Curr Nutr Rep
DOI 10.1007/s13668-014-0092-4
PRENATAL, NEONATAL, AND MATERNAL NUTRITION (DK TOBIAS AND M-F HIVERT, SECTION EDITORS)
Diet during Pregnancy and Gestational Weight Gain
Deirdre Tobias & Wei Bao
# Springer Science+Business Media New York 2014
Abstract Excessive gestational weight gain is associated
with a number of health complications for both the mother
and offspring. Trends across developed countries indicate an
increase in gestational weight gain and a substantial number of
women exceeding the recommended amount. Dietary inter-
ventions during pregnancy represent an opportunity to mini-
mize excessive weight gain during the gestational period and
improve perinatal and postpartum health. Several randomized
trials and observational epidemiologic studies have evaluated
aspects of maternal diet, such as the macronutrient composi-
tion, individual foods and beverages, overall dietary patterns,
and caloric restriction with gestational weight gain. This re-
view provides an overview of the current evidence to support
the development of pregnancy dietary recommendations for
the prevention of excessive gestational weight gain.
Keywords Pregnancy . Gestational weight gain . Diet .
Nutrition . Carbohydrate quality . Dietary patterns .
Weight gain . Dietary interventions
D. Tobias (*)
Division of Preventive Medicine, Brigham and Women’s Hospital
and Harvard Medical School, 900 Commonwealth Avenue 3rd Floor,
Boston, MA 02215, USA
e-mail: dtobias@partners.org
D. Tobias
Department of Nutrition, Harvard School of Public Health, 900
Commonwealth Avenue 3rd Floor, Boston, MA 02215, USA
W. Bao
Eunice Kennedy Shriver National Institute of Child Health and
Human Development, 6100 Executive Blvd Room 7B03B, MSC
7510, Bethesda, MD 20892-7510, USA
e-mail: baow2@mail.nih.gov
Introduction
Excessive gestational weight gain (GWG) beyond what is
recommended is associated with numerous short- and long-
term health consequences in both the mother and offspring.
Short-term outcomes include maternal hyperglycemia and
gestational diabetes [1–6], macrosomia and large-for-
gestational-age newborns [7, 8•, 9, 10], delivery by cesarean
section [9, 11, 12], and a number of other potential health
consequences [13]. Associations between excessive GWG
and longer-term outcomes have been observed including ma-
ternal post-partum weight retention and obesity [9, 11, 14–16]
as well as excessive adiposity and obesity in the offspring
[17•, 18–20]. The 2009 Institute of Medicine [21] outlined
recommendations for total GWG of singleton pregnancies
according to maternal prepregnancy World Health
Organization body mass index (BMI) cut-points. This defined
excessive GWG as >35 lbs for normal prepregnancy weight
(BMI 18.5 – 24.9 kg/m2), >25 lbs for overweight (BMI 25.0 –
29.9 kg/m2), and >20 lbs for all classes of obese women (BMI
≥30 kg/m2).
Paralleling the trends of weight gain and obesity in the
general population, the prevalence of pregnant women
gaining above recommended guidelines has reached alarming
proportions [21]. In the Pregnancy Risk Assessment
Monitoring System, the percent of overweight US women
exceeding 25 lbs reached 63.0 % in 2002. Obese women
gaining >20 lbs reached 46.3 %, and normal weight women
gaining >35 lbs reached 38.4 %. Given that excessive GWG is
a risk factor for long-term weight retention, these trends imply
a greater proportion of women entering subsequent pregnan-
cies overweight and obese, further compounding the cycle of
weight gain/weight retention and its numerous health impli-
cations. The increasing prevalence and numerous conse-
quences of excessive GWG highlight the urgent need to
identify modifiable risk factors for its prevention.

