Effect of a cholesterol-lowering diet on maternal, cord, and neonatal lipids, and pregnancy outcome: a randomized clinical trial

Dyslipidemia characterized by low density lipoprotein cholesterol and risk of preterm Birth: A Mendelian randomization study

BACKGROUND

Preterm birth is the leading cause of neonatal mortality worldwide, and dyslipidemia is associated with preterm birth in observational studies. We use Mendelian randomization (MR) analyses to uncover the causal association between blood lipid levels and preterm birth.

METHODS

We extracted uncorrelated (R2 < 0.001) single-nucleotide polymorphisms strongly associated (p < 5 × 10-8) with blood lipids from genome wide association studies of FinnGen database and UK Biobank participants. Inverse variance weighted method was the main MR analysis. Sensitivity analyses including genetic pleiotropy, heterogeneity, and directionality of causality were conducted.

RESULTS

The study included 115,082 participants with lipid measurements, 8,507 patients with preterm birth. Increasing apolipoprotein B (odds ratio (OR), 1.12[95 % CI, 1.02-1.23]; p = 0.019), low-density lipoprotein cholesterol (OR, 1.11[95 % CI, 1.00-1.22]; p = 0.040), non-high-density lipoprotein cholesterol (OR, 1.12[95 % CI, 1.01-1.24]; p = 0.026), remnant cholesterol (OR, 1.11[95 % CI, 1.00-1.23]; p = 0.047) and total free cholesterol (OR, 1.11[95 % CI, 1.01-1.23]; p = 0.037) were associated with increased risk of preterm delivery. Moreover, triglycerides in low-density lipoprotein were causally associated with the risk of PTB. Our sensitivity analysis yielded robust results, uncovering no evidence of horizontal pleiotropy or reverse causal relationships.

CONCLUSION

Our investigation unveils the adverse impact of dyslipidemia on preterm birth, with a particular emphasis on the detrimental effect of elevated low-density lipoprotein cholesterol.

Lipid metabolism during pregnancy: consequences for mother and child

PURPOSE OF REVIEW

Accommodating fetal growth and development, women undergo multiple physiological changes during pregnancy. In recent years, several studies contributed to the accumulating evidence about the impact of gestational hyperlipidemia on cardiovascular risk for mother and child. This review aims to provide a comprehensive overview of the current research on lipid profile alterations during pregnancy and its associated (cardiovascular) outcomes for mother and child from a clinical perspective.

RECENT FINDINGS

In a normal pregnancy, total and LDL-cholesterol levels increase by approximately 30-50%, HDL-cholesterol by 20-40%, and triglycerides by 50-100%. In some women, for example, with familial hypercholesterolemia (FH), a more atherogenic lipid profile is observed. Dyslipidemia during pregnancy is found to be associated with adverse (cardiovascular) outcomes for the mother (e.g. preeclampsia, gestational diabetes, metabolic syndrome, unfavorable lipid profile) and for the child (e.g. preterm birth, large for gestational age, preatherosclerotic lesions, unfavorable lipid profile).

SUMMARY

The lipid profile of women during pregnancy provides a unique window of opportunity into the potential future cardiovascular risk for mother and child. Better knowledge about adverse outcomes and specific risk groups could lead to better risk assessment and earlier cardiovascular prevention. Future research should investigate implementation of gestational screening possibilities.

Rethinking causal assumptions about maternal BMI, gestational weight gain, and adverse pregnancy outcomes

BACKGROUND

The aim of this study was to evaluate commonly assumed causal relationships between body mass index (BMI), gestational weight gain (GWG), and adverse pregnancy outcomes, which have formed the basis of guidelines and interventions aimed at limiting GWG in women with overweight or obesity. We explored relationships between maternal BMI, total GWG (as a continuous variable and as 'excessive' GWG), and pregnancy outcomes (including infant birthweight measures and caesarean birth).

METHODS

Analysis of individual participant data (IPD) from the i-WIP (International Weight Management in Pregnancy) Collaboration, from randomised trials of diet and/or physical activity interventions during pregnancy reporting GWG and maternal and neonatal outcomes. Women randomised to the control arm of 20 eligible randomised trials (4370 of 8908 participants) from the i-WIP dataset of 36 randomised trials (total 12,240 women). The main research questions were to characterise the relationship between maternal BMI and (a) total GWG, (b) the risk of 'excessive' GWG (using the Institute of Medicine's guidelines), and (c) adverse pregnancy outcomes as mediated via GWG versus other pathways to determine the extent to which the observed effect of maternal BMI on pregnancy outcomes is mediated via GWG. We utilised generalised linear models and regression-based mediation analyses within an IPD meta-analysis framework.

RESULTS

Mean GWG decreased linearly as maternal BMI increased; however, the risk of 'excessive' GWG increased markedly at BMI category thresholds (i.e. between the normal and overweight BMI category threshold and between the overweight and obese BMI category threshold). Increasing maternal BMI was associated with increased risk of all pregnancy outcomes assessed; however, there was no evidence that this effect was mediated via effects on GWG.

CONCLUSIONS

There is evidence of a meaningful relationship between maternal BMI and GWG and between maternal BMI and adverse pregnancy outcomes. There is no evidence that the effect of maternal BMI on outcomes is via an effect on GWG. Our analyses also cast doubt on the existence of a relationship between 'excessive' GWG and adverse pregnancy outcomes. Our findings challenge the practice of actively managing GWG throughout pregnancy.

Bioactive metabolites of OMEGA-6 and OMEGA-3 fatty acids are associated with inflammatory cytokine concentrations in maternal and infant plasma at the time of delivery

BACKGROUND & AIMS

Inflammation is necessary for a healthy pregnancy. However, unregulated or excessive inflammation during pregnancy is associated with severe maternal and infant morbidities, such as pre-eclampsia, abnormal infant neurodevelopment, or preterm birth. Inflammation is regulated in part by the bioactive metabolites of omega-6 (n-6) and omega-3 (n-3) fatty acids (FAs). N-6 FAs have been shown to promote pro-inflammatory cytokine environments in adults, while n-3 FAs have been shown to contribute to the resolution of inflammation; however, how these metabolites affect maternal and infant inflammation is still uncertain. The objective of this study was to predict the influence of n-6 and n-3 FA metabolites on inflammatory biomarkers in maternal and umbilical cord plasma at the time of delivery.

METHODS

Inflammatory biomarkers (IL-1β, IL-2, IL-6, IL-8, IL-10, and TNFα) for maternal and umbilical cord plasma samples in 39 maternal-infant dyads were analyzed via multi-analyte bead array. Metabolites of n-6 FAs (arachidonic acid and linoleic acid) and n-3 FAs (eicosapentaenoic acid and docosahexaenoic acid) were assayed via liquid chromatography-mass spectrometry. Linear regression models assessed relationships between maternal and infant inflammatory markers and metabolite plasma concentrations.

RESULTS

Increased plasma concentrations of maternal n-6 metabolites were predictive of elevated pro-inflammatory cytokine concentrations in mothers; similarly, higher plasma concentrations of umbilical cord n-6 FA metabolites were predictive of elevated pro-inflammatory cytokine concentrations in infants. Higher plasma concentrations of maternal n-6 FA metabolites were also predictive of elevated pro-inflammatory cytokines in infants, suggesting that maternal n-6 FA status has an intergenerational impact on the inflammatory status of the infant. In contrast, maternal and cord plasma concentrations of n-3 FA metabolites had a mixed effect on inflammatory status in mothers and infants, which may be due to the inadequate maternal dietary intake of n-3 FAs in our study population.

CONCLUSIONS

Our results reveal that maternal FA status may have an intergenerational impact on the inflammatory status of the infant. Additional research is needed to identify how dietary interventions that modify maternal FA intake prior to or during pregnancy may impact maternal and infant inflammatory status and associated long-term health outcomes.

Urinary 8-hydroxy-2'-deoxyguanosine levels and preterm births: a prospective cohort study from the Japan Environment and Children's Study

OBJECTIVES

To evaluate the association between urinary 8-hydroxy-2'-deoxyguanosine (U8-OHdG) level-a marker of oxidative stress-and the incidence of preterm births (PTBs).

DESIGN

Prospective cohort study.

SETTING

The Japan Environment and Children's Study (JECS).

PARTICIPANTS

Data from 92 715 women with singleton pregnancies at and after 22 weeks of gestation who were enrolled in the JECS, a nationwide birth cohort study, between 2011 and 2014 were analysed. U8-OHdG levels were assessed once in the second/third trimester using liquid chromatography-tandem mass spectrometry. Participants were categorised into the following three or five groups: low (<1.95 ng/mg urinary creatinine (Cre)), moderate (1.95-2.94 ng/mg Cre) and high (≥2.95 ng/mg Cre) U8-OHdG groups, or groups with <1.87, 1.87-2.20, 2.21-2.57, 2.58-3.11 and ≥3.12 ng/mg Cre. For stratification, participants with representative causes for artificial PTB were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

Adjusted OR (aOR) for PTB before 37 and 34 weeks of gestation were calculated using a multivariable logistic regression model while adjusting for confounding factors; the moderate or lowest U8-OHdG group was used as the reference, respectively.

RESULTS

The aORs for PTB before 37 weeks of gestation in the high U8-OHdG group were 1.13 (95% CI 1.05 to 1.22) and 1.13 (95% CI 1.04 to 1.23) after stratification. The aOR for PTB before 37 weeks in the fourth group was 0.90 (95% CI 0.81 to 0.99). After stratification, the aORs for PTB before 37 and 34 weeks in the fifth group were 1.15 (95% CI 1.03 to 1.29) and 1.46 (95% CI 1.08 to 1.97), respectively.

CONCLUSIONS

High U8-OHdG levels were associated with increased PTB incidence, especially in participants without representative causes for artificial PTB. Our results can help identify the mechanisms leading to PTB, considering the variable aetiologies of this condition; further validation is needed to clarify clinical impacts.

