Effects of Mediterranean Diet or Mindfulness-Based Stress Reduction on Prevention of Small-for-Gestational Age Birth Weights in Newborns Born to At-Risk Pregnant Individuals: The IMPACT BCN Randomized Clinical Trial

Mediterranean Diet Adherence beyond Boundaries: Sociodemographic and Pregnancy-Related Determinants among Saudi Women

Although the expected benefits of the Mediterranean diet (MD) are comprehensive, its implementation is hampered by poor adherence. Several factors can affect adherence to MD guidelines. The current study aimed to explore sociodemographic and pregnancy-related determinants of MD adherence among Saudi women. A correlational cross-sectional research design was conducted on a snowball sample of 774 pregnant women from the Najran region, Saudi Arabia, using an online survey between February and May 2024. A self-administered questionnaire consisting of sociodemographic data, pregnancy-related characteristics, and the MD scale was used for data collection. The current study showed that only 32.2% of participants had high adherence to the MD, and 57.6% had moderate adherence. Regarding sociodemographic determinants of MD adherence, highly educated, older women with lower pre-pregnancy body mass index (BMI) and higher monthly income increased the probability of high adherence to the MD (p < 0.05). In addition, being physically active before or during pregnancy significantly increased the woman's probability of having higher adherence to the MD (p < 0.05). Concerning pregnancy-related determinants, having a planned pregnancy and regular antenatal care (ANC) increased the woman's probability of high adherence to the MD by nearly 1.3 times (p < 0.05). In addition, low adherence to the MD increases the risk of gestational diabetes. In conclusion, numerous sociodemographic and pregnancy-related determinacies can significantly affect a woman's adherence to the MD. Healthcare providers should address these determinants during the planning and implementation of pregnant women's nutritional counseling to make the counseling process woman-centered and more effective.

Validation of a pregnancy-adapted Mediterranean Diet Adherence Screener (preg-MEDAS): a validation study nested in the Improving Mothers for a better PrenAtal Care Trial BarCeloNa (IMPACT BCN) trial

BACKGROUND

Non-time-consuming and easy-to-administer dietary assessment tools specific for pregnancy are needed.

OBJECTIVES

The aim of this validation study nested in the IMPACT BCN (Improving Mothers for a better PrenAtal Care Trial BarCeloNa) trial is to determine the concurrent validity of the 17-item pregnancy-adapted Mediterranean diet score (preg-MEDAS) and to analyze whether changes in the preg-MEDAS score were associated with maternal favorable dietary and cardiometabolic changes after 3 mo of intervention in pregnant women.

METHODS

Dietary data was collected in 812 participants using the preg-MEDAS and a 151-item validated food frequency questionnaire (FFQ) at baseline (19-23 wk gestation) and final visit (31-34 wk gestation). Concurrent preg-MEDAS validity was evaluated by Pearson and intraclass correlation coefficients, κ statistic, and Bland-Altman methods.

RESULTS

The preg-MEDAS had a good correlation with the FFQ (r = 0.76 and intraclass correlation coefficient 0.75). The agreement of each of the preg-MEDAS items ranged from 40.9% to 93.8% with a substantial agreement mean concordance (κ = 0.61). A 2-point increase in preg-MEDAS was associated with a decrease in maternal mean and systolic blood pressure (β: -0.51 mmHg; 95% confidence interval [CI]: -0.97, -0.04 mmHg and -0.87 mmHg; 95% CI: -1.48, -0.26 mmHg, respectively).

CONCLUSIONS

The preg-MEDAS displays good validity for assessing adherence to the Mediterranean diet, allowing detection of dietary changes over time. In addition, changes observed in preg-MEDAS are significantly associated with a decrease in maternal blood pressure. Therefore, we propose preg-MEDAS as a rapid and simple dietary assessment tool during pregnancy. This trial was registered at clinicaltrials.gov as NCT03166332.

Association of vitamin D intake during pregnancy with small vulnerable newborns: a population-based cohort study

Maternal vitamin D deficiency is common worldwide and has a significant impact on newborns. However, whether vitamin D intake during pregnancy is related to small vulnerable newborns (SVN) has not been confirmed. Thus, we sought to examine the relationship between maternal vitamin D intake, including vitamin D supplementation and dietary intake, and the risk of SVN. A total of 2980 Chinese mother-infant pairs were included in this study. Information on vitamin D supplementation and dietary intake was prospectively collected through face-to-face interviews. The outcomes assessed included low birth weight (LBW), preterm birth (PTB), small for gestational age (SGA), and SVN (having LBW, PTB, or SGA). Logistic regression models were used to evaluate the association of vitamin D intake with different types of SVN, and a restricted cubic spline function was modeled to explore their dose-response associations. Compared to the lowest total vitamin D intake in the first trimester, the highest total vitamin D intake was associated with a 50.0% decrease in the SGA risk (OR: 0.50, 95% CI: 0.26, 0.96) and a 41.0% decrease in the SVN risk (OR: 0.59, 95% CI: 0.36, 0.95). Similar protective results were observed between vitamin D supplementation in the first trimester and SGA and SVN risks. Moreover, a significant L-shaped relationship was identified for total vitamin D intake, vitamin D supplementation, and dietary intake with the risk of different types of SVN. In conclusion, higher total vitamin D intake and supplementation in the first trimester were associated with a reduced risk of SGA and SVN.

Prevention of Pregnancy Complications Using a Multimodal Lifestyle, Screening, and Medical Model

Prevention of pregnancy complications related to the "great obstetrical syndromes" (preeclampsia, fetal growth restriction, spontaneous preterm labor, and stillbirth) is a global research and clinical management priority. These syndromes share many common pathophysiological mechanisms that may contribute to altered placental development and function. The resulting adverse pregnancy outcomes are associated with increased maternal and perinatal morbidity and mortality and increased post-partum risk of cardiometabolic disease. Maternal nutritional and environmental factors are known to play a significant role in altering bidirectional communication between fetal-derived trophoblast cells and maternal decidual cells and contribute to abnormal placentation. As a result, lifestyle-based interventions have increasingly been recommended before, during, and after pregnancy, in order to reduce maternal and perinatal morbidity and mortality and decrease long-term risk. Antenatal screening strategies have been developed following extensive studies in diverse populations. Multivariate preeclampsia screening using a combination of maternal, biophysical, and serum biochemical markers is recommended at 11-14 weeks' gestation and can be performed at the same time as the first-trimester ultrasound and blood tests. Women identified as high-risk can be offered prophylactic low dose aspirin and monitored with angiogenic factor assessment from 22 weeks' gestation, in combination with clinical assessment, serum biochemistry, and ultrasound. Lifestyle factors can be reassessed during counseling related to antenatal screening interventions. The integration of lifestyle interventions, pregnancy screening, and medical management represents a conceptual advance in pregnancy care that has the potential to significantly reduce pregnancy complications and associated later life cardiometabolic adverse outcomes.

Effect of Mediterranean diet or mindfulness-based stress reduction during pregnancy on placental volume and perfusion: A subanalysis of the IMPACT BCN randomized clinical trial

INTRODUCTION

The IMPACT BCN trial-a parallel-group randomized clinical trial where 1221 pregnant women at high risk for small-for-gestational age (SGA) newborns were randomly allocated at 19- to 23-week gestation into three groups: Mediterranean diet, Mindfulness-based Stress reduction or non-intervention-has demonstrated a positive effect of Mediterranean diet and Stress reduction in the prevention of SGA. However, the mechanism of action of these interventions remains still unclear. The aim of this study is to investigate the effect of Mediterranean diet and Stress reduction on placental volume and perfusion.

MATERIAL AND METHODS

Participants in the Mediterranean diet group received monthly individual and group educational sessions, and free provision of extra-virgin olive oil and walnuts. Women in the Stress reduction group underwent an 8-week Stress reduction program adapted for pregnancy, consisting of weekly 2.5-h and one full-day sessions. Non-intervention group was based on usual care. Placental volume and perfusion were assessed in a subgroup of randomly selected women (n = 165) using magnetic resonance (MR) at 36-week gestation. Small placental volume was defined as MR estimated volume <10th centile. Perfusion was assessed by intravoxel incoherent motion.

RESULTS

While mean MR placental volume was similar among the study groups, both interventions were associated with a lower prevalence of small placental volume (3.9% Mediterranean diet and 5% stress reduction vs. 17% non-intervention; p = 0.03 and p = 0.04, respectively). Logistic regression showed that small placental volume was significantly associated with higher risk of SGA in both study groups (OR 7.48 [1.99-28.09] in Mediterranean diet and 20.44 [5.13-81.4] in Stress reduction). Mediation analysis showed that the effect of Mediterranean diet on SGA can be decomposed by a direct effect and an indirect effect (56.6%) mediated by a small placental volume. Similarly, the effect of Stress reduction on SGA is partially mediated (45.3%) by a small placental volume. Results on placental intravoxel incoherent motion perfusion fraction and diffusion coefficient were similar among the study groups.

CONCLUSIONS

Structured interventions during pregnancy based on Mediterranean diet or Stress reduction are associated with a lower proportion of small placentas, which is consistent with the previously observed beneficial effects of these interventions on fetal growth.