Diet has the potential to play a key role in weight manage-
ment during pregnancy. Pregnant women are in frequent
contact with health care providers and may be uniquely mo-
tivated to adhere to recommendations to adopt healthier life-
style choices. Previous systematic reviews and meta-analyses
have evaluated the role of lifestyle interventions in pregnancy
with GWG outcomes [22–24, 25••, 26]. For example, a meta-
analysis of randomized trials published in 2011 by Tanentsapf
et al [25••] identified 13 publications evaluating the effects of
dietary interventions on GWG. The interventions were asso-
ciated with a pooled weighted mean difference of -1.92 kg
(95 % confidence interval [CI]=-3.65, -0.19) less weight gain,
and trended towards a reduction in excessive GWG (OR=
0.90, 95 % CI=0.77, 1.05) compared with control groups.
Most of these dietary interventions, however, also included
physical activity regimes, insulin therapy, and other lifestyle
or behavioral components. Therefore, conclusions about the
independent role of diet on GWG cannot be drawn from this,
and similar studies.
The relationships between dietary factors and body weight
have been extensively studied in the general population; how-
ever, findings from weight-loss trials or observational studies
of gradual long-term weight change in non-pregnant adults
may not be generalizable to pregnant women. Thus, the iden-
tification of efficacious and safe dietary recommendations for
the prevention of excessive weight gain in the gestational
period has the potential to impact several critical pregnancy-
related health outcomes.
Therefore, the aim of this review is to summarize the
current evidence surrounding diet and total or excessive
GWG. Insufficient or inadequate GWG is an important and
significant global public health concern, but is beyond the
scope of this review. This review included evidence from both
published clinical trials and observational epidemiologic stud-
ies. For the latter, we considered studies in which dietary
factors were evaluated in models adjusting for other risk
factors for GWG due to the substantial bias from the correla-
tions between diet with other lifestyle and participant charac-
teristics (e.g., smoking status, physical activity, prepregnancy
BMI). Therefore, we excluded publications that only pre-
sented crude or unadjusted estimates or correlations be-
tween dietary factors and weight gain outcomes. This
review includes a discussion of the current evidence for
specific macronutrients (i.e., fats, carbohydrates, or pro-
tein), individual foods and beverages, dietary patterns,
and energy (calorie) intake, and their relationships with
total and excessive GWG.
Macronutrients
The macronutrient composition of the diet has been exten-
sively researched in the general population with no consensus
Curr Nutr Rep
reached on the relevance or ideal distribution of calories from
carbohydrates, fats, and proteins for weight management
[27–29]. Macronutrients contribute the caloric energy in the
diet, and it is, therefore, understandable why the balance of
carbohydrates, fats, and proteins may be targeted for weight
loss and the prevention of weight gain. The effects of low-fat
and low-carbohydrate dietary interventions for weight loss
have been examined in a number of short-term, randomized
clinical trials in non-pregnant individuals, although significant
heterogeneity, concerns with adherence, and loss-to-follow-up
make results difficult to interpret [28–30]. Overall, data from
weight loss trials do not convincingly support any one specific
distribution of macronutrients for long-term success in weight
management. Furthermore, evidence from weight loss trials
may not be applicable to pregnant populations, where preven-
tion of excessive weight gain, rather than weight loss, is the
outcome of interest.
One small randomized clinical trial among 46 pregnant
overweight and obese US women directly compared the
effects of low-fat (25 % energy from fat, 55 % from
carbohydrates) versus low-carbohydrate (45 % energy
from carbohydrates, 35 % from fat) ad libitum (i.e., no
calorie restriction) dietary interventions, with some study
foods provided [31]. Weight gain between enrollment (13
– 28 weeks gestational age) through 36 weeks gestational
age was not significantly different between the two groups
(low-fat: 6.4 kg, low-carbohydrate: 6.9 kg; p=0.74).
Fats, carbohydrates, and proteins have also been evaluated
in observational studies [32–35]. No associations were ob-
served for total fat intake with total GWG or odds of excessive
GWG in a small prospective cohort [34] or a cross-sectional
analysis of the US National Health and Nutrition Examination
Survey (NHANES) database [36]. Similarly, saturated fat was
not related to GWG outcomes in four studies [32–34, 36].
