European Review for Medical and Pharmacological Sciences 2024; 28: 2750-2759

Effect of Nutrition and Behavior Modification

Program (NBMP) on maternal and neonatal
outcomes among hyperglycemic mothers
P. PREMALATHA1, H.M.A. MAHA2, H.A. SHADIA1, V. KRISHNARAJU3, K. PRABAHAR4,
N.T. MATHAR MOHIDEEN5, V. VINOTH PRABHU4, B. PREMA6, R.M. MASHAT7,
E.L. SAMPAYAN1, A.E. HALA8,9, A.A.Z. MARWA8,10, G. KANDASAMY11,
R. AHMED12,13, M.A. MERVAT1,14
1
College of Nursing, Mahalah Branch for Girls, King Khalid University, Abha, Asir, Saudi Arabia
2
Public Health Department, College of Applied Medical Sciences, King Khalid University, Abha,
Asir, Saudi Arabia
3
Department of Pharmacology, College of Pharmacy, King Khalid University, Abha, Asir, Saudi Arabia
4
Department of Pharmacy Practice, Faculty of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia
5
Department of Medical-Surgical Nursing, Faculty of Nursing, University of Tabuk, Tabuk, Saudi Arabia
6
Department of Nursing, Faculty of Applied Medical Sciences, University of Hafr Al Batin, Hafr Al
Batin, Saudi Arabia
7
College of Home Economics, Nutrition and Food Sciences, King Khalid University, Abha, Asir,
Saudi Arabia
8
Department of Psychiatric and Mental Health Nursing, Faculty of Nursing, Tanta University,
Tanta, Egypt
9
Department of Psychiatric and Mental Health Nursing, Faculty of Nursing, King Abdul Aziz
University, Saudi Arabia
10
Department of Psychiatric and Mental Health Nursing, College of Nursing, KSAU-HS, King
Abdullah International Medical Research Center, Al Ahsa, Saudi Arabia
11
Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Asir, Saudi Arabia
12
Department of Natural Products and Alternative Medicine, Faculty of Pharmacy, University of
Tabuk, Tabuk, Saudi Arabia
13
Department of Pharmaceutics, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
14
Department of Family and Community Health Nursing, Faculty of Nursing, Menoufia University,
Egypt

Abstract. – OBJECTIVE: Hyperglycemic individualized NBMP from their diagnosis of hy-

mothers and their offspring are at increased perglycemia until delivery.
risk of various maternal and neonatal complica- RESULTS: The results showed a significant
tions such as macrosomia, future type 2 diabe- difference in blood glucose between the study
tes, and metabolic abnormalities. Early diagno- periods and groups at p<0.05 as per repeated
sis and individualized dietary management, ex- ANOVA. Also, diet scores had a significant influ-
ercise, and emotional well-being are expected ence on BMI and glycemic control at p<0.05. Lo-
to reduce these risks. The study aims to identify gistic regression models, adjusted for potential
the effect of the Nutrition and Behavior Modifi- confounders including baseline blood glucose,
cation Program (NBMP) on maternal and neona- age, economic status, previous GDM, family his-
tal outcomes of hyperglycemic mothers. tory of DM as well as baseline BMI, diet score,
PATIENTS AND METHODS: A pre-experimen- physical activity, and maternal well-being score,
tal study was performed among 89 hyperglyce- indicated that the NBMP reduced the blood glu-
mic mothers. Glycemic control at 28 and 36 cose and BMI significantly at p<0.05 in the study
weeks, weight gain during pregnancy, pre-ec- group. NBMP also reduced the risk of SGA/LGA
lampsia, pregnancy-induced hypertension and preterm/post-mature birth, as well as in-
(PIH), mode of delivery, duration of exercise, creased the exercise duration and emotional
emotional well-being, neonates’ birth weight, well-being of mothers.
incidence of hypoglycemia, and NICU admis- CONCLUSIONS: The study’s conclusions
sion were compared among the study and con- draw attention to the possible roles that ma-
trol groups. The intervention group received an ternal wellness, physical activity, and diet may

