Pre-pregnancy BMI and pregnancy anxiety in women with gestational diabetes mellitus: mediating effects of blood glucose and lipid levels1

doi:10.21203/rs.3.rs-1952539/v1

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Research Article

Pre-pregnancy BMI and pregnancy anxiety in women with gestational diabetes mellitus: mediating effects of blood glucose and lipid levels¹

https://doi.org/10.21203/rs.3.rs-1952539/v1

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Background: Body mass index (BMI) before pregnancy and blood glucose and lipid levels during and before pregnancy are associated with anxiety among pregnant women with gestational diabetes mellitus (GDM). No study has further explored the relationship between these factors. Our study is the first to explore the effects of blood glucose and lipids on the relationship between BMI and anxiety in pregnant women with GDM using mediation analysis.

Methods: Pregnant women diagnosed with GDM after completing the oral glucose tolerance test during pregnancy were followed up from January 2019 to December 2021. Collecting basic information including age, education level, annual family income, pre-pregnancy BMI, gestational age, history of abortion, family history of anxiety and diabetes, sleep status, and other information.

Results: After adjusting for relevant influencing factors, Pre-pregnancy BMI, FBG, HbA1c, 2hPG, and TG were still significantly correlated with the pregnancy anxiety scores . The results of the mediating effect model suggested that pre-pregnancy BMI significantly influenced the pregnancy anxiety scores in women with GDM (P<0.001); FBG, 2hPG, HbA1c, and TG significantly mediated the effect of BMI on the pregnancy anxiety scores, respectively, and played a partial mediator role between BMI and the pregnancy anxiety scores of pregnant women with GDM.

Conclusion: Pre-pregnancy BMI was associated with pregnancy anxiety among pregnant women with GDM. High BMI before pregnancy can lead to increased anxiety . Blood glucose and lipid levels during pregnancy play a part in the influence of BMI before pregnancy on anxiety .

anxiety

blood glucose

blood lipids

mediating effects

gestational diabetes mellitus

Recently, the incidence of gestational diabetes mellitus (GDM) among pregnant women is increasing [1], and poor blood glucose control in patients with GDM can lead to adverse pregnancy outcomes, posing a serious threat to both pregnant women and the fetus [2]. Therefore, pregnant women in this high-risk group suffer greater psychological pressure than healthy pregnant women [1–2]. The studies further showed that anxiety can increase the risk of GDM, and pregnant women diagnosed with GDM are also more susceptible to depression, anxiety, and stress [3–6].More than 40% of patients with GDM experience anxiety[7–8]. .At the same time, anxious pregnant women with gestational diabetes were more likely to have a variety of adverse maternal and infant outcomes through some studies[9–12].

The mediation effect model is an important method to explore the connection between factors. When an independent variable X can influence a dependent variable Y through an intermediate variable M, it indicates that M is an intermediate variable and plays an intermediate effect between X and Y. Recently, mediating effect analysis has not only been applied in psychology and other social science research fields, but also in medical research; several studies [14–16] have analyzed the relationship between relevant variables by establishing mediating effect models. Therefore, this study is the first to explore the effects of blood glucose and lipids on the relationship between pre-pregnancy BMI and pregnancy anxiety among pregnant women with GDM using mediation effect analysis.

Research status of BMI and pregnancy anxiety in pregnant women with GDM

Currently, obesity before pregnancy are increasingly common. Globally, the prevalence of overweight or obese women during pregnancy is rising rapidly, with current prevalence estimates ranging from 12.3–63.5% [16–18]. Overweight and obesity before pregnancy have a variety of adverse health consequences for both mother and child [19]. In a recent meta-analysis [20], the study found that women who were obese at the time of conception were more likely to have anxiety and depression symptoms during pregnancy than women of normal weight. Similarly, relevant studies also demonstrate that the BMI is positively correlated with anxiety during pregnancy[20–22].