Project Viva, a large prospective US pregnancy cohort, esti-
mated the exchange of 5 % of calories from carbohydrates for
type of dietary fats among 1,388 women with repeated
prepregnancy food frequency questionnaires and technician-
measured body weights [33]. The associations between sub-
stitution of carbohydrates for saturated fat, polyunsaturated
fat, or trans fats were null. However, replacing carbohydrates
with monounsaturated fat was associated with a significant
37 % lower odds of experiencing excessive GWG (95 % CI=
0.40, 0.99). In a cross-sectional analysis of 224 US pregnant
women, Lagiou et al [35] found a significant direct relation-
ship with between animal fats and GWG through week 27 (p
for trend <0.0001), but no association for vegetable fat.
Three studies assessing total intake of calories from protein
found no evidence of a relationship with GWG [32, 33, 36].
However, the cross-sectional analysis by Lagiou et al [35]
observed a direct relationship between total protein and mid-
pregnancy weight gain, indicating a 3.11-kg greater weight
gain for each one standard deviation increase in protein intake
Curr Nutr Rep
(p for trend <0.0001). The percent of energy from carbohy-
drates in participants’ current diets was not related to GWG in
the cross-sectional NHANES analysis [36]. However, Lagiou
et al [35] observed an inverse relationship between carbohy-
drate intake and mid-pregnancy GWG, with -5.22 kg less
weight gain for each one standard deviation increase in total
carbohydrate intake (p for trend <0.0001).
Measures of carbohydrate quality have also been examined
in relation to GWG. The glycemic index ranks carbohydrate-
containing foods by their postprandial glucose response with a
higher glycemic index value indicating a greater response
[37]. The glycemic load additionally factors in the total
amount of carbohydrates contained in a serving. A small
clinical trial compared the effects of low versus high glycemic
index dietary interventions in 62 pregnant women in Australia
[38]. Although the low glycemic index intervention group
significantly reduced their glycemic index during pregnancy,
there was no difference in GWG compared to the high glyce-
mic index intervention group (low GI=11.5 kg, high GI=
10.1 kg; p=0.16). Two randomized trials compared low gly-
cemic index dietary interventions with other healthy control
diets that did not have a glycemic index focus [39••, 40••].
Moses et al [39••] found no differences in total GWG or
excess GWG among 576 women receiving detailed dietary
education to follow a low glycemic index diet versus an
overall healthy eating diet of the same macronutrient compo-
sition and intervention intensity (total GWG: low GI=10.2 kg,
healthy eating=10.3 kg; p=0.7; excessive GWG: p=0.17). A
trial among 107 pregnant women in Mexico with gestational
diabetes or type 2 diabetes was conducted to examine the
effect of two low-carbohydrate diets, with one intervention
arm receiving additional instruction to consume only low
glycemic index carbohydrates [40••]. Similar to the Moses
et al trial, participants in the low glycemic index group sig-
nificantly reduced the glycemic index of their diet, but no
differences in total GWG were observed; however, women in
the low glycemic index group were significantly less likely to
be classified as having excessive GWG (low GI=9.8 %, no GI
instruction = 34.8 %; p=0.002). A fourth randomized trial
among 800 pregnant women in Ireland compared a low gly-
cemic index diet education to standard care (i.e., no formal
dietary advice given) [41]. In this trial, the intervention group
gained less weight (low GI=11.5 kg, standard care=12.6 kg;
p=0.003) and was less likely to be classified as having exces-
sive GWG (low GI = 33.2 %, standard care = 44.7 %;
p=0.009). In addition to there being significant differences
in glycemic index at the end of the pregnancy between the two
groups, the intervention group also reported a significantly
lower total energy intake. Dietary glycemic load was evaluat-
ed in three large prospective cohorts for its relationship with
total and excessive GWG [33, 42, 43]. Null associations were
observed in two US cohorts [33, 42]. However, glycemic load
was associated with the rate of weight gain in mid-pregnancy
(gestational weeks 12 through 30) among 47,003 participants
of the Danish National Birth Cohort (p for trend<0.001) [43].