2750 Corresponding Author: Premalatha Paulsamy, MD; e-mail: pponnuthai@kku.edu.sa

 Effect of NBMP on maternal and neonatal outcomes among hyperglycemic mothers

have in reducing risks for both hyperglycemic outcomes include hypoglycemia, hypocalcemia,
mothers and their newborns. The NBMP result- hyperbilirubinemia, polycythemia7, respiratory
ed in higher adherence to lifestyle changes. Fur-
ther research on a larger sample of hypergly- distress syndrome (RDS), neonatal mortality, and
cemic mothers is recommended to expand the stillbirth8.
generalizability of the findings One of the most important aspects of manag-
Key Words: ing HIP is diet. In addition to keeping the moth-
Hyperglycemia in pregnancy, Maternal outcomes, er’s blood sugar levels within a normal limit, a
Neonate, Low birth weight, Preterm, Large for ges- sufficient and well-balanced diet is crucial for
tational age, Nutritional and behavior modification, promoting ideal fetal development. As the main
Lifestyle modification. dietary factor affecting postprandial blood sugar
levels, carbohydrates are the focus of nutritional
interventions for HIP. Maternal glucose regula-
Introduction tion may be impacted by the kind (complex vs.
simple), quantity, and distribution of carbohy-
Globally, the prevalence of diabetes is rising, drates during the day. For example, it has been
especially in developing nations like China and proposed that diets high in dietary fiber with a
India, where they account for most of the rising low glycemic index can help pregnant women
burden. By 2030, India is expected to have the with HIP better control their postprandial glucose
largest number of diabetics worldwide, which levels9.
raises grave concerns1. Beyond the inherent sus- The nutritional intervention for pregnant wom-
ceptibility of South Asians to diabetes, factors en with hyperglycemia is like working with a
contributing to the increased prevalence include double-edged sword. An increased chance of
aging populations, urbanization, rising rates of macrosomia or Large for Gestational age (LGA)
obesity, energy-dense foods, and sedentary life- babies results from inadequate management of
styles2. Additionally, obesity increases the risk of the mother’s blood glucose levels. However, if
hyperglycemia in pregnancy (HIP), which affects dietary guidelines are overly rigid or calorie
up to 1 in 5 of all pregnancies3. The increased consumption is low, there may be a chance that
demands of the fetus in the second and third the fetus will not get enough nutrients, which
trimesters of pregnancy, along with hormonal could result in SGA10. These results highlight the
alterations (hormones generated by the placenta complex interplay among fetal development out-
that resist insulin), cause pregnant women to comes, gestational diabetes mellitus, and mother
require two to three times the usual dose of insu- nutrition. Therefore, encouraging broad dietary
lin4. From week 20, there is a substantial increase patterns rather than individualized nutrient sup-
in insulin requirements because of a marked de- plementation may be necessary to maximize
crease in insulin sensitivity until week 335. mother and baby health outcomes, particularly in
Hyperglycemia during pregnancy presents pregnancies complicated by GDM11.
concerns for both the mother and the fetus in In a Spanish randomized trial12, the impact of
both the immediate and distant future. The Inter- dietary patterns on the incidence of SGA was
national Diabetes Federation (IDF) reports3 that investigated. Following a Mediterranean diet was
pregnant women with some kind of hypergly- found to dramatically lower the incidence of
cemia account for 16.8% of live births globally. SGA when compared with usual care. Gestational
Pre-existing type 1 or type 2 diabetes that either weight gain and a lower BMI before conception
developed before pregnancy or was discovered have been linked to the prevalence of SGA13.
during prenatal testing accounts for 16% of cases According to a study performed in India14,
of gestational diabetes mellitus (GDM), which gestational glucose intolerance (GGI) and DM
causes the majority (84%) of cases. during pregnancy were found to be 16.8% and
Hyperglycemia may interfere with regular 11.6% prevalent, correspondingly. Gestational
metabolic processes that take place throughout age, pre-pregnancy BMI, gestational weight gain,
pregnancy4, impacting fetal growth and devel- history of diabetes in the family, PCOS, large for
opment. Due to the mother’s altered glucose gestational age, and GDM in earlier pregnancies
metabolism and possible vascular complications, were found to be correlated with HIP.
the fetus may not receive enough nutrients, which GDM nutrition management is essentially a
might impede the fetus’ growth and raise the careful balancing approach. Although keeping the
risk of SGA6. In addition, other adverse neonatal mother’s blood glucose within a target range is the