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.

Protocol for a 20-year follow-up after a randomized controlled trial of a Mediterranean diet in pregnancy: maternal and offspring risk factors for cardiovascular disease

Background

An inadequate maternal diet during pregnancy can impair offspring health and may increase the risk of cardiovascular disease later in life. The purpose of the proposed study is to assess the risk factors associated with cardiovascular disease in both mothers and their offspring 20 years following their participation in a Mediterranean diet intervention trial during pregnancy.

Methods

The "Cardiovascular Risk Reduction Diet In Pregnancy" (CARRDIP) study was a randomized controlled trial performed between 1999 and 2001. The participants were randomized to adhere to either a Mediterranean diet or their regular diet during pregnancy. An extensive amount of data such as diet information, ultrasound measurements, anthropometry, and biomarkers from these mothers during pregnancy and their offspring in the neonatal period were collected. The mother-offspring pairs (n = 269) from the CARRDIP study will be invited to participate in a clinical examination and blood sample collection. This follow-up study, conducted 20 years after the original CARRDIP study, will investigate cardiovascular risk factors in mothers and offspring. The primary outcome will be the blood pressure of the offspring. In addition, the study will explore various aspects of cardiovascular health, including metabolic and inflammatory status, clinical history, and body composition of the participants.

Discussion

Previous studies investigating the effects of nutrition during pregnancy on maternal and offspring health have been either observational studies, animal studies, or randomized controlled trials with a follow-up period of less than 5 years. This project aims to study the long-term effects of dietary intervention during pregnancy on maternal and offspring cardiovascular risk markers.

Clinical Trial Registration

Clinicaltrials.gov, identifier (NCT05030922).

An evidence review and nutritional conceptual framework for pre-eclampsia prevention

Pre-eclampsia is a serious complication of pregnancy, and maternal nutritional factors may play protective roles or exacerbate risk. The tendency to focus on single nutrients as a risk factor obscures the complexity of possible interactions, which may be important given the complex nature of pre-eclampsia. An evidence review was conducted to compile definite, probable, possible and indirect nutritional determinants of pre-eclampsia to map a nutritional conceptual framework for pre-eclampsia prevention. Determinants of pre-eclampsia were first compiled through an initial consultation with experts. Second, an expanded literature review was conducted to confirm associations, elicit additional indicators and evaluate evidence. The strength of association was evaluated as definite relative risk (RR) < 0·40 or ≥3·00, probable RR 0·40-0·69 or 1·50-2·99, possible RR 0·70-0·89 or 1·10-1·49 or not discernible RR 0·90-1·09. The quality of evidence was evaluated using Grading of Recommendations, Assessment, Development and Evaluation. Twenty-five nutritional factors were reported in two umbrella reviews and twenty-two meta-analyses. Of these, fourteen were significantly associated with pre-eclampsia incidence. Higher serum Fe emerged as a definite nutritional risk factors for pre-eclampsia incidence across populations, while low serum Zn was a risk factor in Asia and Africa. Maternal vitamin D deficiency was a probable risk factor and Ca and/or vitamin D supplementation were probable protective nutritional factors. Healthy maternal dietary patterns were possibly associated with lower risk of developing pre-eclampsia. Potential indirect pathways of maternal nutritional factors and pre-eclampsia may exist through obesity, maternal anaemia and gestational diabetes mellitus. Research gaps remain on the influence of household capacities and socio-cultural, economic and political contexts, as well as interactions with medical conditions.

Interrogating Components of 2 Diet Quality Indices in Pregnancy using a Supervised Statistical Mixtures Approach

BACKGROUND

The Healthy Eating Index (HEI)-2015 and Alternative Healthy Eating Index (AHEI)-2010 evaluate diet holistically in pregnancy. However, it remains unclear how individual index components interact to contribute to health.

OBJECTIVES

To evaluate associations of HEI-2015 and AHEI-2010 components with gestational length using traditional and novel statistical methods in a prospective cohort.

METHODS

Pregnant women completed a 3-mo food-frequency questionnaire (FFQ) at median 13 wk gestation to calculate the HEI-2015 or AHEI-2010. Covariate-adjusted linear regression models evaluated associations of HEI-2015 and AHEI-2010 total scores and individual components (one at a time and simultaneously adjusted) with gestational length. Covariate-adjusted weighted quantile sum regression models evaluated 1) associations of HEI-2015 or AHEI-2010 components as mixtures with gestational length and 2) contributions of components to these associations.

RESULTS

Each 10-point increase in HEI-2015 and AHEI-2010 total score was associated with 0.11 (95% CI: -0.05, 0.27) and 0.14 (95% CI: 0.00, 0.28) wk longer gestation, respectively. In individual or simultaneously adjusted HEI-2015 models, higher intakes of seafood/plant proteins, total protein foods, greens/beans, and saturated fats but lower intakes of added sugars and refined grains were associated with longer gestational length. For the AHEI-2010, higher intake of nuts/legumes and lower intake of sugar-sweetened beverages (SSBs)/fruit juice were associated with longer gestational length. Jointly, 10% increases in HEI-2015 or AHEI-2010 mixtures were associated with 0.17 (95% CI: 0.001, 0.34) and 0.18 (95% CI: 0.05, 0.30) wk longer gestational length, respectively. Seafood/plant protein, total protein foods, dairy, greens/beans, and added sugars were the largest contributors to the HEI-2015 mixture. Nuts/legumes, SSBs/fruit juice, sodium, and DHA/EPA were the largest contributors to the AHEI-2010 mixture. Associations were less precise but consistent in women with spontaneous labors.

CONCLUSIONS

Compared to traditional methods, associations of diet index mixtures with gestational length were more robust and identified unique contributors. Additional studies could consider interrogating these statistical approaches using other dietary indices and health outcomes.

Key Components of Antenatal Lifestyle Interventions to Optimize Gestational Weight Gain: Secondary Analysis of a Systematic Review

Importance

Randomized clinical trials have found that antenatal lifestyle interventions optimize gestational weight gain (GWG) and pregnancy outcomes. However, key components of successful interventions for implementation have not been systematically identified.

Objective

To evaluate intervention components using the Template for Intervention Description and Replication (TIDieR) framework to inform implementation of antenatal lifestyle interventions in routine antenatal care.

Data Sources

Included studies were drawn from a recently published systematic review on the efficacy of antenatal lifestyle interventions for optimizing GWG. The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, MEDLINE, and Embase were searched from January 1990 to May 2020.

Study Selection

Randomized clinical trials examining efficacy of antenatal lifestyle interventions in optimizing GWG were included.

Data Extraction and Synthesis

Random effects meta-analyses were used to evaluate the association of intervention characteristics with efficacy of antenatal lifestyle interventions in optimizing GWG. The results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. Data extraction was performed by 2 independent reviewers.

Main Outcomes and Measures

The main outcome was mean GWG. Measures included characteristics of antenatal lifestyle interventions comprising domains related to theoretical framework, material, procedure, facilitator (allied health staff, medical staff, or researcher), delivery format (individual or group), mode, location, gestational age at commencement (<20 wk or ≥20 wk), number of sessions (low [1-5 sessions], moderate [6-20 sessions], and high [≥21 sessions]), duration (low [1-12 wk], moderate [13-20 wk], and high [≥21 wk]), tailoring, attrition, and adherence. For all mean differences (MDs), the reference group was the control group (ie, usual care).

Results

Overall, 99 studies with 34 546 pregnant individuals were included with differential effective intervention components found according to intervention type. Broadly, interventions delivered by an allied health professional were associated with a greater decrease in GWG compared with those delivered by other facilitators (MD, -1.36 kg; 95% CI, -1.71 to -1.02 kg; P < .001). Compared with corresponding subgroups, dietary interventions with an individual delivery format (MD, -3.91 kg; 95% CI -5.82 to -2.01 kg; P = .002) and moderate number of sessions (MD, -4.35 kg; 95% CI -5.80 to -2.89 kg; P < .001) were associated with the greatest decrease in GWG. Physical activity and mixed behavioral interventions had attenuated associations with GWG. These interventions may benefit from an earlier commencement and a longer duration for more effective optimization of GWG.

Conclusions and Relevance

These findings suggest that pragmatic research may be needed to test and evaluate effective intervention components to inform implementation of interventions in routine antenatal care for broad public health benefit.

The Effect of Maternal Dietary Patterns on Birth Weight for Gestational Age: Findings from the MAMI-MED Cohort

Limited evidence exists on the effects of maternal dietary patterns on birth weight, and most studies conducted so far did not adjust their findings for gestational age and sex, leading to potentially biased conclusions. In the present study, we applied a novel method, namely the clustering on principal components, to derive dietary patterns among 667 pregnant women from Catania (Italy) and to evaluate the associations with birth weight for gestational age. We identified two clusters reflecting distinct dietary patterns: the first one was mainly characterized by plant-based foods (e.g., potatoes, cooked and raw vegetables, legumes, soup, fruits, nuts, rice, wholemeal bread), fish and white meat, eggs, butter and margarine, coffee and tea; the second one consisted mainly of junk foods (sweets, dips, salty snacks, and fries), pasta, white bread, milk, vegetable and olive oils. Regarding small gestational age births, the main predictors were employment status and primiparity, but not the adherence to dietary patterns. By contrast, women belonging to cluster 2 had higher odds of large for gestational age (LGA) births than those belonging to cluster 1 (OR = 2.213; 95%CI = 1.047-4.679; p = 0.038). Moreover, the odds of LGA increased by nearly 11% for each one-unit increase in pregestational BMI (OR = 1.107; 95%CI = 1.053-1.163; p < 0.001). To our knowledge, the present study is the first to highlight a relationship between adherence to an unhealthy dietary pattern and the likelihood of giving birth to a LGA newborn. This evidence adds to the current knowledge about the effects of diet on birth weight, which, however, remains limited and controversial.