Evidence from randomized trials does not support a benefit of
a lower glycemic index diet for GWG outcomes when com-
pared with other intervention diets. A low glycemic index diet,
however, was associated with a lower risk of excessive GWG
among women with diabetes, and when compared with par-
ticipants receiving no dietary intervention. Findings from
observational data also do not support a relationship between
carbohydrate quality, as measured by glycemic index and
glycemic load, with total GWG. A large prospective Danish
cohort, however, did observe an association between glycemic
load with mid-pregnancy weight gain. For dietary fiber, one
large cohort reported no association with GWG [33], while a
small study of 30 participants observed an inverse association
with late-pregnancy weight gain [44].
Overall, there is insufficient evidence to recommend spe-
cific macronutrient compositions, including low-fat or low-
carbohydrate dietary interventions, for the prevention of ex-
cessive GWG. Based on limited but consistent observational
findings, saturated fat does not appear to be associated with
excessive GWG risk. It is unclear whether carbohydrate
quality confers additional benefits for weight management
in pregnancy above and beyond other healthful dietary
interventions. Evidence for the role of protein, fiber, and
other aspects of macronutrients (e.g., types of fat) in
GWG, are scare.
Foods/Beverages
Recommendations based on individual foods and food groups
may be easily amenable to public health guidelines. A number
of individual foods and beverages have been associated with
weight gain in the general population, including potatoes,
sugar-sweetened beverages, processed and unprocessed
meats, and low intakes of fruits and vegetables, whole grains,
nuts, and dairy products such as yogurt [27, 45–48].
Individual foods have also been evaluated among pregnant
women for their relationship with GWG.
Fruits and vegetables have been evaluated in observational
studies with mixed findings [33, 36, 49, 50]. A prospective
cohort study among 595 US pregnant women found a signif-
icantly lower GWG (-1.81 lbs) among women consuming >3
servings/day of fruits and vegetables in mid-pregnancy com-
pared with <3 servings/day after adjusting for several potential
confounders [49]. A cross-sectional analysis of pregnant
NHANES participants found a significant greater odds
(OR=3.8, 95 % CI=1.1 – 13.2) of exceeding GWG guidelines
for women who consumed low amounts of total vegetables
compared with higher amounts [36]. This study did not find
associations for total or whole fruits, or dark green and orange
vegetables, and legumes. Two additional prospective cohorts

reported null associations for fruits and vegetables with risk of
excessive GWG [33, 50], although one study among low-
income urban women was small and likely under-powered
to detect a significant association [50].
Servings per day of total dairy intake was related to total
GWG (0.23 kg, 95 % CI=0.05, 0.41) and odds of excessive
GWG (OR=1.09, 95 % CI=1.01, 1.19) in Project Viva par-
ticipants. These results were limited to whole-milk dairy,
however, while low-fat dairy was not associated with GWG.
The estimates were attenuated when adjusted for total energy,
suggesting that dairy may be associated with weight gain
through intake of excess calories. Self-reported “drinking
more milk” vs. not in late pregnancy was associated with a
greater odds of excessive GWG (OR=1.82, 95 % CI=1.08,
1.36) among 406 participants of an Icelandic pregnancy co-
hort, although few additional dietary and lifestyle factors were
adjusted for in this analysis [51]. The number of glasses of
milk [49], total dairy products [50], and milk or milk products
[36] were not related to excessive GWG in three additional
studies.
The Project Viva cohort observed a significant inverse
relationship between servings per day of sugar-sweetened
beverages and total GWG (-0.46 kg, 95 % CI=-0.87, -0.05).
