Adequacy of nutritional intake from food and supplements in a cohort of pregnant women in Québec, Canada: the 3D Cohort Study (Design, Develop, Discover)

Exposure to prenatal excess or imbalanced micronutrients leads to long-term perturbations in one-carbon metabolism, trimethylamine-N-oxide and DNA methylation in Wistar rat offspring

Prenatal multivitamins, including folic acid, are commonly consumed in excess, whereas choline, an essential nutrient and an important source of labile methyl groups, is underconsumed. Here, we characterized profiles of one-carbon metabolism and related pathways and patterns of DNA methylation in offspring exposed to excess or imbalanced micronutrients prenatally. Pregnant Wistar rats were fed either recommended 1× vitamins (RV), high 10× vitamins (HV), high 10× folic acid with recommended choline (HFolRC), or high 10× folic acid with no choline (HFolNC). Offspring were weaned to a high-fat diet for 12 weeks. Circulating metabolites were analyzed with a focus on the hypothalamus, an area known to be under epigenetic regulation. HV, HFolRC, and HFolNC males had higher body weight (BW) and lower plasma choline and methionine consistent with lower hypothalamic S-adenosylmethionine (SAM):S-adenosylhomocysteine (SAH) and global DNA methylation compared with RV. HV and HFolNC females had higher BW and lower plasma 5-methyltetrahydrofolate and methionine consistent with lower hypothalamic global DNA methylation compared with RV. Plasma dimethylglycine (DMG) and methionine were higher as with hypothalamic SAM:SAH and global DNA methylation in HFolRC females without changes in BW compared with RV. Plasma trimethylamine and trimethylamine-N-oxide were higher in males but lower in females from HFolRC compared with RV. Network modeling revealed a link between the folate-dependent pathway and SAH, with most connections through DMG. Final BW was negatively correlated with choline, DMG, and global DNA methylation. In conclusion, prenatal intake of excess or imbalanced micronutrients induces distinct metabolic and epigenetic perturbations in offspring that reflect long-term nutritional programming of health.

Vitamin D, Folate, Vitamin B12, and Iron Status in Pregnant/Postpartum Old Order Anabaptist Women in Southwestern Ontario

Purpose: To assess vitamin D, folate, vitamin B12, and iron status in Old Order Anabaptist (OOA) pregnant/postpartum women.Methods: Blood was analyzed for plasma 25 hydroxy vitamin D (25(OH)D), red blood cell (RBC) folate, serum vitamin B12, and iron status indicators. Dietary intakes (food and supplements) from 3-day estimated records were compared to Dietary Reference Intakes and Canada's Food Guide (2007).Results: Fifty women participated in this descriptive cross-sectional study. Concentrations of 25(OH)D were low (<50 nmol/L for 20% and < 75 nmol/L for 63%); 42% had total vitamin D intakes < estimated average requirement (EAR). All women had RBC folate above the 1360 mmol/L cut-off. Nineteen percent had folate intakes upper limit. One woman had low serum vitamin B12 (<148 pmol/L); serum vitamin B12 was high (>652 pmol/L) for 24%. None had vitamin B12 intakes  Collapse

Key Words

• Anabaptist
• anabaptiste
• femmes enceintes post-partum
• fer
• folate
• iron
• pregnant postpartum women
• vitamin B12
• vitamin D
• vitamine B12
• vitamine D

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MESH Headings Collapse

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Affiliation(s)

Janis A Randall Simpson Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, ON
Natalee Miller Huron Perth Public Health, Stratford, ON
Taylor Hartwig Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, ON
Jane Leach Huron Perth Public Health, Stratford, ON
Melissa Purdy Huron Perth Public Health, Stratford, ON
Emily Roth Countryside Midwifery Services, Milverton, ON
Victoria Mok Siu Department of Pediatrics, Western University, London, ON
Cynthia Soulliere Countryside Midwifery Services, Milverton, ON
Jacqui Tam Huron Perth Public Health, Stratford, ON
Ann Watt Huron Perth Public Health, Stratford, ON

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Women in Canada are consuming above the upper intake level of folic acid but few are meeting dietary choline recommendations in the second trimester of pregnancy: data from the CHILD cohort study

There is concern that during a low-risk pregnancy, women are consuming more than recommended (400 µg/day) supplemental folic acid and may not meet recommendations for other nutrients. The objective of this study was to determine folic acid supplement use and dietary folate intakes in the second trimester (week 18) of pregnancy in women (n = 2996) in the Canadian CHILD cohort study. Vitamin B12 and choline intakes were also assessed because they are metabolically related to folate. The majority of participants (71.6%) were consuming a daily prenatal supplement. Twenty-eight percent of women (n = 847) reported consuming a folic acid supplement and of these women, 45.3% had daily supplemental folic acid intakes above the upper intake level (UL; 1000 µg/day). Daily dietary folate intakes were (mean (SD)) 575 (235) DFE µg/day. In contrast, only 24.8% of women met the dietary choline adequate intake (AI) recommendation (AI ≥ 450 mg/day) with a mean (SD) intake of 375 (151) mg/day. Further understanding of the impact of supplemental folic acid intake above the UL and low choline intake during pregnancy requires further investigation.

The effects of pregnancy-related changes in eating attitudes and behaviours on nutritional status

BACKGROUND

During pregnancy, the requirements of essential nutrients for the mother and foetus increase. The changes in pregnant women's eating behaviours may vary according to their sociodemographic characteristics. It is important to meet these increased requirements and understand the factors influencing eating habits during pregnancy.

OBJECTIVES

This study aimed to determine the effects of changes in pregnant women's eating attitudes and behaviours and their sociodemographic characteristics on their meeting status for nutrient recommendations.

METHODS

Sociodemographic information, eating behaviours, and attitudes of 656 pregnant women were obtained in face-to-face interviews between February and June 2020. Food consumption records were taken with a 24-hour recall method and evaluated according to the estimated average requirement value.

RESULTS

The average age of pregnant women was 29.0 ± 5.2 years, 28.0% were high school graduates, and 69.2% were non-working. The frequency of intakes below the estimated mean requirement value were iron, folic acid, vitamin B6, niacin, and calcium. It was demonstrated that there was a significant difference in snack consumption based on the working status and nutrition information obtained (P < .05). Getting nutrition information, age, education level, working status, and pre-pregnancy body mass index significantly increased food consumption (P < .05).

CONCLUSION

Inadequate nutrient intake is a common public health problem in pregnant women. It is necessary to identify the sociodemographic characteristics that negatively impact pregnant women's nutritional status and to develop nutrition and health education programs based on these features.

Gestational diabetes mellitus is associated with distinct folate-related metabolites in early and mid-pregnancy: A prospective cohort study

AIMS

This study aimed to evaluate the association between gestational diabetes mellitus (GDM) and circulating folate metabolites, folic acid (FA) intake, and the methylenetetrahydrofolate reductase (MTHFR) and methionine synthase reductase (MTRR) genotype.

MATERIALS AND METHODS

A prospective pregnancy cohort study was conducted in Beijing, China, from 2022 to 2023. Circulating folate metabolites, including red blood cell (RBC) 5-methyltetrahydrofolate (5-MTHF), 5, 10-methylene-tetrahydrofolate (5,10-CH2-THF), 5- formyltetrahydrofolate (5-CHO-THF), and unmetabolised folic acid (UMFA), and plasma homocysteine (HCY), 5-MTHF, and methylmalonic acid (MMA), were determined at 6-17 weeks and 20-26 weeks of gestation. FA intake and the MTHFR and MTRR genotype were also examined. GDM was diagnosed between 24 and 28 weeks of pregnancy by a 75-g oral glucose tolerance test (OGTT). The association between the folate status and GDM was ascertained using multivariate generalised linear models, logistic regression models, and restricted cubic spline regression, adjusting for potential confounders.

RESULTS

The study included 2032 pregnant women, of whom 392 (19.29%) developed GDM. UMFA above the 75th percentile (≥P75) [adjusted OR (aOR) (95% confidence interval [CI]) = 1.36 (1.01-1.84)], UMFA ≥ P90 [aOR (95% CI) = 1.82 (1.23-2.69)], and HCY ≥ P75 [aOR (95% CI) = 1.40 (1.04-1.88)] in early pregnancy, and RBC 5-MTHF [aOR (95% CI) = 1.48 (1.10-2.00)], RBC 5,10-CH2-THF [aOR (95% CI) = 1.55 (1.15-2.10)], and plasma 5-MTHF [aOR (95% CI) = 1.36 (1.00-1.86)] in mid-pregnancy ≥ P75 are associated with GDM. Higher UMFA levels in early pregnancy show positive associations with the 1-h and 2-h glucose levels during the OGTT, and higher HCY levels are associated with increased fasting glucose levels during the OGTT. In comparison, RBC 5- MTHF and 5,10-CH2-THF, and plasma 5- MTHF in mid-pregnancy are positively associated with the 1-h glucose level (p < 0.05). The MTHFR and MTRR genotype and FA intake are not associated with GDM.

