Adolescents' Attachment-Related Insecurity with Custodial Grandmothers: Relations to Their Internalizing and Externalizing Symptoms.

Pregnancy is a distinct physiological period during which both overnutrition and undernutrition can adversely affect maternal and fetal health. Gestational diabetes mellitus (GDM) is defined as glucose intolerance with onset or first recognition during pregnancy. It is one of the most common metabolic complications of gestation. GDM increases the risk of adverse perinatal outcomes. These include maternal metabolic disturbances, preeclampsia, preterm birth, and cesarean section (–). For offspring, GDM is associated with macrosomia, neonatal hypoglycemia, and long-term metabolic disorders (, ). In recent years, with the improvement of living standards, dietary habits and trends have changed. People tend to choose ultra-processed foods with high energy and low nutrient density, and the high sugar, high salt, and high-fat diet patterns are becoming increasingly prominent (). The incidence of diabetes during pregnancy is increasing year by year. The global burden of GDM is substantial. According to the International Diabetes Federation, the standardized prevalence of GDM is estimated at 14.0% based on the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria (). The prevalence of GDM in China is also a cause for concern. A meta-analysis indicated that the prevalence of GDM after 2010 has reached 15.6%; moreover, according to another study, the prevalence has increased sharply from 4% in 2010 to 21% in 2020, demonstrating a rapidly growing trend (, ). Given its rising prevalence and dual impact on maternal and child health, effective strategies for GDM prevention are needed. Dietary modification plays an important role in GDM prevention and management (). However, current dietary assessment tools have certain limitations. Commonly used diet quality indices are narrow in scope and built on outdated food components, particularly neglecting ultra-processed foods (UPFs), which have been increasingly recognized as a risk factor for adverse metabolic outcomes (). The dietary Obesity-Prevention Score (DOS) is a food-based assessment tool that evaluates the relationship between individual dietary quality and obesity prevention by rating 14 groups of foods (with an overall DOS score potential range of 14–42) (). In non-pregnant populations, higher DOS has been associated with lower risks of overweight and obesity, less annual weight gain, and improved cardiometabolic profiles. These include lower blood pressure and favorable lipid levels (, ). Higher DOS has also been linked to a reduced risk of type 2 diabetes (). However, no significant association was observed between DOS and polycystic ovary syndrome (). Collectively, these findings suggest that DOS is a promising dietary pattern for metabolic health. The established benefits of DOS in the general population are supported by current research. However, unique metabolic changes are present during pregnancy, and these changes differ from those in the non-pregnant state. But given that excessive gestational weight gain is a major driver of GDM, the architecture of DOS is considered suitable for the identification of obesogenic dietary patterns, which are regarded as crucial during pregnancy. Therefore, this study was designed to explore the association between DOS and GDM. Furthermore, the potential pathways through which a high-quality diet might influence GDM are unknown. These may include increased intake of specific food groups, such as fruits, vegetables, or plant protein. Therefore, this study was conducted to examine the association between the DOS and GDM risk in pregnant women, and to assess whether this association is modified by energy intake status. This study further aims to identify key foods that play an important role and explore their dose-response relationship.