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 Table of Contents  
Year : 2020  |  Volume : 1  |  Issue : 2  |  Page : 100-102

Inclusion of stress management protocols in the management of gestational diabetes mellitus: Re-visiting Indian guidelines

1 Department of Community Medicine, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
2 Department of Community Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
3 Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission23-Jun-2020
Date of Decision31-Jul-2020
Date of Acceptance16-Sep-2020
Date of Web Publication15-Dec-2020

Correspondence Address:
Dr. Surabhi Mishra
Department of Community Medicine, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Swami Ram Nagar, Jolly Grant, Dehradun - 248 016, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_100_20

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Gestational diabetes mellitus (GDM) has emerged as a country-wide public health problem. Beyond perinatal implications, GDM is recognized as precursor for most chronic lifestyle diseases. Despite this, the existing Indian guidelines didn't address stress management during pregnancy. In this regard, the present manuscript aims to identify the paralleled need of stress management during pregnancy and suggests related operational strategies for possible inclusion within the existing GDM guidelines of India. As psychological stress in India is already being managed under National Mental Health Programme (NMHP), national level integration of NMHP and Reproductive and Child Health (RCH) will go a long way in providing comprehensive GDM care by avoiding duplication of services and effective utilization of scarce resources.

Keywords: Hyperglycemia in pregnancy, India, national guidelines, psychological stress

How to cite this article:
Mishra S, Rao CR, Bhadoria AS, Bhattacharya S. Inclusion of stress management protocols in the management of gestational diabetes mellitus: Re-visiting Indian guidelines. J Med Evid 2020;1:100-2

How to cite this URL:
Mishra S, Rao CR, Bhadoria AS, Bhattacharya S. Inclusion of stress management protocols in the management of gestational diabetes mellitus: Re-visiting Indian guidelines. J Med Evid [serial online] 2020 [cited 2022 Aug 7];1:100-2. Available from: http://www.journaljme.org/text.asp?2020/1/2/100/303546

  Introduction Top

Six years back in 2014,[1] and later in 2018,[2] the government of India (GoI) for the first time addressed gestational diabetes mellitus (GDM) as an emerging public health problem in their national guidelines.[1],[2] India reporting the pooled GDM prevalence of 8.9%[3] with 1.3 billion populations represents a large subset at high-risk for impending complications. These implications are way beyond perinatal; unlike most obstetric conditions that usually resolve following delivery, GDM marks the beginning of Type-II diabetes mellitus (DM) and obesity's vicious cycle among the affected mother-child duos.[4] Abnormal hyperglycaemias during the antenatal phase are, therefore, also recognised as the precursor of lifestyle diseases. As GDM development is the cumulative result of the interplay among many individual risk factors, each singular factor needs specific addressal.[5],[6]

Pregnancy, by high merit to its intrinsic emotional element, is a potential stressful aftermath. If a woman develops additional abnormal hyperglycaemia during her pregnancy, the toll of her psychological stress is likely to become higher. At present, national guidelines on GDM care in India[1],[2] are recommending GDM management through strict glycaemic control. They had identified medical nutrition therapy (MNT), insulin therapy, physical activity, intensive blood glucose monitoring and self-care as the usual cornerstones in its clinical care.[7] However, the recommendations fail to address the pertinent issue of antenatal stress management. Among the lack of operational stress management protocols in the guidelines, efforts are going halfway. Therefore, to complete the GDM care spectrum, the present commentary aims to highlight the role of maternal perceived stress on GDM (the precursor of lifestyle diseases), suggest paralleled need of stress management during pregnancy and related operational strategies for possible inclusion within the existing Indian guidelines.

  Maternal Perceived Stress: A Determinant of Gestational Diabetes Mellitus Top

There exists ample number of studies within and outside India, in different hierarchies of evidence, that have recognised high maternal perceived stress as one of the significant determinants for GDM.[8],[9],[10],[11],[12],[13],[14] In a prospective matched casecontrol study conducted in coastal Karnataka (south India) identified higher odds of GDM among those with high perceived stress during pregnancy compared to those with low as measured on Cohen 10-item perceived stress scale (PSS-10);[8] though no correlation was noted with maternal blood glucose levels following the oral glucose tolerance test.[9] Another observational study from Tamil Nadu (South India) revealed more than half of GDM women (52.8%) need clinical attention for GDM-induced stress when measured on the gestational diabetes stress scale-mobile application in the study.[10] Outside India, a prospective cohort study in an Amsterdam-based teaching hospital showed 36% GDM women had elevated diabetes distress on problem areas at diabetes scale with a statistically significant positive association with adverse pregnancy outcomes (odds ratio [OR] =4.70, P = 0.02).[11] In 2014, another prospective cohort study conducted among 1115 Hispanic women found higher odds of GDM (OR: 2.6; 95% confidence interval: 1.0–6.9) among women with heightened stress during early-to-mid-pregnancy compared to those with no change or a decrease in stress on Cohen PSS-14.[12] Chasan-Taber et al. conducted another prospective cohort study among a cohort of 632 Hispanic women seeking prenatal care and identified a positive association between high mean perceived stress on Cohen PSS and GDM; with depressed women showing higher odds of GDM compared to controls (P = 0.041).[13] Kubo et al., in a secondary cross-sectional study conducted among 1,353 GDM women, reported higher educated GDM positive women more frequently in lower stress categories compared to those less educated (P = 0.02).[14]