CONCLUSIONS

Elevated levels of UMFA and HCY during early pregnancy, along with elevated RBC 5-MTHF and 5,10-CH2-THF and plasma 5-MTHF during mid-pregnancy, are associated with GDM. These findings indicate distinct connections between different folate metabolites and the occurrence of GDM.

Supplement use in relation to dietary intake in pregnancy: an analysis of the Swedish GraviD cohort

We aimed to study supplement use in relation to dietary intake among pregnant women in Sweden, and adherence to the Nordic Nutrition Recommendations among supplement and non-supplement users. Pregnant women were recruited at registration to antenatal care in 2013–2014. In third trimester, supplement use was collected using a questionnaire, and dietary intake was collected using a FFQ. The majority (64 %) of the 1044 women reported use of one or more supplements. Among all, 0–23 % reported dietary intakes above recommended intake (RI) of vitamin D, folate, Fe and Se. Median dietary intakes of thiamine (1·4 v. 1·3 mg P = 0·013), phosphorus (1482 v. 1440 mg P = 0·007), folate (327 v. 316 µg P = 0·02), Fe (12 v. 11·5 mg P = 0·009), Mg (361 v. 346 mg P < 0·001) and Zn (10·7 v. 10·4 mg P = 0·01) were higher among supplement users compared with non-users. Larger proportions of supplement users than non-users adhered to RI of dietary intakes of thiamine (42 % v. 35 % P = 0·04) and Mg (75 % v. 69 % P = 0·05). Among non-users, a minority had dietary intakes above RI for vitamin D (6 %), folate (10 %) and Fe (21 %). The majority (75–100 %) of supplement users had total intakes above RI for most nutrients. In conclusion, supplement use contributed substantially to reaching RI for vitamin D, folate and Fe. Supplement users had a higher dietary intake of several nutrients than non-users. This highlights that non-supplement users are at risk of inadequate nutrient intakes during pregnancy, suggesting a need for heightened awareness of nutritional adequacy for pregnant women.

Supplementation with (6S)-5-methyltetrahydrofolic acid appears as effective as folic acid in maintaining maternal folate status while reducing unmetabolised folic acid in maternal plasma: a randomised trial of pregnant women in Canada

Folic acid supplementation is recommended during pregnancy to support healthy fetal development; (6S)-5-methyltetrahydrofolic acid ((6S)-5-MTHF) is available in some commercial prenatal vitamins as an alternative to folic acid, but its effect on blood folate status during pregnancy is unknown. To address this, we randomised sixty pregnant individuals at 8-21 weeks' gestation to 0·6 mg/d folic acid or (6S)-5-MTHF × 16 weeks. Fasting blood specimens were collected at baseline and after 16 weeks (endline). Erythrocyte and serum folate were quantified via microbiological assay (as globally recommended) and plasma unmetabolised folic acid (UMFA) via LC-MS/MS. Differences in biochemical folate markers between groups were explored using multivariable linear/quantile regression, adjusting for baseline concentrations, dietary folate intake and gestational weeks. At endline (n 54), the mean values and standard deviations (or median, inter-quartile range) of erythrocyte folate, serum folate and plasma UMFA (nmol/l) in those supplemented with (6S)-5-MTHF v. folic acid, respectively, were 1826 (sd 471) and 1998 (sd 421); 70 (sd 13) and 78 (sd 17); 0·5 (0·4, 0·8) and 1·3 (0·9, 2·1). In regression analyses, erythrocyte and serum folate did not differ by treatment group; however, concentrations of plasma UMFA in pregnancy were 0·6 nmol/l higher (95 % CI 0·2, 1·1) in those supplementing with folic acid as compared with (6S)-5-MTHF. In conclusion, supplementation with (6S)-5-MTHF may reduce plasma UMFA by ∼50 % as compared with supplementation with folic acid, the biological relevance of which is unclear. As folate is currently available for purchase in both forms, the impact of circulating maternal UMFA on perinatal outcomes needs to be determined.

Dietitian-led cluster randomised controlled trial on the effectiveness of mHealth education on health outcomes among pregnant women: a protocol paper

INTRODUCTION

Nutrition education is the cornerstone to maintain optimal pregnancy outcomes including gestational weight gain (GWG). Nevertheless, default for appointments is common and often lead to suboptimal achievement of GWG, accompanied with unfavourable maternal and child health outcomes. While mobile health (mHealth) usage is increasing and helps minimising barriers to clinic appointments among pregnant mothers, its effectiveness on health outcomes has been inconclusive. Therefore, this study aimed to address the gap between current knowledge and clinical care, by exploring the effectiveness of mHealth on GWG as the primary outcome, hoping to serve as a fundamental work to achieve optimal health outcomes with the improvement of secondary outcomes such as physical activity, psychosocial well-being, dietary intake, quality of life and sleep quality among pregnant mothers.

METHODS AND ANALYSIS

A total of 294 eligible participants will be recruited and allocated into 3 groups comprising of mHealth intervention alone, mHealth intervention integrated with personal medical nutrition therapy and a control group. Pretested structured questionnaires are used to obtain the respondents' personal information, anthropometry data, prenatal knowledge, physical activity, psychosocial well-being, dietary intake, quality of life, sleep quality and GWG. There will be at least three time points of data collection, with all participants recruited during their first or second trimester will be followed up prospectively (after 3 months or/and after 6 months) until delivery. Generalised linear mixed models will be used to compare the mean changes of outcome measures over the entire study period between the three groups.

ETHICS AND DISSEMINATION

Ethical approvals were obtained from the ethics committee of human subjects research of Universiti Putra Malaysia (JKEUPM-2022-072) and medical research & ethics committee, Ministry of Health Malaysia: NMRR ID-22-00622-EPU(IIR). The results will be disseminated through journals and conferences targeting stakeholders involved in nutrition research.

TRIAL REGISTRATION NUMBER

Clinicaltrial.gov ID: NCT05377151.

Folic acid supplementation in a mouse model of diabetes in pregnancy alters insulin sensitivity in female mice and beta cell mass in offspring

Epidemiological studies have reported discrepant findings on the relationship between folic acid intake during pregnancy and risk for gestational diabetes mellitus (GDM). To begin to understand how folic acid impacts metabolic health during pregnancy, we determined the effects of excess folic acid supplementation (5× recommendation) on maternal and fetal offspring metabolic health. Using a mouse (female C57BL/6J) model of diet-induced diabetes in pregnancy (western diet) and control mice, we show that folic acid supplementation improved insulin sensitivity in the female mice fed the western diet and worsened insulin sensitivity in control mice. We found no unmetabolized folic acid in liver from supplemented mice suggesting the metabolic effects of folic acid supplementation are not due to unmetabolized folic acid. Male fetal (gestational day 18.5) offspring from folic acid supplemented dams (western and control) had greater beta cell mass and density than those from unsupplemented dams; this was not observed in female offspring. Differential sex-specific hepatic gene expression profiles were observed in the fetal offspring from supplemented dams but this differed between western and controls. Our findings suggest that folic acid supplementation affects insulin sensitivity in female mice, but is dependent on their metabolic phenotype and has sex-specific effects on offspring pancreas and liver.

Selecting a dietary supplement with appropriate dosing for 6 key nutrients in pregnancy

BACKGROUND

Most pregnant women in the United States (US) are at risk of inadequate intake of key nutrients during pregnancy from foods alone. Current dietary supplement practices reduce risk of inadequacy for only some nutrients and induce excessive intake of other nutrients.

OBJECTIVES

Our study aimed to estimate the doses of supplementation needed to help most pregnant women achieve the recommended intake without exceeding upper limits for key prenatal nutrients and to identify US dietary supplements providing these doses.

METHODS

We conducted 24-h dietary recalls in 2450 pregnant participants aged 14-50 y from 2007 to 2019. We estimated the usual intake of vitamins A and D, folate, calcium, iron, and ω-3 FAs from foods alone. We calculated the target doses of supplementation needed to shift 90% of participants to consume above the estimated average requirement and keep 90% below the tolerable upper limit. We identified products in the Dietary Supplement Label Database providing these target doses of supplementation.

RESULTS

The target dose for supplementation was ≥198 mcg retinol activity equivalents of total vitamin A (with ≤2063 mcg preformed retinol); 7-91 mcg vitamin D; 169-720 mcg dietary folate equivalents of folic acid; 383-943 mg calcium; 13-22 mg iron; and ≥59 mg ω-3 FAs. Out of 20,547 dietary supplements (including 421 prenatal products), 69 products (33 prenatal) contained all 6 nutrients; 7 products (2 prenatal) contained target doses for 5 nutrients. Only 1 product (not a prenatal) contained target doses for all 6 nutrients, but it currently costs ∼USD200/mo and requires 7 tablets per daily serving.

CONCLUSIONS

Almost no US dietary supplements provide key nutrients in the doses needed for pregnant women. Affordable and convenient products that fill the gap between food-based intake and estimated requirements of pregnancy without inducing excess intake are needed to support pregnant women and their offspring. Am J Clin Nutr 20XX;xx:xx-xx.