Adherence to the Mediterranean diet during pregnancy and behavioural problems at 4 years of age

There is an increasing prevalence of psychological issues in childhood. Lifestyle factors during pregnancy, including maternal nutrition, have been linked to children's behavioural development. This study aims to assess the impact of adherence to the Mediterranean diet during pregnancy on the behavioural problems of children at the age of 4. A total of 231 mother-child pairs were assessed. Maternal adherence to the Mediterranean diet during pregnancy was estimated using a relative Mediterranean Diet Score (rMED). Behavioural outcomes were evaluated through the Child Behaviour Checklist 1½--5, Teacher's Report Form 1½-5, and Behaviour Rating Inventory of Executive Function-Preschool Version questionnaires. The results indicated that a higher rMED score during pregnancy was associated with a reduced probability of obtaining a clinical score for total problems (OR = 0.42; 95% IC from 0.21 to 0.85), including externalising (OR = 0.29; 95% IC from 0.14 to 0.62), attention problems (OR = 0.32; 95%IC from 0.15 to 0.70), attention-deficit/hyperactivity problems (OR = 0.36; 95% IC from 0.15 to 0.87), oppositional defiant problems (OR = 0.06; 95% IC from 0.06 to 0.75), and depressive problems (OR = 0.38; 95% IC from 0.15 to 0.96). This study highlights the importance of maternal diet, especially Mediterranean diet, during gestation for proper child development.

Effects of Mindfulness-Based Interventions on Cardiometabolic-Related Adverse Pregnancy Outcomes: A Systematic Review

BACKGROUND

Growing evidence suggests maternal stress contributes to the development of adverse pregnancy outcomes that are associated with cardiovascular and cardiometabolic risk in birthing persons. Mindfulness-based interventions may positively affect psychological stress in pregnancy and, in turn, reduce stress. However, few study authors have examined the effects of mindfulness-based interventions on adverse pregnancy outcomes that heighten cardiovascular risk.

OBJECTIVE

The aim of this study was to appraise available literature examining the effects of mindfulness-based interventions delivered during pregnancy on adverse pregnancy outcomes associated with future cardiovascular and cardiometabolic disease risk.

METHODS

In this systematic review, multiple electronic databases were searched using major keywords, including "mindfulness-based intervention," "pregnancy," "preterm delivery," "gestational diabetes," "small for gestational age," "preeclampsia," and "hypertension in pregnancy" during February 2023.

RESULTS

Six studies using mindfulness-based interventions during pregnancy were included. The review indicated that these interventions were largely effective at reducing prenatal stress; however, the overall effects of interventions were mixed concerning their impact on pregnancy complications. Study authors examining the effects on gestational diabetes-related outcomes reported significant improvements in blood glucose levels, hemoglobin A 1c , and oral glucose tolerance. Outcomes were mixed or inconclusive related to the effects of interventions on the incidence of preterm birth, birth of a small-for-gestational-age newborn, and preeclampsia.

CONCLUSIONS

Mitigating cardiovascular and cardiometabolic risk-associated adverse pregnancy outcomes through mindfulness-based approaches may represent an emerging field of study. The few studies and limited, mixed findings synthesized in this review indicate that high-validity studies are warranted to examine the effects of mindfulness-based interventions on pregnancy complications that contribute to cardiovascular-related maternal morbidity and suboptimal life course health for diverse birthing persons.

The Mediterranean Diet in Pregnancy: Implications for Maternal Brain Morphometry in a Secondary Analysis of the IMPACT BCN Randomized Clinical Trial

INTRODUCTION

A Mediterranean diet has positive effects on the brain in mid-older adults; however, there is scarce information on pregnant individuals. We aimed to evaluate the effect of a structured Mediterranean diet intervention on the cortical structure of the maternal brain during pregnancy.

METHODS

This study was a secondary analysis of the IMPACT BCN, a randomized clinical trial with 1221 high-risk pregnant women randomly allocated into three groups at 19-23 weeks of gestation: Mediterranean diet intervention, a mindfulness-based stress reduction program, or usual care. Maternal brain magnetic resonance imaging was performed during the third trimester of pregnancy in a random subgroup of participants. For this study, data from the Mediterranean diet and usual groups were analyzed. Maternal dietary intake, adherence to the Mediterranean diet and metabolite biomarkers were evaluated using a food frequency questionnaire, a 17-item dietary screener and plasma/urine samples, respectively.

RESULTS

The cluster-wise analysis showed that the Mediterranean diet group participants (n = 34) had significantly larger surface areas in the right precuneus (90%CI: <0.0001-0.0004, p < 0.001) and left superior parietal (90%CI: 0.026-0.033, p = 0.03) lobules compared to the usual care group participants (n = 37). A larger right precuneus area was associated with high improvements in adherence to the Mediterranean diet, a high intake of walnuts and high concentrations of urinary hydroxytyrosol. A larger left superior parietal area was associated with a high intake of walnuts and high concentrations of urinary hydroxytyrosol.

CONCLUSIONS

The promotion of a Mediterranean diet during pregnancy has a significant effect on maternal brain structure.

Preterm birth in singleton pregnancies conceived by in vitro fertilization or intracytoplasmic sperm injection: an overview of systematic reviews

BACKGROUND

The rate of preterm birth of singletons conceived through in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) is increased, being as high as 15% to 16% across Europe and the United States. However, the underlying etiology, phenotype, and mechanisms initiating preterm birth (PTB) are poorly understood.

OBJECTIVE

To quantify the PTB risk and examine supposed etiology in IVF/ICSI singleton pregnancies compared to naturally conceived.

STUDY DESIGN

Overview of reviews including all available systematic reviews with meta-analysis comparing PTB risk in IVF/ICSI and naturally conceived singletons. A comprehensive search of PubMed/MEDLINE, Embase, Scopus, and Cochrane Library databases was performed up to December 31, 2023. Information available on etiology, phenotype, initiation of PTB, and relevant moderators was retrieved and employed for subgroup analyses. Random-effects meta-analysis models were used for pooling effect measures. Estimates were presented as odds ratios (ORs) with 95% confidence intervals (CIs). The extent of overlap in the original studies was measured using the corrected covered area assessment. The quality of the included reviews was evaluated with the AMSTAR 2 tool. The Grading of Recommendations Assessment, Development and Evaluation approach was applied to rate evidence certainty. The protocol was registered on PROspective Register of Systematic Reviews (CRD42023411418).

RESULTS

Twelve meta-analyses (16,522,917 pregnancies; ˃433,330 IVF/ICSI) were included. IVF/ICSI singletons showed a significantly higher PTB risk compared to natural conception (PTB ˂37 weeks: OR: 1.72, 95% CI: 1.57-1.89; PTB<32 weeks: OR: 2.19, 95% CI: 1.82-2.64). Influential analysis reinforced the strength of this association. Subgroup analyses investigating supposed etiology revealed a comparable risk magnitude for spontaneous PTB (OR: 1.79, 95% CI: 1.56-2.04) and a greater risk for iatrogenic PTB (OR: 2.28, 95% CI: 1.72-3.02). PTB risk was consistent in the subgroup of conventional IVF (OR: 1.95, 95% CI: 1.76-2.15) and higher in the subgroup of fresh only (OR: 1.79, 95% CI: 1.55-2.07) vs frozen-thawed embryo transfers (OR: 1.39, 95% CI: 1.34-1.43). There was minimal study overlap (13%). The certainty of the evidence was graded as low to very low.

CONCLUSION

Singletons conceived through IVF/ICSI have a 2-fold increased risk of PTB compared to natural conception, despite the low certainty of the evidence. There is paucity of available data on PTB etiology, phenotype, or initiation. The greater risk increase is observed in fresh embryo transfers and involves iatrogenic PTB and PTB ˂32 weeks, likely attributable to placental etiology. Future studies should collect data on PTB etiology, phenotype, and initiation. IVF/ICSI pregnancies should undertake specialistic care with early screening for placental disorders, cervical length, and growth abnormalities, allowing appropriate timely follow-up, preventive measures, and therapeutic interventions strategies.

Maternal Plasma Choline during Gestation and Small for Gestational Age Infants

OBJECTIVE

Small for gestational age (SGA) infants are at increased risk for neonatal morbidity and developmental problems in childhood. No current interventions during human pregnancy address this problem. This study investigated the possible relationship between maternal choline concentration during pregnancy and SGA infants.

STUDY DESIGN

Maternal plasma choline concentrations were sampled at 16 and 28 weeks' gestation from women in a public prenatal clinic. Additional factors assessed were maternal age, body mass index, infection, C-reactive protein, hair cortisol, and compliance with prenatal vitamins and folate. Infants below the 10th percentile for gestational age were classified as SGA. Binary logistic regression was used to identify significant associated factors in pregnancies resulting in SGA infants compared with pregnancies resulting in non-SGA infants.

RESULTS

Thirteen (8%) of 159 women had SGA infants. Maternal plasma choline concentrations were low for pregnant participants whose infants were SGA, with the 28-week concentration significantly lower compared with other participants. Plasma choline concentrations ≥7 μM at 28 weeks, consistent with a minimally adequate dietary intake of choline-containing foods, were achieved by only 2 (15%) of mothers with SGA infants, compared with 51% of mothers whose infants were not SGA. Choline concentrations <7 μM at 28 weeks' gestation were associated with an odds ratio for SGA of 16.6 (95% confidence interval: 1.5-189.2, p = 0.023). Other significant factors were female sex and maternal C-reactive protein plasma concentration during gestation.

CONCLUSION

This observational study suggests that higher maternal choline levels may influence the risk for SGA. Maternal plasma choline concentrations are not routinely available in clinical laboratories. However, plasma choline levels can be increased by the mothers' intake of choline or phosphatidylcholine supplements. No nutritional intervention is currently recommended to prevent SGA, but the evidence from this study suggests that further consideration of the role of maternal choline may be warranted.

KEY POINTS

· More females are small for gestational age.. · Low maternal choline is related to small infants.. · Maternal choline ≥7 μM at 28 weeks appears optimal..