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 P. Premalatha, H.M.A. Maha, H.A. Shadia, V. Krishnaraju, K. Prabahar, et al

major goal, caution must be used to make sure that Patients and Methods
dietary recommendations do not unintentionally
result in reduced fetal growth. Preventing compli- Design
cations such as SGA in pregnancies complicated A pre-experimental study was conducted be-
by GDM requires close observation, individual- tween January 2021 and June 2022 to assess the
ized food regimens, and a thorough understanding effect of the Nutrition and Behavior Modifica-
of nutritional requirements during pregnancy. Nu- tion Program (NBMP) on maternal and newborn
merous studies have been done on the prevalence health among mothers with hyperglycemia. The
of GDM and its impact on maternal and newborn study focused on pregnant women who visit-
health. Studies on the effect of a comprehensive ed the antenatal outpatient departments of sec-
intervention of HIP on maternal and newborn out- ondary-level health institutions/Urban Primary
comes are scarce in Tamil Nadu, India. Health Centers in Chennai.
Hence, this study examined the comprehensive
“Nutrition and Behavior Modification Program” Participants and Study Procedures
for hyperglycemic pregnant women, which in- A total of 186 mothers were approached during
cluded tailored recommendations for low-glyce- their first diagnosis of hyperglycemia (14±2.4
mic index diet and exercise, supported by behav- weeks). The selected mothers’ blood glucose was
ior change theories and reinforced by customized monitored after 2 weeks of diet plan to confirm
follow-up. Following the International Associa- glycemic control. Only those mothers who had
tion of Diabetes and Pregnancy Study Group’s achieved glycemic control with dietary recom-
diagnostic guidelines15, we hypothesized that this mendations were included in the study. From
life course approach would lead to a higher inci- the initial number of 186 pregnant women, 89
dence of glycemic control. mothers finally completed the study (Figure 1).

Figure 1. CONSORT flow diagram of the study.

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 Effect of NBMP on maternal and neonatal outcomes among hyperglycemic mothers