Higher Than Recommended Folic Acid Intakes is Associated with High Folate Status Throughout Pregnancy in a Prospective French-Canadian Cohort

BACKGROUND

Folate and vitamin B12 status during pregnancy are important for maternal and neonatal health. Maternal intake and prepregnancy body mass index (ppBMI) can influence biomarker status.

OBJECTIVES

This study aimed to, throughout pregnancy; 1) assess folate and B12 status including serum total folate, plasma total vitamin B12, and homocysteine (tHcy); 2) examine how these biomarkers are associated with intakes of folate and B12 and with ppBMI; and 3) determine predictors of serum total folate and plasma total vitamin B12.

METHODS

In each trimester (T1, T2, and T3), food and supplement intakes of 79 French-Canadian pregnant individuals were assessed by 3 dietary recalls (R24W) and a supplement use questionnaire. Fasting blood samples were collected. Serum total folate and plasma total vitamin B12 and tHcy were assessed by immunoassay (Siemens ADVIA Centaur XP).

RESULTS

Participants were 32.1 ± 3.7 y and had a mean ppBMI of 25.7 ± 5.8 kg/m². Serum total folate concentrations were high (>45.3 nmol/L, T1: 75.4 ± 55.1, T2: 69.1 ± 44.8, T3: 72.1 ± 52.1, P = 0.48). Mean plasma total vitamin B12 concentrations were >220 pmol/L (T1: 428 ± 175, T2: 321 ± 116, T3: 336 ± 128, P < 0.0001). Mean tHcy concentrations were <11 μmol/L across trimesters. Most participants (79.6%-86.1%) had a total folic acid intake above the Tolerable Upper Intake Level (UL, >1000 μg/d). Supplement use accounted for 71.9%-76.1% and 35.3%-41.8% of total folic acid and vitamin B12 intakes, respectively. The ppBMI was not correlated with serum total folate (P > 0.1) but was weakly correlated with and predicted lower plasma total vitamin B12 in T3 (r = -0.23, P = 0.04; r² = 0.08, standardized beta [sβ] = -0.24, P = 0.01). Higher folic acid intakes from supplements predicted higher serum total folate (T1: r² = 0.05, sβ = 0.15, P = 0.04, T2: r² = 0.28, sβ = 0.56, P = 0.01, T3: r² = 0.19, sβ = 0.44, P < 0.0001).

CONCLUSIONS

Most pregnant individuals had elevated serum total folate concentrations, reflecting total folic acid intakes above the UL driven by supplement use. Vitamin B12 concentrations were generally adequate and differed by ppBMI and pregnancy stage.

INFLUENCE OF CHOLESTEROL ENRICHED DIET ON GENES EXPRESSION ENCODING BONE MORPHOGENETIC PROTEIN-2 AND OSTEOCALCIN IN MOUSE MANDIBLE

OBJECTIVE

The aim: To evaluate the mRNA expression of the key regulators of osteogenesis - osteocalcin and BMP-2 in the mouse embryos mandible (17th day of pregnancy) which were borne by females on high-cholesterol diet for 30 days before fertilization and throughout pregnancy.

PATIENTS AND METHODS

Materials and methods: Experimental hypercholesterolemia (2%) was simulated by adding Cholesterol to the diet for 60 days. In experiment were used 40 mature female white mice that were randomly divided to control and experimental groups. The control group were fed with standard chow diet, the experimental group with diet with cholesterol enriched diet (with addition of 2 grams of Cholesterol per 100 grams of standard chow). The mandibles of mouse embryos (E-17) were examined by using molecular genetic methods.

RESULTS

Results: In control group the relative level of BMP-2 mRNA / actin mRNA was 27.0«2.82, the relative level of and osteocalcin mRNA / actin mRNA was 30.5«6,28. In the jaws of animals in the experimental group with cholesterol enriched diet, the expression relative level of BMP-2 was 30.9«5.81 that is by 14,4% higher than in control group. Therefore, the expression level of оsteocalcin, on the contrary, decreased by 22.3% and was 23.7+5.31.

CONCLUSION

Conclusions: Our study report influence of the cholesterol enriched diet (2%) on mRNA expression of BMP-2 and osteocalcin encoding genes. The embryos from mouse on cholesterol enriched diet (2%) had increased level of BMP-2 gene expression, however significantly decreased level of osteocalcin gene expression.

Associations between folic acid supplement use and folate status biomarkers in the first and third trimesters of pregnancy in the Maternal-Infant Research on Environmental Chemicals (MIREC) Pregnancy Cohort Study

BACKGROUND

Achieving optimal folate status during early gestation reduces the risk of neural tube defects (NTDs). While inadequate folate intake remains a concern, it is becoming increasingly common for individuals to consume higher than recommended doses of folic acid (FA) with minimal additional benefit.

OBJECTIVE

Here, we sought to investigate the determinants, including FA supplement dose and use, of plasma total and individual folate vitamer concentrations in the first and third trimesters of pregnancy.

METHODS

Using data from the Maternal-Infant Research on Environmental Chemicals (MIREC) Study, a cohort exposed to mandatory FA fortification, we measured plasma total folate and individual folate vitamer [5-methyltetrahydrofolate (5-methylTHF), unmetabolized FA (UMFA), and non-methyl folates (sum of THF, 5-formylTHF, 5,10-methenyl-THF)] concentrations in the first and third trimesters (n = 1,893). Using linear mixed models, we estimated associations between plasma folate concentrations, total daily supplemental FA intake, plasma vitamin B-12 concentrations, and multiple demographic, maternal, and reproductive factors.

RESULTS

Almost 95% of MIREC study participants met or exceeded the recommended daily supplemental FA intake from supplements (≥400 μg/d), with approximately 25% consuming more than the Tolerable Upper Intake Level (>1000 μg/d). Over 99% of MIREC participants had a plasma total folate status indicative of maximal NTD risk reduction (25.5 nmol/L) regardless of FA supplement dose. UMFA was detected in almost all participants, with higher concentrations associated with higher FA doses. Determinants of adequate FA supplement intake and folate status associated with reduced NTD risk included indicators of higher socioeconomic position, higher maternal age, nulliparity, and lower prepregnancy BMI.

CONCLUSIONS

In the context of mandatory FA fortification, our data indicate that higher-than-recommended FA doses are unwarranted, with the exception of individuals at higher risk for NTDs. Ideally, prenatal supplements would contain 400 rather than 1000 µg FA, thereby enabling the consumption of optimal and safe FA doses.

Diet quality during pregnancy and its association with social factors: 3D Cohort Study (Design, Develop, Discover)

Good diet quality during pregnancy provides adequate nutrition to support both the mothers and the fetus. The objective of this study is to describe the distribution of diet quality during pregnancy and to study the association between social factors and diet quality during pregnancy in a Canadian population. This study was based on 1535 pregnant women who provided dietary information in the 3D Cohort Study in Quebec, Canada. A 3‐day food record was used to collect dietary intake in the second trimester of pregnancy. A Canadian adaption of the Healthy Eating Index (HEI‐C) 2010 was used to quantify diet quality. Univariate and multiple linear regression models were used to calculate unadjusted and adjusted effect estimates and confidence intervals for the association between social factors and HEI‐C. The mean HEI‐C 2010 score in this study was 62.9 (SD: 11.2). Only 4.5% and 8.3% of the pregnant women consumed the recommended amounts of whole grains and ‘greens and beans’, respectively. Diet quality was lower in some subgroups of pregnant women. After multivariable adjustment, lower diet quality was observed in participants who were less educated, younger, overweight or obese before pregnancy, or parous. There was an interaction between ethnicity and immigration status on diet quality in pregnancy. These findings could be useful for health practitioners and policymakers in developing strategies to improve the diet quality of pregnant women.

The diet of the women in Canada still needs improvement, especially regarding whole grains and ‘greens and beans’, where the majority of the women did not meet the recommendations.

Pregnant women who were less educated, younger, overweight or obese before pregnancy, or parous should be targeted for improving diet quality in Canada.

There was an interaction between ethnicity and immigration status on diet quality during pregnancy.

Women Taking a Folic Acid Supplement in Countries with Mandatory Food Fortification Programs May Be Exceeding the Upper Tolerable Limit of Folic Acid: A Systematic Review

Background: In preconception and pregnancy, women are encouraged to take folic acid-based supplements over and above food intake. The upper tolerable limit of folic acid is 1000 mcg per day; however, this level was determined to avoid masking a vitamin B12 deficiency and not based on folic acid bioavailability and metabolism. This review’s aim is to assess the total all-source intake of folate in women of childbearing age and in pregnancy in high-income countries with folate food fortification programs. Methods: A systematic search was conducted in five databases to find studies published since 1998 that reported folate and folic acid intake in countries with a mandatory fortification policy. Results: Women of childbearing age do not receive sufficient folate intake from food sources alone even when consuming fortified food products; however, almost all women taking a folic acid-based supplement exceed the upper tolerable limit of folic acid intake. Conclusions: Folic acid supplement recommendations and the upper tolerable limit of 1000 mcg set by policy makers warrant careful review in light of potential adverse effects of exceeding the upper tolerable limit on folic acid absorption and metabolism, and subsequent impacts on women’s health during their childbearing years.