Fetal growth restriction exhibits various mTOR signaling in different regions of mouse placentas with altered lipid metabolism

Fetal growth restriction (FGR) is a common complication of pregnancy and can have significant impact on obstetric and neonatal outcomes. Increasing evidence has shown that the inhibited mechanistic target of rapamycin (mTOR) signaling in placenta is associated with FGR. However, interpretation of existing research is limited due to inconsistent methodologies and varying understanding of the mechanism by which mTOR activity contributes to FGR. Hereby, we have demonstrated that different anatomic regions of human and mouse placentas exhibited different levels of mTOR activity in normal compared to FGR pregnancies. When using the rapamycin-induced FGR mouse model, we found that placentas of FGR pregnancies exhibited abnormal morphological changes and reduced mTOR activity in the decidual-junctional layer. Using transcriptomics and lipidomics, we revealed that lipid and energy metabolism was significantly disrupted in the placentas of FGR mice. Finally, we demonstrated that maternal physical exercise during gestation in our FGR mouse model was associated with increased fetal and placental weight as well as increased placental mTOR activity and lipid metabolism. Collectively, our data indicate that the inhibited placental mTOR signaling contributes to FGR with altered lipid metabolism in mouse placentas, and maternal exercise could be an effective method to reduce the occurrence of FGR or alleviate the adverse outcomes associated with FGR.

Cardiovascular Disease and the Mediterranean Diet: Insights into Sex-Specific Responses

Cardiovascular disease (CVD) is a leading cause of mortality and disease burden in women globally. A healthy diet is important for the prevention of CVD. Research has consistently favoured the Mediterranean diet as a cardio-protective diet. Several studies have evaluated associations between the Mediterranean diet and cardiovascular outcomes, including traditional risk factors like hypertension, type 2 diabetes mellitus, and obesity. In addition, consistent evidence suggests that the components of the Mediterranean diet have a synergistic effect on cardiovascular risk due to its anti-inflammatory profile and microbiome effects. While the benefits of the Mediterranean diet are well-established, health advice and dietary guidelines have been built on largely male-dominant studies. Few studies have investigated the beneficial associations of the Mediterranean diet in sex-specific populations, including those with non-traditional risk factors that are specific to women, for instance polycystic ovarian syndrome and high-risk pregnancies, or more prevalent in women, such as chronic inflammatory diseases. Therefore, this review aims to provide a comprehensive overview of the current evidence regarding the Mediterranean diet in women in relation to cardiovascular health outcomes.

Food, nutrition, and fertility: from soil to fork

Food and nutrition-related factors, including foods and nutrients consumed, dietary patterns, use of dietary supplements, adiposity, and exposure to food-related environmental contaminants, have the potential to impact semen quality and male and female fertility; obstetric, fetal, and birth outcomes; and the health of future generations, but gaps in evidence remain. On 9 November 2022, Tufts University's Friedman School of Nutrition Science and Policy and the school's Food and Nutrition Innovation Institute hosted a 1-d meeting to explore the evidence and evidence gaps regarding the relationships between food, nutrition, and fertility. Topics addressed included male fertility, female fertility and gestation, and intergenerational effects. This meeting report summarizes the presentations and deliberations from the meeting. Regarding male fertility, a positive association exists with a healthy dietary pattern, with high-quality evidence for semen quality and lower quality evidence for clinical outcomes. Folic acid and zinc supplementation have been found to not impact male fertility. In females, body weight status and other nutrition-related factors are linked to nearly half of all ovulation disorders, a leading cause of female infertility. Females with obesity have worse fertility treatment, pregnancy-related, and birth outcomes. Environmental contaminants found in food, water, or its packaging, including lead, perfluorinated alkyl substances, phthalates, and phenols, adversely impact female reproductive outcomes. Epigenetic research has found that maternal and paternal dietary-related factors can impact outcomes for future generations. Priority evidence gaps identified by meeting participants relate to the effects of nutrition and dietary patterns on fertility, gaps in communication regarding fertility optimization through changes in nutritional and environmental exposures, and interventions impacting germ cell mechanisms through dietary effects. Participants developed research proposals to address the priority evidence gaps. The workshop findings serve as a foundation for future prioritization of scientific research to address evidence gaps related to food, nutrition, and fertility.

Association between the Maternal Mediterranean Diet and Perinatal Outcomes: A Systematic Review and Meta-Analysis

The Mediterranean diet is a global, well-known healthy dietary pattern. This review aims to synthesize the existing evidence on the relationship between the maternal Mediterranean diet during pregnancy and perinatal outcomes, including randomized controlled trials (RCTs) and cohort studies. PubMed, Web of Science, and the Cochrane Library were searched from inception to 10 March, 2023, supplemented by manual screening. A random-effect model was used to estimate pooled sizes with 95% confidence intervals (CIs) for specific outcomes of interest. Data from 5 RCTs and 18 cohort studies with 107,355 pregnant participants were synthesized. In RCTs, it was observed that the maternal Mediterranean diet significantly reduced the incidence of gestational diabetes mellitus [odds ratio (OR), 0.56; 95% CI: 0.34, 0.93], as well as small for gestational age (0.55; 95% CI: 0.35, 0.88). In cohort studies, the highest adherence score to the maternal Mediterranean diet was inversely associated with a lower risk of various adverse pregnancy outcomes, including gestational diabetes mellitus (OR, 0.82; 95% CI: 0.67, 1.00), pregnancy-induced hypertension (0.73; 95% CI: 0.60, 0.89), pre-eclampsia (0.77; 95% CI: 0.64, 0.93), preterm delivery (0.67; 95% CI: 0.49, 0.91), low birth weight (0.70; 95% CI: 0.64, 0.78), intrauterine growth restriction (0.46; 95% CI: 0.23, 0.91), and increased gestational age at delivery (weighted mean difference, 0.11 wk; 95% CI: 0.03, 0.20). Meta-regression analyses did not identify the adjustment for confounders and geographical location as predictive factors for heterogeneity. The results suggest that adherence to the Mediterranean diet during pregnancy appears to be beneficial for perinatal outcomes. Future, larger, and higher-quality RCTs and cohort studies are warranted to confirm the present findings. PROSPERO registration no.: CRD42023406317.

Lipid-focused dietary education intervention in pregnant women: study protocol for an open-label, parallel, randomised, intervention study addressing adverse pregnancy outcomes in China

INTRODUCTION

The incidence of infants who are large-for-gestational-age (LGA) is on the rise in China, and its detrimental effects on health have received increasing attention. Diet-based interventions have the potential to reduce adverse birth outcomes, particularly in decreasing the occurrence of LGA infants. We aim to evaluate the effect of lipid-focused diet education based on the theories of behaviour change in pregnant women on maternal and offspring outcomes through a randomised controlled trial.

METHODS AND ANALYSIS

We have designed an open-label, parallel, multicentre randomised controlled trial in collaboration with three hospitals in Beijing, China.Pregnant women will be recruited before reaching 12 weeks of gestation and will be randomised in a 1:1:1 ratio into three arms: (1) online education arm, (2) pregnancy nutrition checklist and 'one-page flyer' arm and (3) routine antenatal education. The primary outcome LGA will be recorded at birth. Demographic information, physical activity, sleep and medical history will be collected through questionnaires and case cards prior to enrolment. Questionnaires will also be used to collect dietary behaviours and psychosocial factors of pregnant women at enrolment, at 24-28 weeks and 34-36 weeks of gestation. Additionally, information on breastfeeding and complementary food supplementation for infants and young children will be obtained through questionnaires. Physical development indicators of children and taste tests will be assessed 3 years after delivery.

ETHICS AND DISSEMINATION

The study has received ethical approval from the Capital Medical University Ethics Committee and other collaborating study centres. Informed consent will be introduced to pregnant women, and their consent will be obtained. The findings will be reported in relevant national and international academic conferences and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ChiCTR2300071126.

The Management of Preeclampsia: A Comprehensive Review of Current Practices and Future Directions

Preeclampsia (PE) is a disease in pregnancy that is characterized by new-onset hypertension end-organ dysfunction, often occurring after 20 weeks of gestation. Risk factors include a prior history of PE, diabetes, kidney disease, obesity, and high maternal age at pregnancy. Current treatment and management guidelines focus on the management of high blood pressure and any potential complications. The only known curative treatment is termination of pregnancy (either induction of delivery or cesarean section). However, the current guidelines and recommendations lack adequate prediction markers and are unable to prevent maternal and fetal mortality. There also exists a need for multidisciplinary collaborative action in view of the quality of life and psycho-educational counseling.

Mobile Prenatal Education and Its Impact on Reducing Adverse Pregnancy Outcomes: Retrospective Real-World Study

BACKGROUND

Pregnancy is a pivotal phase in a woman's life, demanding special attention to ensure maternal and fetal health. Prenatal education plays a vital role in promoting healthy pregnancies and reducing adverse outcomes for pregnant women. Mobile prenatal education programs have gained traction due to their accessibility and timeliness, especially in light of finite health care resources and the constraints imposed by the COVID-19 pandemic.

OBJECTIVE

This study aims to develop and evaluate the effectiveness of a mobile-based prenatal education program in improving pregnancy outcomes.

METHODS

We developed a mobile-based prenatal education curriculum in collaboration with a multidisciplinary maternal care team from Peking Union Medical College Hospital (PUMCH) in Beijing, China. Data were retrospectively collected from 1941 pregnant women who had registered for the PUMCH mobile prenatal education program and subsequently delivered at PUMCH between May 2021 and August 2022. The study compared pregnancy outcomes between the completing group, which were pregnant women who had completed at least 1 course, and the noncompleting group. We also analyzed differences among course topics within the completing group and assessed course topic popularity among pregnant women.

RESULTS

The PUMCH mobile prenatal education curriculum consists of 436 courses across 9 topics. Out of the participants, a total of 1521 did not complete any courses, while 420 completed at least 1 course. Compared with the noncompleting group, pregnant women who completed courses exhibited a significant reduction in the risk of gestational diabetes mellitus, induced abortion, postpartum infection, fetal intrauterine distress, and neonatal malformation. Among those in the completing group, a total of 86% (361/420) started course completion during the first and second trimesters. Furthermore, completing courses related to topics of pregnancy psychology and pregnancy nutrition was associated with reduced risks of premature rupture of membranes and small for gestational age infants, respectively. Pregnancy psychology and postpartum recovery were the preferred topics among pregnant women.

