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

Leda Chatzi, Michelle Mendez, Raquel Garcia, Theano Roumeliotaki, Jesús Ibarluzea, Adonina Tardón, Pilar Amiano, Aitana Lertxundi, Carmen Iñiguez, 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 pregnancy

Frequency 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)


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 pregnancy


Statistical analysis

The exposure variable of interest: Mediterranean Diet Score

The 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<0.2) were included in the multivariable models

Multivariable log-binomial and linear regression models performed after adjusting for confounders

Evaluation of effect modification (likelihood ratio test (a=0.1)


Food groups intake during pregnancy


0

100

200

300

400

500

600

Med

ian

inta

ke (

g/da

y)

Cer

eals

Veg

etab

les

Legu

mes

Fru

its a

nd n

uts

Fis

h an

d se

afoo

d

Mon

ouns

atur

ated

fatt

y ac

ids

Sat

urat

edfa

tty

acid

s

Dai

ry p

rodu

cts

Mea

t

INMA Atlantic INMA Mediterranean RHEA

Mediterranean Diet Score during pregnancy


3.35

3.45

3.55

3.65

3.75

3.85

3.95

4.05

4.15

4.25M

ean (95% C

.I.)

0

5

10

15

20

25

30

35

40

45

50

Fre

quen

cy %

Diet Scoreof 0-3

Diet Scoreof 4-5

Diet Scoreof 6-8

INMAAtlantic

INMAMediterranean

RHEA


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

birth



β SE Pa β SE Pa β SE Pa

Weightb

MD score, Low Ref. Ref. Ref.

MD score, Medium -26·46 26·03 0·310 55·20 23·52 0·019 -33·67 31·78 0·290

MD score, High -82·85 47·67 0·082 87·78 33·40 0·009 -20·42 42·33 0·630

Lengthc


MD score, Medium -0·16 0·12 0·185 0·13 0·10 0·203 -0·43 0·18 0·077

MD score, High -0·25 0·22 0·245 0·30 0·15 0·040 -0·06 0·24 0·794

Head circumferenced


MD score, Medium 0·03 0·09 0·770 0·03 0·07 0·647 -0·23 0·12 0·049

MD score, High -0·06 0·16 0·711 0·16 0·10 0·121 -0·20 0·16 0·214

Associations between Mediterranean Diet Score* in pregnancy with Foetal Growth Restriction (FGR)



RR 95% CI Pa RR 95% CI Pa RR 95% CI Pa

FGR in Weightb

MD score, Low Ref Ref Ref

MD score, Medium 1·24 0·81, 1·89 0·329 0·76 0·54, 1·06 0·109 1·82 0·95, 3·49 0·071

MD score, High 0·97 0·42, 2·26 0·943 0·50 0·28, 0·90 0·021 1·96 0·90, 4·25 0·089

FGR in Lengthc


MD score, Medium 1·33 0·87, 2·04 0·189 1·01 0·70, 1·47 0·952 1·39 0·72, 2·68 0·330

MD score, High 0·63 0·23, 1·76 0·376 0·95 0·55, 1·62 0·838 0·90 0·35, 2·30 0·821

FGR in Head circumferenced


MD score, Medium 0·88 0·57, 1·34 0·543 1·15 0·80, 1·65 0·459 1·63 0·89, 2·96 0·112

MD score, High 1·11 0·53, 2·33 0·779 1·07 0·63, 1·83 0·800 1·64 0·76, 3·56 0·211

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

Adjusted means of birth weight by Mediterranean Diet Score and maternal

smoking during pregnancy


2950

3000

3050

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3250

MedDiet 0-3 MedDiet 4-6 MedDiet 6-8

We

igh

t (g

r)

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


33.2

33.4

33.6

33.8

34.0

34.2

34.4

MedDiet 0-3 MedDiet 4-6 MedDiet 6-8

He

ad

circ

um

fere

nce

(cm

)

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 restriction”

Detailed 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 association

Strengths Limitations

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

to be continued ……………

To be continued…