Exclusion criteria included having a history of The NBMP called for moderate consumption
any chronic condition such as diabetes mellitus of animal fat and protein (fish, eggs, poultry,
before pregnancy, hypertension, heart disease, and low-fat dairy products were preferred), a
respiratory issues, hepatic disease, or taking fre- restricted intake of processed foods and sweets,
quent medications like corticosteroids and moth- and a regular intake of plant-based foods (fruits,
ers who had assisted pregnancy. The mothers vegetables, whole grains, legumes, and nuts)
from two centers were allotted to the study group with locally available non-refined oils such as
(45 mothers), and those from two other centers sesame oil as the primary source of fat. In ad-
were in the control group (44 mothers). The study dition, the food choices with locally available
centers were selected randomly using a lottery fruits, vegetables, legumes, etc., were also dis-
method, and the distance between the study and cussed on an individual basis. Additionally, the
control group settings was around a 20-24 km significance of a well-balanced diet, the impact
radius to avoid contamination. of anemia, and the consequences of vitamin
The incidence of glycemic control with NBMP and mineral deficiencies for the mother and the
at 28 and 36 weeks was the predetermined prima- fetus were highlighted. In addition, the neces-
ry outcome. The secondary outcomes for mothers sity of physical activity, the mother’s emotional
included weight gain during pregnancy, pre-ec- welfare throughout her pregnancy, compliance
lampsia, pregnancy-induced hypertension (PIH), with additional medicine, and the mix of nutri-
mode of delivery, and their self-reported activity tion supplements were covered. Each mother
levels after 36 weeks. Birth weight, incidence of received a unique, comprehensive menu plan
hypoglycemia, and NICU admission were among according to weight and moderate activity lev-
the additional outcomes of newborns gathered for el of 30 mts for 5 to 7 days a week. At 20, 24,
exploratory and subgroup analysis. The mothers’ 28, and 36-weeks’ gestation, qualified nurses
weight measurements were recorded to the nearest administered individual dietary counseling. To
0.1 kg on calibrated electronic scales (SECA 374, prevent cheating diets, women in the NBMP
Scorpia India Medicare Pvt Ltd, Ghaziabad, India) group were encouraged to remain loyal to the
at baseline (GA 14.8±4.2 weeks), GA 28 and 36 menu plan and physical activity by maintaining
(visits 1, 2, and 3). Blood glucose level was as- a diary, which was monitored by the nurses
sessed using a calibrated glucometer (OneTouch®, every week and discussed in their following
LifeScan Inc., India). In addition to this, maternal counseling sessions.
well-being was assessed using the standardized The behavioral goal of NBMP was to keep
WHO-5 Well-Being Index questionnaire16. It is an gestational weight gain (GWG) between 8-10 kg
easy-to-complete tool for screening psychological and maintain blood glucose below 120 mg/dl.
symptoms, and emotional well-being during preg- The mothers were given a helpline number to call
nancy is a very important attribute. To determine whenever they needed any clarification on diet,
the final score, the raw score is multiplied by 4, exercise, food choices, and when they felt low
with 0 denoting the lowest possible well-being and to ventilate their emotions. Under the guidance
100 the highest possible well-being. The raw score of an obstetrician and a registered nutritionist,
ranges from 0 to 25. four trained registered nurse midwives continu-
ously monitored the pregnant women across the
Intervention research. The obstetrician provided a no-harm
After randomization of the study centers, certificate for the NBMP. Additionally, the moth-
NBMP was given until delivery, along with the ers in the control group were made sure to adhere
standard antenatal care for hyperglycemic moth- to the state government’s recommended regimen
ers. The program began with a single face-to-face for prenatal care and control of blood glucose.
education session conducted with 3-4 mothers. Throughout the duration of the study, confidenti-
The mothers were offered initial one-hour mo- ality and beneficence were guaranteed.
tivational counseling on the benefits of the low The hospital ethics committee examined and
glycemic index with a high fiber diet on glycemic approved the research protocol. In addition to
control and the importance of moderate exercise NBMP, a booklet related to exclusive breastfeed-
for 30 minutes for 5-7 days/week. Personalized ing for 6 months, practical advice to improve their
WhatsApp messages on NBMP were sent once diet, and physical exercise to manage their weight
weekly throughout their pregnancy to motivate effectively postpartum were given as these moth-
them and to bring behavior modifications. ers are prone to develop DM later in life.

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 P. Premalatha, H.M.A. Maha, H.A. Shadia, V. Krishnaraju, K. Prabahar, et al