Association of Mediterranean diet adherence during pregnancy with maternal and neonatal lipid, glycemic and inflammatory markers: The GESTAFIT project

To examine the association of Mediterranean diet (MD) adherence during pregnancy with maternal and neonatal lipid, glycemic, and inflammatory markers. This study included 152 women from the GESTAFIT trial and a subsample of 35 newborns. The Mediterranean Diet Score, derived from food frequency questionnaires, was employed to assess MD adherence. Total cholesterol, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), triglycerides, and glucose were assessed in the mother (at the 16th and 34th gestational weeks [g.w.]) and in cord arterial and venous serum with standard procedures using an autoanalyzer. Pro-inflammatory and anti-inflammatory cytokines (interleukin [IL]-6, IL-8, IL-10, IL-1beta, interferon gamma, and tumour necrosis factor alpha [TNF-α]) were measured with Luminex xMAP technology. A greater MD adherence was associated with higher HDL-C and lower LDL-C, LDL-C/HDL-C ratio, triglycerides, triglycerides/HDL-C ratio, and TNF-α in the mother at the 16th and the 34th g.w. (|β|: 0.191-0.388, p < 0.05). A higher intake of whole grain cereals, fruits, vegetables and fish and a lower intake of sweets were associated with higher HDL-C and lower LDL-C, LDL-C/HDL-C ratio, triglycerides, triglycerides/HDL-C ratio, and TNF-α at the 16th and 34th g.w. (|β|: 0.188-0.334, p < 0.05). No associations were found with the cord arterial and venous serum markers (p > 0.05). A greater MD adherence during pregnancy, driven by a higher intake of whole grain cereals, fruits, vegetables and fish, and a lower intake of sweets, was positively associated with the maternal lipid and inflammatory serum markers throughout gestation. MD adherence during pregnancy was not associated with cord serum markers.

Targeting PCSK9 With Antibodies and Gene Silencing to Reduce LDL Cholesterol

The discovery of PCSK9 and its role in regulating the low-density lipoprotein (LDL) receptor, and the effect of loss-of-function mutations of its gene, identified it as a therapeutic target in 2006. Fully humanized monoclonal antibodies to PCSK9 (alirocumab and evolocumab) proved effective for lowering LDL cholesterol and subsequently for reducing atherosclerotic events in large outcome trials. Suppressing PCSK9 synthesis via gene silencing using inclisiran, a small interfering RNA, is another approach that effectively reduces LDL cholesterol, and a cardiovascular outcome trial is in progress. These treatments are given subcutaneously on a background of maximally tolerated statin treatment and are long-lasting: dosing is once or twice a month, self-administered, for alirocumab and evolocumab, and every 6 months for inclisiran, in the clinic, with an extra dose at 3 months in the initial year of therapy. These 3 agents produce mean LDL reductions of about 55% with no important adverse effects detectable to date. They are indicated in patients with atherosclerotic vascular disease or familial hypercholesterolemia who cannot achieve LDL cholesterol targets with maximally tolerated statin treatment. Such therapy can produce very low plasma LDL cholesterol and PCSK9, but there is no evidence this is harmful. Introduction into clinical practice has been impeded by economic considerations. The barrier to their use has not been scientific or medical, but rather the impact on healthcare resources. Prices have been reduced, but whether they are now cost-effective varies from country to country.

Maternal lipid levels in early pregnancy as a predictor of childhood lipid levels: a prospective cohort study

Background

Maternal lipid levels in early pregnancy are associated with maternal health and foetal growth. It is however unclear if maternal lipids in early pregnancy can be used to predict childhood lipid levels. The aim of this study is to assess the association between maternal and offspring childhood lipid levels, and to investigate the influence of maternal BMI and diet on these associations.

Methods

This study included 2692 women participating in the Generation R study, an ongoing population-based prospective cohort study from early life onwards. Women with an expected delivery date between 2002 and 2006 living in Rotterdam, the Netherlands were included. Total cholesterol, triglycerides and high-density lipoprotein cholesterol (HDL-c) were measured in early pregnancy (median 13.2 weeks [90% range 10.6; 17.1]). Low-density lipoprotein cholesterol (LDL-c), remnant cholesterol and non-HDL-c were calculated. Corresponding lipid measurements were determined in 2692 children at the age of 6 (median 6.0 years [90% range 5.7; 7.5]) and 1673 children 10 years (median 9.7 years [90% range 9.5; 10.3]). Multivariate linear regression analysis was used to examine the association between maternal lipid levels in early pregnancy and the corresponding childhood lipid measurements at the ages of 6 and 10 years while adjusting for confounders.

Results

Maternal lipid levels in early pregnancy are positively associated with corresponding childhood lipid levels 6 and 10 years after pregnancy, independent of maternal body mass index and diet.

Conclusions

Maternal lipid levels in early pregnancy may provide an insight to the lipid profile of children years later. Gestational lipid levels may therefore be used as an early predictor of children’s long-term health. Monitoring of these gestational lipid levels may give a window-of-opportunity to start early interventions to decrease offspring’s lipid levels and possibly diminish their cardiovascular risk later in life. Future studies are warranted to investigate the genetic contribution on maternal lipid levels in pregnancy and lipid levels of their offspring years later.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04905-7.

Implementation of Antenatal Lifestyle Interventions Into Routine Care: Secondary Analysis of a Systematic Review

IMPORTANCE

Lifestyle interventions in pregnancy optimize gestational weight gain and improve pregnancy outcomes, with implementation recommended by the US Preventive Services Task Force. Yet, implementation research taking these efficacy trials into pragmatic translation remains limited.

OBJECTIVE

To evaluate success factors for implementing pregnancy lifestyle interventions into antenatal care settings in a meta-analysis, using the penetration, implementation, participation, and effectiveness (PIPE) impact metric.

DATA SOURCES

Data from a previous systematic review that searched across 9 databases, including MEDLINE, Embase, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and Health Technology Assessment Database, were obtained, in 2 stages, up to May 6, 2020.

STUDY SELECTION

Randomized clinical trials reporting gestational weight gain in singleton pregnancies.

DATA EXTRACTION AND SYNTHESIS

The association of penetration, implementation, and participation with effectiveness of antenatal lifestyle interventions in optimizing gestational weight gain was estimated using random-effects meta-analyses. The Cochrane risk of bias tool, version 1.0, was used to assess risk of bias.

MAIN OUTCOMES AND MEASURES

Penetration (reach), implementation (fidelity), participation, and effectiveness of randomized clinical trials of lifestyle interventions in pregnancy.

RESULTS

Ninety-nine studies with 34 546 participants were included. Only 14 studies reported penetration of target populations. Overall, 38 studies (38.4%) had moderate fidelity, 25 (25.2%) had high fidelity, and 36 (36.4%) had unclear fidelity. Participation was reported in 84 studies (84.8%). Lifestyle interventions were associated with reducing gestational weight gain by 1.15 kg (95% CI, -1.40 to -0.91 kg).

CONCLUSIONS AND RELEVANCE

The findings of this systematic review and meta-analysis suggest that, despite the large body of evidence on efficacy of lifestyle interventions during pregnancy in optimizing gestational weight gain, little guidance is available to inform implementation of this evidence into practice. There is a need to better elucidate implementation outcomes in trial design alongside pragmatic implementation research to improve the health of women who are pregnant and the next generation.

LDL Cholesterol-How Low Can We Go?

Combinations of lipid-lowering agents can often bring LDL cholesterol down to around 40 mg/dL (1 mmol/L). Randomized controlled trials indicate that this reduces the risk of atherosclerotic vascular events with minimal adverse effects. This has raised the question of whether there is any concentration of LDL cholesterol below which further lowering is futile and/or a source of new adverse effects. This article examines several lines of evidence that lead to the conclusion that there is no known threshold below which lowering LDL cholesterol is harmful, but reduction of LDL cholesterol below 25 mg/dL may provide little if any further benefit.

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.

High Maternal Triglyceride Levels Mediate the Association between Pre-Pregnancy Overweight/Obesity and Macrosomia among Singleton Term Non-Diabetic Pregnancies: A Prospective Cohort Study in Central China

This study aimed at examining the risk of macrosomia, in relation to maternal pre-pregnancy overweight/obesity mediated via high maternal triglyceride (mTG) levels. In this prospective study, 24,730 singleton term non-diabetic pregnancies were finally included. Serum mTG levels were measured using fasting blood samples that were collected after 28 weeks of gestation. High mTG levels were defined as values ≥ the 90th percentile. The outcome of interest was macrosomia (≥4000 g). Log-binomial regression was used to assess the mediation path between overweight/obesity, high mTG levels, and macrosomia. The mediation analysis found a total effect of overweight on macrosomia of 0.006 (95% CI, 0.001–0.010), including a direct effect of 0.005 (95% CI, 0.001, 0.009) and indirect effect of 0.001 (95% CI, 0.000–0.001), with an estimated proportion of 11.1% mediated by high mTG levels. Additionally, we also found a total effect of obesity on macrosomia of 0.026 (95% CI, 0.018–0.036), including a direct effect of 0.025 (95% CI, 0.017–0.036) and indirect effect of 0.001 (95% CI, 0.000–0.001), with an estimated proportion of 3.8% mediated by high mTG levels. In conclusion, non-diabetic women with overweight or obesity had an increased risk of macrosomia, and this positive association was partly mediated by high mTG levels.