Current status of research on the relationship between blood glucose level during pregnancy and pre-pregnancy BMI and pregnancy anxiety

In addition to the direct influence of pre-pregnancy BMI on pregnancy anxiety, there is a close relationship between the blood glucose level and negative emotions such as anxiety and depression during pregnancy, as well as pre-pregnancy BMI. The level of glycated hemoglobin (HbA1c) is positive correlation to the scores for anxiety and depression [23–25]. FBG and 2hPG are closely associated with increased anxiety and depressive symptoms in GDM[26–27]. However, BMI levels before pregnancy have a significant influence on FBG and 2hPG levels of patients with GDM [28], suggesting that with the increase of BMI, blood glucose level increases significantly, indicating that both FBG and 2hPG levels are positively associated with BMI before pregnancy [28].

Research status of serum lipid levels, BMI before pregnancy, and pregnancy anxiety

There is also a close connection between lipid levels during pregnancy and BMI before pregnancy and pregnancy anxiety. LDL-C, TC, and TG levels are positively correlated with anxiety and depression [29]; however, HDL-C is negatively correlated with anxiety[30]. Additionally, TG is positively correlated with BMI before pregnancy [21], while TC, LDL-C, and HDL-C are negatively correlated with BMI before pregnancy [31].

At present, many studies have discussed what factors contribute to anxiety in pregnant women with GDM, although these studies only discussed the relationship between a certain influencing factor and anxiety and did not study the correlation between multiple influencing factors. From the above discussion, we can see that there may be a certain relationship between BMI and blood glucose and lipid levels during pregnancy and pregnancy anxiety. Therefore, we conducted the first prospective study to link the role of pre-pregnancy BMI on pregnancy anxiety with blood glucose and lipid levels during pregnancy through mediation effect analysis and to further explore whether blood glucose and lipid levels play a mediating role in the relationship between BMI and pregnancy anxiety in pregnant women with GDM. Our hypotheses were as follows: The mediating effect analysis was conducted to further explore the influence of BMI on the pregnancy anxiety score and regulation process of blood glucose and lipid levels during pregnancy between BMI and pregnancy anxiety scores.

Research participants

Pregnant women who visited the Department of Endocrinology or Obstetrics of the Affiliated Hospital of China Medical University from January 2019 to December 2021 were selected for long-term follow-up. These pregnant women were diagnosed with GDM.According to the 2012 World Health Organization guidelines [32], GDM is defined as meeting or exceeding at least one of the following indicators: (1) 5.1 mmol/L ≤ FPG level < 7.0 mmol/L, (2) 1-h plasma glucose level ≥ 10.0 mmol/L, and (3) 8.5 mmol/L ≤ 2h-PG level < 11.1 mmol/L. Finally, pregnant women with a GDM diagnosis were selected as the research subjects.

Inclusion criteria

(1) GDM was definitively diagnosed after the 75g OGTT test was completed during pregnancy.

(2) Pregnant women with GDM should have completed the measurement of blood glucose (FBG, 2hPG, and HbA1c) and lipid (TG, TC, HDL, and LDL) levels in the endocrinology department or obstetrics department of our hospital during 14–28 weeks of gestation or were able to provide blood glucose or lipid indexes tested in local hospitals during 14–28 weeks of gestation.

(3) Willing to accept the questionnaire survey after being informed of the survey content and able to fill in the questionnaire independently.

(4) Complete clinical data.

Exclusion criteria

(1) Absence of basic information

(2) Patients did not meet the diagnostic criteria of GDM

(3) Patients with other diseases

(4) Those who were unwilling to complete the questionnaire survey

(5) Patients with psychological symptoms, such as compulsion, anxiety, and depression, before pregnancy

The Self-rating Anxiety Scale (SAS)was conducted among pregnant women with GDM,and these women will be grouped according to their SAS scores.

Data collection

The data collected mainly included general demographic data, health data, personal habits, BMI before pregnancy, blood glucose (FBG, 2hPG, and HbA1c) and lipid (TG, TC, HDL, and LDL) levels, and systolic blood pressure levels during pregnancy, pregnancy anxiety, and weight gain during pregnancy.

Questionnaire information

The survey included:

(1) Demographic data: age, education level, annual family income, and others.

(2) Health data: including height before pregnancy, weight before pregnancy, weight gain during pregnancy, gestational age, history of abortion, family history of anxiety, family history of diabetes, and sleep status.