Statistical Analysis I (30.0-34.9 kg/m2), obesity class II (35.0-39.9 kg/

SPSS 23 (IBM Corp., Armonk, NY, USA) m2), and obesity class III (those who weigh more
software was used to handle and analyze data than 40 kg/m2).
using both descriptive and inferential statistics. Most newborns’ birth anthropometry was as-
Data were analyzed using the intention-to-treat sessed by skilled nurses within 48 hours of the
method. Data are presented as standard deviation baby’s birth. The sophisticated SECA 374 elec-
(SD) for symmetric distributions, frequency, and tronic scale was used to measure birth weight
proportion for categorical data. If the continuous precisely. Using conventional methods, the new-
variable had a normal distribution, the student’s born’s crown heel length was measured using
t-test was employed; if not, the Mann-Whitney U locally made, collapsible length boards that were
test was employed using analysis of covariance accurate to 1 mm. Periodically, the nurses re-
(ANCOVA) of repeated data. Differences in body ceived refresher training on data collection tech-
weight changes and glycemic status by gestation niques and anthropometric measuring methodol-
week were examined between the intervention ogies. Standard weights were used to calibrate the
and control groups, and p≤0.05 was considered weighing apparatus.
statistically significant. The baseline data of hyperglycemic mothers
showed that the mean age of the mothers in the
study and control group was 31.1±4.6 vs. 27.9±4.8.
Results The number of primi mothers in the study group
was 19, while the control group had 20. The aver-
Four of the eighty-nine women’s birth and age BMI of both groups was similar (31.7±3.87 vs.
neonatal outcome data were absent because they 32.4±3.1). Eleven mothers in the study group had
had either preterm delivery or did not attend the a previous history of GDM, while only 7 mothers
last visit. They were distributed within the groups in the control group had GDM. Regarding the
randomly. Six in the study group and 7 in the family history of DM, 18 and 23 mothers of the
control group could not achieve glycemic control control and study group respectively, had a fami-
at various points of the study period. They were ly history of DM. On pre-pregnancy blood sugar
referred to the physician, and individualized in- status, 27 and 31 mothers of the study and control
sulin therapy was started. GWG was calculated group had hyperglycemia.
by subtracting the measured weight at the time of Table I shows the comparison of blood glucose
study enrollment from the weight at the 36-week status among hyperglycemic mothers at different
visit. Proteinuria and consistent high blood pres- times of observation. Differences in group means
sure (140/90 mmHg) on more than one occasion were compared using the t-test to compare the
were considered indicators of preeclampsia. If NBMP with the conventional program. For the
the blood pressure satisfied the requirements but study group, the mean blood glucose was 119.1
proteinuria was absent, PIH was diagnosed. The with an SD of 3.08 at baseline, 115.7 with an SD
World Health Organization’s standards17 were of 4.03, and 117.1 with an SD of 2.81 at 28 and
used to classify overweight and obesity: over- 36 weeks of gestation, respectively. A significant
weight/pre-obesity (25-29.9 kg/m2), obesity class difference in the blood glucose status was noted

Table I. Comparison of blood glucose status among hyperglycemic mothers at different periods of observation.

Maternal blood Intervention Comparison

glucose level group mean group mean t-value
(mg/dl) (SD) (SD) p-value

Baseline 119.1 117.3 t=0.846

-3.08 -4.91 p=0.037*
28 weeks 115.7 117.1 t=0.299
-4.03 -3.99 p=0.05*
36 weeks 117.1 118.5 t=0.913
-2.81 -5.05 p=0.05*
Repeated ANOVA F=19.305, F=0.633,
p=0.0471* p=0.532 (NS)

p-value ≤0.05; *Significant.

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 Effect of NBMP on maternal and neonatal outcomes among hyperglycemic mothers

Table II. Effect of the dietary score on the blood glucose and BMI of the hyperglycemic mothers.

Diet score ≤5 6-7 8 9 ≥10 p

Women (n) 6 3 19 21 27
BMI (kg/m2) 33.98 (7.2) 32.08 (4.4) 31.81 (3.87) 30.81 (3.03) 29.7 (2.61) 0.033*
Maternal blood glucose (mg/dl) 126.1 (4.1) 125.8 (3.61) 124.1 (3.37) 122.8 (3.19) 117.0 (2.71) 0.051*

p-value ≤0.05; BMI: body mass index; *Significant.