Inflammatory Bowel Disease and Reproductive Health: From Fertility to Pregnancy—A Narrative Review

Despite the fact that knowledge on obstetrical management of Inflammatory Bowel Diseases (IBDs) has greatly improved over the years, many patients still actively avoid pregnancy for fear of adverse maternal or neonatal outcomes, of adverse effects of pregnancy on the disease activity, of eventual IBD inheritance, or of an increased risk of congenital malformations. Indeed, though data prove that fertility is hardly affected by the disease, a reduced birth rate is nevertheless observed in patients with IBD. Misconceptions on the safety of drugs during gestation and breastfeeding may influence patient choice and negatively affect their serenity during pregnancy or lactation. Moreover, physicians often showed concerns about starting IBD medications before and during pregnancy and did not feel adequately trained on the safety of IBD therapies. IBD-expert gastroenterologists and gynecologists should discuss pregnancy and breastfeeding issues with patients when starting or changing medications in order to provide appropriate information; therefore, pre-conception counselling on an individualized basis should be mandatory for all patients of reproductive age to reassure them that maintaining disease remission and balancing the eventual obstetrical risks is possible.

Efficacy of behavioral interventions in managing gestational weight gain (GWG): A component network meta-analysis

OBJECTIVE

To identify the most effective behavioral components within lifestyle interventions to optimize gestational weight gain (GWG) to inform guidelines, policy and translation into healthcare.

METHODS

Behavioral components were identified from study level data of randomized antenatal lifestyle interventions using a behavioral taxonomy framework and analyzed using component network meta-analysis (NMA). The NMA ranked behavioral combinations hierarchically by efficacy of optimizing GWG. Direct and estimated indirect comparisons between study arms (i.e., control and intervention) and between different component combinations were estimated to evaluate component combinations associated with greater efficacy.

RESULTS

Overall, 32 studies with 11,066 participants were included. Each intervention contained between 3 and 7 behavioral components with 26 different behavioral combinations identified. The majority (n = 24) of combinations were associated with optimizing GWG, with standard mean differences (SMD) ranging from -1.01 kg (95% CI -1.64 to -0.37) and -0.07 kg (-0.38 to 0.24), compared with controls. The behavioral cluster identified as most effective, included components of goals, feedback and monitoring, natural consequences, comparison of outcomes, and shaping knowledge (SMD -1.01 kg [95% CI -1.64 to -0.37]).

CONCLUSION

Findings support the application of goal setting, feedback and monitoring, natural consequences, comparison of outcomes, and shaping knowledge as essential, core components within lifestyle interventions to optimize gestational weight gain.

Maternal early-pregnancy body mass index-associated metabolomic component and mental and behavioral disorders in children

Maternal pre-pregnancy obesity and/or higher body mass index (BMI) have been associated with neurodevelopmental and mental health adversities in children. While maternal metabolomic perturbations during pregnancy may underpin these associations, the existing evidence is limited to studying individual metabolites, not capturing metabolic variation specific to maternal BMI, and not accounting for the correlated nature of the metabolomic measures. By using multivariate supervised analytical methods, we first identified maternal early-pregnancy BMI-associated metabolomic component during pregnancy. We then examined whether this component was associated with mental and behavioral disorders in children, improved the prediction of the child outcomes over maternal BMI, and what proportion of the effect of maternal BMI on the child outcomes this component mediated. Early-pregnancy BMI of 425 mothers participating in the PREDO study was extracted from the national Medical Birth Register. During pregnancy, mothers donated up to three blood samples, from which a targeted panel of 68 metabolites were measured. Mental and behavioral disorders in children followed-up from birth until 8.4-12.8 years came from the Care Register for Health Care. Of the 68 metabolites averaged across the three sampling points, 43 associated significantly with maternal early-pregnancy BMI yielding a maternal early-pregnancy BMI-associated metabolomic component (total variance explained, 55.4%; predictive ability, 52.0%). This metabolomic component was significantly associated with higher hazard of any mental and behavioral disorder [HR 1.45, 95%CI(1.15, 1.84)] and relative risk of having a higher number of co-morbid disorders [RR 1.43, 95%CI(1.12, 1.69)] in children. It improved the goodness-of-model-fit over maternal BMI by 37.7-65.6%, and hence the predictive significance of the model, and mediated 60.8-75.8% of the effect of maternal BMI on the child outcomes. Maternal BMI-related metabolomic perturbations during pregnancy are associated with a higher risk of mental and behavioral disorders in children. These findings may allow identifying metabolomic targets for personalized interventions.

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

IMPORTANCE

Being born small for gestational age (SGA) is a leading cause of perinatal morbidity and mortality with no effective prevention or therapy. Maternal suboptimal nutrition and high stress levels have been associated with poor fetal growth and adverse pregnancy outcomes.

OBJECTIVE

To investigate whether structured interventions based on a Mediterranean diet or mindfulness-based stress reduction (stress reduction) in high-risk pregnancies can reduce the percentage of newborns who were born SGA and other adverse pregnancy outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Parallel-group randomized clinical trial conducted at a university hospital in Barcelona, Spain, including 1221 individuals with singleton pregnancies (19-23 weeks' gestation) at high risk for SGA. Enrollment took place from February 1, 2017, to October 10, 2019, with follow-up until delivery (final follow-up on March 1, 2020).

INTERVENTIONS

Participants in the Mediterranean diet group (n = 407) received 2 hours monthly of individual and group educational sessions and free provision of extra-virgin olive oil and walnuts. Individuals in the stress reduction group (n = 407) underwent an 8-week stress reduction program adapted for pregnancy, consisting of weekly 2.5-hour sessions and 1 full-day session. Individuals in the usual care group (n = 407) received pregnancy care per institutional protocols.

MAIN OUTCOMES AND MEASURES

The primary end point was the percentage of newborns who were SGA at delivery, defined as birth weight below the 10th percentile. The secondary end point was a composite adverse perinatal outcome (at least 1 of the following: preterm birth, preeclampsia, perinatal mortality, severe SGA, neonatal acidosis, low Apgar score, or presence of any major neonatal morbidity).

RESULTS

Among the 1221 randomized individuals (median [IQR] age, 37 [34-40] years), 1184 (97%) completed the trial (392 individuals assigned to the Mediterranean diet group, 391 to the stress reduction group, and 401 to the usual care group). SGA occurred in 88 newborns (21.9%) in the control group, 55 (14.0%) in the Mediterranean diet group (odds ratio [OR], 0.58 [95% CI, 0.40-0.84]; risk difference [RD], -7.9 [95% CI, -13.6 to -2.6]; P = .004), and 61 (15.6%) in the stress reduction group (OR, 0.66 [95% CI, 0.46-0.94]; RD, -6.3 [95% CI, -11.8 to -0.9]; P = .02). The composite adverse perinatal outcome occurred in 105 newborns (26.2%) in the control group, 73 (18.6%) in the Mediterranean diet group (OR, 0.64 [95% CI, 0.46-0.90]; RD, -7.6 [95% CI, -13.4 to -1.8]; P = .01), and 76 (19.5%) in the stress reduction group (OR, 0.68 [95% CI, 0.49-0.95]; RD, -6.8 [95% CI, -12.6 to -0.3]; P = .02).

CONCLUSIONS AND RELEVANCE

In this randomized trial conducted at a single institution in Spain, treating pregnant individuals at high risk for SGA with a structured Mediterranean diet or with mindfulness-based stress reduction, compared with usual care, significantly reduced the percentage of newborns with birth weight below the 10th percentile. Due to important study limitations, these findings should be considered preliminary and require replication, as well as assessment in additional patient populations, before concluding that these treatments should be recommended to patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03166332.

The Efficacy of a Personalized mHealth Coaching Program During Pregnancy on Maternal Diet, Supplement Use, and Physical Activity: Protocol for a Parallel-Group Randomized Controlled Trial

Background

Adequate intake of macro- and micronutrients and adoption of an active lifestyle during pregnancy are essential for optimum maternal and fetal health and offspring development. Dietary counseling and advice regarding adequate physical activity are integral components of antenatal care. Personalized coaching through the use of mobile health (mHealth) that supports behavior modification is an innovative approach that needs exploration.

Objective

Our primary aim is to assess the efficacy of an mHealth program in improving diet, supplement use, and physical activity during pregnancy. Secondary objectives include evaluation of the program’s effect on maternal and offspring health outcomes and assessment of its compliance and usability.

Methods

A randomized controlled trial was initiated at the Aga Khan University Hospital in Karachi, Pakistan, in January 2020. We aim to recruit 300 pregnant women in their first trimester who have smartphones, do not have comorbidities, and are not taking medications. The intervention group will be trained to use an mHealth app called PurUmeed Aaghaz. Through this app, the subjects will report information about their diet, supplement use, and physical activity and will receive personalized advice and three push messages as weekly reminders. The research assistant will obtain similar information from the control group via a paperless questionnaire; this group will receive standard face-to-face counseling regarding diet, supplement use, and physical activity. Data will be collected at enrollment and during four follow-up sessions scheduled 6 weeks apart. Primary study outcomes include improvements in diet (ie, change in mean dietary risk score from baseline to each follow-up), supplement use (ie, changes in mean supplement use score and biochemical levels of folic acid, iron, calcium, and vitamin D on a study subset), and mean duration of reported physical activity (minutes). Secondary study outcomes relate to maternal health (ie, gestational diabetes mellitus, gestational hypertension, pre-eclampsia, and gestational weight gain), newborn health (ie, birth weight and length and gestational age at delivery), and infant health (ie, BMI and blood pressure at 1 year of age). Compliance will be determined by the proportion of participants who complete the 6-month coaching program. Usability will be assessed based on features related to design, interface, content, coaching, perception, and personal benefit.

Results

The study was approved by the Ethics Review Committee of the Aga Khan University in 2017. The recruitment of study participants was completed in September 2021. All follow-ups and outcome assessments are expected to be completed by March 2023 and analysis is expected to be completed by June 2023. We expect the results to be published by the end of 2023.

Conclusions

This study will be an important step toward evaluating the role of mHealth in improving behaviors related to a healthy diet, supplement use, and promotion of physical activity during pregnancy, as well as in influencing maternal and offspring outcomes. If proven effective, mHealth interventions can be scaled up and included in antenatal care packages at tertiary care hospitals of low- and middle-income countries.