Medical history

(1) Evaluation of anxiety during pregnancy: After the pregnant women were definitively diagnosed with GDM, the SAS was used within 1–2 weeks to evaluate their anxiety state. The SAS, compiled by Zung in 1971, is a clinical measurement tool for assessing patients' subjective symptoms of anxiety. The SAS is a self-assessment tool for anxiety with high reliability and validity and is widely used in medical-related studies [33–36]. Participants filled in items according to the contents of the scale. There are a total of 20 test questions on the SAS, all of which adopt a four-level scoring method. The main evaluation items are the frequency of symptom occurrence defined by the following criteria: "A" no or little time; "B" A small part of the time; "C" quite A lot of the time; and "D" for the most part or all of the time (the "A" "B" "C" "D" for "1" "2" "3" "4 scoring points") (Figure.1).

Total rough score = total score of 20 items, demarcation is 40 points.

Standard points = total rough points ×1.25, demarcation points are 50 points. If SAS standard score ≤ 50, it means no anxiety; SAS standard score ≥ 50 points, indicating anxiety, including 50–59 points of mild anxiety, 60–69 points of moderate anxiety, more than 69 points of severe anxiety.

(2) Blood glucose and lipid measurements: Blood glucose (FBG, 2hPG, and HbA1c) and lipid (TG, TC, HDL, LDL) levels were recorded.

Variable definition and assignment

Pregnant women with GDM were divided into two educational background groups (junior college and below and college and above), three annual household income groups (< 60,000RMB [low middle class], 60,000-140,000RMB [middle middle class], and ≥ 140,000RMB [upper middle class]), and three sleep time groups (< 6 h [insufficient sleep], 6–8 h [average sleep], and > 8 h [adequate sleep]). The specific assignment is shown in Table 1.

Table1 Variable assignment table

Variable	Assignment
Level of education	1= Junior college and below；2= University and above
Annual household income（Ten thousand yuan）	1＜6；2=6-14；3＞14
History of abortion Family history of anxiety Family history of diabetes Sleep during pregnancy （h）	1 = Yes；0 = No 1 = Yes；0 = No 1 = Yes；0 = No 1＜6；2=6-8；3＞8

Quality control

Participants were determined strictly in accordance with the inclusion and exclusion criteria for selection. Before filling in the questionnaire, the investigators were trained to assist participants with understanding the research content and significance of each item in the questionnaire; they could ask any questions needed to clarify their doubts in a timely manner. After that, the investigators issued the questionnaire uniformly to each participant and explained the requirements of filling in the questionnaire with the same instructions.

Statistical analyses

First, descriptive analyses were used to describe the general characteristics of the study population. Second, Spearman correlation analysis was used to determine whether there was any correlation between pre-pregnancy BMI, blood glucose, blood lipids, and pregnancy anxiety scores. Factors influencing the pregnancy anxiety scores were analyzed by a binary logistic regression model. Finally, SPSS macro process program designed by Hayes was used to complete data analysis.

Basic participant characteristics

Basic information of the participants is shown in Table 2. 275 pregnant women with GDM were included and divided into the anxiety group (standard score ≥50) or non-anxiety group (standard score <50) according to the anxiety scale scores. There were 85 women in the anxiety group and 190 women in the non-anxiety group, and the prevalence of anxiety was 31%. The pre-pregnancy BMI of the study population was 24.54±3.72 kg/m². The pre-pregnancy BMI in the anxiety group was higher (25.54±3.68 kg/m²) than the control group (24.1±3.66 kg/m²) (P<0.01). The two groups of pregnant women were similar in age, gestational age, weight gain during pregnancy, and family history of diabetes. There were statistically significant differences in blood glucose and lipid levels, systolic blood pressure during pregnancy, history of abortion, mother's cultural degree, family income, family history of anxiety and sleep were statistically significant.