between the study periods and the study and con- difference at p<0.05. The incidence of hypogly-
trol groups at p≤0.05, as per repeated ANOVA. cemia and admission to NICU did not show any
An analysis of variance was used to investigate significant difference between the groups.
the primary effects of the dietary scores of the
two groups on the mothers’ blood sugar levels
and BMI. The data in Table II shows that there Discussion
is a significant difference between the mothers’
blood sugar level and BMI according to the diet A prompt diagnosis and treatment of hypergly-
score, i.e., when the diet score is high, the BMI cemia can be extremely advantageous for both
and blood glucose level were reduced. the mother and the fetus since it is an emerging,
The blood sugar level, adjusted for confound- silent precursor of poor health outcomes. Pre-ec-
ers such as baseline blood glucose, age, eco- lampsia, postpartum hemorrhage, neonatal hy-
nomic status, previous GDM, and family H/o of poglycemia, jaundice, infant respiratory distress
DM, reduced by 4.17 mg/dl in the study group in syndrome, reductions in abortions, stillbirths,
36 weeks from the baseline value as compared obstructed labor, shoulder dystocia, and pregnan-
to mothers in the control group. Similarly, the cy-induced hypertensive disorders are just a few
maternal BMI (kg/m 2) was also reduced by 2.67 of the conditions that can be prevented by iden-
as compared to controls with adjusted confound- tifying women with hyperglycemia during preg-
ers such as baseline BMI, diet score, maternal nancy and putting interventional strategies aimed
wellbeing score, and physical activity, which at controlling glycemic status into practice.
indicated that the NBMP reduced the blood glu- In this study, the hyperglycemic pregnant
cose and BMI significantly in the study group mothers were the samples, and the effect of the
(Table III). Nutrition and Behavior Modification Program
The weight gain did not show a significant (NBMP) on maternal and newborn health was
change among the groups. There was a significant assessed. The average BMI of both the groups
difference between physical activity and mater- was similar (31.7±3.87 vs. 32.4±.3.1). A total of 18
nal well-being between groups at p<0.01 (Table mothers had a previous history of GDM, 41 had a
IV). The newborn outcomes, such as birth weight family history of DM, and 27 and 31 mothers of
and gestational age at birth, showed a significant the study and control group had hyperglycemia

Table III. Blood glucose and BMI at baseline and 36 weeks’ gestation.

Baseline mean 36 weeks’ mean

n (s.d.) (s.d.) Adjusted mean diff. p-value

Blood glucose (mg/dl)

Intervention 45 113.4±3.08 117.1±2.81 -4.17 (7.81-11.67) 0.04a
Comparison 44 118.7±2.91 118.5±5.05
Maternal BMI (kg/m2)
Intervention 45 26.7±3.87 32.08±4.4 -2.67 (3.11-7.46) 0.05b
Comparison 44 28.7±3.1 34.3±5.17

a
Mean group differences adjusted for baseline BG, age, economic status, previous GDM, and family H/o of DM; bMean group
differences adjusted for baseline BMI, diet score, physical activity, and maternal well-being score. p-value ≤0.05; BMI: body
mass index; *Significant.

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 P. Premalatha, H.M.A. Maha, H.A. Shadia, V. Krishnaraju, K. Prabahar, et al

Table IV. The maternal and newborn outcomes of the study population.

Maternal outcome variables Intervention Comparison p

Gestational weight gain 11.19±3.62 12.3±5.08 NS

Overall average physical activity (mts/wk)
Before intervention 71±11 77±14
After intervention 131±12 103±17 0.01*
Maternal well-being score
Before intervention 54±13 59±18 0.01*
After intervention 81±19 67±11
Pregnancy induced hypertension 4 7 NS
Preeclampsia 1 0
Mode of delivery
Normal 11 17 NS
Assisted with episiotomy 13 9
Cesarean 15 11
Newborn outcome variables
Birth weight 2.620±0.560 2.560±0.490 0.01
Gestational age at birth 36.1 (3.3) 34.3 (3.9) 0.04
Incidence of hypoglycemia 9 11 NS
Admission to NICU 7 5 NS
p-value ≤ 0.05; NS: not significant; *Significant.