Trial Registration

ClinicalTrials.gov NCT04216446; https://clinicaltrials.gov/ct2/show/NCT04216446

International Registered Report Identifier (IRRID)

DERR1-10.2196/31611

A systematic review and meta-analysis on the effects of statins on pregnancy outcomes

BACKGROUND AND AIMS

Statins are contraindicated in pregnancy, due to their potential teratogenicity. However, data are still inconsistent and some even suggest a potential benefit of statin use against pregnancy complications. We aimed to investigate the effects of statins on pregnancy outcomes, including stillbirth, fetal abortion, and preterm delivery, through a systematic review of the literature and a meta-analysis of the available clinical studies.

METHODS

A literature search was performed through PubMed, Scopus, and Web of Science up to 16 May 2020. Data were extracted from 18 clinical studies (7 cohort studies, 2 clinical trials, 3 case reports, and 6 case series). Random effect meta-analyses were conducted using the restricted maximum likelihood method. The common effect sizes were calculated as odds ratios (ORs) and their 95% confidence interval (CI) for each main outcome.

RESULTS

Finally, nine studies were included in the meta-analysis. There was no significant association between statin therapy and stillbirth [OR (95% CI) = 1.30 (0.56, 3.02), p=0.54; I² = 0%]. While statin exposure was significantly associated with increased rates of spontaneous abortion [OR (95% CI) = 1.36 (1.10-1.68), p=0.004, I² = 0%], it was non-significantly associated with increased rates of induced abortion [OR (95% CI) = 2.08 (0.81, 5.36), p=0.129, I² = 17.33%] and elective abortion [OR (95% CI) = 1.37 (0.68, 2.76), p=0.378, I² = 62.46%]. A non-significant numerically reduced rate of preterm delivery was observed in statin users [OR (95% CI) = 0.47 (0.06, 3.70), p=0.47, I² = 76.35%].

CONCLUSIONS

Statin therapy seems to be safe as it was not associated with stillbirth or induced and elective abortion rates. Significant increase after statin therapy was, however, observed for spontaneous abortion. These results need to be confirmed and validated in future studies.

Loss of statin treatment years during pregnancy and breastfeeding periods in women with familial hypercholesterolemia

BACKGROUND AND AIMS

Women with heterozygous familial hypercholesterolemia (FH) are recommended to initiate statin treatment at the same age as men (from 8 to 10 years of age). However, statins are contraindicated when pregnancy is planned, during pregnancy and breastfeeding. The aim of the study was to determine the duration of pregnancy-related off-statin periods and breastfeeding in FH women.

METHODS

A cross-sectional study using an anonymous online self-administered questionnaire was conducted. Women with FH were recruited through Lipid Clinics in Norway and Netherlands and national FH patient organizations.

RESULTS

102 women with FH (n = 70 Norwegian and n = 32 Dutch) were included in the analysis. Total length of pregnancy-related off-statin periods was estimated for 80 women where data were available, and was median (min-max) 2.3 (0-14.2) years. Lost statin treatment time was estimated for 67 women where data were available, and was median (min-max) 18 (0-100)% at mean (SD) age of 31 (4.3) years at last pregnancy. More women breastfed in Norway (83%) and for longer time [8.5 [1-42] months] compared to the Netherlands [63%, p = 0.03; 3.6 (0-14) months, p < 0.001]. Eighty-six percent of the women reported need for more information on pregnancy and breastfeeding in relation to FH.

CONCLUSIONS

Young FH women lose years of treatment when discontinuing statins in relation to pregnancy and breastfeeding periods and should be closely followed up to minimize the duration of these off-statin periods. Whether these periods of interrupted treatment increase the cardiovascular risk in FH women needs to be further elucidated.

Maternal Dietary Quality and Dietary Inflammation Associations with Offspring Growth, Placental Development, and DNA Methylation

The ‘Developmental Origins of Health and Diseases’ hypothesis posits that prenatal maternal diet influences offspring growth and later life health outcomes. Dietary assessment has focused on selected nutrients. However, this approach does not consider the complex interactions between foods and nutrients. To provide a more comprehensive approach to public health, dietary indices have been developed to assess dietary quality, dietary inflammation and risk factors for non-communicable diseases. Thus far, their use in the context of placental development is limited and associations with offspring outcomes have been inconsistent. Although epidemiological studies have focused on the role of maternal diet on foetal programming, the underlying mechanisms are still poorly understood. Some evidence suggests these associations may be driven by placental and epigenetic changes. In this narrative review, we examine the current literature regarding relationships between key validated diet quality scores (Dietary Inflammatory Index [DII], Mediterranean diet [MD], Healthy Eating Index [HEI], Alternative Healthy Eating Index [AHEI], Dietary Approaches to Stop Hypertension [DASH], Glycaemic Index [GI] and Glycaemic Load [GL]) in pregnancy and birth and long-term offspring outcomes. We summarise findings, discuss potential underlying placental and epigenetic mechanisms, in particular DNA methylation, and highlight the need for further research and public health strategies that incorporate diet quality and epigenetics.

Cholesterol at ages 6, 12 and 24 months: Tracking and associations with diet and maternal cholesterol in the Infant Cholesterol Study

BACKGROUND AND AIMS

There are indications for tracking of circulating total cholesterol concentration (TC) from childhood to later in life. An increased lifelong TC exposure increases the risk of developing atherosclerosis, however little is known about the determinants of TC early in life. We aimed to describe TC in Norwegian offspring aged 6, 12 and 24 months, and to explore if maternal TC, breastfeeding and offspring diet are associated with offspring TC.

METHODS

In this cross-sectional study, mothers of offspring aged 6 (n = 629), 12 (n = 258) and 24 (n = 263) months completed a questionnaire of the offspring's diet and took home-based dried blood spot samples from themselves and their offspring. The mothers and offspring participating at age 12 months also participated at age 6 months of the offspring.

RESULTS

Offspring TC showed a wide range in all three age groups. Twenty one percent of the offspring had TC ≥ 5.1 mmol/l. There was significant tracking of offspring TC from 6 to 12 months of age (r = 0.42, p < 0.001). Maternal and offspring TC was positively associated in all age groups (0.20 ≤ β ≤ 0.40, p < 0.001 for all). Breastfeeding was positively associated with offspring TC at ages 6 and 12 months (0.05 ≤ β ≤ 0.26, 0.001 ≤ p ≤ 0.03), but not at age 24 months.

CONCLUSIONS

The wide range in TC and probable tracking of TC from infancy to later in life highlights the importance of early identification of children with elevated TC who can benefit from preventive measures.

Fetal Growth Restriction: ACOG Practice Bulletin, Number 227

Fetal growth restriction, also known as intrauterine growth restriction, is a common complication of pregnancy that has been associated with a variety of adverse perinatal outcomes. There is a lack of consensus regarding terminology, etiology, and diagnostic criteria for fetal growth restriction, with uncertainty surrounding the optimal management and timing of delivery for the growth-restricted fetus. An additional challenge is the difficulty in differentiating between the fetus that is constitutionally small and fulfilling its growth potential and the small fetus that is not fulfilling its growth potential because of an underlying pathologic condition. The purpose of this document is to review the topic of fetal growth restriction with a focus on terminology, etiology, diagnostic and surveillance tools, and guidance for management and timing of delivery.

Fetal High-Density Lipoproteins: Current Knowledge on Particle Metabolism, Composition and Function in Health and Disease

Cholesterol and other lipids carried by lipoproteins play an indispensable role in fetal development. Recent evidence suggests that maternally derived high-density lipoprotein (HDL) differs from fetal HDL with respect to its proteome, size, and function. Compared to the HDL of adults, fetal HDL is the major carrier of cholesterol and has a unique composition that implies other physiological functions. Fetal HDL is enriched in apolipoprotein E, which binds with high affinity to the low-density lipoprotein receptor. Thus, it appears that a primary function of fetal HDL is the transport of cholesterol to tissues as is accomplished by low-density lipoproteins in adults. The fetal HDL-associated bioactive sphingolipid sphingosine-1-phosphate shows strong vasoprotective effects at the fetoplacental vasculature. Moreover, lipoprotein-associated phospholipase A2 carried by fetal-HDL exerts anti-oxidative and athero-protective functions on the fetoplacental endothelium. Notably, the mass and activity of HDL-associated paraoxonase 1 are about 5-fold lower in the fetus, accompanied by an attenuation of anti-oxidative activity of fetal HDL. Cholesteryl ester transfer protein activity is reduced in fetal circulation despite similar amounts of the enzyme in maternal and fetal serum. This review summarizes the current knowledge on fetal HDL as a potential vasoprotective lipoprotein during fetal development. We also provide an overview of whether and how the protective functionalities of HDL are impaired in pregnancy-related syndromes such as pre-eclampsia or gestational diabetes mellitus.

Maternal Adherence to the Mediterranean Diet during Pregnancy: A Review of Commonly Used a priori Indexes

Currently, many a priori indexes are being used to assess maternal adherence to the Mediterranean diet (MD) during pregnancy but each with different components, cut-off points, and scoring systems. This narrative review aimed to identify all observational studies utilizing a priori indexes to assess maternal adherence to the MD during pregnancy. A systematic search was conducted in Pubmed until 1 July 2020. Among the 27 studies included, eight different a priori indexes were identified. Studies included a range of 5 to 13 dietary components in their indexes. Only three dietary components-vegetables, fruits, and fish-were common among all indexes. Dairy and alcohol were the only two components modified for pregnancy. All but one study either excluded alcohol from their index or reversed its scoring to contribute to decreased adherence to the MD. Approximately half of the studies established cut-off points based on the distribution of the study population; the others utilized fixed criteria. This review emphasizes the incongruent definitions of the MD impairing effective comparison among studies relating to maternal or offspring health outcomes. Future research should carefully consider the heterogeneous definitions of the MD in a priori indexes and the relevance of incorporating pregnancy-specific nutritional requirements.

