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Supplement Article

Physical activity and maternal obesity: cardiovascular

adaptations, exercise recommendations,
and pregnancy outcomes
Michelle F Mottola

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Although a healthy lifestyle approach is intuitive for obese pregnant women, no
guidelines currently exist to manage these women throughout pregnancy. Women
who are medically prescreened for contraindications can engage in a walking
program three to four times per week, starting at 25 min per session and adding
2 min per week until reaching 40 min, with sessions continuing until delivery. A
target heart rate of 102–124 beats per minute should be promoted for women
20–29 years of age and a rate of 101–120 beats per minute for women 30–39 years
of age. A pedometer step count of 10,000 steps per day is suggested as a goal, as this
level of activity provides important health benefits. Combining healthy eating with a
walking plan prevents excessive weight gain during pregnancy and promotes a
healthy fetal environment.
© 2013 International Life Sciences Institute

INTRODUCTION during pregnancy, there are currently no recommenda-

Women of childbearing age are at a greater risk of
obesity because excessive weight may be gained during
pregnancy and retained after delivery. Guidelines
recommend that obese (prepregnancy body mass index
[BMI] ≥30.0 kg/m2) women gain between 11 lb and 20 lb
(5–9 kg) during pregnancy, at a rate of weight gain of
0.4–0.6 lb (0.2–0.3 kg) per week during the second and
third trimesters, assuming an initial weight gain of up to
4.4 lb (2 kg).1 Prevention of excessive weight gain during
pregnancy is highly recommended to reduce the risk of
obesity, gestational diabetes mellitus, type 2 diabetes,
hypertension, and cardiovascular disease in women of
childbearing age.2 The lifestyle that leads to obesity and
excessive weight gain is often marked by an unhealthy
diet and a lack of physical activity. Obesity has a direct
effect on indicators of health and chronic disease risk, not
only for the pregnant woman but also the developing
fetus.3,4 Although the practice of a healthy lifestyle and the
prevention of excessive weight gain are both important
tions on nutrition and physical activity to guide health-
care workers in the management of the obese pregnant
woman. This article discusses cardiorespiratory adapta-
tions during pregnancy, exercise, and obesity, and pro-
vides exercise guidelines and recommendations for a
healthy lifestyle approach for obese pregnant women,
including a discussion of pregnancy outcome.
CARDIORESPIRATORY CHANGES DURING PREGNANCY
AND RESPONSES TO EXERCISE
Pregnancy may offer protection from cardiovascular
disease in women at low risk of obstetric complications,
as evidence suggests that the maternal cardiovascular
system is remodeled in early gestation by an estrogen-
mediated reduction in vascular tone, which leads to a
primary reduction in afterload and an increase in venous
capacitance,5 reflected in increased resting cardiac output
of about 50% over nonpregnant values.6 An increase in
ventricular cavity dimension without an increase in wall

Affiliation: MF Mottola is with the R. Samuel McLaughlin Foundation – Exercise & Pregnancy Laboratory, School of Kinesiology, Faculty of
Health Sciences, and the Department of Anatomy, Schulich School of Medicine & Dentistry, The University of Western Ontario, London,
Ontario, Canada.
Correspondence: MF Mottola, R. Samuel McLaughlin Foundation – Exercise & Pregnancy Laboratory, The University of Western Ontario,
London, Ontario, Canada N6A 3K7. E-mail: mmottola@uwo.ca. Phone: +1-519-661-2111, ext. 88366. Fax: +1-519-661-2008.