Nutrient supplementation among pregnant women in China: an observational study

OBJECTIVE

To clarify nutrient supplementation usage and primary source of information among pregnant women in China.

DESIGN

This cross-sectional study used information on nutrient supplementation and primary source of information collected via face-to-face interviews. Data on the usage of folic acid, Ca/vitamin D, Fe, vitamins, DHA and other dietary supplements were collected. Primary source of information was categorised as family/relatives, friends/co-workers, the Internet, books/magazines, television/radio, doctors, other people and oneself.

SETTING

Maternal and Child Health Hospital in Chengdu, China.

PARTICIPANTS

One thousand eighty-one Chinese pregnant women aged ≥20 years with singleton pregnancies.

RESULTS

In all three trimesters of pregnancy, usage was highest and most stable for folic acid (81·7 %), followed by vitamins (vitamin A, B-group vitamins, vitamin C and multivitamins; 75·0 %), whereas Ca/vitamin D (51·4 %) and Fe (18·1 %) usage was low, potentially indicating a deficiency risk. All supplementation usage percentages increased with pregnancy duration (P < 0·05). Notably, approximately 10 % of the pregnant women in our study did not use any nutrient supplementation, and this was especially common in early pregnancy. More than 50 % of the women reported getting information on nutrient supplementation from family members, and about 30 % reported getting this information from doctors.

CONCLUSIONS

Among pregnant women in China, awareness about nutrient supplementation increases as the pregnancy progresses, but some types of nutrient supplementation (such as Ca/vitamin D and Fe) remain at low levels. It is necessary to pay more attention to the health education of pregnant women in China, and the influence of family members should be emphasised.

A China Healthy Diet Index-Based Evaluation of Dietary Quality among Pregnant Women in Shanghai across Trimesters and Residential Areas

Good dietary quality among pregnant women is critical for maternal and fetal health. The primary objective of our study was to analyze the dietary quality of pregnant woman and its influencing factors. Pregnant women were enrolled using a multistage, stratified, random-sampling method in Shanghai. We used a personal food frequency questionnaire and a household condiment weighing method for dietary assessments. Participants' scores on the China Healthy Diet Index (CHDI) were analyzed to evaluate diet quality. Significant differences in the median daily intake of almost all food types were found across all trimesters, and all food types were found across all residential areas (urban, suburban and rural). The median of total CHDI score was 71.6 in all subjects, 71.1 in early pregnancy, 71.5 in middle pregnancy and 72.3 in late pregnancy. The results of uni-variate analysis showed that significant differences in CHDI scores were found across trimesters and residential areas. Eighty one point six percent of participants scored below 80 points, indicating general or poor dietary quality. Logistic regression models showed that participants in early and middle pregnancy had lower scores than those in late pregnancy. Women in urban areas had higher scores than those in suburban and rural areas. Most of pregnant women living in Shanghai suffer from a general or poor dietary quality. Education on balance diet should be strengthened to guide pregnant women in making reasonable food choices and intake, especially those living in suburban and rural areas and those in their first and second trimesters.

One carbon metabolism and early development: a diet-dependent destiny

One carbon metabolism (OCM) is critical for early development, as it provides one carbon (1C) units for the biosynthesis of DNA, proteins, and lipids and epigenetic modification of the genome. Epigenetic marks established early in life can be maintained and exert lasting impacts on gene expression and functions later in life. Animal and human studies have increasingly demonstrated that prenatal 1C nutrient deficiencies impair fetal growth, neurodevelopment, and cardiometabolic parameters in childhood, while sufficient maternal 1C nutrient intake is protective against these detrimental outcomes. However, recent studies also highlight the potential risk of maternal 1C nutrient excess or imbalance in disrupting early development. Further studies are needed to delineate the dose-response relationship among prenatal 1C nutrient exposure, epigenetic modifications, and developmental outcomes.

Inadequate vitamin D intake among pregnant women in Malaysia based on revised recommended nutrient intakes value and potential dietary strategies to tackle the inadequacy

BACKGROUND/OBJECTIVES

Recently, the recommended nutrient intakes (RNI) for vitamin D for Malaysian aged 1-70 yrs has been revised from 5 µg/day to 15 µg/day. This study is aimed to assess the adequacy of vitamin D intake based on revised RNI and to recommend several dietary strategies to increase total vitamin D intake.

SUBJECTS/METHODS

Vitamin D intake from both food and supplement of 217 pregnant women was assessed using a validated food frequency questionnaire. Hypothetical effect of expanded supplementation and food fortifications strategies were modelled using the consumption data.

RESULTS

The results revealed that more than half (67.7%) of pregnant women had inadequate vitamin D intake (RNI < 15 µg/day). The modelling results demonstrated the potential of universal provision of 10 µg/day of multivitamins supplements in increasing vitamin D intake. Moreover, mandatory fortification of both milk and malted drink at single level of 5 µg/serving would lead to increase in vitamin D intake of Malaysians, particularly pregnant women.

CONCLUSIONS

The outcome of this study can be used as a reference for public health professionals to re-evaluate the existing Malaysian food fortification policies and supplementation recommendation for vitamin D for pregnant women.

Longitudinal Assessment of Vitamin D Status across Trimesters of Pregnancy

BACKGROUND

The evolution of vitamin D status across pregnancy trimesters and its association with prepregnancy body mass index (ppBMI; in kg/m2) remain unclear.

OBJECTIVES

We aimed to 1) assess trimester-specific serum total 25-hydroxyvitamin D [25(OH)D] concentrations, 2) compare those concentrations between ppBMI categories, and 3) examine associations between 25(OH)D concentrations, ppBMI, and vitamin D intake.

METHODS

As part of a prospective cohort study, 79 pregnant women with a mean age of 32.1 y and ppBMI of 25.7 kg/m2 were recruited in their first trimester (average 9.3 weeks of gestation). Each trimester, vitamin D intake was assessed by 3 Web-based 24-h recalls and a Web questionnaire on supplement use. Serum total 25(OH)D was measured by LC-tandem MS. Repeated-measures ANOVA was performed to assess the evolution of 25(OH)D concentrations across trimesters of pregnancy and comparisons of 25(OH)D concentrations between ppBMI categories were assessed by 1-factor ANOVAs. Stepwise regression analyses were used to identify determinants of 25(OH)D concentrations in the third trimester.

RESULTS

Mean ± SD serum total 25(OH)D concentrations increased across trimesters, even after adjustments for ppBMI, seasonal variation, and vitamin D intake from supplements (67.5 ± 20.4, 86.5 ± 30.9, and 88.3 ± 29.0 nmol/L at mean ± SD 12.6 ± 0.8, 22.5 ± 0.8, and 33.0 ± 0.6 weeks of gestation, respectively; P < 0.0001). In the first and third trimesters, women with a ppBMI ≥30 had lower serum total 25(OH)D concentrations than women with a ppBMI <25 (P < 0.05); however, most had concentrations >40nmol/L by the second trimester. Vitamin D intake from supplements was the strongest determinant of third-trimester serum total 25(OH)D concentrations (r2 = 0.246, β = 0.51; P < 0.0001).

CONCLUSIONS

There was an increase in serum total 25(OH)D concentrations across trimesters, independent of ppBMI, seasonal variation, and vitamin D intake from supplements. Almost all women had serum total 25(OH)D concentrations over the 40- and 50-nmol/L thresholds, thus our study supports the prenatal use of a multivitamin across pregnancy.

Knowledge, attitude and practice of physicians regarding periconceptional folic acid for women at low risk of a neural tube defect affected pregnancy

Canadian expert guidelines recommend low-risk women to consume a daily multivitamin supplement containing 400 µg of folic acid (FA) to prevent neural tube defects. Mandatory food fortification coupled with intake of prenatal vitamin/mineral supplements (PVS), most of which contain ≥ 1000 µg-FA, has resulted in an unprecedented shift in Canadian pregnant women folate status. This study assessed the knowledge, attitude and practice (KAP) of physicians regarding periconceptional FA recommendations, intake and health related outcomes, since they play an essential role in promoting appropriate FA intake. Seventy-seven physicians answered the self-administered KAP survey. Only half of physicians knew the correct dose and duration of FA for low-risk women. Approximately 70% were unsure of, or unfamiliar with the most recent guidelines and 60% of physicians most often recommend a ≥ 1000 µg-FA supplement. Knowledge score 1 (KS1), which related to low-risk women, was associated with physicians' attitude toward believing that most PVS contain the recommended amount of FA (p = 0.004). Significant correlations were also found between KS1 and the total practice score (TPS) (r = 0.45, p < 0.0001) as well as between the total knowledge score and TPS (r = 0.38, p = 0.0007). Our findings show that physicians lacking knowledge regarding periconceptional FA is associated with their attitude and practice. Despite a vast majority of physicians being unsure or uncomfortable recommending PVS that are not in line with recommendations, a lack of knowledge and a widely accessible 400 µg-FA PVS, enables a contradictory practice in reality.