Effects of Maternal Nutritional Supplements and Dietary Interventions on Placental Complications: An Umbrella Review, Meta-Analysis and Evidence Map

The placenta is a vital, multi-functional organ that acts as an interface between maternal and fetal circulation during pregnancy. Nutritional deficiencies during pregnancy alter placental development and function, leading to adverse pregnancy outcomes, such as pre-eclampsia, infants with small for gestational age and low birthweight, preterm birth, stillbirths and maternal mortality. Maternal nutritional supplementation may help to mitigate the risks, but the evidence base is difficult to navigate. The primary purpose of this umbrella review is to map the evidence on the effects of maternal nutritional supplements and dietary interventions on pregnancy outcomes related to placental disorders and maternal mortality. A systematic search was performed on seven electronic databases, the PROSPERO register and references lists of identified papers. The results were screened in a three-stage process based on title, abstract and full-text by two independent reviewers. Randomized controlled trial meta-analyses on the efficacy of maternal nutritional supplements or dietary interventions were included. There were 91 meta-analyses included, covering 23 types of supplements and three types of dietary interventions. We found evidence that supports supplementary vitamin D and/or calcium, omega-3, multiple micronutrients, lipid-based nutrients, and balanced protein energy in reducing the risks of adverse maternal and fetal health outcomes. However, these findings are limited by poor quality of evidence. Nutrient combinations show promise and support a paradigm shift to maternal dietary balance, rather than single micronutrient deficiencies, to improve maternal and fetal health. The review is registered at PROSPERO (CRD42020160887).

Prenatal Nutritional Strategies to Reduce the Risk of Preterm Birth

Worldwide, around 15 million preterm babies are born annually, and despite intensive research, the specific mechanisms triggering preterm birth (PTB) remain unclear. Cost-effective primary prevention strategies to reduce PTB are required, and nutritional interventions offer a promising alternative. Nutrients contribute to a variety of mechanisms that are potentially important to preterm delivery, such as infection, inflammation, oxidative stress, and muscle contractility. Several observational studies have explored the association between dietary nutrients and/or dietary patterns and PTB, often with contrasting results. Randomized trial evidence on the effects of supplementation with zinc, multiple micronutrients (iron and folic acid), and vitamin D is promising; however, results are inconsistent, and many studies are not adequately powered for outcomes of PTB. Large-scale clinical trials with PTB as the primary outcome are needed before any firm conclusions can be drawn for these nutrients. The strongest evidence to date for a nutritional solution exists for omega-3 long-chain polyunsaturated fatty acids (LCPUFAs), key nutrients in fish. In 2018, a Cochrane Review (including 70 studies) showed that prenatal supplementation with omega-3 LCPUFAs reduced the risk of PTB and early PTB (EPTB) compared with no omega-3 supplementation. However, the largest trial of omega-3 supplementation in pregnancy, the Omega-3 to Reduce the Incidence of Prematurity (ORIP) trial (n = 5,544), showed no reduction in EPTB and a reduction in PTB only in a prespecified analysis of singleton pregnancies. Exploratory analyses from the ORIP trial found that women with low baseline total omega-3 status were at higher risk of EPTB, and that this risk was substantially reduced with omega-3 supplementation. In contrast, women with replete or high baseline total omega-3 status were already at low risk of EPTB and additional omega-3 supplementation increased the risk of EPTB compared to control. These findings suggest that determining an individual woman's PUFA status may be the most precise way to inform recommendations to reduce her risk of PTB.

Controversies in the prevention of spontaneous preterm birth in asymptomatic women: an evidence summary and expert opinion

Preterm birth prevention is multifaceted and produces many nuanced questions. This review addresses six important clinical questions about preterm birth prevention as voted for by members of the UK Preterm Clinical Network. The questions cover the following areas: preterm birth prevention in 'low-risk' populations; screening for asymptomatic genital tract infection in women at high risk of preterm birth; cervical length screening with cerclage or vaginal pessary in situ; cervical shortening whilst using progesterone; use of vaginal progesterone in combination with cervical cerclage; and optimal advice about intercourse for women at high risk of preterm birth.

Society for Maternal-Fetal Medicine Consult Series #52: Diagnosis and management of fetal growth restriction: (Replaces Clinical Guideline Number 3, April 2012)

Fetal growth restriction can result from a variety of maternal, fetal, and placental conditions. It occurs in up to 10% of pregnancies and is a leading cause of infant morbidity and mortality. This complex obstetrical problem has disparate published diagnostic criteria, relatively low detection rates, and limited preventative and treatment options. The purpose of this Consult is to outline an evidence-based, standardized approach for the prenatal diagnosis and management of fetal growth restriction. The recommendations of the Society for Maternal-Fetal Medicine are as follows: (1) we recommend that fetal growth restriction be defined as an ultrasonographic estimated fetal weight or abdominal circumference below the 10th percentile for gestational age (GRADE 1B); (2) we recommend the use of population-based fetal growth references (such as Hadlock) in determining fetal weight percentiles (GRADE 1B); (3) we recommend against the use of low-molecular-weight heparin for the sole indication of prevention of recurrent fetal growth restriction (GRADE 1B); (4) we recommend against the use of sildenafil or activity restriction for in utero treatment of fetal growth restriction (GRADE 1B); (5) we recommend that a detailed obstetrical ultrasound examination (current procedural terminology code 76811) be performed with early-onset fetal growth restriction (<32 weeks of gestation) (GRADE 1B); (6) we recommend that women be offered fetal diagnostic testing, including chromosomal microarray analysis, when fetal growth restriction is detected and a fetal malformation, polyhydramnios, or both are also present regardless of gestational age (GRADE 1B); (7) we recommend that pregnant women be offered prenatal diagnostic testing with chromosomal microarray analysis when unexplained isolated fetal growth restriction is diagnosed at <32 weeks of gestation (GRADE 1C); (8) we recommend against screening for toxoplasmosis, rubella, or herpes in pregnancies with fetal growth restriction in the absence of other risk factors and recommend polymerase chain reaction for cytomegalovirus in women with unexplained fetal growth restriction who elect diagnostic testing with amniocentesis (GRADE 1C); (9) we recommend that once fetal growth restriction is diagnosed, serial umbilical artery Doppler assessment should be performed to assess for deterioration (GRADE 1C); (10) with decreased end-diastolic velocity (ie, flow ratios greater than the 95th percentile) or in pregnancies with severe fetal growth restriction (estimated fetal weight less than the third percentile), we suggest weekly umbilical artery Doppler evaluation (GRADE 2C); (11) we recommend Doppler assessment up to 2-3 times per week when umbilical artery absent end-diastolic velocity is detected (GRADE 1C); (12) in the setting of reversed end-diastolic velocity, we suggest hospitalization, administration of antenatal corticosteroids, heightened surveillance with cardiotocography at least 1-2 times per day, and consideration of delivery depending on the entire clinical picture and results of additional evaluation of fetal well-being (GRADE 2C); (13) we suggest that Doppler assessment of the ductus venosus, middle cerebral artery, or uterine artery not be used for routine clinical management of early- or late-onset fetal growth restriction (GRADE 2B); (14) we suggest weekly cardiotocography testing after viability for fetal growth restriction without absent/reversed end-diastolic velocity and that the frequency be increased when fetal growth restriction is complicated by absent/reversed end-diastolic velocity or other comorbidities or risk factors (GRADE 2C); (15) we recommend delivery at 37 weeks of gestation in pregnancies with fetal growth restriction and an umbilical artery Doppler waveform with decreased diastolic flow but without absent/reversed end-diastolic velocity or with severe fetal growth restriction with estimated fetal weight less than the third percentile (GRADE 1B); (16) we recommend delivery at 33-34 weeks of gestation for pregnancies with fetal growth restriction and absent end-diastolic velocity (GRADE 1B); (17) we recommend delivery at 30-32 weeks of gestation for pregnancies with fetal growth restriction and reversed end-diastolic velocity (GRADE 1B); (18) we suggest delivery at 38-39 weeks of gestation with fetal growth restriction when the estimated fetal weight is between the 3rd and 10th percentile and the umbilical artery Doppler is normal (GRADE 2C); (19) we suggest that for pregnancies with fetal growth restriction complicated by absent/reversed end-diastolic velocity, cesarean delivery should be considered based on the entire clinical scenario (GRADE 2C); (20) we recommend the use of antenatal corticosteroids if delivery is anticipated before 33 6/7 weeks of gestation or for pregnancies between 34 0/7 and 36 6/7 weeks of gestation in women without contraindications who are at risk of preterm delivery within 7 days and who have not received a prior course of antenatal corticosteroids (GRADE 1A); and (21) we recommend intrapartum magnesium sulfate for fetal and neonatal neuroprotection for women with pregnancies that are <32 weeks of gestation (GRADE 1A).

Maternal profile according to Mediterranean diet adherence and small for gestational age and preterm newborn outcomes

OBJECTIVE

The objective was to evaluate maternal Mediterranean diet (MD) pattern adherence during pregnancy and its association with small for gestational age (SGA) and preterm birth. A secondary objective of the current study was to describe the sociodemographic, lifestyle and obstetric profile of the mothers studied as well as the most relevant paternal and newborn characteristics.

DESIGN

The current study is a two-phase retrospective population-based study of maternal dietary habits during pregnancy and their effect on newborn size and prematurity. The descriptive first phase examined maternal dietary habits during pregnancy along with the maternal sociodemographic, lifestyle and obstetric profile in a cross-sectional period study. In the second phase, newborn outcomes were evaluated in a nested case-control study. Adherence to MD during pregnancy was measured with the Spanish version of Kidmed index.

