Is Mediterranean Diet during pregnancy protective for fetal growth restriction? Results from two prospective cohort studies in Spain and Greece Leda Chatzi,

Is Mediterranean Diet during pregnancy protective for fetal growth restriction? Results from two prospective cohort studies in Spain and GreeceLeda Chatzi, Michelle Mendez, Raquel Garcia, Theano Roumeliotaki, Jess Ibarluzea, Adonina Tardn, Pilar Amiano, Aitana Lertxundi, Carmen Iiguez, Jesus Vioque, Manolis Kogevinas, Jordi Sunyer

On behalf of the INMA and the RHEA birth cohorts study groupsBritish Journal of Nutrition, 2011

Diet in pregnancy

It is certain thatthe significance of correct nutrition in child-bearing does not begin in pregnancy itself or even in the adult female before pregnancy. It looms large as soon as a female child is born and indeed in its intrauterine life..

Edward Mellanby, 1933

Mediterranean Diet

Trichopoulou, 2003

Research Hypotheses/Aims of the study: To determine prospectively the association between adherence to the Mediterranean Diet in pregnancy and fetal growth in the two large population based mother-child cohorts in the Mediterranean area (INMA and RHEA mother-child cohorts)

Diet assessment

The Rhea FFQ: FFQ on 250 items, 17 food groups, completed by personal interview in mid pregnancy (14th-18th week of gestation) Frequency of consumption: per day, week, and/or per month. Photographs were used to visualize small, medium and large portion sizes for each food item Mixed dishes: standard recipes were used when available, otherwise new recipes that matched the description of the food were made and the intake of foods from different items was aggregated. Nutrient analysis: Based on the UK Nutrient Databank (McCance and Widdowson's, 6th edition 2002).

The Greek Mother & Child Cohort Study The Greek Mother & Child Cohort Study

INMA STUDY INMA AtlanticINMA Mediterranean

The Greek Mother & Child Cohort Study INMA STUDY Diet assessment

The INMA FFQ: FFQ on 100 items, to assess usual food and nutrient intakes during the first trimester of pregnancyFrequency of consumption: 9 possible intake frequency categories, ranging from never or less than once per month to 6 or more times per day. Standard units or reference serving sizes were specified for each food item. Nutrient analysis: Primarily obtained from the US Department of Agriculture food-composition tables and other published sources.

Maternal adherence to the Mediterranean Diet during pregnancy

Med Diet Score (adapted from Trichopoulou et al)

Protective compounds: +1 if equal or above median intakeFruits and nuts, vegetables, legumes, fish, cereals, dairy products,

Detrimental compounds: 0 if equal or above medianMeat

Fat intake: Ratio of daily consumption of monounsaturated lipids to saturated lipids

Not included in the index: Alcohol consumption

The INMA and Rhea Mother & Child Cohort Studies

Fetal Growth Assessment

Anthropometric measures at birth: Birth weight (BW), birth length (BL), head circumference (HC), Fetal growth restriction: customized definition of impaired growth taking into account constitutional characteristics (gest age; parental anthropometry; primiparous mother; infant sex)

The INMA and Rhea Mother & Child Cohort Studies

Potential Confounders

Maternal, Paternal age, Maternal, Paternal social class and education, Maternal pre-pregnancy BMI (kg/m2), Maternal smoking during pregnancy, ParitySupplement use during pregnancy, Alcohol intake during pregnancy, Total Energy Intake during pregnancyThe INMA and Rhea Mother & Child Cohort Studies

Statistical analysis

The exposure variable of interest: Mediterranean Diet ScoreThe outcome variable of interest: Birth weight (BW), birth length (BL), head circumference (HC), and foetal growth restriction. All variables related with the outcome in the bivariate models (p

Food groups intake during pregnancyThe INMA and Rhea Mother & Child Cohort Studies

Mediterranean Diet Score during pregnancyThe INMA and Rhea Mother & Child Cohort Studies

All models were adjusted for gender, gestational age, maternal smoking during pregnancy, maternal age and total energy intake using linear regression models.a P values for values for each component from the regression modelb Also adjusted for: INMA Atlantic: parity, maternal BMI, paternal education and parental social class; INMA Mediterranean: parity, parental BMI, and maternal social class; RHEA: maternal BMI and education.c Also adjusted for: INMA Atlantic: parity, maternal BMI, paternal age and maternal social class; INMA Mediterranean: parity, maternal BMI, and maternal social class; RHEA: maternal height and education.d Also adjusted for: INMA Atlantic: parity, maternal BMI and education; INMA Mediterranean: parity, maternal BMI, maternal education and alcohol intake; RHEA: maternal BMI and education.* Mediteranean Diet score, Low: 0-3; Medium: 4-5; High: 6-8 Associations between Mediterranean Diet Score in pregnancy with anthropometric measurements at birthThe INMA and Rhea Mother & Child Cohort Studies