Key words: exercise prescription, healthy lifestyle, obese pregnant women, walking

doi:10.1111/nure.12064
Nutrition Reviews® Vol. 71(Suppl. 1):S31–S36 S31
thickness,7 an increase in aortic capacitance,8 and a reduc-
tion in peripheral vascular resistance all occur around the
same time.9 In addition, the early pregnancy-induced
changes in cardiac output are thought to occur in
response to an increase in resting heart rate (HR), as most
of the 15–20 beat increase in HR over nonpregnant values
occurs in the first trimester.10 Stroke volume also
increases by approximately 10% at the end of the first
trimester11 and occurs before significant enhancement in
maternal blood volume,5 which may increase by up to
50% above nonpregnant values by late pregnancy.12
Pregnancy-induced hormones that reduce peripheral
vascular resistance also activate the renin-angiotensin
system, leading to increased secretion of an antidiuretic
hormone (arginine vasopressin) to retain fluid and main-
tain or slightly reduce blood pressure.5
Similarly,there are pregnancy-induced adaptations to
the maternal respiratory system as remodeling and expan-
sion of the thoracic cage occur, leading to a higher dia-
phragmatic midposition,13 which results in a reduction in
residual volume and expiratory reserve volume. This leads
to an increase in inspiratory capacity, though the effect on
vital capacity is minimal.14 One of the most substantial
physiological pregnancy-induced changes, which possibly
serves to protect the fetus, is an increase in respiratory
sensitivity to carbon dioxide. This change is observed early
in pregnancy and causes an increase in tidal volume and
minute ventilation, leading to a reduction in arterial
carbon dioxide tension and an augmentation in arterial
oxygen tension.15 These changes create a buffer zone, pos-
sibly to protect the fetus from acute elevations in maternal
carbon dioxide,16 and the early increase in maternal
minute ventilation may prevent fetal hypercapnia and
acidosis throughout pregnancy.17
Many healthy pregnant women complain of
respiratory discomfort (dyspnea), especially in late
pregnancy, both at rest and after exertion.18 Perceptions
of respiratory effort and dyspnea appear to be reduced
during submaximal steady-state exercise throughout ges-
tation.19 It may be that the maternal anatomical and
mechanical adaptations of the respiratory system reduce
airway resistance, preserve breathing mechanics, and
minimize the effort of ventilation, thereby reducing
dyspnea with the concomitant increase in minute venti-
lation during exercise.20 Resting oxygen uptake
(expressed as mL/kg/min) reflects the increase in body
mass during pregnancy and thus declines slightly during
each trimester.21
Pregnancy and aerobic conditioning are biological
processes that involve striking physiological adaptations
that may occur in the same direction or in opposite direc-
tions, depending on the specific variable being studied.21
Although absolute oxygen uptake is well preserved in
women who maintain physical activity, maximum exer-
S32
cise stress testing is not recommended during pregnancy.
Functional cardiac reserve (maximum HR minus resting
HR) is decreased during pregnancy because of elevated
resting HR, and the magnitude of heart rate reserve
(HRR) is also decreased compared with nonpregnant
values.21 Because maternal HR increases at a slower rate
in response to increases in exercise intensity, target HR
zones for exercise prescription must be derived from
pregnant women. The efficiency of standard submaximal
exercise for body-weight-supported exercise, such as
cycling, does not change during pregnancy, yet for
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weight-bearing exercise, such as walking, the energy
requirement increases in proportion to the maternal
mass gain.22
OBESITY AND CARDIORESPIRATORY ALTERATIONS
Obesity may influence pregnancy by causing major
health risks to both the mother and the fetus, as obese
pregnant women are at increased risk of cardiovascular
disease, gestational diabetes, and delivering large- or
small-for-gestational-age infants. Moreover, obese
women may have more complications during pregnancy
and birth.3 In addition, recent evidence indicates that the
fetal environment, especially as related to maternal
prepregnancy BMI, and excessive gestational weight gain
both increase risk factors for future chronic disease in the
offspring.4 Obesity in the nonpregnant individual affects
every major organ system, lowering the work rate
(amount of work done at a given HR) and oxygen uptake
and independently decreasing the mechanical efficiency
of breathing as a result of both the increased deposition of
adipose tissue on the chest and abdomen and the
decreased compliance of the ribcage, resulting in the
characteristic rapid shallow breathing.23 Obesity also
increases metabolic cost due to the increase in the energy
needed to move larger limbs, the increased work of
breathing, and a decreased peripheral motor efficiency.20
Cardiorespiratory responses to and work efficiency of
graded treadmill exercise in healthy nonpregnant women
(n = 14), in normal-weight (prepregnant BMI 18.9–
24.9 kg/m2) pregnant women (n = 20), and in obese
(prepregnant BMI ≥ 30.0 kg/m2) pregnant women (n =
20) matched for age were compared to assess the effects of
obesity on pregnant women at 16–20 weeks of gestation
while exercising.24 Treadmill exercise was chosen instead
of bike exercise to simulate normal daily living tasks.