Food consumption and household income of pregnant and lactating women

OBJECTIVE

To look at the relationship between food consumption patterns and household income in pregnant and lactating women, in Malili District, East Luwu Regency, South Sulawesi.

METHOD

This study was an analytical survey, using a cross-sectional approach with 128 respondents consisting of 42 pregnant women and 86 lactating mothers. Data collection using questionnaires with interview techniques. Data analysis using bivariate analysis using the chi-square test and fisher exact test.

RESULTS

Of the total respondents there were high-risk age <20 years and >35 years 20%, low education 47%, housewives 84%, and low income 45%, high income 55%. The results showed that nutritional intake obtained a value of p=0.002 (p<0.05) which showed that there were differences in fat intake in pregnant women and breastfeeding mothers, whereas in energy, protein, carbohydrate, vitamin C, and FE intake there were no differences. In the consumption pattern, fruit intake, vegetable intake has no relationship with household income but the chi-square test on staple foods obtained a value of p=0.03 (p<0.05) which indicates that there is a relationship between food consumption and income.

CONCLUSION

There is a relationship between staple food consumption and household income in pregnant and lactating women.

Nutrient Intake during Pregnancy and Adherence to Dietary Recommendations: The Mediterranean PHIME Cohort

Few studies provide a detailed description of dietary habits during pregnancy, despite the central role of nutrition for the health of the mother and offspring. This paper describes the dietary habits, energy and nutrient intake in pregnant women from four countries belonging to the Mediterranean PHIME cohort (Croatia, Greece, Italy and Slovenia) and evaluates their adherence to the European Food Safety Authority (EFSA) recommendations. A total of 1436 women were included in the present analysis. Maternal diet was assessed using a food frequency questionnaire (FFQ). The mean macro and micronutrient intakes were estimated and compared with the dietary reference values (DRVs). The percentage distribution of the 16 food groups in the total intake of each macronutrient was estimated. All women shared a similar diet during pregnancy; almost all the women in the four countries exceeded the DRV for sugars, and the total fat intake was above the DRV in most women in all the countries, as was the contribution of saturated fatty acids (SFAs) to the total energy intake. In all four countries, we observed an increased risk of micronutrient deficiency for iron, folate and vitamin D. Shared guidelines, implemented at both the national and European level, are essential to improve the maternal nutritional status during pregnancy.

Gestational Folate and Folic Acid Intake among Women in Canada at Higher Risk of Pre-Eclampsia

BACKGROUND

Periconceptional folic acid (FA) supplementation is recommended to prevent neural tube defects; however, the extent to which recommendations are met through dietary sources and supplements is not clear.

OBJECTIVES

Our objective was to evaluate the dietary and supplemental intakes of FA in a Canadian pregnancy cohort and to determine the proportions of pregnant women exceeding the Estimated Average Requirement (EAR) and Tolerable Upper Intake Level (UL).

METHODS

FACT (the Folic Acid Clinical Trial) was an international multicenter, randomized, double-blinded, placebo-controlled, phase III trial investigating FA for the prevention of pre-eclampsia in high-risk pregnancies. Participants were enrolled from Canadian sites at 8-16 weeks of gestation. Dietary and supplemental FA intake data were collected through participant interviews and FFQs at the time of FACT enrollment. Categorical data were summarized as n (%) and continuous data as median (IQR).

RESULTS

This study included 1198 participants. Participants consumed 485 μg dietary folate equivalents (DFE)/d (IQR: 370-630 μg DFE/d) from dietary sources of folate and FA. Through diet alone, 43.4% of participants consumed ≥520 μg DFE/d, the EAR for pregnant individuals. Of the 91.9% of participants who consumed daily FA supplements, 0.4% consumed <400 μg FA/d and 96.0% consumed ≥1000 μg/d, the UL for FA. Median (IQR) total folate intake was 2167 μg DFE/d (2032-2325 μg DFE/d); 95.3% of participants met or exceeded the EAR from all sources, but 1069 (89.2%) participants exceeded the UL.

CONCLUSIONS

The majority of participants in this Canadian pregnancy cohort did not consume the recommended amount of folate from dietary sources. However, most prenatal supplements contained 1000 μg FA, resulting in the majority of women exceeding the UL. With no additional benefit associated with FA intakes beyond the UL for most women, modification of prenatal supplement formulations may be warranted to ensure women meet but do not exceed recommended FA intakes.FACT was registered at clinicaltrials.gov as NCT01355159 and at isrctn.com as ISRCTN23781770.

Folic Acid Status and Associated Factors for Pregnant Chinese Women - China, 2015

What is already known on this topic?

Low folate status in pregnancy has been associated with multiple adverse pregnancy outcomes, including neural tube defects, congenital heart defects, fetal growth restriction, low birth weight, and preterm delivery. Low folate status is common in China, especially in northern areas.

What is added by this report?

Folate status remains suboptimal among pregnant Chinese women in 2015. Folate concentration was in the widespread in rural area (9.88ng/mL) and especially in the northern of China (9.10ng/mL). Pregnant women in the last trimester had the lowest folic acid concentration (9.18 ng/mL). Taking folic acid supplements every day would achieve adequate serum folate concentrations (10.87 ng/mL vs. 10.11 ng/mL vs. 9.38 ng/mL, P<0.001).

What are the implications for public health practice?

Folic acid interventions should be strengthened, especially for pregnant women in rural areas and in northern China, those with junior school or below education, those pregnant during spring and winter, or those with late pregnancy.

Nutritional adequacy and the role of supplements in the diets of Indigenous Australian women during pregnancy

OBJECTIVE

To determine sources of key nutrients contributing towards nutritional adequacy during pregnancy (fibre, calcium, iron, zinc and folate) in a cohort of women carrying an Indigenous child.

DESIGN

Analysis of cross-sectional data from a prospective longitudinal cohort study that followed Indigenous women through pregnancy.

SETTING

Women recruited via antenatal clinics in regional and remote locations in NSW, Australia as part of the Gomeroi gaaynggal project.

PARTICIPANTS

One hundred and fifty-two pregnant Australian women who identified as Indigenous or carrying an Indigenous child.

MEASUREMENTS AND FINDINGS

Measurement outcomes included demographic information, smoking status, anthropometrics (weight and height,), self-reported pre-pregnancy weight, health conditions and dietary information (24-hour food recall). Findings indicate the inadequate intake of key pregnancy nutrients in this cohort. Supplements contributed to the nutrient adequacy of the cohort with 53% reporting use. As expected, predominant sources of fibre were from core food groups, whereas calcium was attained from a range of sources including food and beverages, with small amounts from supplementation. Importantly, supplements contributed significant amounts of iron, zinc and folate.

KEY CONCLUSIONS

There is limited literature on Indigenous Australian maternal nutrition. This study highlights the key dietary contributors of nutritional adequacy during pregnancy for the cohort and that supplementation may be considered a viable source of nutrients during pregnancy for these women. Few women met national nutrient recommendations. The findings present an opportunity to optimise nutrient intakes of Indigenous pregnant women.

IMPLICATIONS FOR PRACTICE

Culturally appropriate targeted interventions to optimise dietary intakes of Indigenous Australian pregnant women is required. Collaborative support of health workers, Indigenous Australian communities, dietitians, and researchers to raise awareness of nutrition during pregnancy is imperative to achieving nutrient targets and optimising pregnancy outcomes. Targeted interventions provide positive opportunities to achieve improvements.

Do the Dietary Intakes of Pregnant Women Attending Public Hospital Antenatal Clinics Align with Australian Guide to Healthy Eating Recommendations?

The maternal diet influences the long-term health status of both mother and offspring. The current study aimed to compare dietary intakes of pregnant women compared to food and nutrient recommendations in the Australian Guide to Healthy Eating (AGHE) and Nutrient Reference Values (NRVs). Usual dietary intake was assessed in a sample of women in their 3rd trimester of pregnancy attending antenatal outpatient clinics at John Hunter Hospital, Newcastle, New South Wales (NSW). Dietary intake was measured using the Australian Eating Survey, a validated, semi-quantitative 120-item food frequency questionnaire. Daily food group servings and nutrient intakes were compared to AGHE and NRV targets. Of 534 women participating, none met the AGHE recommendations for all food groups. Highest adherence was for fruit serves (38%), and lowest for breads and cereals (0.6%). Only four women met the pregnancy NRVs for folate, iron, calcium, zinc and fibre from food alone. Current dietary intakes of Australian women during pregnancy do not align with national nutrition guidelines. This highlights the importance of routine vitamin and mineral supplementation during pregnancy, as intakes from diet alone may commonly be inadequate. Future revisions of dietary guidelines and pregnancy nutrition recommendations should consider current dietary patterns. Pregnant women currently need more support to optimise food and nutrient intakes.