Table2 Comparison of basic characteristics between two groups of pregnant women with GDM

Variable

Population N=275

Anxiety group

n=85

No anxiety group

n=190

Age，Mean±SD

Gestational age，Mean±SD

Pre-pregnancy BMI（Kg/ m²），

Mean±SD

Weight gain during pregnancy（Kg），Mean±SD

History of abortion (%)

Yes

Level of education (%)

Junior college and below

University and above

Systolic blood pressure（mmHg），Mean±SD

Anxiety scale score *，

M（Q1,Q3）

Blood glucose *, M（Q1,Q3）

FPG（mmol/L），

2hPG（mmol/L）

HbA1c（%）

Lipid *, M（Q1,Q3）

TG（mmol/L）

TC（mmol/L）

HDL-C（mmol/L）

LDL-C（mmol/L）

31.79±3.92

25.39±3.92

24.54±3.72

7.25±4.90

175(63.64)

100(36.36)

73(36.14)

202(63.86)

126.55±5.38

41.25(35-51.25)

5.59(5.12-6.19)

7.50(6.45-8.63)

5.50(5.20-6.10)

2.34(1.95-3.12)

4.73(4.18-5.79)

1.68(1.42-2.03)

2.89(2.35-3.49)

31.58±4.46

25.67±2.74

25.54±3.68

7.20±2.96

43(50.59)

42(49.41)

32(37.65)

53(63.25)

130.25±4.76

53.75(51.25-56.25)

6.08(5.47-7.03)

8.55(7.48-9.80)

5.97(5.40-6.70)

2.82(2.22-3.62)

5.83(4.76-6.52)

1.55(1.36-1.71)

3.29(2.84-4.07)

31.89±3.66

25.27±1.30

24.10±3.66

7.23±5.57

132（69.47）

58（30.53）

41(21.58)

149(78.42)

124.89±4.79

37.50(33.75-41.25)

5.47(5.06-5.93)

7.12(6.28-7.96)

5.40(5.10-5.87)

2.28(1.71-2.96)

4.39(3.76-5.29)

1.83(1.48-2.11)

2.65(2.20-3.37)

0.54

0.10

＜0.01

0.90

＜0.01

Annual household income（Ten thousand yuan）(%)

＜6

6-14

＞14

25（9.09）

200（72.73）

50(18.18)

12（14.12）

61(71.74)

12(14.14)

13(6.84)

139(73.16)

38（20.00）

＜0.01

Family history of anxiety (%)

Yes

Family history of diabetes (%)

Yes

The amount of sleep（h）(%)

＜6

6-8

＞8

263(95.64)

12(4.36)

199（72.36）

76（27.64）

34（12.36）

135（49.09）

108(38.55)

76（89.41）

9(10.59)

60(70.59)

25(29.41)

15(17.65)

56（65.88）

16（16.47）

187(98.42)

3(1.58)

139(73.16)

51(26.84)

19（10.00）

79（41.58）

92（48.48）

＜0.01

0.66

＜0.01

Note: Continuous variables were expressed by mean ± standard deviation and compared by T test. The classification variables were expressed by frequency (percentage) and compared by Chi-square test. *Anxiety scale scores, blood glucose (FBG, 2hPG, HbA1c), and blood lipid (TG, TC, HDL, AND LDL) did not follow normal distribution after testing, so median (interquartile spacing) was used for comparison using Wilcoxon rank-sum test.

Correlation analysis of blood glucose, blood lipids, pre-pregnancy BMI, and anxiety score of pregnant women with GDM

The correlation between pre-pregnancy BMI, blood glucose and lipid levels during pregnancy, and anxiety scores was analyzed(Table 3). The BMI before pregnancy was positively correlated with anxiety. There was a positive correlation between FBG, 2hPG, and HbA1c and the anxiety scores of pregnant women with GDM. TG, TC, and LDL-C during pregnancy were positively correlated with anxiety, but HDL and the GDM anxiety score is irrelevant.

Table3 Correlation analysis of blood glucose, blood lipid, pre-pregnancy BMI and anxiety score of GDM pregnant women

Variable	GDM maternal anxiety score
Variable	r	P
Pre-pregnancy BMI	0.19**	0.002
FBG	0.27***	<0.001
2hPG	0.43***	<0.001
HbA1c	0.29***	<0.001
TG	0.31***	<0.001
TC HDL LDL-C	0.47* -0.08 0.41*	<0.001 0.180 <0.001

*p<0.05; **p<0.01；***p<0.001

Correlation analysis between pre-pregnancy BMI and blood glucose and lipids

The correlation between pre-pregnancy BMI and blood glucose and lipid levels during pregnancy was analyzed(Table 4). Pre-pregnancy BMI was positively correlated with FBG, 2hPG, and HbA1c during pregnancy. BMI before pregnancy was positively correlated with TG levels during pregnancy and was negatively correlated with HDL levels during pregnancy. There was no correlation between pre-pregnancy BMI and TCand LDL-C during pregnancy.