The results showed that exercise duration and peak
treadmill speed were lower in pregnant normal-weight
women (23.9 ± 4.9 min; 1.6 ± 0.2 m/s; P < 0.01) than in
nonpregnant women (33.7 ± 4.9 min; 2.0 m/s) and were
further reduced in pregnant obese women (19.6 ±
2.8 min; 1.4 ± 0.1 m/s; P < 0.01), indicating a limitation to
performing exercise, although HR and work rate were not
Nutrition Reviews® Vol. 71(Suppl. 1):S31–S36
significantly different between groups.24 In addition, the
ventilatory response both at rest and to exercise increases
during pregnancy and is further augmented by obesity.
However, contrary to the ventilatory response, the normal
increase in HR and the concurrent diminished HRR seen
in normal-weight pregnant women during exercise
was not further affected by obesity at standardized
submaximal exercise levels of 50 (mild intensity) and 100
(moderate intensity) watts.24 It was concluded that healthy
obese pregnant women have the aerobic capacity to under-
take structured walking activities at standardized
submaximal levels,which lends support to the feasibility of
exercise prescription for this population group.25
EXERCISE GUIDELINES FOR OBESE PREGNANT WOMEN
In Canada, a medical prescreening tool called the PAR-
med-X for Pregnancy26 can be used by healthcare provid-
ers to screen for contraindications to exercise and to
provide guidelines for exercise prescription based on the
FITT (frequency, intensity, time, and type of activity)
principle.26 It provides target HR ranges, based on age,
that were validated in pregnant normal-weight women at
an intensity of 60–80% of maximum oxygen capacity27 to
monitor intensity. For overweight and obese pregnant
women who are medically prescreened, this intensity may
be too strong and may prevent them from exercising. The
American College of Sports Medicine28 suggested that
previously sedentary overweight and obese pregnant
women should start an aerobic exercise program at an
intensity equivalent to 20–39% of maximum aerobic
(heart and lung) capacity, which indicates the lowest level
of physical activity that would provide health benefits.28
Using a graded treadmill exercise test in 106 pregnant
overweight (prepregnancy BMI ≥ 25.0–29.9 kg/m2) and
obese (prepregnancy BMI ≥ 30.0 kg/m2) women, target
HR zones based on age were validated at the lower exer-
cise intensity suggested by the American College of
Sports Medicine.29 Based on the results, target HR zones
of 102–124 beats per minute (bpm) for women 20–29
years of age and 101–120 bpm for women 30–39 years
of age were suggested for use in exercise intensity pre-
scription in medically prescreened, previously sedentary
overweight and obese pregnant women.29
Walking appears to be the most popular activity for
pregnant women.30 The frequency of other types of physi-
cal activity decreases as pregnancy progresses, but the
frequency of walking has been shown to increase.30 These
observations suggest that walking is an important aerobic
activity that should not be ignored, as it may
help maintain aerobic fitness in pregnant women.