Tracking of Maternal Diet from Pregnancy to Postpregnancy: A Systematic Review of Observational Studies

We systematically reviewed studies to examine changes in women's diets from pregnancy to the postpregnancy period and sought to understand the characteristics of women making these changes. From a search of 4 databases and up to November 2019, 17 studies met our inclusion criteria. They reported changes in various dietary aspects. Mixed findings were reported for changes in energy and micronutrient intakes. Most studies reported significant decreases in fruit and vegetable consumption, diet quality, and adherence to a healthier dietary pattern during the transition from pregnancy to postpregnancy, whereas increases in discretionary food and fat intakes were observed. Women with lower education level, lower income, and/or who worked full-time tended to have poorer dietary behaviors postpregnancy. Further research, with better aligned dietary measurement time points during pregnancy and postpartum and standardization of dietary assessment tools, is needed for future studies to be comparable. The systematic review protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews as CRD42020158033.

Nutrient Intake during Pregnancy and Post-Partum: ECLIPSES Study

Pregnancy and post-partum are critical periods in which nutritional intake is essential to maternal and child health. Our aim was to describe dietary intake during pregnancy and post-partum and assess its adequacy. A longitudinal study was conducted on 793 pregnant women. Data about maternal characteristics, health, diet and lifestyle were assessed. Energy and nutritional intake were compared to the Recommended Dietary Allowances (RDA). The results showed that the intake of energy (82.6%), protein (80.6%) and carbohydrate (99.5%) was adequate (above 80% of RDA) during pregnancy, as were vitamins C, B2 and B12; but vitamin D, iron and folate intake were a long way from RDA (below 35%). Similar results were observed for the post-partum period although fiber, and vitamins E and C decreased compared to intake during pregnancy. In conclusion, although nutritional requirements increase during gestation, pregnant women did not increase their energy and nutritional intake during pregnancy and postpartum and they had a high risk of deficient intake of vitamin D, iron and folates during pregnancy, and therefore, of developing an unfavorable nutritional status, contrary to health recommendations. These findings underscore the necessity of intensive nutrition programs during and after pregnancy.

Is natural (6S)-5-methyltetrahydrofolic acid as effective as synthetic folic acid in increasing serum and red blood cell folate concentrations during pregnancy? A proof-of-concept pilot study

Background

North American health authorities recommend 0.4 mg/day folic acid before conception and throughout pregnancy to reduce the risk of neural tube defects. Folic acid is a synthetic form of folate that must be reduced by dihydrofolate reductase and then further metabolized. Recent evidence suggests that the maximal capacity for this process is limited and unmetabolized folic acid has been detected in the circulation. The biological effects of unmetabolized folic acid are unknown. A natural form of folate, (6S)-5-methyltetrahydrofolic acid (Metafolin®), may be a superior alternative because it does not need to be reduced in the small intestine. Metafolin® is currently used in some prenatal multivitamins; however, it has yet to be evaluated during pregnancy.

Methods/design

This double-blind, randomized trial will recruit 60 pregnant women aged 19–42 years. The women will receive either 0.6 mg/day folic acid or an equimolar dose (0.625 mg/day) of (6S)-5-methyltetrahydrofolic acid for 16 weeks. The trial will be initiated at 8–21 weeks’ gestation (after neural tube closure) to reduce the risk of harm should (6S)-5-methyltetrahydrofolic acid prove less effective. All women will also receive a prenatal multivitamin (not containing folate) to ensure adequacy of other nutrients. Baseline and endline blood samples will be collected to assess primary outcome measures, including serum folate, red blood cell folate and unmetabolized folic acid. The extent to which the change in primary outcomes from baseline to endline differs between treatment groups, controlling for baseline level, will be estimated using linear regression. Participants will have the option to continue supplementing until 1 week postpartum to provide a breastmilk and blood sample. Exploratory analyses will be completed to evaluate breastmilk and postpartum blood folate concentrations.

Discussion

This proof-of-concept trial is needed to obtain estimates of the effect of (6S)-5-methyltetrahydrofolic acid compared to folic acid on circulating biomarkers of folate status during pregnancy. These estimates will inform the design of a definitive trial which will be powered to assess whether (6S)-5-methyltetrahydrofolic acid is as effective as folic acid in raising blood folate concentrations during pregnancy. Ultimately, these findings will inform folate supplementation policies for pregnant women.

Trial registration

ClinicalTrials.gov, ID: NCT04022135. Registered on 14 July 2019.

Impact of mothers' early life exposure to low or high folate on progeny outcome and DNA methylation patterns

The dynamic patterning of DNA and histone methylation during oocyte development presents a potentially susceptible time for epigenetic disruption due to early life environmental exposure of future mothers. We investigated whether maternal exposure to folic acid deficient and supplemented diets starting in utero could affect oocytes and cause adverse developmental and epigenetic effects in next generation progeny. Female BALB/c mice (F0) were placed on one of four amino acid defined diets for 4 weeks before pregnancy and throughout gestation and lactation: folic acid control (rodent recommended daily intake; Ctrl), 7-fold folic acid deficient, 10-fold folic acid supplemented or 20-fold folic acid supplemented diets. F1 female pups were weaned onto Ctrl diets, mated to produce the F2 generation and the F2 offspring were examined at E18.5 for developmental and epigenetic abnormalities. Resorption rates were increased and litter sizes decreased amongst F2 E18.5-day litters in the 20-fold folic acid supplemented group. Increases in abnormal embryo outcomes were observed in all three folic acid deficient and supplemented groups. Subtle genome-wide DNA methylation alterations were found in the placentas and brains of F2 offspring in the 7-fold folic acid deficient , 10-fold folic acid supplemented and 20-fold folic acid supplemented groups; in contrast, global and imprinted gene methylation were not affected. The findings show that early life female environmental exposures to both low and high folate prior to oocyte maturation can compromise oocyte quality, adversely affecting offspring of the next generation, in part by altering DNA methylation patterns.

Food and nutrient intake and adherence to dietary recommendations during pregnancy: a Nordic mother-child population-based cohort

Background

A woman's food intake during pregnancy has important implications not only for herself but also for the future health and well-being of her child. Suboptimal dietary quality has been consistently reported in many high-income countries, reflecting poor adherence to dietary guidelines.

Objective

This study aimed to explore the intake of food and nutrients in a cohort of pregnant women in Norway and their adherence to Nordic Nutrition Recommendations (NNR) and Norwegian food-based guidelines (NFG).

Design

We investigated the dietary intake in 1,674 pregnant women from the mother-child birth cohort, PreventADALL, recruited at approximately 18-week gestational age. Dietary intake was assessed by an electronic validated food frequency questionnaire (PrevFFQ) in the first half of pregnancy.

Results

Total fat intake was within the recommended intake (RI) range in most women; however, the contribution of saturated fatty acids to the total energy intake was above RI in the majority (85.2%) of women. Carbohydrate intake was below RI in 43.9% of the women, and 69.5% exceeded the RI of salt. Intakes of fiber, vegetables, and fish were high in a large part of the population. Many women had a high probability of inadequate intakes of the following key micronutrients during pregnancy: folate (54.4%), iron (49.6%), calcium (36.2%), vitamin D (28.7%), iodine (24.4%), and selenium (41.3%). A total of 22.8% women reported an alcohol intake of >1 g/day, and 4.4% reported an alcohol intake of >10 g/day. Women with higher educational levels showed a tendency towards healthier eating habits, except for higher intakes of alcohol and coffee, compared to women with lower educational level.

Discussion

Excessive saturated fat intake and limited intake of many important micronutrients during pregnancy were common, potentially increasing the risk for adverse pregnancy and birth outcomes.

Conclusions

This study highlights the need for improved nutritional guidance to pregnant women across all educational levels.

Adequacy of Nutrients Intake among Jordanian Pregnant Women in Comparison to Dietary Reference Intakes

Objective: Maternal nutrition is considered an important pillar in the pregnancy outcomes for both mother and infant. A mother’s malnutrition and inadequate nutrient intake is associated with many undesirable pregnancy outcomes. Hence, assessing the nutritional status of the mother in the early stages of the pregnancy and preventing any inadequacy can preclude many health problems for both mother and infant. Therefore, this study aimed to assess the adequacy of nutrient intakes among Jordanian pregnant women as compared to their corresponding dietary reference intakes (DRIs). Methods: This cross-sectional study was conducted at a major University Hospital in Jordan. Three hundred pregnant women were invited to participate in the study and 286 agreed to participate. Fifty pregnant women were enrolled at week 9, then 96 pregnant women were at week 20 and 137 pregnant women were at week 30 of pregnancy. The participants completed the interview-based demographic questionnaire, pregnancy physical activity questionnaire, and quantitative food frequency questionnaire (FFQ). Results: The mean energy intake was 2768.9 ± 767.8 kcal/day and it was significantly higher in the 3rd trimester (p < 0.05). Women in the 3rd trimester consumed significantly more protein, carbohydrates, and sugar than women in the 1st and 2nd trimesters (p < 0.05). The pregnant women in the 3rd trimester consumed more sodium than women in the 1st and 2nd trimesters (p < 0.05). The vitamin K intake was significantly (p = 0.045) lower in the 2nd trimester than the 1st and 3rd trimesters. The calcium intake was significantly higher in the 3rd trimester than the 1st and 2nd trimesters (p = 0.021). The total micronutrient (vitamins B1, B2, B3, B6, B12, and D, calcium, and iron) intakes derived from dietary supplements and food sources throughout the 3 trimesters was significantly higher in the 3rd trimester than the 1st and 2nd trimesters (p < 0.05). The vitamin D, calcium, and iron intakes had the most significant increases between the 1st and 3rd trimesters (p < 0.001), while folic acid intake was significantly higher in the 1st trimester than the 2nd and 3rd trimester (p < 0.001). Most women exceeded the tolerable upper intake level (UL) for sodium in all trimesters, while 82% of women exceeded the UL of folic acid in the 1st trimester and from the supplement, not the diet. Conclusion: While the intake of some nutrients from food alone remains below the DRIs in the diets of pregnant women, the intake of other nutrients is above the UL. Raising the awareness of pregnant women about their diet and how a supplement intake can reduce the risk of inadequate intake for many micronutrients and improve their pregnancy outcomes is of great importance.

