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Counselling, lifestyle and physical activity in maternity care -study (NELLI) 

Physical activity and diet are both known to have favorable effects on insulin resistance during pregnancy. The aim of the study was to investigate, whether counseling on diet, physical activity and gestational weight gain during pregnancy could prevent gestational diabetes. 

Pilot study (2007–2008)  

A non-randomized controlled trial was conducted in three intervention and three control maternity and child health clinics in primary health care in Finland. Altogether, 132 pregnant and 92 postpartum women and 23 public health nurses (PHN) participated in the study. The intervention consisted of individual counselling on physical activity and diet at five routine visits to a PHN and of an option for supervised group exercise until 37 weeks’ gestation or ten months postpartum. The control clinics continued their usual care.  


1) Feasibility of the trial: The study protocol was mostly feasible to implement, which encourages conducting large trials in comparable settings.  

  • Original publication: Kinnunen TI, Aittasalo M, Koponen P, Ojala K, Mansikkamäki K, Weiderpass E, Fogelholm M, Luoto R. Feasibility of a controlled trial aiming to prevent excessive pregnancy-related weight gain in primary health care. BMC Pregnancy and Childbirth 2008;8:37, doi: 10.1186/1471-2393-8-37 

2) Effects on weight gain: Counselling helped pregnant women to maintain the proportion of high-fibre bread and to increase vegetable, fruit and fibre intakes, but was unable to prevent excessive gestational weight gain. 

  • Original publication: Kinnunen TI, Pasanen M, Aittasalo M, Fogelholm M, Hilakivi-Clarke L, Weiderpass E, Luoto R. Preventing excessive weight gain during pregnancy. A controlled trial in primary health care. Eur J Clin Nutr 2007;61:884-891. 

3) Effects on physical activity: Counseling encouraged pregnant women to sustain their moderate-intensity leisure-time physical activity and was feasible in routine practices. No effects were observed if counseling was initiated postpartum. 

  • Original publication: Aittasalo M, Pasanen M, Fogelholm M, Kinnunen T, Ojala K, Luoto R. Physical activity counseling in maternity and child health care. A controlled trial. BMC Women’s Health 2008:8:14. doi:10.1186/1472-6874-8-1. 

Main study (2009–2017)  

A cluster-randomized controlled trial was conducted in 14 municipalities in the southern part of Finland. Pairwise randomization was performed in order to take into account socioeconomic differences. Recruited women were at 8–12 weeks’ gestation and fulfilled at least one of the following criteria: body mass index ≥25 kg/m², history of earlier gestational glucose intolerance, macrosomic newborn (> 4500 g), age ≥ 40 years, first or second degree relative with history of type 1 or 2 diabetes. Main exclusion criterion was pathological oral glucose tolerance test (OGTT) at 8–12 weeks’ gestation. 

In the intervention clinics the trial included several counseling sessions embedded into routine maternity visits: one on physical activity at 8–12 weeks’ gestation, one on diet at 16–18 weeks’ gestation and 3–4 booster sessions during other routine visits. In the control clinics women received usual care. 

Information on height, weight gain and other gestational factors was obtained from maternity cards. Physical activity, dietary intake and quality of life were assessed with questionnaires during pregnancy and at 1-year postpartum. Blood samples for lipid status, hormones, insulin and OGTT were taken at 8–12 and 26–28 weeks’ gestation and 1 year postpartum. 

  • Original publication on study design:  
    Luoto R, Kinnunen T, Aittasalo M, Ojala K, Mansikkamäki K, Toropainen E, Kolu P, Vasankari T. Prevention of gestational diabetes: design of a cluster-randomized controlled trial and one-year follow-up. BMC Pregnancy and Childbirth 2010;10(1):39.  


1) Effects on the prevention of gestational diabetes mellitus and large-for-gestational-age newborns: The intervention was effective in controlling birthweight of the newborns, but failed to have an effect on maternal GDM.   

  • Original publication: Luoto R, Kinnunen TI, Aittasalo M, Kolu P, Raitanen J, et al. (2011) Primary Prevention of Gestational Diabetes Mellitus and Large-for-Gestational-Age Newborns by Lifestyle Counseling: A Cluster-Randomized Controlled Trial. PLoS Med 8(5): e1001036. doi:10.1371/journal.pmed.1001036. 

2) Effects on gestational weight gain: The intervention had minor effects on GWG among women who were at increased risk for GDM. In order to prevent excessive GWG, additional focus on restriction of energy intake may be needed.  

  • Original Publication: Kinnunen TI, Raitanen J, Aittasalo M, Luoto R. Preventing excessive gestational weight gain – a secondary analysis of a cluster-ranodmised controlled trial. Eur J Clin Nutr 2012;66:1344-1350 

3) Effects on physical activity: Physical activity counseling had no effects on the duration of total or intensity-specific weekly LTPA. However, it was able to reduce the decrease in the weekly frequency of total and moderate-to-vigorous-intensity LTPA from baseline to the end of second trimester and was feasibly embedded into routine practices. 

  • Original publication: Aittasalo M, Raitanen J, Kinnunen TU, Ojala K, Kolu P, Luoto R. Is intensive counseling in maternity care feasible and effective in promoting physical activity among women at risk for gestational diabetes? Secondary analysis of a cluster randomized NELLI study in Finland. Int J Behav Nutr Phys Act 2012;9:104.  

4) Effects on food habits and dietary intake: The intervention improved diet towards the recommendations in pregnant women at increased risk for GDM suggesting the counselling methods could be implemented in maternity care. 

  • Original publication: Kinnunen T, Puhkala J, Raitanen J, Ahonen S, Aittasalo M, Virtanen S, Luoto R. Effects of dietary counselling on food habits and dietary intake of Finnish pregnant women at increased risk for gestational diabetes – a secondary analysis of a cluster-randomized controlled trial. Maternal & Child Nutrition 2014;10(2):184-97. doi: 10.1111/j.1740-8709.2012.00426.x. 


Validity and repeatability of short pregnancy leisure time physical activity questionnaire  

Seventy-nine women with uncomplicated pregnancies and maximum of 33 weeks’ gestation participated in the study. After the first questionnaire they entered 7-day leisure time physical activity and pedometer counts in a logbook and completed the second leisure time physical activity questionnaire. Validity was assessed with Spearman’s rank correlation coefficients by comparing the second leisure time physical activity questionnaire with pedometer counts and logbook. For describing repeatability, change in the mean, geometric mean ratio, typical error, coefficient of variation (CV,%) and Bland-Altman plots were used. 


The questionnaire was valid for assessing moderate to vigorous-intensity leisure time physical activity but its individual repeatability proved weak. 

  • Original publication: Aittasalo M, Pasanen M, Fogelholm M, Ojala K. Validity and repeatability of a short pregnancy leisure time physical activity questionnaire. Journal of physical activity and health 2010;7:109-118. 


  • Minna Aittasalo, Senior Researcher  
  • minna.aittasalo(a)  


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