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Objective To quantify the association between a combination of healthy lifestyle factors before pregnancy (healthy body weight, healthy diet, regular exercise, and not smoking) and the risk of gestational diabetes.

Design Prospective cohort study.

Setting Nurses’ Health Study II, United States.

Participants 20 136 singleton live births in 14 437 women without chronic disease.

Main outcome measure Self reported incident gestational diabetes diagnosed by a physician, validated by medical records in a previous study.

Results Incident first time gestational diabetes was reported in 823 pregnancies. Each lifestyle factor measured was independently and significantly associated with risk of gestational diabetes. The combination of three low risk factors (non-smoker, ≥150 minutes a week of moderate to vigorous physical activity, and healthy eating (top two fifths of Alternate Healthy Eating Index-2010 adherence score …