The Association Between Dietary Intake Before and During Pregnancy, Weight Status and - PowerPoint Presentation

1. The Association Between Dietary Intake Before and During Pregnancy, Weight Status and Maternal-Fetal Outcomes: A Review of EvidenceJamie Stang, PhD, MPH, RDNUniversity of MinnesotaSchool of Public HealthDivision of Epidemiology and Community Health

2. Concepts to CoverHow does dietary intake before pregnancy affect maternal-fetal outcomes?How does dietary intake during pregnancy affect maternal-fetal outcomes?Does weight status prior to pregnancy affect maternal-fetal outcomes?What is the relationship between gestational weight gain (GWG) and maternal-fetal outcomes?

3. Nutrition-Related Goals during PregnancyOptimize birthweightOptimal weight gain and rate of gainOptimal intake of macro- and micronutrientsPrevention of congenital anomaliesManage or prevent complications, e.g. iron deficiency anemia, hypertension, gestational diabetes

4. Physiological Changes that Affect Nutrition Needs in PregnancyFirst half of pregnancy is anabolic for the motherSecond half of pregnancy is catabolic for mother and anabolic for fetusCHO metabolism changes dramatically 5% to 19% of pregnancies develop GDM5% to 10% of pregnancies experience a hypertensive disorder3% experience preeclampsia17% of women with gestational hypertension go on to develop preeclampsiaCardiac output peaks earlier than plasma volume 50% increase in blood volume but only 20% increase in RBCs = hemodilution Pregnancy associated with increases in visceral fat stores and waist circumferenceAbdominal fat increases during pregnancyNon-subcutaneous abdominal fat increases 6-12 months postpartum

5. Energy/Nutrient Needs Change in PregnancyKcals needs increase in response to increased metabolic rate, secondary to fetal growth rateIncreases in macronutrients also follow metabolic needsFluid needs increase to 3 litersChanges in micronutrient needs related to changes in renal function and fetal demandWeight gain recommendations and practices are somewhat controversialData suggest that current recommendations probably reduce risk of maternal-fetal complicationsWeight loss in pregnancy not considered safe so pre-conception and postpartum weight status are important

6. P/B-24 ProjectThe Pregnancy and Birth to 24 Months (P/B-24) Project was initiated to examine diet-related topics of public health importance during pregnancy, infancy, and toddlerhood Funded by USDA and DHHS (CDC)Technical Expert Collaborative (TEC) subcommittee convened to examine relationships between dietary patterns prior to and during pregnancy and select maternal and fetal outcomesDietary patterns were examined, not individual nutrients, to inform food programs and policiesStoody, et al Am J Clin Nutr 2019;109(Suppl):685S–697S

7. Prenatal Nutrition and Birth OutcomesTwo systematic reviews assessed relationships between dietary patterns before and during pregnancy and 1) gestational age at birth 2) gestational age- and sex-specific birth weight 9 databases searched from Jan 1980 to Jan 2017 PubMed, Embase, and CochraneTwo analysts independently screened articles using a priori inclusion and exclusion criteriaData were extracted from articlesRisk of bias was assessed Raghavan et al. Am J Clin Nutr 2019;109(Suppl):729S–756S

8. Prenatal Nutrition and Birth OutcomesData synthesized qualitativelyConclusion statement was drafted for each questionEvidence supporting each conclusion was gradedOf 9,103 studies identified:11 were included for gestational age outcome7 cohorts and 1 randomized controlled trial (RCT) 21 were included for birth weight outcomes 19 cohorts and 2 RCTsSample size ranged were generally small to adequate290 – 72,072 participants; avg = 3143

9. Dietary Guidelines for AmericansPregnancy Subcommittee TEC Report“Evidence is insufficient to estimate the association between dietary patterns before pregnancy and gestational age at birth as well as the risk of preterm birth” “Insufficient evidence exists to estimate the association between dietary patterns before pregnancy and birth weight outcomes. There are not enough studies available to answer this question”

10. Dietary Guidelines for Americans, Pregnancy Subcommittee Report“Limited but consistent evidence suggests that certain dietary patterns during pregnancy are associated with a lower risk of preterm birth and spontaneous preterm birth. These protective dietary patterns are higher in vegetables; fruits; whole grains; nuts, legumes, and seeds; and seafood (preterm birth, only) and lower in red and processed meats and fried foods. “No conclusion can be drawn on the association between dietary patterns during pregnancy and birth weight outcomes. Although research is available, the ability to draw a conclusion is restricted by inconsistency in study findings, inadequate adjustment of birth weight for gestational age and sex, and variation in study design, dietary assessment methodology, and adjustment of key confounding factors.”

