Obesity has emerged as a significant public health challenge faced by healthcare providers worldwide. The World Health Organization is deeply concerned about the escalating prevalence of overweight and obesity. Recent estimates from the United States indicate that 39.6% of American adults are classified as obese [1], and similar trends have been observed in various European countries. Data on the prevalence of overweight and obesity among adults from 20 European countries revealed the highest rates in Slovenia (20.8%), Estonia (19.7%), and the United Kingdom (19.2%) [2].

Africa is also grappling with the growing issue of overweight and obesity. Between 1993 and 2004, the prevalence of obesity among women of reproductive age doubled or tripled in 12 African countries [3]. North African countries, particularly Egypt, exhibited high obesity rates, reaching 48.2% [4]. In Morocco, obesity is three times more prevalent in women (29%) compared with men (11.0%) [5].

Obesity in pregnant women is a common obstetric risk factor leading to several complications in mothers and infants. Women with overweight and obesity face antenatal risks such as gestational diabetes [6], hypertension, and preeclampsia [7]. A high pre-pregnancy body mass index (BMI) is associated with peripartum complications, including cesarean delivery and hemorrhage. Additionally, overweight and obesity are strong predictors of postpartum morbidity. The offspring of women with obesity are at an increased risk of being macrocosmic [8] and large for their gestational age at birth. Furthermore, maternal obesity can raise the risk of the offspring developing metabolic and cardiovascular diseases later in life [9]. Certain types of congenital disabilities, like spina bifida, are more likely in the offspring of mothers with obesity [10, 11]. Maternal obesity can increase the risk of childhood obesity [12].

Therefore, pregnant women must monitor their gestational weight gain (GWG) to ensure it is within the recommended range. The Institute of Medicine (IOM) recommends that healthy women gain between 11.5 kg and 16 kg during pregnancy. In contrast, women with obesity or overweight should gain between 5 kg and 9 kg, and women who are underweight should gain between 12.5 kg and 18 kg [13].

Despite the increasing attention given to maternal obesity, there are limited studies on women with obesity and overweight to investigate the effectiveness of lifestyle interventions aimed at controlling GWG and improving pregnancy outcomes. Existing evidence suggests that interventions focused on dietary habits and physical activity may positively reduce the incidence of pregnancy complications such as gestational diabetes [14, 15]. However, the outcomes of such interventions in women with obesity and overweight vary, with some studies showing limited success in improving pregnancy outcomes and reducing GWG [16, 17].

In Moroccan society, the issue of obesity is compounded by its perception among women as a symbol of beauty and well-being. We observed a lack of awareness among pregnant women regarding the risks associated with maternal obesity. Accordingly, our objective was to investigate the effects of an awareness-raising intervention through a brochure on the risks of maternal obesity. We also aimed to encourage positive behavioral changes among women with obesity and overweight, including improved dietary habits, increased physical activity, and better weight management during pregnancy. The ultimate goal was to enhance the overall maternal and fetal health outcomes.

The baseline characteristics of the intervention and control groups are shown in Table 1. The intervention group had a significantly higher BMI, indicating a higher proportion of women with obesity (p 0.05). No significant differences were observed between the groups for any other variables.

Table 2 shows an increase in vitamin use in both groups between the first and third trimesters, but without statistical significance (p = 0.542, p = 0.424). Similar changes in dietary habits and snacking were observed between the two groups, with no statistically significant differences in dietary habits (p $>$ 0.05). However, snacking in the third trimester showed a statistically significant difference, with the control group reporting a slight increase (p 0.05). Additionally, the number of meals increased slightly in the control group during the third trimester, and this difference was statistically significant. Sports practice was comparable between the two groups in the first trimester (p = 0.204) but increased in the intervention group during the third trimester. However, this difference was not statistically significant (p $>$ 0.05).

GWG, obstetric and neonatal outcomes are presented in Table 3. The intervention affected GWG, with the intervention group showing a lower median (range) GWG compared to the control group, although the difference was not statistically significant (p = 0.075).

The incidence of gestational diabetes, hypertension, anemia, mode of delivery and the distribution of gestational weeks was comparable between the two groups without statistical differences (p $>$ 0.05).

