al Diabetes Tech & Ther 2012
Option of dialing dedicated toll-free number or
use Internet with unique log-in and password
Can append message
IVR: 45 s speaking
Internet: unlimited text input
Data and messages queued
for clinician to respond via
portal

30. Homko et al Diabetes Tech & Ther 2012
Patient’s message from IVR plays back as wav file
Nurse can respond by typing
IVR: text-to-voice function
Internet: text

31. Homko et al Diabetes Tech & Ther 2012
Automated 3 phone call reminders
for missed data transmission
If still no response, the
nurse can reset reminders
(another 3 calls) or call the
patient directly to follow up.

32. Homko et al Diabetes Tech & Ther 2012
NS difference in
maternal blood
glucose
NS difference in
LGA infants
Adding telephone access and
reminders increased transmission
rates of data in the intervention
group.
Telemedicine system increased
contact between women and their
health team but had no impact on
outcomes.

33. EXERCISE
TELECARE
SMS
POSTPARTUM

34. DIAMIND Randomized Trial
POSTPARTUM SMS REMINDERS FOR GDM
P Women with GDM in recent
pregnancy, with mobile phone,
normal blood glucose before
discharge
I SMS group (n=140); SMS
reminder for OGTT at 6 wks
postpartum and 3 & 6 mos if
required
C Control group (n =140); SMS
at 6 mos postpartum
O OGTT at 6 mos postpartum
M Randomized parallel group
van Ryswyk et al Diabetic Medicine 2015

35. SMS 1 SMS 2 SMS 3
6 wks
postpartum
3 mos
postpartum
6 mos
postpartum
NATIONAL GESTATIONAL
DIABETES REGISTER
Sends postal reminders 12-16
weeks after expected due date
SMS GROUP
CONTROL GROUP
if required if required
van Ryswyk et al Diabetic Medicine 2015
SMS sent automatically based on date of birth
of baby using Clickatell bulk SMS gateway

36. DIAMIND Randomized Trial
POSTPARTUM SMS REMINDERS FOR GDM
OGTT attendance at 6 mos
SMS group: 104 (77.6%)
Control group: 103 (76.8%)
RR 1.01, 95% CI 0.89-1.15
>83% received postal
reminders from National
Gestational Diabetes Register
van Ryswyk et al Diabetic Medicine 2015

37. EXERCISE
TELECARE
SMS
POSTPARTUM

38. @ENDOCRINE_WITCH
Iris Thiele Isip Tan MD, MSc
Director, UP Manila Interactive Learning Center
Chief, UP Medical Informatics Unit
Professor, UP College of Medicine