CONCLUSIONS

The study demonstrates the potential of mobile-based prenatal education programs in improving pregnancy outcomes and supporting health care providers in delivering effective prenatal education. The rise of mobile prenatal education presents an opportunity to improve maternal and child health outcomes. Further research and broader implementation of such programs are warranted to continually improve maternal and child health.

The effect of earthquake experience on pregnancy outcomes: A systematic review and meta-analysis

OBJECTIVES

Pregnant women are vulnerable to the health consequences of earthquakes, experiencing stress and limited access to healthcare. Despite the widespread impact of these events, knowledge about their effects on pregnancy outcomes is scarce and inconsistent. This systematic review and meta-analysis aimed to evaluate the available evidence, estimate the overall effect, and identify key research gaps about earthquake on pregnant women.

STUDY DESIGN

A comprehensive search of English-language peer-reviewed articles was conducted using PubMed and Web of Science Core Collection. Various combinations of keywords related to earthquakes and pregnancy outcomes were used. Studies comparing quantitative data on pregnancy outcomes between earthquake-affected and unaffected pregnant women were included. Random and fixed-effects models were used to estimate the pooled effect size.

RESULTS

The meta-analysis revealed no significant difference in preterm delivery rates (OR: 1.18; 95 % CI: 0.94-1.47; I2 = 75 %; five studies, 26,365 women) and low birth weight (LBW) infant delivery rates (OR: 1.19; 95 % CI: 0.83-1.71; I2 = 72 %; three studies, 16,127 women) between the earthquake-affected and control groups. However, a statistically significant increase in small-for-gestational-age (SGA) infants was observed in the earthquake-affected group (OR: 1.25; 95 % CI: 1.08-1.43; I2 = 0 %; two studies, 10,238 women). Data on miscarriage and stillbirth rates were not suitable for meta-analysis.

CONCLUSIONS

Limited evidence suggests that exposure to earthquakes may be associated with adverse pregnancy outcomes. Further studies are needed to confirm the increased risk of SGA in the affected population and to inform disaster management plans by enhancing our understanding of the adversities associated with earthquake exposure through more comprehensive epidemiologic research.

Effects of Mediterranean diet or mindfulness-based stress reduction on fetal and neonatal brain development: a secondary analysis of a randomized clinical trial

BACKGROUND

Maternal suboptimal nutrition and high stress levels are associated with adverse fetal and infant neurodevelopment.

OBJECTIVE

This study aimed to investigate if structured lifestyle interventions involving a Mediterranean diet or mindfulness-based stress reduction during pregnancy are associated with differences in fetal and neonatal brain development.

STUDY DESIGN

This was a secondary analysis of the randomized clinical trial Improving Mothers for a Better Prenatal Care Trial Barcelona that was conducted in Barcelona, Spain, from 2017 to 2020. Participants with singleton pregnancies were randomly allocated into 3 groups, namely Mediterranean diet intervention, stress reduction program, or usual care. Participants in the Mediterranean diet group received monthly individual sessions and free provision of extra-virgin olive oil and walnuts. Pregnant women in the stress reduction group underwent an 8-week mindfulness-based stress reduction program adapted for pregnancy. Magnetic resonance imaging of 90 fetal brains was performed at 36 to 39 weeks of gestation and the Neonatal Neurobehavioral Assessment Scale was completed for 692 newborns at 1 to 3 months. Fetal outcomes were the total brain volume and lobular or regional volumes obtained from a 3-dimensional reconstruction and semiautomatic segmentation of magnetic resonance images. Neonatal outcomes were the 6 clusters scores of the Neonatal Neurobehavioral Assessment Scale. Multiple regression analyses were conducted to assess the association between the interventions and the fetal and neonatal outcomes.

RESULTS

When compared with the usual care group, the offspring exposed to a maternal Mediterranean diet had a larger total fetal brain volume (mean, 284.11 cm3; standard deviation, 23.92 cm3 vs 294.01 cm3; standard deviation, 26.29 cm3; P=.04), corpus callosum (mean, 1.16 cm3; standard deviation, 0.19 cm3 vs 1.26 cm3; standard deviation, 0.22 cm3; P=.03), and right frontal lobe (44.20; standard deviation, 4.09 cm3 vs 46.60; standard deviation, 4.69 cm3; P=.02) volumes based on magnetic resonance imaging measures and higher scores in the Neonatal Neurobehavioral Assessment Scale clusters of autonomic stability (mean, 7.4; standard deviation, 0.9 vs 7.6; standard deviation, 0.7; P=.04), social interaction (mean, 7.5; standard deviation, 1.5 vs 7.8; standard deviation, 1.3; P=.03), and range of state (mean, 4.3; standard deviation, 1.3 vs 4.5; standard deviation, 1.0; P=.04). When compared with the usual care group, offspring from the stress reduction group had larger fetal left anterior cingulate gyri volume (1.63; standard deviation, 0.32 m3 vs 1.79; standard deviation, 0.30 cm3; P=.03) based on magnetic resonance imaging and higher scores in the Neonatal Neurobehavioral Assessment Scale for regulation of state (mean, 6.0; standard deviation, 1.8 vs 6.5; standard deviation, 1.5; P<.01).

CONCLUSION

Maternal structured lifestyle interventions involving the promotion of a Mediterranean diet or stress reduction during pregnancy were associated with changes in fetal and neonatal brain development.

Impact of the trait anxiety during pregnancy on birth weight: an observational cohort study

To explore the effects of antenatal anxiety on fetal growth an observational cohort study was performed, including a cohort of 204 women with singleton pregnancies during the strict lockdown of the COVID-19 pandemic in 2020. Psychosocial factors, maternal demographics, obstetric outcomes, social support (Medical Outcomes Study Social Support Survey, MOS-SSS), and symptoms of anxiety (State-Trait Anxiety Inventory, STAIs and STAIt) and depression (Edinburgh Postpartum Depression Scale, EPDS) were studied as potential predictors of low birth weight. Main outcome measures were birth weight, head circumference and length. Results showed a negative correlation between STAIt score (trait anxiety) and birth weight percentile (r = -0.228, p = .047). In the univariate linear regression analysis, a lower maternal weight and BMI before pregnancy, parity, increased STAIt score and preterm birth below 37 weeks of gestation (p = .008, p = .015, p = .028, p = .047 and p = .022, respectively) were identified as predictive risk factors for low birth weight, whereas in the multivariate lineal regression analysis only a lower maternal weight before pregnancy and an increased STAIt score were independent predictors for low birth weight (p = .020, p = .049, respectively). To conclude, anxiety during pregnancy impacts birth weight, and specifically the trait anxiety, is a predictor for low birth weight.

Mediterranean diet and female reproductive health over lifespan: a systematic review and meta-analysis

OBJECTIVE

We conducted a systematic review and meta-analysis of the effects of Mediterranean diet on female reproductive health outcomes over the life-course.

DATA SOURCES

We searched PubMed, Embase, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov to identify eligible studies published till February 2022. Eligible references from identified studies and review articles were also considered.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials, prospective cohort studies, or nested case-control studies examining Mediterranean diet and major female reproductive outcomes over the lifespan, including clinical outcomes from childhood to adulthood (menarche, polycystic ovary syndrome, endometriosis, and outcomes related to fertility, pregnancy, and menopause), were included for review.

METHODS

Two independent reviewers screened and performed data extraction and risk-of-bias assessment. We performed random-effects meta-analysis to obtain summary relative risks and 95% confidence intervals for major female reproductive outcomes. Subgroup analyses were performed for several pregnancy outcomes according to timing of the interventions for randomized controlled trials and timing of the dietary assessment for observational studies.

RESULTS

Thirty-two studies (9 randomized controlled trials, 22 prospective cohort studies, and 1 nested case-control study) involving 103,204 predominantly White women (>95%) were included. The pooled relative risk (95% confidence interval) comparing randomization to Mediterranean diet vs a control diet based on 7 randomized controlled trials was 0.74 (0.55-0.99) for gestational diabetes mellitus, 0.45 (0.26-0.76) for preterm birth, 0.71 (0.51-1.00) for gestational hypertension, and 0.82 (0.54-1.22) for preeclampsia; the effect sizes for preterm birth were greater in randomized controlled trials that initiated the interventions in first trimester vs after first trimester (P heterogeneity=.02). We observed inverse associations for all the above-mentioned pregnancy outcomes based on 9 cohort studies. There was suggestive evidence of favorable associations between Mediterranean diet adherence with fertility and gestational weight management. Limited studies suggested associations between higher Mediterranean diet adherence and later time to menarche and fewer vasomotor menopausal symptoms, null associations for polycystic ovary syndrome-like phenotype and pregnancy loss, and positive associations for luteal phase deficiency.

CONCLUSION

Adherence to Mediterranean diet may lower risks of adverse pregnancy outcomes among predominantly White populations. For fertility-related outcomes, available evidence supporting potential beneficial effects is suggestive yet limited. For other reproductive outcomes across the lifespan, data remains sparse.

Association of Maternal Diet with Infant Birthweight in Women with Gestational Diabetes Mellitus

OBJECTIVE

This study aimed to explore the potential impact of pre-pregnancy and early pregnancy maternal nutrition on the incidence of small-for-gestational-age neonates (SGA) in women with gestational diabetes mellitus (GDM).

METHODS

A prospective cohort study was conducted between 2020 and 2022 at the 3rd Department of Obstetrics and Gynaecology (School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece). Pregnant women from routine care were surveyed about their dietary habits during two distinct periods: six months prior to pregnancy (period A) and from the onset of pregnancy until the oral glucose tolerance test at 24-28 gestational weeks (period B). The intake of various micronutrients and macronutrients was quantified from the questionnaire responses. Logistic regression models, adjusted for potential confounders including age, pre-pregnancy body mass index (BMI), smoking status, physical activity and parity, were used to evaluate the association between nutrient intake and small-for-gestational-age neonate incidence.