Diet in Early Pregnancy: Focus on Folate, Vitamin B12, Vitamin D, and Choline

Purpose: Prenatal multivitamins are recommended in pregnancy. This study assessed food and supplement intakes of folate, vitamin B12 (B12), vitamin D, and choline in pregnant women living in Southern Ontario in comparison with current recommendations. Methods: Women recruited to the Be Healthy in Pregnancy RCT (NCT01693510) completed 3-day diet/supplement records at 12-17 weeks gestation. Intakes of folate, B12, vitamin D, and choline were quantified and compared with recommendations for pregnant women. Results: Folate intake (median (min, max)) was 1963 μg/day dietary folate equivalents (153, 10 846); 90% of women met the Estimated Average Requirement (EAR) but 77% exceeded the Tolerable Upper Intake Level (UL) (n = 232). B12 intake was 12.1 μg/day (0.3, 2336); 96% of women met the EAR with 7% exceeding the EAR 100-fold (n = 232). Vitamin D intake was 564 IU/day (0.0, 11 062); 83% met the EAR, whereas 1.7% exceeded the UL (n = 232). Choline intake was 338 mg/day (120, 1016); only 18% met the Adequate Intake and none exceeded the UL (n = 158). Conclusion: To meet the nutrient requirements of pregnancy many women rely on prenatal vitamins. Reformulating prenatal multivitamin supplements to provide doses of vitamins within recommendations to complement a balanced healthy diet would ensure appropriate micronutrient intakes for pregnant women.

The Importance of Maternal Folate Status for Brain Development and Function of Offspring

The importance of an adequate periconceptional maternal folate status to prevent fetal neural tube defects has been well demonstrated and resulted in the recommendation for women to use folic acid supplements during the periconception period. The importance of maternal folate status for offspring neurodevelopment and brain health is less well described. We reviewed the current evidence linking maternal folate status before conception and during pregnancy with neurodevelopment and cognition of the offspring. We discuss both animal and human studies. Preclinical research revealed the importance of maternal folate status for several key processes required for normal neurodevelopment and brain functioning in the offspring, including DNA synthesis, regulation of gene expression, synthesis of phospholipids and neurotransmitters, and maintenance of healthy plasma homocysteine concentrations. Human observational studies are inconclusive; about half have shown a positive association between maternal folate status and cognitive performance of offspring. Whereas some studies suggest a positive association between maternal folate intake and cognition of offspring during childhood, data from interventional studies are too limited to conclude that there is a direct effect. Future preclinical studies are needed to help us characterize the behavioral effects, understand the underlying mechanisms, and to establish an optimal dosage and time window of folate supplementation. Moreover, more conclusive data from well-designed human observational studies and randomized controlled trials are needed to determine whether current recommendations for folic acid supplementation during pregnancy cover the needs for normal cognitive development in the offspring.

Global inequities in dietary calcium intake during pregnancy: a systematic review and meta-analysis

BACKGROUND

Evidence shows that adequate calcium intake during pregnancy reduces the risk of hypertensive disorders of pregnancy. In most low- and middle-income countries (LMICs) the daily calcium intake is well below recommendations. Mapping calcium intake during pregnancy worldwide and identifying populations with low calcium intake will provide the evidence base for more targeted actions to improve calcium intake.

OBJECTIVE

To assess dietary calcium intake during pregnancy worldwide.

SEARCH STRATEGY

MEDLINE and EMBASE (from July 2004 to November 2017).

SELECTION CRITERIA

Cross-sectional, cohort, and intervention studies reporting calcium intake during pregnancy.

DATA COLLECTION AND ANALYSIS

Five reviewers working in pairs independently performed screening, extraction, and quality assessment. We reported summary measures of calcium intake and calculated the weighted arithmetic mean for high-income countries (HICs) and LMICs independently, and for geographic regions, among studies reporting country of recruitment, mean intake, and total number of participants. When available, inadequate intakes were reported.

MAIN RESULTS

From 1880 citations 105 works met the inclusion criteria, providing data for 73 958 women in 37 countries. The mean calcium intake was 948.3 mg/day (95% CI 872.1-1024.4 mg/day) for HICs and 647.6 mg/day (95% CI 568.7-726.5 mg/day) for LMICs. Calcium intakes below 800 mg/day were reported in five (29%) countries from HICs and in 14 (82%) countries from LMICs.

CONCLUSION

These results are consistent with a lack of improvement in calcium dietary intake during pregnancy and confirm the gap between HICs and LMICs, with alarmingly low intakes recorded for pregnant women in LMICs. From the public health perspective, in the absence of specific local data, calcium supplementation of pregnant women in these countries should be universal.

TWEETABLE ABSTRACT

Despite dietary recommendations, women in LMICs face pregnancy with diets low in calcium.

Changes in Micronutrient Intake and Status, Diet Quality and Glucose Tolerance from Preconception to the Second Trimester of Pregnancy

Data on changes in dietary intake and related blood parameters throughout pregnancy are scarce; moreover, few studies have examined their association with glucose homeostasis. Therefore, we monitored intake of folate, vitamin B6, vitamin B12, vitamin D and iron, their status markers, and diet quality from preconception to the second trimester of pregnancy, and we examined whether these dietary factors were associated with glucose homeostasis during pregnancy. We included 105 women aged 18⁻40 years with a desire to get pregnancy or who were already <24 weeks pregnant. Women at increased gestational diabetes (GDM) risk were oversampled. Measurements were scheduled at preconception (n = 67), and 12 (n =53) and 24 weeks of pregnancy (n =66), including a fasting venipuncture, 75-grams oral glucose tolerance test, and completion of a validated food frequency questionnaire. Changes in micronutrient intake and status, and associations between dietary factors and glucose homeostasis, were examined using adjusted repeated measures mixed models. Micronutrient intake of folate, vitamin B6 and vitamin D and related status markers significantly changed throughout pregnancy, which was predominantly due to changes in the intake of supplements. Micronutrient intake or status levels were not associated with glucose homeostasis, except for iron intake (FE µg/day) with fasting glucose (β = -0.069 mmol/L, p = 0.013) and HbA1c (β = -0.4843 mmol, p = 0.002). Diet quality was inversely associated with fasting glucose (β = -0.006 mmol/L for each DHD15-index point, p = 0.017). It was shown that micronutrient intakes and their status markers significantly changed during pregnancy. Only iron intake and diet quality were inversely associated with glucose homeostasis.

Trimester-Specific Assessment of Diet Quality in a Sample of Canadian Pregnant Women

The present study aimed to (1) examine changes in diet quality throughout pregnancy and (2) identify maternal characteristics associated with trimester-specific diet quality. Pregnant women (n = 79) were recruited in their 1st trimester of pregnancy and completed, at each trimester, three web-based 24-hour dietary recalls, from which the Canadian Healthy Eating Index (HEI) was calculated. Physical activity, nutrition knowledge, and socio-demographic web-questionnaires were also completed. Although no variation in total HEI scores was observed across trimesters, we found an overall decrease in the following subscores: adequacy, total fruits and vegetables, unsaturated fats and saturated fats (p < 0.05). In the 1st trimester, overweight and obese pregnant women had a lower diet quality in comparison with normal-weight and underweight women (HEI scores: 63.1 ± 11.9 vs. 68.0 ± 9.3; p = 0.04). In the 3rd trimester, women younger than 28 years old, with no university degree, poorer nutrition knowledge and who reside in an urban setting, had a lower diet quality (p < 0.05). In conclusion, less educated, younger women who reside in an urban setting may be at a higher risk of poor diet quality in late pregnancy and could benefit from public health programs.