11. Dietary Patterns and Gestational Age Outcomes‘vegetable, fruit and white rice’; ‘prudent’; ‘traditional’; ‘seafood’, and ‘high protein/fruit’ dietary patterns showed 9% to 69% reduction in risk of PTB15% reduction in late PTB 15% - 45% reduction in spontaneous PTB15% to 38% reduction in induced/iatrogenic PTBDietary patterns higher in red and processed meats and fried foods associated with greater risk 53% to 55% overall increased risk of PTB18% to 92% increased risk of spontaneous PTB70% increased risk of induced PTB (70%)

12. Prenatal Nutrition and Maternal OutcomesSystematic review examined the relationships between dietary patterns before and during pregnancy and 1) Hypertensive disorders of pregnancy (HDP) Included gestational hypertension, pre-eclampsia and chronic hypertension with super-imposed pre-eclampsia2) Gestational diabetes (GDM)9 databases searched from January 1980 to January 2017PubMed, Embase and CochraneArticles independently screened by two analysts using a priori inclusion and exclusion criteriaRaghavan et al. Am J Clin Nutr 2019;109(Suppl):705S–728S.

13. Prenatal Nutrition and Maternal OutcomesRelevant information was extracted for included articlesRisk of bias was assessedOf 9,103 studies identified:8 studies were included for HDP4 cohorts, 1 randomized controlled trial (RCT) 11 studies included for GDM 6 cohorts, 1 RCT Sample sizes were too small to adequate 12 – 15,254 participants ; avg = 3063

14. Dietary Patterns and Pregnancy Outcomes“Limited evidence in healthy Caucasian women suggests that dietary patterns before and during pregnancy that are higher in vegetables, fruits, whole grains, nuts, legumes, fish, and vegetable oils and lower in meat and refined grains are associated with a reduced risk of hypertensive disorders of pregnancy, including preeclampsia and gestational hypertension” “Not all components of the assessed dietary patterns were associated with all hypertensive disorders. Evidence is insufficient to estimate the association between dietary patterns before pregnancy and risk of hypertensive disorders of pregnancy in minority women and those of lower socioeconomic status”

15. Prenatal Nutrition and HDP5 of the 8 studies showed an association between dietary patterns before and during pregnancy and risk of HDP Dietary patterns higher in vegetables, fruits, whole grains, nuts, legumes, fish and vegetable oils reduced riskHigh vegetable diet = 16% - 22% reduced risk of HDPMediterranean/New Nordic diets = 29% - 42% reduced risk of HDPHigher intakes of meats, refined grains and processed foods were associated with increased riskHigh processed food/Western diet = 21% increased riskNon-adherence to Mediterranean diet = 41% increased risk

16. Prenatal Nutrition and GDM “Limited but consistent evidence suggests that certain dietary patterns before pregnancy are associated with a reduced risk of gestational diabetes mellitus. Evidence is insufficient to estimate the association between dietary patterns during pregnancy and risk of gestational diabetes mellitus.”

17. Prenatal Nutrition and GDM Dietary patterns before pregnancy were associated with reduced risk of GDM in 8 of 11 studiesInsufficient evidence to examine dietary patterns during pregnancy and risk of GDMProtective patterns prior to pregnancy were higher in vegetables, fruits, whole grains, nuts, legumes, fish and lower in red and processed meatsMediterranean/DASH diets = 10% to 44% reduced risk of GDMHigh red meat diet pattern = 20% to 55% increased risk of GDMWestern diet = 14% to 63% increased risk of GDM

18. Summary of P/B-24 TEC Subcommittee FindingsHealthy dietary patterns before pregnancy are associated with reduced risk of maternal complications, specifically HDP and GDMMediterranean, DASH, New Nordic, Prudent and similar dietary patternsUnhealthy dietary patterns before pregnancy associated with increased risk of HDP and GDMWestern, processed food and other similar dietary patternsHealthy dietary patterns during pregnancy associated with reduced risk of preterm birth and HDP but not infant birthweight or GDM riskUnhealthy dietary patterns during pregnancy associated with increased risk of preterm birth and HDP

19. Obesity and Pregnancy Outcomes

20. Conditions Associated with Obesity During Pregnancy PregnancyOBESITYSource: Adapted from Bray GA, 2003

21. Obesity and Pregnancy OutcomesWomen who enter pregnancy obese have more pregnancy complications and are increased risk for poor infant outcomes risk of miscarriage25% to 37% increased risk risk NTDs compared to normal weight women with same folate intakes and family historyOverweight = 35%  of congenital anomalyObese = 38%  of congenital anomaly risk for C-section deliveryEach BMI unit = 7%  in risk of C-section delivery risk for post delivery infection, excessive blood loss