RESULTS

In total, 850 women were screened and of these, 90 (11%) were diagnosed with gestational diabetes mellitus and were included in the study. There were significant associations between the intake of specific nutrients and the occurrence of small-for-gestational-age neonates; higher fat intake compared to non-small for gestationa age during period B (aOR: 1.1, p = 0.005) was associated with an increased risk for small-for-gestational-age neonates, while lower intake of carbohydrates (g) (aOR: 0.95, p = 0.005), fiber intake (aOR: 0.79, p = 0.045), magnesium (aOR: 0.96, p = 0.019), and copper (aOR:0.01, p = 0.018) intake during period B were significantly associated with a decreased risk for small-for-gestational-age neonates.

CONCLUSIONS

The findings of this study highlight the potential role of maternal nutrition in modulating the risk of small for gestational age neonatesamong women with gestational diabetes mellitus. The results advocate for further research on the assessment and modification of both pre-pregnancy and early pregnancy nutrition for women, especially those at higher risk of gestational diabetes mellitus, to reduce the risk of gestational diabetes mellitus.

Metabolic and feeding adjustments during pregnancy

Eating behaviours are determined by the integration of interoceptive and environmental inputs. During pregnancy, numerous physiological adaptations take place in the maternal organism to provide an adequate environment for embryonic growth. Among them, whole-body physiological remodelling directly influences eating patterns, commonly causing notable taste perception alterations, food aversions and cravings. Recurrent food cravings for and compulsive eating of highly palatable food can contribute to the development and maintenance of gestational overweight and obesity with potential adverse health consequences for the offspring. Although much is known about how maternal eating habits influence offspring health, the mechanisms that underlie changes in taste perception and food preference during pregnancy (which guide and promote feeding) are only just starting to be elucidated. Given the limited and diffuse understanding of the neurobiology of gestational eating patterns, the aim of this Review is to compile, integrate and discuss the research conducted on this topic in both experimental models and humans. This article sheds light on the mechanisms that drive changes in female feeding behaviours during distinct physiological states. Understanding these processes is crucial to improve gestational parent health and decrease the burden of metabolic and food-related diseases in future generations.

Diet quality and nutrient density in pregnant women according to adherence to Mediterranean diet

Background and aims

The dietary pattern followed during pregnancy, specifically healthy dietary patterns such as the Mediterranean diet, is a key factor in the mother's and the offspring's health. Pregnant women dietary intake is not enough to cover the micronutrient requirements of pregnancy, and higher adherence to the Mediterranean diet may improve dietary quality and nutritional density. The aim of the present study was to describe the dietary nutrient intake and diet quality during pregnancy and to evaluate whether a high adherence to Mediterranean diet was associated with a more adequate intake of micronutrients.

Methods

This was a cross-sectional study with 1,356 pregnant women selected during the routine second trimester ultrasound scan (19-23 weeks' gestation). Energy and nutrient intake were calculated using a validated 151-item semi-quantitative food frequency questionnaire and nutrient density was estimated dividing the absolute nutrient intake by total energy intake. Adherence to the Mediterranean diet was evaluated with a 17-item Mediterranean diet adherence score. The criterion used for risk of inadequate nutrient intake has been set below two thirds (2/3) of the dietary reference intakes. The differences were assessed by multivariate linear regression models adjusted for confounders.

Results

A significant proportion of pregnant women had an inadequate intake of macro and micronutrient that was lower in those with high adherence to the Mediterranean diet (≥12 points, n = 122, 19%), including calcium (the Mediterranean diet high adherence 2.5% vs. low adherence 26.7%, p < 0.001), magnesium (0% vs. 7.6%, p = 0.001), iron (24.5% vs. 74.1%, p < 0.001), and vitamin B9 (0% vs. 29.8%, p < 0.001), vitamin C (0% vs. 1.9%, p = 0.033), and vitamin D (61.5% vs. 92.8%, p < 0.001) intake. High adherence to Mediterranean diet was associated with higher intake of protein, monounsaturated fatty acids, fiber, vitamins (B1, B9, C, D), calcium, magnesium, iron, zinc, phosphor, potassium, essential fatty acids, and α-linolenic acid, and with a lower intake of α-linoleic acid and trans fatty acids as compared to low adherence to Mediterranean diet.

Conclusion

High adherence to Mediterranean diet was associated with higher diet quality and lower proportion of inadequate micro and macronutrient intake. The Mediterranean diet promotion, particularly among pregnant women, may be a useful and public health strategy to avoid overweight and nutrient deficiencies.

Effect of a Mediterranean Diet or Mindfulness-Based Stress Reduction During Pregnancy on Child Neurodevelopment: A Prespecified Analysis of the IMPACT BCN Randomized Clinical Trial

Importance

Maternal suboptimal nutrition and high stress levels are associated with adverse fetal and childhood neurodevelopment.

Objective

To test the hypothesis that structured interventions based on a Mediterranean diet or mindfulness-based stress reduction (MBSR) during pregnancy improve child neurodevelopment at age 2 years.

Design, Setting, and Participants

This was a prespecified analysis of the parallel-group Improving Mothers for a Better Prenatal Care Trial Barcelona (IMPACT BCN) randomized clinical trial, which was conducted at a university hospital in Barcelona, Spain, from February 2017 to March 2020. A total of 1221 singleton pregnancies (19 to 23 weeks' gestation) with high risk of delivering newborns who were small for gestational age were randomly allocated into 3 groups: a Mediterranean diet intervention, an MBSR program, or usual care. A postnatal evaluation with the Bayley Scales of Infant and Toddler Development, 3rd Edition (Bayley-III), was performed. Data were analyzed from July to November 2022.

Interventions

Participants in the Mediterranean diet group received monthly individual and group educational sessions and free provision of extra virgin olive oil and walnuts. Those in the stress reduction group underwent an 8-week MBSR program adapted for pregnancy. Individuals in the usual care group received pregnancy care per institutional protocols.

Main Outcomes and Measures

Neurodevelopment in children was assessed by Bayley-III at 24 months of corrected postnatal age.

Results

A total of 626 children (293 [46.8%] female and 333 [53.2%] male) participated at a mean (SD) age of 24.8 (2.9) months. No differences were observed in the baseline characteristics between intervention groups. Compared with children from the usual care group, children in the Mediterranean diet group had higher scores in the cognitive domain (β, 5.02; 95% CI, 1.52-8.53; P = .005) and social-emotional domain (β, 5.15; 95% CI, 1.18-9.12; P = .01), whereas children from the stress reduction group had higher scores in the social-emotional domain (β, 4.75; 95% CI, 0.54-8.85; P = .02).

Conclusions and Relevance

In this prespecified analysis of a randomized clinical trial, maternal structured lifestyle interventions during pregnancy based on a Mediterranean diet or MBSR significantly improved child neurodevelopmental outcomes at age 2 years.

Trial Registration

ClinicalTrials.gov Identifier: NCT03166332.

Can Dietary Patterns Impact Fertility Outcomes? A Systematic Review and Meta-Analysis

There are conflicting results on the effect of diet on fertility. This study aimed to assess the effect of different dietary patterns on fertility outcomes in populations who conceive spontaneously and those requiring assisted reproductive technology (ART). A systematic search and meta-analysis were performed for studies investigating dietary patterns or whole diets in reproductive aged women requiring ART or conceived naturally. Outcomes were live births, pregnancy rates and infertility rates. In amount of 15,396 studies were screened with 11 eligible studies. Ten different diet patterns were grouped broadly into categories: Mediterranean, Healthy or Unhealthy. For the Mediterranean diet, on excluding high risk-of-bias studies (n = 3), higher adherence was associated with improved live birth/pregnancy rates in ART [OR 1.91 (95% CI 1.14-3.19, I² 43%)] (n = 2). Adherence to various Healthy diets was associated with improved ART outcomes (ProFertility diet and Dutch Dietary Guidelines) and natural conception outcomes (Fertility diet). However, due to the variability in Healthy diets' components, results were not pooled. Studies demonstrated preliminary evidence for the role of dietary patterns or whole diets in improving pregnancy and live birth rates. However, due to heterogeneity across the literature it is currently unclear which diet patterns are associated with improvements in fertility and ART outcomes.

Effects of a Mediterranean Diet Intervention on Maternal Stress, Well-Being, and Sleep Quality throughout Gestation-The IMPACT-BCN Trial

Stress and anxiety are frequent occurrences among pregnant women. We aimed to evaluate the effects of a Mediterranean diet intervention during pregnancy on maternal stress, well-being, and sleep quality throughout gestation. In a randomized clinical trial, 1221 high-risk pregnant women were randomly allocated into three groups at 19-23 weeks' gestation: a Mediterranean diet intervention, a Mindfulness-Based Stress Reduction program, or usual care. All women who provided self-reported life-style questionnaires to measure their anxiety (State Trait Anxiety Inventory (STAI), Perceived Stress Scale (PSS)), well-being (WHO Five Well Being Index (WHO-5)), and sleep quality (Pittsburgh sleep quality index (PSQI)) at enrollment and at the end of the intervention (34-36 weeks) were included. In a random subgroup of 106 women, the levels of cortisol and related metabolites were also measured. At the end of the intervention (34-36 weeks), participants in the Mediterranean diet group had significantly lower perceived stress and anxiety scores (PSS mean (SE) 15.9 (0.4) vs. 17.0 (0.4), p = 0.035; STAI-anxiety mean (SE) 13.6 (0.4) vs. 15.8 (0.5), p = 0.004) and better sleep quality (PSQI mean 7.0 ± 0.2 SE vs. 7.9 ± 0.2 SE, p = 0.001) compared to usual care. As compared to usual care, women in the Mediterranean diet group also had a more significant increase in their 24 h urinary cortisone/cortisol ratio during gestation (mean 1.7 ± SE 0.1 vs. 1.3 ± SE 0.1, p < 0.001). A Mediterranean diet intervention during pregnancy is associated with a significant reduction in maternal anxiety and stress, and improvements in sleep quality throughout gestation.