Ruchat et al.31 investigated the effect of a maternal
walking program of low intensity (30% HRR) or vigorous
intensity (70% HRR) on cardiorespiratory responses to
Nutrition Reviews® Vol. 71(Suppl. 1):S31–S36
standard submaximal treadmill exercise in normal-weight
(prepregnancy BMI 18.5–24.9 kg/m2) women before
and after an 18-week intervention, starting at 16–20
weeks of pregnancy. The results suggested that both exer-
cise intensity groups experienced an improvement in
submaximal aerobic capacity, with greater improvement
observed in the vigorous-intensity group. However,
women in both groups presented similar gestational
weight gain, and all delivered healthy babies, showing that
prenatal walking of low or vigorous intensity, combined
with healthy eating, is an important component of a
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healthy pregnancy in normal-weight women.31 It would
seem reasonable to suggest that walking, combined with a
healthy dietary plan, would also be beneficial in obese
pregnant women at low obstetric risk.
The American College of Obstetricians and Gyne-
cologists32 suggests that medically prescreened pregnant
women can exercise on most if not all days of the week,
while the latest guidelines for Americans suggest that exer-
cise be spread throughout the week.33 However, the fre-
quency of structured exercise,especially in late pregnancy,
was found to be a determinant of birth weight in a case-
controlled study of 526 women.The odds of giving birth to
a small-for-gestational age baby was 4.6 times more likely
for women who engaged in structured exercise more than
five times per week and 2.6 times more likely for women
who engaged in structured exercise two or fewer times per
week, regardless of exercise intensity or duration of activ-
ity.34 Small-for-gestational-age babies are at risk for
obesity and cardiovascular disease later in life.4 Structured
exercise performed three to four times per week,with a day
of rest between each exercise day, would seem ideal and
may also help reduce fatigue.26
Overweight and obese pregnant women who, after
medical prescreening, wish to start a structured walking
program should initially attempt 25 min per session,
adding 2 min per session each week until reaching 40 min
per session,35 which can be maintained until delivery,
even if it is necessary to reduce the intensity or to include
rest intervals.25 The best time to progress is in the second
trimester, when the risks and discomforts of pregnancy
are lowest.25,26 Another way to confirm the appropriate
intensity is to use the “talk test,” which indicates that the
intensity is appropriate if an obese pregnant woman can
carry on a conversation while walking.26
HEALTHY LIFESTYLE APPROACH FOR OBESE
PREGNANT WOMEN
Although a healthy lifestyle approach is intuitive for
obese pregnant women, no guidelines currently exist to
help manage these women throughout their pregnancy.
Gestational weight gain guidelines exist that suggest
women who are classified as obese before pregnancy
S33
(BMI ≥ 30.0 kg/m2) should gain between 11 lb and 20 lb
(5–9 kg) at a rate of weight gain of 0.4–0.6 lb (0.2–0.3 kg)
per week during the second and third trimesters, assum-
ing an initial weight gain of up to 4.4 lb (2 kg).1 Excessive
weight gain above the recommended range for pregnant
women may result in excess fat stores along with the
associated health risks for mother and fetus.36
A healthy lifestyle is a balance between eating
nutritious foods (not “eating for two” but eating twice
as healthy), watching portion sizes, and being physically
active.36 A recent study examined the effects of a
Nutrition and Exercise Lifestyle Intervention Program
(NELIP) on the prevention of excessive weight gain in
overweight (prepregnancy BMI ≥ 25.0–29.9 kg/m2) and
obese (prepregnancy BMI ≥ 30.0 kg/m2) pregnant
women. The goals of the nutrition component of NELIP
were to individualize the total energy intake as follows: 1)
energy intake of approximately 2,000 kcal/day (8,360 kJ/
day), with a restriction not exceeding 33% of total energy
intake; 2) total carbohydrate intake of 40–55% of total
energy intake, with carbohydrate intake distributed
throughout the day; 3) three balanced meals and three to
four snacks per day, emphasizing complex carbohydrates
and low-glycemic-index foods; 4) total fat intake individu-
alized to 30% of total energy intake (substituting