Supplement Use and Dietary Sources of Folate, Vitamin D, and n-3 Fatty Acids during Preconception: The GLIMP2 Study

An adequate nutritional status during the preconception period is important, particularly for folate, vitamin D, and n-3 fatty acids (i.e., EPA+DHA). We aimed to determine supplement intake and the main dietary sources of folate, vitamin D, and EPA+DHA using the data of 66 Dutch women aged 18–40 years who wished to become pregnant. Additionally, associations of these intakes with their blood levels were examined. Dietary intake was assessed with a validated food frequency questionnaire, and supplement use with a structured questionnaire. 25-hydroxyvitamin D levels were determined in serum and folate and phospholipid EPA+DHA levels in plasma. Partial Spearman’s correlations, restricted cubic splines and trend analyses over tertiles of nutrient intakes were performed to examine intake-status associations. A large proportion of women did not meet the Dutch recommended intakes of folate (50%), vitamin D (67%), and EPA+DHA (52%). Vegetables were the main contributor to dietary folate intake (25%), oils and fats to dietary vitamin D intake (39%), and fish to dietary EPA+DHA intake (69%). Fourteen percent of the women had an inadequate folate status and 23% an inadequate vitamin D status. Supplemental folate intake, supplemental and dietary vitamin D intake and dietary EPA+DHA intake were significantly associated with their blood levels. In conclusion, even in our highly educated population, a large proportion did not achieve recommended folate, vitamin D and n-3 fatty acid intakes. Promotion of folate and vitamin D supplement use and fish consumption is needed to improve intakes and blood levels of these nutrients in women who wish to become pregnant.

Trimester-Specific Dietary Intakes in a Sample of French-Canadian Pregnant Women in Comparison with National Nutritional Guidelines

Diet during pregnancy greatly impacts health outcomes. This study aims to measure changes in dietary intakes throughout trimesters and to assess pregnant women’s dietary intakes in comparison with current Canadian nutritional recommendations. Seventy-nine pregnant women were recruited and completed, within each trimester, three Web-based 24-h dietary recalls and one Web questionnaire on supplement use. Dietary intakes from food, with and without supplements, were compared to nutritional recommendations throughout pregnancy. Energy and macronutrient intakes remained stable throughout pregnancy. A majority of women exceeded their energy and protein requirements in the first trimester, and fat intakes as a percentage of energy intakes were above recommendations for more than half of the women in all trimesters. Supplement use increased dietary intakes of most vitamins and minerals, but 20% of women still had inadequate total vitamin D intakes and most women had excessive folic acid intakes. This study showed that pregnant women did not increase their energy intakes throughout pregnancy as recommended. Furthermore, although prenatal supplementation reduces the risk of inadequate intake for most micronutrients, there is still a risk of excessive folic acid and insufficient vitamin D intake, which needs further investigation.

Adequacy of nutritional intake during pregnancy in relation to prepregnancy BMI: results from the 3D Cohort Study

Our study compares adequacy of nutritional intakes among pregnant women with different prepregnancy BMI and explores associations between nutritional intakes during pregnancy and both prepregnancy BMI and gestational weight gain (GWG). We collected dietary information from a large cohort of pregnant Canadian women (n 861) using a 3-d food record. We estimated usual dietary intakes of energy (E), macronutrients and micronutrients using the National Cancer Institute method. We also performed Pearson's correlations between nutritional intakes and both prepregnancy BMI and GWG. In all BMI categories, intakes considered suboptimal (by comparison with estimated average requirements) were noted for Fe, vitamin D, folate, vitamin B6, Mg, Zn, Ca and vitamin A. Total fat intakes were above the acceptable macronutrient distribution range (AMDR) for 36 % of the women. A higher proportion of obese women had carbohydrate intakes (as %E) below the AMDR (v. normal-weight and overweight women; 19 v. 9 %) and Na intakes above the tolerable upper intake level (v. other BMI categories; 90 v. 77-78 %). In all BMI categories, median intakes of K and fibre were below adequate intake. Intakes of several nutrients (adjusted for energy) were correlated with BMI. Correlations were detected between energy-adjusted nutrient intakes and total GWG and were, for the most part, specific to certain BMI categories. Overweight and obese pregnant women appear to be the most nutritionally vulnerable. Nutrition interventions are needed to guide pregnant women toward their optimal GWG while also meeting their nutritional requirements.

Efeito de uma intervenção educativa na gravidez: ensaio clínico randomizado em cluster

Resumo Objetivo Avaliar os efeitos de uma intervenção educativa no conhecimento, na atitude e na prática das gestantes sobre o uso dos alimentos regionais. Métodos Ensaio clínico controlado randomizado em cluster, unicego, com dois grupos paralelos. O estudo foi realizado no período de janeiro a setembro de 2013. Alocação randômica dos conglomerados foi definida pelo processo de alocação aleatória simples. Na ocasião foi utilizado um sorteio entre os conglomerados/cluster e depois foi realizada uma alocação aleatória para escolha das USs. Desta maneira, o conglomerado A fez parte do GI e o conglomerado B do GC. Participaram 91 gestantes no GI (cartilha educativa) e 94 gestantes no GC (consulta pré-natal de risco habitual). Resultados O efeito da cartilha educativa no grupo de intervenção apresentou significância estatística (p<0,001) no sétimo e trigésimo dia pós-intervenção, quando comparados com o grupo controle e aumento da prevalência com adequabilidade do conhecimento, atitude e prática quanto ao uso dos alimentos regionais. Conclusão A cartilha educativa foi uma intervenção eficaz para melhorar o conhecimento, atitude e prática das gestantes quanto ao uso dos alimentos regionais. Registro Brasileiro de Ensaios Clínicos (ReBEC): RBR 7mhyzt.

Nutritional approach to preeclampsia prevention

PURPOSE OF REVIEW

Although not fully understood, the physiopathology of preeclampsia is thought to involve an abnormal placentation, diffuse endothelial cell dysfunction and increased systemic inflammation. As micronutrients play a key role in placental endothelial function, oxidative stress and expression of angiogenic factors, periconceptional micronutrient supplementation has been proposed to reduce the risk of preeclampsia. However, recent studies reported conflicting results.

RECENT FINDINGS

Calcium intake (>1 g/day) may reduce the risk of preeclampsia in women with low-calcium diet. Data from recently updated Cochrane reviews did not support routine supplementation of vitamins C, E or D for either the prevention or treatment of preeclampsia. Evidences are also poor to support zinc or folic acid supplementation for preeclampsia prevention. Dark chocolate, flavonoid-rich food, and long-chain polyunsaturated fatty acids might also be candidates for prevention of preeclampsia.

SUMMARY

Through antioxidant, anti-inflammatory or vasoactive proprieties, micronutrients are good candidates for preeclampsia prevention. Calcium supplementation is recommended to prevent preeclampsia in women with low-calcium intake. Despite positive clinical and in-vitro data, strong evidence to support periconceptional supplementation of other micronutrients for preeclampsia risk-reduction is still lacking. Further studies are also needed to evaluate the benefit of nutritional supplementation such as chocolate and long-chain polyunsaturated fatty acids.

Low Dietary Folate Interacts with MTHFD1 Synthetase Deficiency in Mice, a Model for the R653Q Variant, to Increase Incidence of Developmental Delays and Defects

Background

Suboptimal folate intake, a risk factor for birth defects, is common even in areas with folate fortification. A polymorphism in methylenetetrahydrofolate dehydrogenase 1 (MTHFD1), R653Q (MTHFD1 c.1958 G > A), has also been associated with increased birth defect risk, likely through reduced purine synthesis.

Objective

We aimed to determine if the interaction of MTHFD1 synthetase deficiency and low folate intake increases developmental abnormalities in a mouse model for MTHFD1 R653Q.

Methods

Female Mthfd1S+/+ and Mthfd1S+/- mice were fed control or low-folate diets (2 and 0.3 mg folic acid/kg diet, respectively) before mating and during pregnancy. Embryos and placentas were examined for anomalies at embryonic day 10.5. Maternal 1-carbon metabolites were measured in plasma and liver.

Results

Delays and defects doubled in litters of Mthfd1S+/- females fed low-folate diets compared to wild-type females fed either diet, or Mthfd1S+/- females fed control diets [P values (defects): diet 0.003, maternal genotype 0.012, diet × maternal genotype 0.014]. These adverse outcomes were associated with placental dysmorphology. Intrauterine growth restriction was increased by embryonic Mthfd1S+/- genotype, folate deficiency, and interaction of maternal Mthfd1S+/- genotype with folate deficiency (P values: embryonic genotype 0.045, diet 0.0081, diet × maternal genotype 0.0019). Despite a 50% increase in methylenetetrahydrofolate reductase expression in low-folate maternal liver (P diet = 0.0007), methyltetrahydrofolate concentration decreased 70% (P diet <0.0001) and homocysteine concentration doubled in plasma (P diet = 0.0001); S-adenosylmethionine decreased 40% and S-adenosylhomocysteine increased 20% in low-folate maternal liver (P diet = 0.002 and 0.0002, respectively).

Conclusions

MTHFD1 synthetase-deficient mice are more sensitive to low folate intake than wild-type mice during pregnancy. Reduced purine synthesis due to synthetase deficiency and altered methylation potential due to low folate may increase pregnancy complications. Further studies and individualized intake recommendations may be required for women homozygous for the MTHFD1 R653Q variant.