SETTING

Obstetrics ward of the La Fe Hospital in Valencia.

PARTICIPANTS

All mother-child pairs admitted after delivery during a 12-month period starting from January 2018 were assessed for eligibility. A total of 1118 provided complete outcome data after signing informed consent.

RESULTS

14·5 % met the criteria of poor adherence (PA); 34·8 %, medium adherence (MA); and 50·7 %, optimal adherence (OA). Medium adherence to MD was associated in the adjusted scenarios with a higher risk of giving birth to a preterm newborn. No association was found between MD adherence and SGA.

CONCLUSIONS

Early intervention programmes geared towards pregnant women, where women were aided in reaching OA to MD, might reduce the risk of preterm newborn.

Computer-based tailored dietary counselling improves the nutrient adequacy of the diet of French pregnant women: a randomised controlled trial

During pregnancy, mothers-to-be should adapt their diet to meet increases in nutrient requirements. Pregnant women appear to be keener to adopt healthier diets, but are not always successful. The objective of the present study was to determine whether a guided, stepwise and tailored dietary counselling programme, designed using an optimisation algorithm, could improve the nutrient adequacy of the diet of pregnant women, beyond generic guidelines. Pregnant women (n 80) who attended Notre-Dame-de-Bon-Secours Maternity Clinic were randomly allocated to the control or intervention arm. Dietary data were obtained twice from an online 3-d dietary record. The nutrient adequacy of the diet was calculated using the PANDiet score, a 100-point diet quality index adapted to the specific nutrient requirements for pregnancy. Women were supplied with generic dietary guidelines in a reference booklet. In the intervention arm, they also received nine sets of tailored dietary advice identified by an optimisation algorithm as best improving their PANDiet score. Pregnant women (n 78) completed the 12-week dietary follow-up. Initial PANDiet scores were similar in the control and intervention arms (60·4 (sd 7·3) v. 60·3 (sd 7·3), P = 0·92). The PANDiet score increased in the intervention arm (+3·6 (sd 9·3), P = 0·02) but not in the control arm (-0·3 (sd 7·3), P = 0·77), and these changes differed between arms (P = 0·04). In the intervention arm, there were improvements in the probabilities of adequacy for α-linolenic acid, thiamin, folate and cholesterol intakes (P < 0·05). Tailored dietary counselling using a computer-based algorithm is more effective than generic dietary counselling alone in improving the nutrient adequacy of the diet of French women in mid-pregnancy.

Effect of proinflammatory diet before pregnancy on gestational age and birthweight: The Japan Environment and Children's Study

The daily diet plays a role in systematic inflammation and may be one of the causes of preterm birth. We aimed to examine the effect of a daily proinflammatory diet before pregnancy on gestational age and birthweight using a large birth cohort in Japan. We used data of singleton pregnancies in the Japan Environment and Children's Study involving live birth from 2011 to 2014 to calculate the dietary inflammatory index. We used individual meals with 30 food parameters from a semiquantitative food frequency questionnaire, which assessed diet intake before pregnancy. Participants were categorized according to the quartile of dietary inflammatory index. A multiple logistic regression model was used to estimate the risk of a proinflammatory diet on preterm birth (PTB) before 37 or 34 weeks and low birthweight (LBW) less than 2,500 or 1,500 g, accounting for maternal age, body mass index before pregnancy, smoking status, education, and household income. After applying our inclusion criteria, 89,329 participants were eligible for the present study. Multiple regression analysis showed that the proinflammatory diet had an increased risk of PTB < 34 weeks (adjusted odds ratio: 1.29, 95% confidence interval [1.07, 1.55]) and <2,500‐g LBW (adjusted odds ratio: 1.08, 95% confidence interval [1.01, 1.16]) compared with the control. In conclusion, a proinflammatory diet before pregnancy was a risk factor for PTB < 34 weeks and LBW < 2,500 g. Therefore, proinflammatory diet needs to be controlled to improve perinatal prognosis.

Effects of maternal diets on preterm birth and low birth weight: a systematic review

Current evidence indicates that maternal diets before and during pregnancy could influence rates of preterm birth, low birth weight (LBW) and small for gestational age (SGA) births. However, findings have been inconsistent. This review summarised evidence concerning the effects of maternal diets before and during pregnancy on preterm birth, LBW and SGA. Systematic electronic database searches were carried out using PubMed, Embase, Scopus and Cochrane library using the preferred reporting items for systematic reviews and meta-analyses guidelines. The review included forty eligible articles, comprising mostly of prospective cohort studies, with five randomised controlled trials. The dietary patterns during pregnancy associated with a lower risk of preterm birth were commonly characterised by high consumption of vegetables, fruits, whole grains, fish and dairy products. Those associated with a lower risk of SGA also had similar characteristics, including high consumption of vegetables, fruits, legumes, seafood/fish and milk products. Results from a limited number of studies suggested there was a beneficial effect on the risk of preterm birth of pre-pregnancy diet quality characterised by a high intake of fruits and proteins and less intake of added sugars, saturated fats and fast foods. The evidence was mixed for the relationship between maternal dietary patterns during pregnancy and LBW. These findings indicate that better maternal diet quality during pregnancy, characterised by a high intake of vegetables, fruits, whole grains, dairy products and protein diets, may have a synergistic effect on reducing the risk of preterm birth and SGA.

Can a Simple Dietary Screening in Early Pregnancy Identify Dietary Habits Associated with Gestational Diabetes?

Gestational diabetes mellitus (GDM) is predominantly a lifestyle disease, with diet being an important modifiable risk factor. A major obstacle for the prevention in clinical practice is the complexity of assessing diet. In a cohort of 1651 Icelandic women, this study examined whether a short 40-item dietary screening questionnaire administered in the 1st trimester could identify dietary habits associated with GDM. The dietary variables were aggregated into predefined binary factors reflecting inadequate or optimal intake and stepwise backward elimination was used to identify a reduced set of factors that best predicted GDM. Those binary factors were then aggregated into a risk score (range: 0–7), that was mostly characterised by frequent consumption of soft drinks, sweets, cookies, ice creams and processed meat. The women with poor dietary habits (score ≥ 5, n = 302), had a higher risk of GDM (RR = 1.38; 95%CI = 3, 85) compared with women with a more optimal diet (score ≤ 2, n = 407). In parallel, a pilot (n = 100) intervention was conducted among overweight and obese women examining the effect of internet-based personalized feedback on diet quality. Simple feedback was given in accordance with the answers provided in the screening questionnaire in 1st trimester. At the endpoint, the improvements in diet quality were observed by, as an example, soft drink consumption being reduced by ~1 L/week on average in the intervention group compared to the controls. Our results suggest that a simple dietary screening tool administered in the 1st trimester could identify dietary habits associated with GMD. This tool should be easy to use in a clinical setting, and with simple individualized feedback, improvements in diet may be achieved.

Preterm Birth: A Narrative Review of the Current Evidence on Nutritional and Bioactive Solutions for Risk Reduction

Preterm birth (PTB) (<37 weeks of gestation) is the leading cause of newborn death and a risk factor for short and long-term adverse health outcomes. Most cases are of unknown cause. Although the mechanisms triggering PTB remain unclear, an inappropriate increase in net inflammatory load seems to be key. To date, interventions that reduce the risk of PTB are effective only in specific groups of women, probably due to the heterogeneity of its etiopathogenesis. Use of progesterone is the most effective, but only in singleton pregnancies with history of PTB. Thus, primary prevention is greatly needed and nutritional and bioactive solutions are a promising alternative. Among these, docosahexaenoic acid (DHA) is the most promising to reduce the risk for early PTB. Other potential nutrient interventions include the administration of zinc (possibly limited to populations with low nutritional status or poor zinc status) and vitamin D; additional preliminary evidence exists for vitamin A, calcium, iron, folic acid, combined iron-folate, magnesium, multiple micronutrients, and probiotics. Considering the public health relevance of PTB, promising interventions should be studied in large and well-designed clinical trials. The objective of this review is to describe, summarize, and discuss the existing evidence on nutritional and bioactive solutions for reducing the risk of PTB.

Nutritional Lifestyle Intervention in Obese Pregnant Women, Including Lower Carbohydrate Intake, Is Associated With Increased Maternal Free Fatty Acids, 3-β-Hydroxybutyrate, and Fasting Glucose Concentrations: A Secondary Factorial Analysis of the European Multicenter, Randomized Controlled DALI Lifestyle Intervention Trial

OBJECTIVE

In our randomized controlled trial, we investigated the impact of healthy eating (HE) aiming for restricted gestational weight gain (GWG) and physical activity (PA) interventions on maternal and neonatal lipid metabolism.

RESEARCH DESIGN AND METHODS

Obese pregnant women (n = 436) were included before 20 weeks' gestation and underwent glucose testing (oral glucose tolerance test) and lipid profiling at baseline and 24-28 and 35-37 gestational weeks after an at least 10-h overnight fast. This secondary analysis had a factorial design with comparison of HE (n = 221) versus no HE (n = 215) and PA (n = 218) versus no PA (n = 218). Maternal changes in triglycerides (TG), LDL cholesterol, HDL cholesterol, free fatty acids (FFAs), and leptin from baseline to end of pregnancy and neonatal outcomes were analyzed using general linear models with adjustment for relevant parameters.