monounsaturated fatty acids for saturated and trans-fatty
acids); 5) protein intake of 20–30% of energy; and 6)
micronutrient and fluid intakes in accordance with those
recommended for pregnant women.35 The nutrition
component was based on medical nutrition therapy given
to women with gestational diabetes. The exercise
component of NELIP was based on previous work29 and
consisted of a mild walking program (30% of HRR)
to facilitate compliance. All women were medically
prescreened using the PARmed-X for Pregnancy,26 and all
started the program between 16 weeks and 20 weeks of
gestation. The exercise program began with 25 min of
walking per session, three to four times per week. Each
subsequent week thereafter, the exercise time increased by
2 min, until a maximum of 40 min was reached and
maintained until delivery.35 Pedometers were worn to
count steps, and steps were recorded in exercise logs to
monitor activity.35
Comparison of preintervention (16–20 weeks of ges-
tation) with postintervention (34–36 weeks of gestation)
data showed that NELIP participants decreased their
mean daily total energy intake from 2,228.0 ± 474.6 kcal
to 1,900.2 ± 343 kcal, and daily carbohydrate intake
dropped from 318.5 ± 155.1 g to 259.1 ± 93.9 g, while the
percentage of daily energy from protein increased from
16.9 ± 2.4% to 18.4 ± 2.3% (P < 0.05). The average daily
pedometer step count before the intervention program
was 5,677.6 ± 1,738.0 steps. The step counts at 25 min
(length of initial exercise session) were, on average,
S34
2,861 ± 287.7 steps, which increased to 4,406.9 ± 461.0
steps at 40 min per session. When mean daily steps were
added to the steps taken at the end of the program (40 min
of structured walking), the women were taking more than
10,000 steps, which brought them from a preintervention
rating of “low active” or “sedentary” on the activity index
used to “active” at the end of the program.37 Maintaining a
physical activity index rating of “active” or above is recom-
mended to achieve a healthy lifestyle in the nonpregnant
population.37 In addition, the average HR of the NELIP
participants was 118 ± 6.8 bpm, which was within the
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range for aerobic benefits to occur.31
In terms of birth outcome, the women in the NELIP
program were compared with a cohort of women
matched by prepregnancy BMI, maternal age, and parity
(matched 4 to 1). Infant birth weight and gestational age
at delivery did not differ between the NELIP and the
matched control women. However, when stratified by
BMI, 3.2% of the overweight NELIP women had babies
weighing between 4.0 kg and 4.5 kg, compared with 18%
of the matched controls (P = 0.048). No babies born to the
NELIP women weighed less than 2.5 kg, whereas 3.5% of
the babies born to the matched controls had birth weights
below 2.5 kg. The rate of cesarean delivery was similar in
both groups: 4.6% among the NELIP women and 7%
among the matched controls. In addition, 3% of NELIP
women developed gestational diabetes mellitus (no
insulin required), compared with 7.8% (with 55% of those
needing insulin) of those in the matched control group.35
Excessive weight gain was successfully prevented in
80% of the NELIP women, many of whom had difficulty
with weight loss programs in the year before the current
pregnancy.36 This is an important finding because many
of the multiparous women (84%) had experienced exces-
sive weight retention (10.3 kg) from previous pregnan-
cies. In addition, before taking part in the NELIP
program, many participants had already experienced
excessive weight gain (4.5 kg) that was substantially more
than the suggested guideline of 2 kg for women in the first
trimester.1 However, while in NELIP, subsequent weight
gain was on average 6.8 ± 4.1 kg (0.38 ± 0.2 kg/week),
with a total pregnancy weight gain of 12.0 ± 5.7 kg and
excessive weight gain occurring before NELIP began, at
16 weeks of gestation.35
Excessive weight gain during pregnancy is an
important issue that needs further examination, especially
with regard to pregnancy outcome. Davenport et al.38
examined whether timing of excessive weight gain, before
16 weeks (usual time for the NELIP intervention to be
initiated), after 16 weeks (i.e., during the intervention), or
at both time points, was important when assessing birth
weight and body fatness of newborns at delivery. In a