Although birth weight was slightly higher in the intervention group, resulting in more children with macrosomia, the difference was not statistically significant (p $>$ 0.05).

Admission to the NICU was comparable between the two groups and was not statistically significant (p $>$ 0.05).

Few studies have evaluated the effects of lifestyle interventions on GWG and pregnancy outcomes, and even fewer have focused on mothers with overweight or obesity. To the best of our knowledge, this is the first longitudinal study in Morocco to detect the effects of raising awareness among pregnant women with overweight or obesity regarding the risks associated with maternal obesity. The goal was to encourage participants to maintain their weight within the recommended range through a balanced diet and regular physical activity by increasing their knowledge, understanding, and consciousness of these risks.

This intervention did not significantly affect lifestyle behaviors during pregnancy in either group, except for the number of meals and snacking. Additionally, we noticed that the intervention group became slightly more active in the third trimester than in the first trimester, emphasizing the importance of physical activity during pregnancy in the brochure. However, the difference remained statistically insignificant; most participants maintained a sedentary lifestyle.

Several studies exploring the effects of lifestyle interventions on nutrition and physical activity in pregnant women have yielded inconsistent findings [16, 18]. For instance, one study involving women with overweight and obesity found that lifestyle interventions based on a brochure and active education were effective in improving nutritional habits but did not significantly impact physical activity or GWG [16]. Conversely, another study that implemented community-based group exercise sessions, home exercise instructions, and dietary counseling demonstrated increased physical activity, improved dietary habits, and reduced excessive GWG in pregnant women living in an urban setting [18].

In our study, GWG decreased in the intervention group, although this reduction was not statistically significant. This trend is consistent with findings from a meta-analysis that reported a successful reduction in GWG by modulating diet and physical activity during pregnancy [19]. In contrast, recent studies have found no effect on GWG [20, 21, 22].

The Pregnancy and neonatal outcomes were comparable in both groups, and the intervention had no major impact on these outcomes. These findings align with previous studies [21, 23, 24, 25].

Our findings have significant implications for primary care physicians involved in the care of women with obesity or overweight. Promoting awareness of maternal obesity risks and healthy lifestyle behaviors during pregnancy does not substantially improve physical activity levels or overall lifestyle patterns. However, it remains imperative for physicians to guide patients in prioritizing the maintenance of a healthy prenatal BMI, which is crucial for mitigating obstetric complications and enhancing maternal and neonatal health outcomes. Moreover, our study underscores the challenge of implementing effective lifestyle interventions in this population, prompting the consideration of innovative strategies such as personalized dietary counseling and supervised exercise programs. These findings highlight the complexity of addressing lifestyle behaviors in this population and emphasize the necessity for tailored and multidisciplinary interventions, underscoring the pivotal role of primary care physicians in supporting these women throughout pregnancy.

Our research intervention led to a reduction in GWG in the intervention group; however, this reduction was not statistically significant. The intervention did show a significant effect on snacking habits and the number of meals but was otherwise ineffective in changing other lifestyle behaviors or improving pregnancy and neonatal outcomes.

Although the sample size was small, these findings suggest that while interventions during pregnancy can have some benefits, they may not be sufficient for achieving comprehensive lifestyle changes. Therefore, there is a need to emphasize pre-pregnancy interventions to promote dietary and lifestyle changes more effectively before conception. Further research with a larger study population is still required to evaluate these interventions and to assess their short and long-term effects.

BMI, body mass index; GWG, gestational weight gain; NCIU, neonatal intensive care unit.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

SL, ML and SS designed the research study, SS performed the research and analyzed the data. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

The study was approved by the regional delegation of the Moroccan Ministry of Health (Approval number 4269 delivered on 02 June 2021). Oral consent was obtained from participants after being informed about the study objectives with assurance of the anonymity and confidentiality of the women’s responses. Although the study does not involve clinical interventions or medical procedures, it was conducted in accordance with the ethical principles of the Declaration of Helsinki.

This research received no external funding.

The authors declare no conflict of interest.