before pregnancy. As per a study14 done in In- mothers significantly. Elevated levels of adipos-
dia, pre‑pregnancy weight and BMI, weight gain ity or BMI in infancy, childhood, and adulthood
during the pregnancy, family history of diabetes, have been associated with excess gestational
PCOS, macrosomia, and GDM in prior preg- weight gain (GWG), and this has also been
nancies were found to be significant with GDM, connected to an increased risk of obesity in
which aligns with our findings. offspring22-24. According to recent research 25-28,
In the present study, the differences in group higher GWG increases postpartum weight re-
means were compared using the t-test and the tention 25,26 and has longer-term consequences
repeated ANOVA, which showed a significant dif- on the risk of obesity27,28. Our findings were
ference between the study and control group val- consistent with the results of another study by
ues. Similarly, some clinical research18,19 showed Ferrari et al29 that the women participating in
that tailored nutritional intervention had a positive the lifestyle intervention experienced a weekly
effect on regulating and stabilizing blood sugar rate of GWG that was lower than that of usual
levels, suggesting that tailored nutritional inter- care [mean 0.26 kg (SD=0.15) vs. 0.32 kg (0.13);
vention has a great deal of potential for stabilizing mean between-group difference -0.07 kg per
plasma glucose in individuals with GDM. Ac- week, 95% CI -0.09 to -0.04].
cording to a meta-analysis, nutrition therapy that The present study findings also show that after
modifies daily dietary intake of carbohydrates, the following factors were considered as con-
fats, energy, and low Glycemic Index foods can re- founders, baseline blood glucose, age, economic
duce pregnancy weight gain in mothers, reduce the status, previous GDM, and family H/o of DM,
incidence of macrosomia, and possibly even lower the NBMP had significantly reduced the BMI
the risk of cesarean sections in GDM mothers20. and blood glucose level among the hyperglycemic
Hence, for GDM mothers, a tailored food plan can mothers. Also, the NBMP increased the physical
help minimize the risk of excess weight gain and activity and maternal well-being of the mothers.
large for gestational age newborns21. This finding was also suggested by Skouteris et
GDM can be classified as A1GDM and al30, who affirmed that future behavioral therapies
A2GDM. The classification of gestational diabe- should focus on psychological elements such as
tes managed without medication and responsive motivation, self-esteem, body image issues, and
to nutritional therapy is diet-controlled ges- mood to affect behavior, which may influence the
tational diabetes (GDM) or A1GDM. In the maternal and newborn outcomes of the hypergly-
present study, the diet score has influenced the cemic mothers. Newborn outcomes, such as birth
BMI and blood glucose levels of hyperglycemic weight and gestational age at birth, have been

2756
 Effect of NBMP on maternal and neonatal outcomes among hyperglycemic mothers

significantly influenced by the NBMP, while oth- It emphasized the possible impact of dietary com-
ers were not. A meta-analysis revealed significant ponents, exercise, and the emotional well-being of
variation in results, but diet and exercise modi- mothers during pregnancy on the decrease of risk
fications were successful in lowering gestational factors in mothers and their offspring. Determining
weight gain31 overall. Depending on gestational the socio-demographic characteristics such as blood
weight gain, a recent study32 found that being over- glucose, BMI, and level of physical activity, as well
weight or obese before being pregnant was linked as the emotional well-being of the mothers through-
to a higher risk of SGA in people with GDM. out pregnancy, provides crucial information for be-
Moreover, according to a recent meta-anal- havioral and nutritional therapy, as well as perinatal
ysis33, women with GDM are more likely to care. Preventing the complications of GDM de-
acquire T2DM (RR=7.43, 95% CI=4.79-11.51). pends on preventing obesity, effective nutrition, and
Women had a relative risk of 4.69 within 5 years physical activity intervention that produces weight
of an index pregnancy complicated by GDM; this loss. Preventive strategies aimed at both individual
risk more than quadrupled to 9.34 in those stud- and societal levels are needed to control the growing
ied beyond 5 years postpartum. According to an epidemic of diabetes. We also suggest that behav-
Indian study34, 16 years after the index pregnancy, ior-based interventions must be more systematically
pregnant women with GDM had a 3-fold higher designed, evaluated, and reported with a larger
lifetime risk of developing T2DM than pregnant sample size to advance our knowledge and clear the
women without GDM. According to research, by path for the best possible pregnancy and neonatal
the age of 17, one-third of children born to wom- outcomes.
en with GDM exhibit signs of impaired glucose
tolerance (IGT) or type 2 diabetes35. Thus, while
managing hyperglycemia during pregnancy, it is
imperative to ensure that the mother’s diet is not Conflict of Interest
only balanced in macronutrients, but adequate The authors declare that they have no conflicts of interest.
physical activity and psychological well-being are
also essential to safeguard against potential com-
plications for the mother and the fetus. This will Data Availability
also reduce the complications of T2DM, obesity, The data presented in this study are available upon request
and other related complications among the moth- to the corresponding author.
ers and their offspring in their later life.