INMA Atlantic INMA Mediterranean RHEA SEPaSEPaSEPaWeightbMD score, LowRef.Ref.Ref.MD score, Medium-264626030310552023520019-336731780290MD score, High-828547670082877833400009-204242330630LengthcMD score, LowRef.Ref.Ref.MD score, Medium-01601201850130100203-0430180077MD score, High-02502202450300150040-0060240794Head circumferencedMD score, LowRef.Ref.Ref.MD score, Medium00300907700030070647-0230120049MD score, High-00601607110160100121-0200160214

Associations between Mediterranean Diet Score* in pregnancy with Foetal Growth Restriction (FGR)The INMA and Rhea Mother & Child Cohort Studies All models were adjusted for maternal smoking during pregnancy, maternal age and total energy intakea P values for each component from the log-binomial model.b Also adjusted for: INMA Atlantic: maternal social class; INMA Mediterranean: maternal BMI and maternal social class; RHEA: paternal age and maternal education.c Also adjusted for: INMA Atlantic and INMA Mediterranean: maternal education; RHEA: paternal education.d Also adjusted for: INMA Atlantic: paternal age, maternal BMI and education; INMA Mediterranean: maternal BMI, alcohol intake, education and social class; RHEA: maternal alcohol intake and education. * Mediteranean Diet score, Low: 0-3; Medium: 4-5; High: 6-8

INMA Atlantic INMA Mediterranean RHEA RR95% CIPaRR95% CIPaRR95% CIPaFGR in WeightbMD score, LowRefRefRefMD score, Medium124081, 1890329076054, 1060109182095, 3490071MD score, High097042, 2260943050028, 0900021196090, 4250089FGR in LengthcMD score, LowRefRefRefMD score, Medium133087, 2040189101070, 1470952139072, 2680330MD score, High063023, 1760376095055, 1620838090035, 2300821FGR in Head circumferencedMD score, LowRefRefRefMD score, Medium088057, 1340543115080, 1650459163089, 2960112MD score, High111053, 2330779107063, 1830800164076, 3560211

Adjusted means of birth weight by Mediterranean Diet Score and maternal smoking during pregnancy The INMA and Rhea Mother & Child Cohort Studies INMA-Atlantic: Non Smokers (), Smokers (); INMA-Mediterannean: Non Smokers (), Smokers (); RHEA: Non Smokers (), Smokers (). All models were adjusted for maternal age and total energy intake, gender and gestational age. Models for weight were also adjusted for: INMA-Atlantic: parity, maternal BMI, paternal education and parental social class; INMA-Mediterannean: parity, parental BMI, and maternal social class; RHEA: maternal BMI and education.

Adjusted means of head circumference by Mediterranean Diet Score and maternal smoking during pregnancy The INMA and Rhea Mother & Child Cohort Studies INMA-Atlantic: Non Smokers (), Smokers (); INMA-Mediterannean: Non Smokers (), Smokers (); RHEA: Non Smokers (), Smokers (). All models were adjusted for maternal age and total energy intake, gender and gestational age. Models for head circumference were also adjusted: INMA-Atlantic: parity, maternal BMI and education; INMA-Mediterranean: parity, maternal BMI, maternal education and alcohol intake; RHEA: maternal BMI and education.

Population based cohort design.Customised definition of foetal growth restrictionDetailed data for dietary intake during pregnancy; Total energy intake Multivariate analysis; exclusion criteria

Self-reported diet during pregnancy Unknown confounding factors linked both with fetal growth and diet during pregnancy that could explain this associationStrengthsLimitationsStrengths and limitations of the present study

Conclusions.. MD during pregnancy is not homogeneous within the Mediterranean area.

A high adherence to MD may modify the detrimental effectof smoking on birth size.

Complex underlying processes explain findings

The INMA and Rhea Mother & Child Cohort Studies

The Greek Mother & Child Cohort Study The Greek Mother & Child Cohort Study to be continued

To be continued

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