Effect of Adherence to the Mediterranean Diet on Maternal Iron Related Biochemical Parameters during Pregnancy and Gestational Weight Gain

Gestation is a crucial life stage for both women and offspring, and outcomes are affected by many environmental factors, including diet. The Mediterranean dietary pattern (MD) is considered a healthy eating pattern that can provide the nutritional requirements of pregnancy. Meanwhile, iron deficiency anemia is one of the most frequent complications related to pregnancy. This study aimed to evaluate how the level of adherence to the MD influences maternal gestational weight gain and specific iron-related maternal biochemical parameters during the pregnancy. Accordingly, an observational, population-based study using data from pregnant women conducted over the entire course of their pregnancy was carried out. Adherence to the MD was assessed once using the MEDAS score questionnaire. Of the 506 women studied, 116 (22.9%) were classified as demonstrating a high adherence, 277 (54.7%) a medium adherence, and 113 (22.3%) a low adherence to the MD. No differences were observed in gestational weight gain among the MD adherence groups but the adequacy of weight gain did vary among the groups, with the proportions of inadequate (insufficient or excessive) weight gain presenting the most notable differences. Total anemia prevalence was 5.3%, 15.6%, and 12.3%, respectively, during the first, second, and third trimesters. For iron-related biochemical parameters, no differences are observed among the adherence groups during pregnancy. With high adherence to the MD as the reference group, the crude odds of iron deficiency diagnosis are significant in the first trimester for both the medium [OR = 2.99 (1.55-5.75)] and low [OR = 4.39 (2.15-8.96)] adherence groups, with deficient adherence to the Mediterranean dietary pattern being responsible for 66.5% (35.5-82.6) and 77.2% (53.5-88.8) of the risk of iron deficiency diagnosis for medium and low adherence, respectively. However, adjusted odds ratios were not significant, possibly due to the small sample size. Our data suggest that MD adherence could be related to gestational weight gain adequacy and that optimal adherence could reduce iron deficiency and/or anemia during pregnancy in the studied population.

The Interplay between Maternal Nutrition and Oxidative Stress

This Special Issue of Nutrients, "The Interplay between Maternal Nutrition and Oxidative Stress", was designed to contribute to our understanding of "oxidative stress" in pregnancy [...].

Relationship between the Mediterranean Diet Score in Pregnancy and the Incidence of Asthma at 4 Years of Age: The Japan Environment and Children's Study

Several scoring methods for the Mediterranean diet, which is considered as a healthy diet, are available, but studies that have compared more than one of these scores are rare. In addition, the applicability of Mediterranean diet scoring has not been sufficiently examined outside of Mediterranean regions. We collected data on the Mediterranean diet during pregnancy and the incidence of type 1 allergies in offspring from the Japan Environment and Children's Study. Using multiple Mediterranean diet scoring methods, we analyzed the effect of adherence to the Mediterranean diet in pregnancy on the allergies of the offspring. Overall, 46,532 pairs of mothers and children were analyzed. In Japan, a high adherence to the Mediterranean diet during pregnancy was associated with a lower incidence of asthma in the offspring (odds ratio: 0.896, 95% confidence interval: 0.835, 0.962). Furthermore, we found that the selection of the Mediterranean diet scoring method and the setting of the reference value significantly altered the results. Our findings suggest that an appropriate selection of scoring methods and a reference value for food items are important to analyze the effects of adherence to the Mediterranean diet inside and outside of Mediterranean regions.

Maternal Dietary Inflammatory Potential and Offspring Birth Outcomes in a Chinese Population

BACKGROUND

Chronic inflammation perturbations during pregnancy may impact fetal growth; however, research on the association between dietary inflammation and birth outcomes is limited and inconsistent.

OBJECTIVES

This study seeks to assess whether the dietary inflammatory potential is related to birth outcomes among pregnant women in China.

METHODS

A total of 7194 mothers aged 17-46 y and their infants in China were included in this cross-sectional study. Dietary intake was assessed by a FFQ, which yielded scores on the energy-adjusted dietary inflammatory index (E-DII). Birth outcomes included birth weight, gestational age, birth weight z score, low birth weight (LBW), macrosomia, preterm birth, small-for-gestational-age (SGA), large-for-gestational-age (LGA), and birth defects. Generalized estimating equation and restricted cubic spline fit each outcome on continuous or quartiles of E-DII after adjusting for covariates.

RESULTS

The maternal E-DII ranged from -5.35 to 6.77. Overall, birth weight and gestation age (mean ± SD) were 3267.9 ± 446.7 g and 39.6 ± 1.3 wk, respectively, and the birth weight z score was 0.02 ± 1.14. A total of 3.2% of infants were born with LBW, 6.1% with macrosomia, 3.0% were preterm birth, 10.7% were born SGA, 10.0% were born LGA, and 2.0% were born with birth defects. E-DII was associated with a 9.8 g decrease in birth weight (95% CI: -16.9, -2.6) and a 1.09-fold (95% CI: 1.01, 1.18), 1.11-fold (95% CI: 1.02, 1.21), and 1.12-fold (95% CI: 1.02, 1.24) greater risk of LBW, preterm birth, and birth defects, respectively. The maternal E-DII score was nonlinearly associated with gestational age (P for linearity = 0.009, P for curvature = 0.044).

CONCLUSIONS

Among pregnant Chinese women, proinflammatory diets during pregnancy were related to reduced offspring birth weight and an increased risk of LBW, preterm birth, and birth defects. These findings might inform potential prevention strategies for pregnant women in China.

An automatic pipeline for atlas-based fetal and neonatal brain segmentation and analysis

BACKGROUND AND OBJECTIVE

The automatic segmentation of perinatal brain structures in magnetic resonance imaging (MRI) is of utmost importance for the study of brain growth and related complications. While different methods exist for adult and pediatric MRI data, there is a lack for automatic tools for the analysis of perinatal imaging.

METHODS

In this work, a new pipeline for fetal and neonatal segmentation has been developed. We also report the creation of two new fetal atlases, and their use within the pipeline for atlas-based segmentation, based on novel registration methods. The pipeline is also able to extract cortical and pial surfaces and compute features, such as curvature, local gyrification index, sulcal depth, and thickness.

RESULTS

Results show that the introduction of the new templates together with our segmentation strategy leads to accurate results when compared to expert annotations, as well as better performances when compared to a reference pipeline (developing Human Connectome Project (dHCP)), for both early and late-onset fetal brains.

CONCLUSIONS

These findings show the potential of the presented atlases and the whole pipeline for application in both fetal, neonatal, and longitudinal studies, which could lead to dramatic improvements in the understanding of perinatal brain development.

Maternal hemodynamic profile during pregnancy and in the post-partum in hypertensive disorders of pregnancy and fetal growth restriction

BACKGROUND

Maternal cardiovascular changes, occurring since the beginning of pregnancy, are necessary for normal placentation and regular evolution of pregnancy.

OBJECTIVE

This study aimed to compare the hemodynamic profiles and cardiac remodeling of women with hypertensive disorders of pregnancy and either appropriate for gestational age fetuses or growth-restricted fetuses, women with normotensive pregnancies complicated by fetal growth restriction, and women with uncomplicated pregnancies, during pregnancy and the postpartum period.

STUDY DESIGN

A prospective longitudinal case-control design was used for this study. Over the study period, 220 eligible women with singleton pregnancies were selected for the analysis and divided into 4 groups: (1) hypertensive disorders of pregnancy with appropriate for gestational age fetuses; (2) hypertensive disorders of pregnancy with fetal growth restriction; (3) normotensive fetal growth restriction; and (4) controls. Ultrasound fetal biometry and fetoplacental Doppler velocimetry were performed at recruitment. Maternal hemodynamic assessment using transthoracic echocardiography was performed at the time of recruitment by a dedicated cardiologist blinded to maternal clinical data. The same assessments were performed in 104 patients at 32 weeks (interquartile range, 24-40) after delivery by the same cardiologist.

RESULTS

During pregnancy, women in the hypertensive-disorders-of-pregnancy-fetal-growth-restriction group showed significantly lower cardiac output and increased compared with those in the control group. These values were associated with concentric remodeling of the left ventricle owing to relatively increased wall thickness, which was not accompanied by an increase in left ventricular mass. Isolated fetal growth restriction presented similar but less important hemodynamic changes; however, there was no change in relative wall thickness. At postpartum follow-up, the hemodynamic parameters of women in the hypertensive-disorders-of-pregnancy-fetal-growth-restriction and isolated-fetal-growth-restriction groups reverted to values similar to those of the control group. Only 8.3% of women in these groups experienced hypertension even in the postpartum period, and asymptomatic stage-B cardiac failure was observed for 17% at echocardiography. In the group of women with hypertensive disorders of pregnancy and appropriate for gestational age fetuses, cardiac output increased as in normal pregnancies, but total vascular resistance was significantly higher; hypertension then occurred, along with ventricular concentric hypertrophy and diastolic dysfunction. At postpartum follow-up, women in the hypertensive-disorders-of-pregnancy-appropriate-for-gestational-age-fetus group showed significantly higher mean arterial pressure, total vascular resistance, and left ventricular mass compared with those in the control group. Persistent hypertension and asymptomatic stage-B cardiac failure were observed in 39.1% and 13% of women in the former group, respectively.