Table4 Correlation analysis of blood glucose, blood lipids and BMI before pregnancy

Variable	Pre-pregnancy BMI
Variable	r	P
FBG	0.25***	<0.001
2hPG	0.26***	<0.001
HbA1c	0.34***	<0.001
TG	0.16**	0.007
TC HDL LDL-C	0.09 -0.14* 0.09	0.143 0.018 0.129

*p<0.05; **p<0.01；***p<0.001

Association among pre-pregnancy BMI, blood glucose and lipids, and anxiety in pregnant women with GDM

The above correlation analysis revealed that FBG, 2hPG, HbA1c, and TG during pregnancy were significantly positively correlated with not only the pregnancy anxiety scores, but also with pre-pregnancy BMI. Therefore, we further explored the relationship between blood glucose (FBG, 2hPG, and HbA1c) and lipid (TG) during pregnancy and pre-pregnancy BMI and the pregnancy anxiety score through regression analysis. Since the pregnancy anxiety scores for pregnant women with GDM were not normally distributed, the anxiety of pregnant women with GDM was regarded as a binary classification variable (with anxiety, without anxiety), and the relationship between pre-pregnancy BMI, pregnancy blood glucose (FBG, 2hPG, and HbA1c) and lipid (TG) levels, and anxiety of pregnant women with GDM was investigated by using a binary logistic regression model. Additionally, maternal systolic blood pressure during pregnancy, maternal education level, annual family income, previous history of abortion, family history of anxiety, and sleep during pregnancy were included in the regression model as the final adjustment factors based on the research results and reference of relevant literature. Finally, logistic regression analysis of pre-pregnancy BMI, blood glucose and lipid levels during pregnancy, and anxiety of pregnant women with GDM is shown in Table 5.

Table5 Logistic regression analysis of pre-pregnancy BMI, blood glucose, blood lipids and anxiety in pregnant women with GDM

Variable	Anxiety in pregnant women with GDM
Variable	OR（95%CI）	ORa（95%CI）
Pre-pregnancy BMI FBG	1.11 (1.04,1.19) * 2.60 (1.87,3.62) *	1.11 (1.01,1.22) * 1.86 (1.24,2.81) *
2hPG	1.99 (1.62,2.46) *	1.73 (1.33,2.27) *
HbA1c	2.64 (1.85,3.77) *	2.02 (1.26,3.23) *
TG	1.67 (1.32,2.17) *	1.26 (1.05,1.67) *

Note: ORa: The OR value adjusted by incorporating maternal systolic blood pressure during pregnancy, maternal education level, annual family income, previous history of abortion, family history of anxiety and sleep during pregnancy into the binary Logistic regression model. * denotes p ＜ 0.05.

Mediating effects of blood glucose and lipid on pre-pregnancy BMI and pregnancy anxiety scores

The abovementioned research results demonstrated that FBG, 2hPG, HbA1c, and TG were not only correlated with pre-pregnancy BMI, but also significantly correlated with the pregnancy anxiety scores. In addition, a logistic regression model was used to evaluate statistical significance after adjusting maternal systolic blood pressure during pregnancy, maternal education level, annual family income, previous history of abortion, family history of anxiety, and sleep during pregnancy. Therefore, these results indicate that FBG, 2hPG, HbA1c, and TG may play a mediating role in the relationship between pre-pregnancy BMI and the pregnancy anxiety scores of pregnant women with GDM. Accordingly, a bootstrap method was used to test the mediating effect among variables, with pre-pregnancy BMI as the independent variable X, FBG, 2hPG, HbA1c, and TG levels as the mediating variable M, and the pregnancy anxiety score as the dependent variable Y [35].