  Existing Indian Guidelines on Stress Management in Type II Diabetes Prevention Top

Today, it is well-known that stress of any form stimulates unhealthy hyperglycaemia, that along with high insulin resistance can influence intrauterine milieu towards pro-inflammation. This, in turn, may prove causing long-term harm to the growing fetus.[15] It can program the fetus towards the development of lifestyle diseases later in life through varying mechanisms.[16],[17],[18] Despite this, there are no recommended protocols on how to identify and manage stress to prevent/manage GDM among Indian women. The available guidelines,[1],[2] as suggested by the Ministry of Health and Family Welfare (MoHFW), are presently focusing on MNT and physical activity as the only available nonpharmacological therapeutic options against GDM.

On the other hand, the Ministry of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) under GoI had already recommended ways to manage stress within Type II DM prevention/management guidelines.[19] They had identified meditation, prayer, sports, exercises, yoga and other recreational activities helping in promote mental health. Later in 2018, the Indian Council of Medical Research (ICMR) went further to advocate on practicing yoga and meditation–a recognised traditional Indian system for developing stress coping skills–under expert guidance.[20] Although these recommendations were released following judicious consultation with Ayurvedic physicians,[19] they are acting more like a blind coverage to all Indian individuals.[19] The guidelines do not elaborate on how to operationally stratify individuals based on their baseline psychological stress levels before their management in community (risk approach). Queries such as how should an individual/family practice or avail these measures, who can act as expert in Yoga/meditation in the community await addressal and planning at the micro-level. Nevertheless, AYUSH[19] and ICMR[20] guidelines though not complete in itself have recognised the importance of positive mental health in DM prevention/management.

  Potential Role of Mental Health Programme in Diabetes Prevention Top

In 2015, the MOHFW released another set of operational guidelines under the National Mental Health Programme (NMHP) for the technical implementation of various activities approved for providing comprehensive mental health services –prevention, promotion and long-standing continuing care – at the district level.[21] The programme mainly covers common mental, neurological and substance use disorders, namely., depression, anxiety disorders, psychosis, drug abuse, dementia, etc., and has approved a set of activities for operational implementation during 12th-year plan under the National Health Mission (NHM)-noncommunicable diseases Flexi pool. Utilising a three-tier health-care delivery model under state's NHM, the perceived stress of these forms can now be managed/prevented within the district in any setting (primary health centre [PHC], community health centre [CHC] and district hospital [DH]) and at any level (individual, family and/or community). The approved activities envisage the formation of an eight-membered district MHP team of qualified/trained mental health professionals at DH trained to identify, manage and refer psychiatric patients for the above-mentioned disorders. This team consists of one psychiatrist, one clinical psychologist, one psychiatric nurse, one psychiatric social worker, one community nurse, one monitoring and evaluation officer, one case registry assistant and one ward assistant. NMHP has also approved for one medical officer and one clinical psychologist/psychiatric social worker, and two community health workers (CHWs) at CHC and PHC, respectively. Their main role includes identification, management, referral, rehabilitation and follow-up care of psychiatric patients. In addition, community awareness regarding early clinical signs/symptoms of mental disorders and the availability of mental health services will also be carried out by front-line health workers (CHWs and grass-root workers) under each PHC. This will also help in improving the general health-seeking behaviour of the community for mental illnesses.

Considering the scarcity of public health specialists in the mental health field in India, especially within the technical protocols for GDM prevention/management,[1],[2] the above suggested operational norms under NMHP can be applied to prevent GDM/Type II DM at the community level as well.


In India, psychological stress is already being managed under NMHP by GoI. With available evidences on perceived stress adversely impacting GDM care in India, this calls for NMHP-Reproductive and Child Health (RCH) integration at the national level so that operational stress management protocols can be developed and included within the existing recommendations for GDM care. This will not only avoid duplication of services but will also allow effective utilisation of scarce resources available in the country. In the wake of already existing strategies, if the base of NMHP-based stress management/preventive strategies is extended to RCH as well (both executed under MoHFW, GoI), the pregnant population, especially those with GDM will too be benefitted by the expected positive outcomes.