cohort of 172 women, 33.7% of whom were normal weight
(prepregnancy BMI ≥ 18.5–24.9 kg/m2), 33.7% of whom
Nutrition Reviews® Vol. 71(Suppl. 1):S31–S36
were overweight (prepregnancy BMI ≥ 25.0–29.9 kg/m2),
and 32.6% of whom were classified as obese
(prepregnancy BMI ≥ 30.0 kg/m2), all women were
initiated into the NELIP between 16 weeks and 20 weeks
of gestation. Weight gain was assessed before the
intervention (up to 16–20 weeks of gestation) and from
the start of the intervention to delivery (after 16–20 weeks
of gestation). Women were stratified, based on
prepregnancy BMI category, as follows: 1) appropriate
gestational weight gain that was within the Institute of
Medicine recommendations1 for the first and second
halves of pregnancy (overall appropriate); 2) appropriate
gestational weight gain in the first half of pregnancy, but
excessive gestational weight gain in the second half of
pregnancy (late excessive); 3) excessive gestational weight
gain in the first half of pregnancy, but appropriate
gestational weight gain in the second half of pregnancy
(early excessive); and 4) excessive gestational weight
gain throughout pregnancy (overall excessive). Infant
birth weight and adiposity (according to the Catalano
et al.39 equation) were compared between groups. After
controlling for maternal prepregnancy BMI, maternal age,
infant gestational age at delivery, and gender of the infant,
it was found that those women who gained excessively
prior to the intervention and then gained within the
Institute of Medicine guidelines1 (early excessive) and
those women who gained excessively throughout
pregnancy (overall excessive) gave birth to babies with
excess normative infant body fat.38 In addition, the timing
of excessive maternal weight gain, specifically during the
first half of pregnancy, was a stronger predictor of infant
body fat at birth than total maternal weight gain,regardless
of prepregnancy BMI.38 These preliminary results warrant
further research on the timing of healthy lifestyle
interventions and the impact of such interventions on
prevention of excessive gestational weight gain and
pregnancy outcomes.
CONCLUSION
Women of childbearing age are at a greater risk of obesity
because excessive weight may be gained during preg-
nancy and retained after delivery. Therefore, adherence to
recommendations about the amount of weight a woman
should gain during pregnancy (with particular attention
to BMI status) may prevent chronic disease risks for a
mother and her offspring. Currently, there are no recom-
mendations on nutrition and physical activity to guide
healthcare workers in the management of obese pregnant
women. Healthy obese pregnant women have the aerobic
capacity to undertake structured walking activities,
which lends support to the feasibility of exercise
prescription for this population group. By adopting the
FITT principle of exercise prescription, it is suggested that
Nutrition Reviews® Vol. 71(Suppl. 1):S31–S36
obese pregnant women who are medically prescreened for
contraindications to exercise can engage in physical activ-
ity three to four times per week (Frequency), using a target
HR range of 102–124 bpm for women 20–29 years of age
and a range of 101–120 bpm for women 30–39 years of age
while maintaining the ability to carry on a conversation
(intensity), starting with 25 min per session and adding
2 min per week until sessions reach 40 min (time per
session), and continuing until delivery. Walking (type) is
the most popular activity among pregnant women and can
be monitored by using pedometer step counts, which can
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be a great motivator.An aim of approximately 10,000 steps
per day is suggested in order to obtain health benefits.
Combining healthy eating with a walking plan will help
prevent excessive weight gain and promote a healthy fetal
environment and pregnancy outcome. Further research is
necessary to determine the optimal timing of initiating
healthy lifestyle interventions to prevent excessive gesta-
tional weight gain in obese pregnant women and the sub-
sequent impact on infant health and body fatness.
Acknowledgments
Funding. Funding provided by the Canadian Institutes of
Health Research (CIHR) and the Rx&D Health Research
Foundation of Canada.
Declaration of interest. The authors have no relevant
interests to declare.
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