Finally, the analysis results of the mediating effects of FBG, 2hPG, HbA1c, and TG between pre-pregnancy BMI and the pregnancy anxiety score are shown in Tables 6 and 7. The total effect of pre-pregnancy BMI on pregnant women with GDM was significant (P=0.001), indicating that pregnant women with GDM and high pre-pregnancy BMI are more likely to experience higher anxiety scores during pregnancy. Additionally, FBG, 2hPG, HbA1c, and TG significantly mediate the influence of pre-pregnancy BMI on the pregnancy anxiety scores of pregnant women with GDM, and the indirect effect of blood glucose (FBG, 2hPG, and HbA1c) on the pregnancy anxiety scores of pregnant women with GDM is significantly stronger than the effect of blood lipids (TG) (Table 7). In conclusion, FBG, 2hPG, HbA1c, and TG play a partially mediating role in the relationship between pre-pregnancy BMI and the pregnancy anxiety scores of pregnant women with GDM. Further, based on the relationship among the above variables, the relevant path graph was constructed (Figure 2).

Table6 Test results of mediating effects of blood glucose and blood lipids on pre-pregnancy BMI and pregnancy anxiety scores

Independent variable (X)	Intervening variable（M）	Dependent variable（Y）	a	b	c	c’
Pre-pregnancy BMI	FBG	Anxiety scores	0.06***	2.88***	0.46***	0.29*
Pre-pregnancy BMI	2hPG	Anxiety scores	0.11***	2.39***	0.46***	0.19
Pre-pregnancy BMI	HbA1c	Anxiety scores	0.06***	2.94***	0.46***	0.28*
Pre-pregnancy BMI	TG	Anxiety scores	0.05**	2.04***	0.46***	0.35**

a：The direct effect of an independent variable on a mediator variable b：The direct effect of a mediating variable on a dependent variable c：The total effect of independent variables on dependent variables c’： Indirect effects of independent variables on dependent variables. *p<0.05; **p<0.01；***p<0.001

Table7 The mediating effects of blood glucose and blood lipids on pre-pregnancy BMI and pregnancy anxiety scores

Project

Effect of value

Standard error

95% confidence upper bound

95% confidence lower bound

Total effect（c）

FBG

Indirect effect

Direct effect

0.46

0.17

0.29

0.13

0.05

0.13

0.19

0.08

0.03

0.72

0.27

0.04

2hPG

Indirect effect Direct effect

0.26

0.19

0.06

0.12

0.15

-0.05

0.39

0.44

HbA1c

Indirect effect Direct effect

0.18

0.28

0.05

0.13

0.09

0.18

0.28

0.53

Indirect effect Direct effect

0.11

0.35

0.05

0.13

0.02

0.09

0.21

0.61

Our study aimed to further investigate whether blood glucose and lipids mediate the relationship between pre-pregnancy BMI and pregnancy anxiety in pregnant women with GDM. We confirmed the bidirectional association between blood glucose and lipid levels during pregnancy and BMI and anxiety during pregnancy through correlation and regression analyses. The mediation effect analysis further confirmed that pre-pregnancy BMI had a significant effect on the pregnancy anxiety scores in pregnant women with GDM. In addition, FBG, 2hPG, HbA1c, and TG also mediated the effect of pre-pregnancy BMI on the pregnancy anxiety scores in pregnant women with GDM. Lastly, FBG, 2hPG, HbA1c, and TG did play a partial mediating role in the relationship between pre-pregnancy BMI and the pregnancy anxiety scores of GDM pregnant women.

Recently, the incidence of gestational diabetes has increased and this disease can cause great harm to pregnant women and fetuses.. Clinical evidence for gestational diabetes suggests that women experience extreme mood changes during pregnancy and are more likely to experience anxiety; negative emotions during pregnancy can cause maternal and infant complications.
Previous research indicates that women with GDM had a higher tendency to develop prenatal depression, anxiety, and stress[37-38]. Meanwhile, women with low income, low socioeconomic status, and low education levels have a higher incidence of prenatal anxiety and depression [39]. Adverse birth history and a family history of depression or anxiety are associated with anxiety and depression [40-43]. Our results indicate that the incidence of adverse history of abortion, family history of anxiety, low income, and low educational level in the anxious group was higher than that of those in the non-anxious group. In addition, our study also found that the average systolic blood pressure of the anxiety group is higher than the control group during pregnancy. This may be due to negative emotions, such as anxiety experienced by pregnant women with GDM for whom neuroendocrine changes occur constantly, thus enhancing the hypothalamus-pituitary-adrenal cortex system and sympathetic adrenal medullary system activity, leading to endothelial cell shrinkage and increased systolic blood pressure. Additionally, our results also revealed that pregnant women with GDM in the anxiety group had less sleep time than those in the control group.