CONCLUSION

Pregnancies with hypertensive disorders of pregnancy and fetal growth restriction and normotensive pregnancies with fetal growth restriction were associated with the hemodynamic profile of lower heart rate and cardiac output, most likely because of abnormal adaptation to pregnancy, as confirmed by abnormal changes from pregnancy to the postpartum period. The heart rates and cardiac output of women in the hypertensive-disorders-of-pregnancy-appropriate-for-gestational-age-fetus group showed changes opposite to those observed in the hypertensive-disorders-of-pregnancy-fetal-growth-restriction and fetal-growth-restriction groups. Obesity and other metabolic risk factors, significantly prevalent in women in the hypertensive-disorders-of-pregnancy-appropriate-for-gestational-age-fetus group, predispose to hypertension and cardiovascular diseases during pregnancy and the postpartum period, potentially offering a window for personalized prevention. Such preventive strategies could differ in women with hypertensive disorders of pregnancy and fetal growth restriction characterized by poor early placental development.

Cardiac remodeling from the fetus to adulthood

Prenatal cardiac remodeling refers to in utero changes in the fetal heart that occur as a response to an adverse intrauterine environment. In this article, we will review the main mechanisms leading to cardiac remodeling and dysfunction, summarizing and describing the major pathological conditions that have been reported to be related to this in utero plastic adaptive process. We will also recap the current evidence regarding the persistence of fetal cardiac remodeling and dysfunction, both in infancy and later in adult life. Moreover, we will discuss primary, secondary, and tertiary preventive measures and future clinical and research aspects.

Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders: A Randomized Clinical Trial

Importance

Anxiety disorders are common, highly distressing, and impairing conditions. Effective treatments exist, but many patients do not access or respond to them. Mindfulness-based interventions, such as mindfulness-based stress reduction (MBSR) are popular and can decrease anxiety, but it is unknown how they compare to standard first-line treatments.

Objective

To determine whether MBSR is noninferior to escitalopram, a commonly used first-line psychopharmacological treatment for anxiety disorders.

Design, Setting, and Participants

This randomized clinical trial (Treatments for Anxiety: Meditation and Escitalopram [TAME]) included a noninferiority design with a prespecified noninferiority margin. Patients were recruited between June 2018 and February 2020. The outcome assessments were performed by blinded clinical interviewer at baseline, week 8 end point, and follow-up visits at 12 and 24 weeks. Of 430 individuals assessed for inclusion, 276 adults with a diagnosed anxiety disorder from 3 urban academic medical centers in the US were recruited for the trial, and 208 completed the trial.

Interventions

Participants were 1:1 randomized to 8 weeks of the weekly MBSR course or the antidepressant escitalopram, flexibly dosed from 10 to 20 mg.

Main Outcomes and Measures

The primary outcome measure was anxiety levels as assessed with the Clinical Global Impression of Severity scale (CGI-S), with a predetermined noninferiority margin of -0.495 points.

Results

The primary noninferiority sample consisted of 208 patients (102 in MBSR and 106 in escitalopram), with a mean (SD) age of 33 (13) years; 156 participants (75%) were female; 32 participants (15%) were African American, 41 (20%) were Asian, 18 (9%) were Hispanic/Latino, 122 (59%) were White, and 13 (6%) were of another race or ethnicity (including Native American or Alaska Native, more than one race, or other, consolidated owing to low numbers). Baseline mean (SD) CGI-S score was 4.44 (0.79) for the MBSR group and 4.51 (0.78) for the escitalopram group in the per-protocol sample and 4.49 (0.77) vs 4.54 (0.83), respectively, in the randomized sample. At end point, the mean (SD) CGI-S score was reduced by 1.35 (1.06) for MBSR and 1.43 (1.17) for escitalopram. The difference between groups was -0.07 (0.16; 95% CI, -0.38 to 0.23; P = .65), where the lower bound of the interval fell within the predefined noninferiority margin of -0.495, indicating noninferiority of MBSR compared with escitalopram. Secondary intent-to-treat analyses using imputed data also showed the noninferiority of MBSR compared with escitalopram based on the improvement in CGI-S score. Of patients who started treatment, 10 (8%) dropped out of the escitalopram group and none from the MBSR group due to adverse events. At least 1 study-related adverse event occurred for 110 participants randomized to escitalopram (78.6%) and 21 participants randomized to MBSR (15.4%).

Conclusions and Relevance

The results from this randomized clinical trial comparing a standardized evidence-based mindfulness-based intervention with pharmacotherapy for the treatment of anxiety disorders found that MBSR was noninferior to escitalopram.

Trial Registration

ClinicalTrials.gov Identifier: NCT03522844.

Systematic Review and Critical Evaluation of Quality of Clinical Practice Guidelines on Nutrition in Pregnancy

Objective: To report the quality and clinical heterogeneity of the published clinical practice guidelines (CPGs) on nutrition in pregnancy. Methods: MEDLINE, Embase, Scopus, and ISI Web of Science databases were searched. The following aspects related to nutrition in pregnancy were addressed: specific requirements during pregnancy, description of a balanced diet, weight gain, prevention of food-borne, nutrition in peculiar sub-groups of women, and maternal or perinatal outcomes. The assessment of the risk of bias and quality assessment of the included CPGs were performed using “The Appraisal of Guidelines for REsearch and Evaluation (AGREE II)” tool divided in six quality domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, editorial independence. Mean ± standard deviation (SD) was used to summarize the scores across all the guidelines per domain. The quality of each guideline was computed using the scoring system proposed by Amer et al. A cut-off of >60% was sued to define a CGP as recommended. Results: Eighteen CPGs were included. There was a substantial heterogeneity in the recommended dose for vitamins, folic acid, and micronutrient intake during pregnancy among the different published CPGs. 27.8% (5/18) of the CPGs recommended a daily intake of folic acid of 200 mcg, 38.8% (7/18) 400 mcg, 16.7% (3/18) 600 mcg while the remaining CPGs suggested dose between 400 and 600−800 mc per day. Adequate maternal hydration was advocated in the large majority of included CPGs, but a specific amount of water intake was not reported in 83.3% (15/18) cases. There was also significant heterogeneity in various other aspects of nutrition recommendation among the different CPGs, including gestational weight gain (55.5%), prevention of food-borne diseases in pregnancy (72.2%), nutrition in particular groups of pregnant women (83.3%), maternal and perinatal outcomes (72.2%). The AGREE II standardized domain scores for the first overall assessment (OA1) had a mean of 65% but only half scored more than 60%. Conclusion: The published CPGs on nutrition in pregnancy show an overall good methodology, but also a substantial heterogeneity as regard as different major aspects on nutrition in pregnancy.

Association of a Mediterranean Diet Pattern With Adverse Pregnancy Outcomes Among US Women

Importance

The Mediterranean diet pattern is inversely associated with the leading causes of morbidity and mortality, including metabolic diseases and cardiovascular disease, but there are limited data on its association with adverse pregnancy outcomes (APOs) among US women.

Objective

To evaluate whether concordance to a Mediterranean diet pattern around the time of conception is associated with lower risk of developing any APO and individual APOs.

Design, Setting, and Participants

This prospective, multicenter, cohort study, the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be, enrolled 10 038 women between October 1, 2010, and September 30, 2013, with a final analytic sample of 7798 racially, ethnically, and geographically diverse women with singleton pregnancies who had complete diet data. Data analyses were completed between June 3, 2021, and April 7, 2022.

Exposures

An Alternate Mediterranean Diet (aMed) score (range, 0-9; low, 0-3; moderate, 4-5; and high, 6-9) was computed from data on habitual diet in the 3 months around conception, assessed using a semiquantitative food frequency questionnaire.

Main Outcomes and Measures

Adverse pregnancy outcomes were prospectively ascertained and defined as developing 1 or more of the following: preeclampsia or eclampsia, gestational hypertension, gestational diabetes, preterm birth, delivery of a small-for-gestational-age infant, or stillbirth.

Results

Of 7798 participants (mean [SD] age, 27.4 [5.5] years), 754 (9.7%) were aged 35 years or older, 816 (10.5%) were non-Hispanic Black, 1294 (16.6%) were Hispanic, and 1522 (19.5%) had obesity at baseline. The mean (SD) aMed score was 4.3 (2.1), and the prevalence of high, moderate, and low concordance to a Mediterranean diet pattern around the time of conception was 30.6% (n=2388), 31.2% (n=2430), and 38.2% (n=2980), respectively. In multivariable models, a high vs low aMed score was associated with 21% lower odds of any APO (adjusted odds ratio [aOR], 0.79 [95% CI, 0.68-0.92]), 28% lower odds of preeclampsia or eclampsia (aOR, 0.72 [95% CI, 0.55-0.93]), and 37% lower odds of gestational diabetes (aOR, 0.63 [95% CI, 0.44-0.90]). There were no differences by race, ethnicity, and prepregnancy body mass index, but associations were stronger among women aged 35 years or older (aOR, 0.54 [95% CI, 0.34-0.84]; P = .02 for interaction). When aMed score quintiles were evaluated, similar associations were observed, with higher scores being inversely associated with the incidence of any APO.

Conclusions and Relevance

This cohort study suggests that greater adherence to a Mediterranean diet pattern is associated with lower risk of APOs, with evidence of a dose-response association. Intervention studies are needed to assess whether dietary modification around the time of conception can reduce risk of APOs and their downstream associations with future development of cardiovascular disease risk factors and overt disease.

Pre-pregnancy check-up of maternal vascular status and associated phenotype is crucial for the health of mother and offspring

Abstract

Cardiovascular disease remains the leading cause of disease burden globally with far-reaching consequences including enormous socio-economic burden to healthcare and society at large. Cardiovascular health is decisive for reproductive function, healthy pregnancy and postpartum. During pregnancy, maternal cardiovascular system is exposed to highly increased haemodynamic stress that significantly impacts health status of the mother and offspring. Resulting from sub-optimal maternal health conditions overlooked in pre-pregnancy time, progressive abnormalities can be expected during pregnancy and postpartum. Contextually, there are two main concepts to follow in the framework of predictive, preventive and personalised medicine, namely to develop:

1. advanced screening of sub-optimal health conditions in young populations to predict and prevent individual health risks prior to planned pregnancies

2. in-depth companion diagnostics during pregnancy to predict and prevent long-lasting postpartum health risks of the mother and offspring.