22. Obesity and Gestational Hypertensive DisordersHypertension is among top 3 causes of maternal mortality10% of women 18-44 years old have hypertension15% among 35-44 year old femalesRates of hypertension have nearly doubled in 2 decadesRacial and ethnic disparities in hypertension among women 19% among non-Hispanic black women9% among non-Hispanic white women8% among other racial/ethnic groupsSchummers et al. Obstet Gyncecol 2015; Lo et al. Curr Opin Obstet Gynceol 2013; Robbins et al. MMWR 2014

23. Obesity and Gestational Hypertensive DisordersRisks for hypertension and pre-eclampsia in pregnancy follow pre-pregnancy weight trendsWomen who are overweight or obese at conception are at more than 6 times the risk (OR = 6.31, CI: 4.30 – 9.26)Risk increases incrementally with class of obesityObese women 3 to 8 times more likely to develop pre-eclampsia10% prevalence among women with class I obesity12.8% prevalence among women with class II obesity16.3% prevalence among women with class III obesity3.4% prevalence among normal weight womenSchummers et al Obstet Gynecol 2015; Bautista-Castano et al PLoS One 2013; Gaillard et al Obesity 2013; El-Chaar et al. J Obstet Gynaecol Can 2013

24. Obesity and Gestational DiabetesWomen obese at conception are up to 6 times more likely to develop GDM than normal weight womenRisk increases incrementally with class of obesity9.7% prevalence with class I obesity13.7% prevalence with class II obesity16.6% prevalence with class III obesity6.1% prevalence among ideal weight womenWomen who experience GDM are 13 times more likely to develop type 2 diabetes later in lifeMore than half will experience GDM in subsequent pregnanciesSchummers et al Obstet Gynecol 2015; Bautista-Castano et al PLoS One 2013; Gaillard et al Obesity 2013; El-Chaar et al. J Obstet Gynaecol Can 2013

25. Obesity, Gestational Hypertension, Gestational Diabetes and Long-Term Health Outcomes of WomenGestational hypertension and gestational diabetes are strong co-morbid contributors to long-term health among womenGestational hypertension and pre-eclampsia both double risk of a woman developing type 2 diabetes within 17 years of pregnancyWomen who develop both gestational diabetes and hypertension or pre-eclampsia are at 13 to 18-times higher risk for developing type 2 diabetes later in lifeInsulin resistance is an underlying physiological condition in gestational hypertension, pre-eclampsia and gestational diabetesWomen with either pre-eclampsia or hypertension but without GDM have been shown to be at 3 times the risk of developing type 2 diabetes within 1-4 years after delivery suggesting that insulin resistance persists in some womenFeig et al 2013; Engeland et al Eur J Epidem 2011; Schummers et al Obstet Gynecol 2015; Bautista-Castano et al PLoS One 2013; Gaillard et al Obesity 2013; El-Chaar et al. J Obstet Gynaecol Can 2013

26. Obesity and DeliveryWomen who are obese prior to pregnancy are twice as likely to require induction of labor4 times the risk of induced labor secondary to hypertensionUp to 11 times the risk for induction secondary to pre-eclampsia or GDMC-section delivery twice as common among obese compared to ideal weight women26.5% prevalence among ideal weight women38.2% among class I obese women43.1% among class II obese women49.7% among class III obese womenPostpartum hemorrhage is doubled among primiparous obese womenFyfe et al BMC Preg Childbirth 2012; ACOG Comm Opinion 548 2013;

27. Prepregnancy Weight and Birth DefectsOverweight and obesity prior to pregnancy is an independent risk factor for some birth defectsNTDs (esp spina bifida)Cardiac defectsHypospadiaOmphalocele Anorectal atresia and limb reduction (obesity only)Underweight prior to pregnancy is a risk for defectscleft lip and palateOverweight Prior to pregnancy protective factor for one specific birth defectgastroschisis

28. Omphalocele

29. Gestational Weight Gain and Maternal-Fetal Health Outcomes

30. Obesity and Gestational Weight GainPrepregnancy BMI StatusBMITotal Weight Gain (lb)Rate of Weight Gain, 2nd & 3rd Trimester (lb/week)Underweight< 18.528-401 (1 - 1.3)Normal Weight18.5-24.925-351 (0.8 - 1)Overweight25.0 - 29.915-250.6 (0.5 - 0.7)Obese (all classes)> 30.011-200.5 (0.4 - 0.6)NAS Inst of Medicine 2009

31. Fewer than 1 in 4 obese pregnant women gains within the IOM-recommended rangeDeputy et al. Ob Gyn 2015

32. Obesity and Gestational Weight GainNAS IOM 2009

33. 2.01.01.5Adjusted odds ratio (95% CI)Gestational diabetes (GDM)MacDonald et al. Epidemiology 2017Grade 1 obesen = 179 casesGrade 2 obesen = 129 casesGrade 3 obesen = 96 cases