  Conclusion Top

The integration of NMHP and RCH in the wake of a positive association between GDM and perceived stress will go a long way in preventing lifestyle diseases.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Guidelines for Diagnosis and Management of Gestational Diabetes Mellitus. New Delhi, India: Ministry of Health and Family Welfare, New Concept Information Systems; 2014. Available from: http://nhm. gov.in/images/pdf/programmes/maternal-health/guidelines/National_ Guidelines_for_Diagnosis_&_Management_of_Gestational_Diabetes_ Mellitus.pdf. [Last accessed on 2020 Apr 27].   Back to cited text no. 1
Government of India. Maternal and Health Division, Diagnosis and Management of Gestational Diabetes Mellitus: Technical and Operational Guidelines. New Delhi, India: Ministry of Health & Family Welfare, New Concept Information Systems; 2018. Available from:https://nhm.gov.in/New_Updates_2018/NHM_Components/ RMNCH_MH_Guidelines/Gestational-Diabetes-Mellitus.pdf. [Last accessed on 2020 Apr 27].   Back to cited text no. 2
Li KT, Naik S, Alexander M, Mathad JS. Screening and diagnosis of gestational diabetes in India: A systematic review and meta-analysis. Acta Diabetol 2018;55:613-25.   Back to cited text no. 3
Mishra S, Rao CR, Bhadoria AS, Kumar R, Aggarwal P, Vyas S, et al. A step towards real-time implementation of GDM guidelines in India: Review of Gaps in RCH Programme. J Family Med Prim Care 2020; DOI:10.4103/jfmpc.jfmpc_611_20.   Back to cited text no. 4
Mishra S, Rao CR, Bhadoria AS, Mohanty S, Kishore S, Chaudhary AS. Life-cycle approach for Prevention of Gestational Diabetes Mellitus. Clin Epidemiol Global Health 2019;7:418-23. Available from: https:// www.sciencedirect.com/science/article/pii/S2213398418302045. [Last accessed on 2020 Apr 27].   Back to cited text no. 5
Mishra S, Bhadoria AS, Kishore S, Kumar R. Gestational Diabetes Mellitus 2018 guidelines: An update. J Family Med Prim Care 2018;7:1169-72.   Back to cited text no. 6
[PUBMED]  [Full text]  
Morampudi S, Balasubramanian G, Gowda A, Zomorodi B, Patil AS. The challenges and recommendations for gestational diabetes mellitus care in India: A review. Front Endocrinol (Lausanne) 2017;8:56.   Back to cited text no. 7
Mishra S, Shetty A, Rao CR, Nayak S, Kamath A. Risk factors for gestational diabetes mellitus: A prospective case-control study from Southern India. Clin Epidemiol Global Health 2020;8:1082-88.   Back to cited text no. 8
Mishra S, Shetty A, Rao CR, Nayak S, Kamath A. Effect of maternal antepartum perceived stress on gestational diabetes mellitus risk: A prospective case-control study. Diabetes Metab Syndr: Clin Res Rev 2020;14:1163-9.   Back to cited text no. 9
Srinivasan A, Krishnarajan D, Saranya P, Jithin TG, Thomas S, Varadharajan V. Assessment of gestational diabetes mellitus related stress using a specific scale administered as an online mobile application. Int J Pharm Pharm Sci 2019;11:101-5.   Back to cited text no. 10
Schmidt CB, Voorhorst I, van de Gaar VH, Keukens A, Potter van Loon BJ, Snoek FJ, et al. Diabetes distress is associated with adverse pregnancy outcomes in women with gestational diabetes: A prospective cohort study. BMC Pregnancy Childbirth 2019;19:223.   Back to cited text no. 11
Silveira ML, Whitcomb BW, Pekow P, Braun B, Markenson G, Dole N, et al. Perceived psychosocial stress and glucose intolerance among pregnant Hispanic women. Diabetes Metab 2014;40:466-75.   Back to cited text no. 12
Chasan-Taber L, Fortner RT, Gollenberg A, Buonnaccorsi J, Dole N, Markenson G. A prospective cohort study of modifiable risk factors for gestational diabetes among Hispanic women: Design and baseline characteristics. J Womens Health (Larchmt) 2010;19:117-24.   Back to cited text no. 13
Kubo A, Ferrara A, Brown SD, Ehrlich SF, Tsai AL, Quesenberry CP Jr., et al. Perceived psychosocial stress and gestational weight gain among women with gestational diabetes. PLoS One 2017;12:e0174290.   Back to cited text no. 14
McCullough LE, Miller EE, Calderwood LE, Shivappa N, Steck SE, Forman MR, et al. Maternal inflammatory diet and adverse pregnancy outcomes: Circulating cytokines and genomic imprinting as potential regulators? Epigenetics 2017;12:688-97.   Back to cited text no. 15
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Government of India. Guidelines for prevention and management of Diabetes. Central Council for Research in Ayurvedic Sciences. Ministry of AYUSH. New Delhi, India: Government of India; Available from: http://www.ccras.nic.in/sites/default/files/Guidelines_for_prevention_ and_management_of_Diabetes.pdf. [Last accessed on 2020 Apr 27].   Back to cited text no. 19
Indian Council of Medical Research. ICMR Guidelines for Management of Type 2 Diabetes 2018. New Delhi, India: Indian Council of Medical Research; 2018. Available from: https://main.icmr.nic.in/sites/default/ files/guidelines/ICMR_GuidelinesType2diabetes2018_0.pdf. [Last accessed on 2020 May 23].   Back to cited text no. 20
Government of India. Guidelines for Implementing District Level Activities under the National Mental Health Programme during the 12th Five Year Plan. National Mental Health Programme. New Delhi: Government of India; 2015. Available from: https://main.mohfw.gov.in/ sites/default/files/56464578341436263710_0_0.pdf. [Last accessed on 2020 Jul 02].  Back to cited text no. 21


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