Data collected in the current study demonstrate group-specific complications to health of the mother and offspring and clinical relevance of the related phenotyping in pre-pregnant mothers. Diagnostic approach proposed in this study revealed its great clinical utility demonstrating important synergies between cardiovascular maladaptation and connective tissue dysfunction. Co-diagnosed pre-pregnancy low BMI of the mother, connective tissue dysfunction, increased stiffness of peripheral vessels and decreased blood pressure are considered a highly specific maternal phenotype useful for innovative screening programmes in young populations to predict and prevent severe risks to health of the mother and offspring. This crucial discovery brings together systemic effects characteristic, for example, for individuals with Flammer syndrome predisposed to the phenotype-specific primary vascular dysregulation, pregnancy-associated risks, normal tension glaucoma, ischemic stroke at young age, impaired wound healing and associated disorders. Proposed maternal phenotyping is crucial to predict and effectively protect both the mother and offspring against health-to-disease transition. Pre-pregnancy check-up focused on sub-optimal health and utilising here described phenotypes is pivotal for advanced health policy.

Plain English abstract

Cardiovascular health is decisive for reproductive function and healthy pregnancy. During pregnancy, maternal cardiovascular system may demonstrate health-to-disease transition relevant for the affected mother and offspring. Overlooked in pre-pregnancy time, progressive abnormalities can be expected during pregnancy and lifelong. Here we co-diagnosed maternal pre-pregnancy low bodyweight with systemic effects which may increase risks of pregnancy, eye and heart disorders and ischemic stroke at young age, amongst others. Innovative screening  programmes focused on sub-optimal health in young populations to predict and to mitigate individual health risks prior to pregnancy is an essential innovation for health policy proposed.

Adherence to Mediterranean Diet and Its Association with Maternal and Newborn Outcomes

Background: Pregnancy is a crucial stage in a woman’s life and can be affected by epigenetic and environmental factors. Diet also plays a key role in gestation. This study aimed to evaluate how a greater or lesser adherence to the Mediterranean Diet (MD) influences specific parameters of mother and newborn. Methods: After delivery, the women participating in the study answered a questionnaire: demographic information; anthropometric data (pre-pregnancy weight, height, and gestational weight gain); dietary habits information (adherence to MD before and during pregnancy, using the validated Mediterranean Diet Adherence Screener (MEDAS), quality of protein intake); pregnancy information (onset of complications, cesarean/vaginal delivery, gestational age at birth, birth weight, birth length); and clinical practitioner for personalized dietary patterns during pregnancy. Results: A total of 501 respondents have been included in the study, and 135 were excluded for complications. Women who followed the advice of clinical nutritionists showed better adherence to MD (p = 0.02), and the baby’s birth weight was higher (p = 0.02). Significant differences in gestational weight gain (p < 0.01) between groups with dissimilar diet adherence were demonstrated. Conclusion: Our data demonstrate a significant relationship between adherence to MD and birthweight.

Mediterranean Diet in Developmental Age: A Narrative Review of Current Evidences and Research Gaps

Numerous studies in recent decades have shown that Mediterranean diet (MD) can reduce the risk of developing obesity in pediatric patients. The current narrative review summarizes recent evidence regarding the impact of MD across the different stages of child development, starting from fetal development, analyzing breastfeeding and weaning, through childhood up to adolescence, highlighting the gaps in knowledge for each age group. A literature search covering evidence published between 1 January 2000 and 1 March 2022 and concerning children only was conducted using multiple keywords and standardized terminology in PubMed database. A lack of scientific evidence about MD adherence concerns the age group undergoing weaning, thus between 6 months and one year of life. In the other age groups, adherence to MD and its beneficial effects in terms of obesity prevention has been extensively investigated, however, there are still few studies that correlate this dietary style with the incidence of non-communicable diseases. Furthermore, research on multi-intervention strategy should be implemented, especially regarding the role of education of children and families in taking up this healthy dietary style.

Maternal Dietary Inflammatory Index during Pregnancy Is Associated with Perinatal Outcomes: Results from the IMPACT BCN Trial

The information available on the effects of maternal dietary habits on systemic inflammation and adverse maternal outcomes is limited. We aimed to evaluate whether Dietary Inflammatory Index (DII) score during pregnancy is associated with maternal body mass index (BMI), Mediterranean diet (MD) adherence, and perinatal outcomes. At 19−23 weeks’ gestation, 1028 pregnant women were recruited. Dietary information was assessed using a 17-item dietary score to evaluate MD adherence and a validated 151-item food frequency questionnaire. DII score was established according to 33 food and nutritional proinflammatory and anti-inflammatory items. Participants were distributed into tertiles according to the DII score, where a lower DII score (first tertile) represented an anti-inflammatory diet and the third tertile represented the more proinflammatory diet. Maternal characteristics and perinatal outcomes were collected, and newborns’ birthweight percentiles were calculated. Adjusted logistic regression models were used to assess the association of the DII score with maternal and perinatal characteristics, setting the third tertile as the reference group. Women in the third tertile showed lower adherence to MD score compared to the first tertile: median (25th to 75th percentile) 9 (7 to 11) vs. 6 (4.25 to 8), p < 0.001. The proinflammatory diet was significantly associated with a higher maternal pre-pregnancy BMI (adjusted β = 0.88; 95% CI: 0.31 to 1.45) and lower newborn’s birthweight percentile (adjusted β = −9.84th; 95% CI: −19.6 to −0.12). These data show that a proinflammatory diet profile may be associated with maternal overweight and fetal undergrowth.

Comment on Yeste et al. Polyphenols and IUGR Pregnancies: Intrauterine Growth Restriction and Hydroxytyrosol Affect the Development and Neurotransmitter Profile of the Hippocampus in a Pig Model. Antioxidants 2021, 10, 1505

Intrauterine growth restriction (IUGR) affects 5–10% of newborns and increases the risks of intrauterine demise, neonatal morbidity, and death. In their recent publication, Yeste et al. found the benefits of hydroxytyrosol supplementation on brain remodeling from an IUGR pig model. Additionally, we found a significant decrease in phenolic alcohol (tyrosol and hydroxytyrosol) intake in IUGR pregnant women. Altogether, these findings support the notion that dietetic interventions, through supplementation but mostly via a balanced diet, can ameliorate IUGR complications. Furthermore, diet intervention combined with early biomarkers may allow clinicians to eventually anticipate IUGR diagnosis and help avoid one of the most frequent causes of newborn mortality and morbidity.

Perinatal Origins of Adult Disease and Opportunities for Health Promotion: A Narrative Review

The “developmental origins of health and disease” (DOHaD) hypothesis refers to the influence of early developmental exposures and fetal growth on the risk of chronic diseases in later periods. During fetal and early postnatal life, cell differentiation and tissue formation are influenced by several factors. The interaction between genes and environment in prenatal and early postnatal periods appears to be critical for the onset of multiple diseases in adulthood. Important factors influencing this interaction include genetic predisposition, regulation of gene expression, and changes in microbiota. Premature birth and intrauterine growth restriction (IUGR) are other important factors considered by the DOHaD hypothesis. Preterm birth is associated with impaired or arrested structural or functional development of key organs/systems, making preterm infants vulnerable to cardiovascular, respiratory, and chronic renal diseases during adulthood. Growth restriction, defined as impaired fetal growth compared to expected biological potential in utero, is an additional negative factor increasing the risk of subsequent diseases. Environmental factors implicated in the developmental programming of diseases include exposure to pollution, stress, drugs, toxic agents, nutrition, and exercise. The DOHaD may explain numerous conditions, including cardiovascular, metabolic, respiratory, neuropsychiatric, and renal diseases. Potential antenatal and postnatal preventive measures, interventions, and future directions are discussed.

Highlighting the trajectory from intrauterine growth restriction to future obesity

During the last decades several lines of evidence reported the association of an adverse intrauterine environment, leading to intrauterine restriction, with future disease, such as obesity and metabolic syndrome, both leading to increased cardiovascular and cancer risk. The underlying explanation for this association has firstly been expressed by the Barker's hypothesis, the "thrifty phenotype hypothesis". According to this hypothesis, a fetus facing an adverse intrauterine environment adapts to this environment through a reprogramming of its endocrine-metabolic status, during the crucial window of developmental plasticity to save energy for survival, providing less energy and nutrients to the organs that are not essential for survival. This theory evolved to the concept of the developmental origin of health and disease (DOHaD). Thus, in the setting of an adverse, f. ex. protein restricted intrauterine environment, while the energy is mainly directed to the brain, the peripheral organs, f.ex. the muscles and the liver undergo an adaptation that is expressed through insulin resistance. The adaptation at the hepatic level predisposes to future dyslipidemia, the modifications at the vascular level to endothelial damage and future hypertension and, overall, through the insulin resistance to the development of metabolic syndrome. All these adaptations are suggested to take place through epigenetic modifications of the expression of genes without change of their amino-acid sequence. The epigenetic modifications leading to future obesity and cardiovascular risk are thought to induce appetite dysregulation, promoting food intake and adipogenesis, facilitating obesity development. The epigenetic modifications may even persist into the next generation even though the subsequent generation has not been exposed to an adverse intrauterine environment, a notion defined as the "transgenerational transfer of environmental information". As a consequence, if the increased public health burden and costs of non-communicable chronic diseases such as obesity, hypertension, metabolic syndrome and type 2 diabetes have to be minimized, special attention should be laid to the healthy lifestyle habits of women of reproductive age, including healthy diet and physical activity to be established long before any pregnancy takes place in order to provide the best conditions for both somatic and mental health of future generations.