34. Bodnar et al. Epidemiology 2016Bodnar et al. Obesity 2016Cesarean deliveryLGA birthPretermSGA birthEquivalent total weight gain at 40 weeks, kg-8.2-4.01.89.921IOM-recommended rangeGrade 2 obesity:Multiple, competing outcomes of varying severity37Equivalent total weight gain at 40 weeks, kg-4.01.89.92137Infant death

35. Preterm birth at <37 weeksBodnar et al. Epidemiology 2016Grade 1 obese (n=12,881 cases)Grade 2 obese (n=4701 cases)Grade 3 obese (n=4701 cases)35 kg~21 kg at 40 weeks

36. Preventing Excessive Gestational Weight Gain2 intervention groups = Physical Activity (PA) and Physical Activity + Diet (PA+D) plus control groupCounseled by dietitian to walking at least 11,000 steps/day PA+D group also counseled by dietitian every 2 weeks regarding a 1,200 – 1,675 kcal Mediterranean-type diet (based on trimester)Gestational weight gain significantly lower in both intervention groups compared to the control groupMore women in intervention groups gained within IOM guidelines55% in PA+D group 49% in PA 37% of women in the control group Gestational weight gain reduced by an additional 1.38 kg among those who used a pedometer Women in the PA+D group had a lower rate of emergency cesarean deliveries compared to the other groups

37. Preventing Excessive Gestational Weight Gain100 women were randomized to counseling or control group n=57 intervention group, n=43 control groupLifestyle counseling Balanced diet of 40% CHO, 30% protein, 30% fat20-30 mins physical activity 3-5 times/week Intervention group gained significantly less than controls28.7 lb compared with 35.6 lb61% of intervention group gained within IOM guidelines 49% of controls gained with IOM guidelines

38. Prevention of Excessive Gestational Weight Gain50 obese Danish women (n=23 intervention, n=27 control) Intervention includedTen, 1-hour consultations with dietitian Balanced diet with energy restriction based on individual estimated requirements plus fetal growth allowance (30% fat, 15% to 20% protein, 50% to 55% CHO) Total weight gain was reduced significantlyIntervention group gained 6.6 kg Control group gained 13.3 kg Weekly weight gain from enrollment to 36 weeks gestation was significantly reduced 0.18 kg/week in intervention group 0.26 kg/week in control group Intervention group had significantly lower weight at 4 weeks post-partum.

39. Prevention of Excessive Gestational Weight Gain124 pregnant overweight or obese women Intervention n=63 and control n=61 Intervention included nutrition and mental health education5-minute nutrition consultation prior to each prenatal visitWeight self-monitoringPsychology evaluation and treatment Increased intake of water, fresh fruits & vegetables, home-cooked mealsReduction in carbonated beverages, juices, convenience foods, fast foods Intervention group gained 7 kg, control group gained 13.8kg

40. Prevention of Excessive GWG: Results of Dietary InterventionsIntervention studies focused on dietary counseling had 3.36 kg reduction in GWGEffective interventions included at least 6 weeks of educational classes or counseling that focused on behavioral change strategies to improve dietary intakeReductions on poor maternal outcomes noted33% reduction in risk of preeclampsia70% reduction in risk of gestational hypertension32% reduction in risk of preterm birth48% reduction in risk for gestational diabetesNo significant increases in poor infant outcomesInfants were 0.07 kg lighter 27% reduction in the risk for LGA69% reduction in shoulder dystocia were observedNo effects on low birthweight or SGA

41. 2020-2025 Dietary Guidelines for AmericansQuestions specific to pregnancy are included as systematic review topicsWhat is the relationship between dietary patterns consumed during pregnancy and risk of gestational diabetes?What is the relationship between dietary patterns consumed during pregnancy and risk of hypertensive disorders during pregnancy?What is the relationship between dietary patterns consumed during pregnancy and gestational age at birth?What is the relationship between dietary patterns consumed during pregnancy and birth weight standardized for gestational age and sex?What is the relationship between dietary patterns consumed during pregnancy and gestational weight gain?What is the relationship between dietary patterns consumed during pregnancy and micronutrient status?

42. What is the relationship between specific nutrients from supplements and/or fortified foods consumed before and during pregnancy and lactation and micronutrient status? What is the relationship between specific nutrients from supplements and/or fortified foods consumed before and during pregnancy and lactation and risk of gestational diabetes?What is the relationship between specific nutrients from supplements and/or fortified foods consumed before and during pregnancy and lactation and risk of hypertensive disorders during pregnancy?What is the relationship between specific nutrients from supplements and/or fortified foods consumed before and during pregnancy and lactation and human milk composition and quantity?What is the relationship between specific nutrients from supplements and/or fortified foods consumed before and during pregnancy and lactation and developmental milestones, including neurocognitive development?What is the relationship between maternal diet during pregnancy and lactation and risk of infant and child food allergies and atopic allergic diseases?