At present, the prevalence of overweight or obese women during pregnancy is rapidly increasing worldwide [16-17], and its incidence is estimated to range from 12.3% to 63.5% [18]. Recently, the incidence of GDM is also increasing, and more than 40% of patients with GDM experience anxiety during pregnancy, indicating a high prevalence of anxiety in women with GDM [10-11].Some studies [20-21,44] have found a positive dose-response correlation between BMI and prenatal anxiety, depression, and other adverse emotions. However, another recent study failed to detect an association between the two [45]. Our correlation analysis demonstrated a significant positive correlation between pre-pregnancy BMI and the pregnancy anxiety scores of pregnant women with GDM, suggesting that pregnant women with GDM with high pre-pregnancy BMI were more likely to display a high anxiety score during pregnancy. This correlation remained statistically significant after regression analysis excluding maternal systolic blood pressure during pregnancy, maternal education level, annual family income, previous history of abortion, family history of anxiety, and sleep during pregnancy, which was consistent with previous findings [17].

Most studies only discuss the relationship between BMI and prenatal anxiety before childbirth or only blood glucose and lipid levels, as well as the connection between anxiety during the second trimester; there are no further studies of the relationship between the four, lacking blood glucose and lipid level directions to explore the relationship between BMI and anxiety during pregnancy before childbirth. Pre-pregnancy BMI is not only correlated with anxiety during pregnancy, but also significantly correlated with blood lipids and glucose during pregnancy. Blood glucose and blood lipid levels during pregnancy are also correlated with anxiety during pregnancy. Therefore, this study is the first to explore the effects of blood glucose and lipids on the relationship between pre-pregnancy BMI and pregnancy anxiety in pregnant women with GDM using mediation analysis.

We found that the higher the pre-pregnancy BMI of GDM, the more serious the degree of anxiety during pregnancy. FBG, 2hPG, HbA1c, and TG of pregnant women with GDM play a role in the influence of pre-pregnancy BMI on pregnancy anxiety, and the effect of blood glucose (FBG, 2hPG, and HbA1c) on the influence of pre-pregnancy BMI on pregnancy anxiety was significantly stronger than that of blood lipids (TG).

Ethics approval and consent to participate

The study received ethical approval and all participants volunteered to participate

Availability of data and material

All data generated or analyzed during this study are included in this

published article.

Acknowledgments

We gratefully acknowledge Wenshu Yu for providing intellectual support and technical assistance.

Consent

All authors agreed to publish.

Authors’ Contributions

We acknowledge that all authors have contributed significantly. Hong OuYang devised the project, collected material and wrote the manuscript. Na Wu helped with the discussion, supervised the project and provided critical feedback.

Funding

This research was supported by the National Natural Science Foundation of China (No.81700706), the 345 Talent Project of Shengjing hospital, the Clinical research project of Liaoning Diabetes Medical Nutrition Prevention Society (No.LNSTNBYXYYFZXH-RS01B), the Natural Science Foundation of Liaoning Province (No. 2021-MS-182), the Science Foundation of Liaoning Education Department (No. LK201603), and the Virtual simulation experiment teaching project of China Medical University(No.2020-47).

Conflicts of Interest

The authors have no conflicts of interest to declare.

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Pre-pregnancy BMI and pregnancy anxiety in women with gestational diabetes mellitus: mediating effects of blood glucose and lipid levels¹

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Introduction

Research status of BMI and pregnancy anxiety in pregnant women with GDM

Research status of serum lipid levels, BMI before pregnancy, and pregnancy anxiety

Methods

Research participants

Inclusion criteria

Exclusion criteria

Data collection

Questionnaire information

Medical history

Variable definition and assignment

Statistical analyses

Results

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