RESULTS

At 24-28 weeks' gestation, FFAs (mean ± SD, 0.60 ± 0.19 vs. 0.55 ± 0.17 mmol/L, P < 0.01) were increased after adjustment for FFA at baseline, maternal age, BMI at time of examination, gestational week, insulin resistance, self-reported food intake, self-reported physical activity, and maternal smoking, and GWG was lower (3.3 ± 2.6 vs. 4.3 ± 2.8 kg, P < 0.001, adjusted mean differences -1.0 [95% CI -1.5; -0.5]) in HE versus no HE. Fasting glucose levels (4.7 ± 0.4 vs. 4.6 ± 0.4 mmol/L, P < 0.05) and 3-β-hydroxybutyrate (3BHB) (0.082 ± 0.065 vs. 0.068 ± 0.067 mmol/L, P < 0.05) were higher in HE. Significant negative associations between carbohydrate intake and FFA, 3BHB, and fasting glucose at 24-28 weeks' gestation were observed. No differences between groups were found in oral glucose tolerance test or leptin or TG levels at any time. Furthermore, in PA versus no PA, no similar changes were found. In cord blood, elevated FFA levels were found in HE after full adjustment (0.34 ± 0.22 vs. 0.29 ± 0.16 mmol/L, P = 0.01).

CONCLUSIONS

HE intervention was associated with reduced GWG, higher FFAs, higher 3BHB, and higher fasting glucose at 24-28 weeks of gestation, suggesting induction of lipolysis. Increased FFA was negatively associated with carbohydrate intake and was also observed in cord blood. These findings support the hypothesis that maternal antenatal dietary restriction including carbohydrates is associated with increased FFA mobilization.

From conception to infancy - early risk factors for childhood obesity

Maternal lifestyle during pregnancy, as well as early nutrition and the environment infants are raised in, are considered relevant factors for the prevention of childhood obesity. Several models are available for the prediction of childhood overweight and obesity, yet most have not been externally validated. Moreover, the factors considered in the models differ among studies as the outcomes manifest after birth and depend on maturation processes that vary between individuals. The current Review examines and interprets data on the early determinants of childhood obesity to provide relevant strategies for daily clinical work. We evaluate a selection of prenatal and postnatal factors associated with child adiposity. Actions to be considered for preventing childhood obesity include the promotion of healthy maternal nutrition and weight status at reproductive age and during pregnancy, as well as careful monitoring of infant growth to detect early excessive weight gain. Paediatricians and other health-care professionals should provide scientifically validated, individual nutritional advice to families to counteract excessive adiposity in children. Based on systematic reviews, original papers and scientific reports, we provide information to help with setting up public health strategies to prevent overweight and obesity in childhood.

Impact of maternal education on response to lifestyle interventions to reduce gestational weight gain: individual participant data meta-analysis

OBJECTIVES

To identify if maternal educational attainment is a prognostic factor for gestational weight gain (GWG), and to determine the differential effects of lifestyle interventions (diet based, physical activity based or mixed approach) on GWG, stratified by educational attainment.

DESIGN

Individual participant data meta-analysis using the previously established International Weight Management in Pregnancy (i-WIP) Collaborative Group database (https://iwipgroup.wixsite.com/collaboration). Preferred Reporting Items for Systematic reviews and Meta-Analysis of Individual Participant Data Statement guidelines were followed.

DATA SOURCES

Major electronic databases, from inception to February 2017.

ELIGIBILITY CRITERIA

Randomised controlled trials on diet and physical activity-based interventions in pregnancy. Maternal educational attainment was required for inclusion and was categorised as higher education (≥tertiary) or lower education (≤secondary).

RISK OF BIAS

Cochrane risk of bias tool was used.

DATA SYNTHESIS

Principle measures of effect were OR and regression coefficient.

RESULTS

Of the 36 randomised controlled trials in the i-WIP database, 21 trials and 5183 pregnant women were included. Women with lower educational attainment had an increased risk of excessive (OR 1.182; 95% CI 1.008 to 1.385, p =0.039) and inadequate weight gain (OR 1.284; 95% CI 1.045 to 1.577, p =0.017). Among women with lower education, diet basedinterventions reduced risk of excessive weight gain (OR 0.515; 95% CI 0.339 to 0.785, p = 0.002) and inadequate weight gain (OR 0.504; 95% CI 0.288 to 0.884, p=0.017), and reduced kg/week gain (B -0.055; 95% CI -0.098 to -0.012, p=0.012). Mixed interventions reduced risk of excessive weight gain for women with lower education (OR 0.735; 95% CI 0.561 to 0.963, p=0.026). Among women with high education, diet based interventions reduced risk of excessive weight gain (OR 0.609; 95% CI 0.437 to 0.849, p=0.003), and mixed interventions reduced kg/week gain (B -0.053; 95% CI -0.069 to -0.037,p<0.001). Physical activity based interventions did not impact GWG when stratified by education.

CONCLUSIONS

Pregnant women with lower education are at an increased risk of excessive and inadequate GWG. Diet based interventions seem the most appropriate choice for these women, and additional support through mixed interventions may also be beneficial.

Maternal Dietary Patterns and Birth Outcomes: A Systematic Review and Meta-Analysis

Findings on the relations of maternal dietary patterns during pregnancy and risk of preterm birth and offspring birth size remain inconclusive. We aimed to systematically review and quantify these associations. We searched MEDLINE, Embase, CENTRAL, and CINAHL up to December 2017. Three authors independently conducted a literature search, study selection, data extraction, and quality assessment. Summary effect sizes were calculated with random effects models and studies were summarized narratively if results could not be pooled. We included 36 studies and pooled results from 25 observational studies (167,507 participants). Two common dietary patterns-"healthy" and "unhealthy"-were identified. Healthy dietary patterns-characterized by high intakes of vegetables, fruits, wholegrains, low-fat dairy, and lean protein foods-were associated with lower risk of preterm birth (OR for top compared with bottom tertile: 0.79; 95% CI: 0.68, 0.91; I2 = 32%) and a weak trend towards a lower risk of small-for-gestational-age (OR: 0.86; 95% CI: 0.73, 1.01; I2 = 34%). Only statistically data-driven healthy dietary patterns, and not dietary index-based patterns, were associated with higher birth weight (mean difference: 67 g; 95% CI: 37, 96 g; I2 = 75%). Unhealthy dietary patterns-characterized by high intakes of refined grains, processed meat, and foods high in saturated fat or sugar-were associated with lower birth weight (mean difference: -40 g; 95% CI: -61, -20 g; I2 = 0%) and a trend towards a higher risk of preterm birth (OR: 1.17; 95% CI: 0.99, 1.39; I2 = 76%). Data from observational studies indicate that greater adherence to healthy dietary patterns during pregnancy is significantly related to lower risk of preterm birth. No consistent associations with birth weight and small- or large-for-gestational-age were observed.

Effect of Adherence to Mediterranean Diet during Pregnancy on Children's Health: A Systematic Review

The traditional Mediterranean diet has been shown to be a healthy eating pattern that protects against the development of many diseases in adults and children. Pregnancy is a critical period of plasticity during which foetal development may be significantly influenced by different environmental factors, including maternal nutrition. In this context, several studies have examined the potential benefits of adherence to a Mediterranean diet during pregnancy on birth outcomes, considering the Mediterranean diet as a whole rather than focusing on the effect of its individual components. In this review, we systematically summarized and discussed results of studies investigating the protective role of Mediterranean diet against foetal growth, prematurity, neural tube defects and other congenital pathologies, asthma and allergy, body weight and metabolic markers. Although current data are insufficient and randomized control trials are needed, growing evidence suggests the beneficial effect of the Mediterranean diet during pregnancy on children's health. In this sense, strategies aiming to promote adherence to this dietary pattern might be of considerable importance to public health.

The Effects of Vegetarian and Vegan Diet during Pregnancy on the Health of Mothers and Offspring

Vegetarian and vegan diets have increased worldwide in the last decades, according to the knowledge that they might prevent coronary heart disease, cancer, and type 2 diabetes. Althought plant-based diets are at risk of nutritional deficiencies such as proteins, iron, vitamin D, calcium, iodine, omega-3, and vitamin B12, the available evidence shows that well planned vegetarian and vegan diets may be considered safe during pregnancy and lactation, but they require a strong awareness for a balanced intake of key nutrients. A review of the scientific literature in this field was performed, focusing specifically on observational studies in humans, in order to investigate protective effects elicited by maternal diets enriched in plant-derived foods and possible unfavorable outcomes related to micronutrients deficiencies and their impact on fetal development. A design of pregestational nutrition intervention is required in order to avoid maternal undernutrition and consequent impaired fetal growth.

Dietary patterns before and during pregnancy and maternal outcomes: a systematic review

BACKGROUND

Hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) are common maternal complications during pregnancy, with short- and long-term sequelae for both mothers and children.

OBJECTIVE

Two systematic review questions were used to examine the relation between 1) dietary patterns before and during pregnancy, 2) HDP, and 3) GDM.

METHODS

A search was conducted from January 1980 to January 2017 in 9 databases including PubMed, Embase, and Cochrane. Two analysts independently screened articles using a priori inclusion and exclusion criteria; data were extracted from included articles, and risk of bias was assessed. After qualitative synthesis, a conclusion statement was drafted for each question and the evidence supporting the conclusion was graded.

RESULTS

Of the 9103 studies identified, 8 [representing 4 cohorts and 1 randomized controlled trial (RCT)] were included for HDP and 11 (representing 6 cohorts and 1 RCT) for GDM. Limited evidence in healthy Caucasian women with access to health care suggests dietary patterns before and during pregnancy that are higher in vegetables, fruits, whole grains, nuts, legumes, fish, and vegetable oils and lower in meat and refined grains are associated with reduced risk of HDP, including preeclampsia and gestational hypertension. Limited but consistent evidence suggests certain dietary patterns before pregnancy are associated with reduced risk of GDM. These protective dietary patterns are higher in vegetables, fruits, whole grains, nuts, legumes, and fish and lower in red and processed meats. Most of the research was conducted in healthy, Caucasian women with access to health care. Insufficient evidence exists on the associations between dietary patterns before and during pregnancy and risk of HDP in minority women and those of lower socioeconomic status, and dietary patterns during pregnancy and risk of GDM.

CONCLUSIONS

Although some conclusions were drawn from these systematic reviews, more research is needed to address gaps and limitations in the evidence.