Strengths and Limitations Authors’ Contributions

This study has strengths and limitations. To Conceptualization, P.P., H.M.A.M., H.A.S., V.K., and K.P.;
Methodology, P.P., H.A.S., V.K., N.T.M.M., V.V.P., P.B.,
our knowledge, this is the first study assessing the and R.M.M.; Software, G.K., E.L.S., V.K., A.A.Z.M., and
impact of NBMP on the hyperglycemic mothers M.A.M.; Validation, P.P., H.A.S., and K.P.; formal analy-
in the selected population. The methodology used sis, P.P., H.A.S., V.K., N.T.M.M., V.V.P., P.B., A.A.Z.M., and
was proper and thorough and the questionnaire R.M.M; resources, P.P., H.M.A.M., H.A.S., V.K., and K.P.;
used was validated. For ethical reasons, both data curation, P.P., H.A.S., V.K., N.T.M.M., V.V.P., P.B.,
R.A., and R.M.M.; writing-original draft preparation, P.P.,
study and control group mothers were carefully H.M.A.M., H.A.S., V.K., and K.P.; writing-review and edit-
monitored throughout the pregnancy for any de- ing, R N.T.M.M., V.V.P., P.B., A.A.Z.M., R.A., and R.M.M.;
viations in health by the trained healthcare pro- visualization, G.K., E.L.S., V.K., R.A., and M.A.M.; su-
fessionals though only the study group underwent pervision, P.P., V.K., and G.K.: project administration,
the intervention. However, the sample size was P.P., V.K., H.M.A.M., and E.L.S. All authors have read and
agreed to the published version of the manuscript.
not large, and therefore, any generalization of the
results needs to be made with caution.
Informed Consent
Written informed consent was obtained from the study par-
Conclusions ticipants.

In a presentation on the strategy of “primordial

prevention” of diabetes, the present study has tried Ethics Approval
to shed light on various aspects of NBMP to reduce The Ethics Committee of Vee Care Hospitals, Chennai, gave
the risk factors in hyperglycemic pregnant mothers. an ethical clearance with IEC/2020-26, dated 29.11.2020.

2757
 P. Premalatha, H.M.A. Maha, H.A. Shadia, V. Krishnaraju, K. Prabahar, et al

Funding 10) Bhowmik B, Siddique T, Majumder A, Mdala I,

This research was funded by the Deanship of Scientific Re- Hossain IA, Hassan Z, Jahan I, Moreira NCDV,
search at King Khalid University, K.S.A, Grant number: Alim A, Basit A, Hitman GA, Khan AKA, Hussain
RGP 2/92/44. A. Maternal BMI and nutritional status in early
pregnancy and its impact on neonatal outcomes
at birth in Bangladesh. BMC Pregnancy Child-
birth 2019; 19: 413.
ORCID ID 11) Apostolopoulou A, Tranidou A, Chroni V, Tsa-
P. Premalatha: 0000-0001-5117-480X kiridis I, Magriplis E, Dagklis T, Chourdakis M. As-
sociation of Maternal Diet with Infant Birthweight
in Women with Gestational Diabetes Mellitus. Nu-
Acknowledgments trients 2023; 15: 4545.
The authors extend their sincere appreciation to the Dean- 12) Crovetto F, Crispi F, Casas R, Martín-Asuero A,
ship of Scientific Research at King Khalid University for Borràs R, Vieta E, Estruch R, Gratacós E; IM-
funding this study through the Large Research Group Proj- PACT BCN Trial Investigators. Effects of Mediter-
ect under grant number RGP 2/92/44. We also extend grati- ranean Diet or Mindfulness-Based Stress Reduc-
tude to the mothers and their families of both the study and tion on Prevention of Small-for-Gestational Age
control groups and the research assistants. Birth Weights in Newborns Born to At-Risk Preg-
nant Individuals: The IMPACT BCN Randomized
Clinical Trial. JAMA 2021; 326: 2150-2160.
13) Costanza J, Camanni M, Ferrari M.M, De Cos-
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