This paradoxical finding may be explained in part by reverse
causation bias, which may occur if women at low risk of
gaining excessive weight are more likely to consume sugar-
sweetened beverages than high-risk women during pregnancy.
It is possible that women may begin or continue to drink
sugar-sweetened beverages if they perceive their weight gain
is under control, resulting in a biased inverse relationship with
GWG. No relationship between sugar-sweetened beverages
and GWG was observed among the small prospective cohort
of low-income urban women [50].
A non-blinded randomized clinical trial of 90 preg-
nant women in Italy did not observe differences in
GWG between women allotted a daily dose of one dark
chocolate bar versus controls asked to maintain their
usual pregnancy diet [52]. However, an observational
cohort found the self-reported eating of “more sweets”
in early pregnancy was associated with a greater odds
of excessive GWG (OR=2.52, 95 % CI=1.10, 5.77; p=
0.029), although it is unknown what types of sweets
would have been considered in this response [51]. For
fried foods, the Project Viva prospective cohort found a
borderline significant 1.21 kg greater GWG (95 % CI=-
1.93, 4.34) and greater odds of excessive GWG (OR=
4.24, 95 % CI=1.04, 17.18) for each additional serving
per day [33]. However, the small cohort of low-income
urban women found no association between fried or fast
food intake or potato chip consumption with total or
excessive GWG [50]. Intake of whole grains and meats
during pregnancy were not associated with GWG among
US participants in Project Viva or NHANES [33, 36].
Curr Nutr Rep
Overall, evidence to support recommendations to increase
or decrease specific foods is inconclusive due to the hetero-
geneity in findings, study designs, and study quality at this
time. Overwhelming evidence for individual items seen in the
general population, such as that for sugar-sweetened bever-
ages, could be considered for pregnant populations unless
otherwise indicated by future studies [47, 53].
Dietary Patterns
Dietary patterns have been associated with weight gain and
obesity in non-pregnant populations and thus may be relevant
for GWG [54, 55]. Dietary patterns provide a unique approach
to studying the role of diet in weight management [56].
Recommendations based on overall patterns can be more
readily adopted in the clinical setting because they offer a
complete picture of healthful and unhealthful dietary factors
[57]. Furthermore, pattern analysis has the ability to account
for potential synergistic effects between combinations of
foods and nutrients that might not otherwise be identified
when components are studied individually.
Few observational studies have examined the independent
associations of dietary patterns with GWG outcomes [32, 36,
58]. The prospective Norwegian Mother and Child Cohort
Study evaluated the New Nordic Diet in mid-pregnancy with
the risk of excessive GWG among 66,597 women [58]. This
healthful dietary pattern score included a higher consumption
of plant foods than meats, wild countryside foods (e.g., game,
fish, seafood, berries), oatmeal, potatoes over pasta, whole
grains over refined grains, milk over juice, and water over
sugar-sweetened beverages. Normal weight (BMI <25.0)
women in the top tertile (greater adherence to the pattern)
had a significant lower odds of excessive GWG (OR=0.93,
95 % CI=0.87-0.99; p=0.02) compared to women in the
bottom third. Conversely, overweight/obese women (BMI
≥25) with in the top tertile for New Nordic Diet score had a
greater odds of excessive GWG compared to women with
lower scores (OR=1.11, 95 % CI=1.00, 1.23; p=0.06).
A second cross-sectional study assessed the 2005 Healthy
Eating Index (HEI-2005) dietary pattern among 490 pregnant
NHANES participants [36]. The HEI-2005 pattern reflects
adherence to the MyPyramid US dietary guidelines, and was
computed for each participant based on a single 24-h recall at
whichever gestational age they happened to be during their
participation in the single NHANES visit. In this study, the
HEI-2005 was not associated with excessive GWG after ad-
justment for a number of potential confounders.
Finally, a retrospective analysis of 3,360 mothers in the
Finnish Type 2 Diabetes Prediction and Prevention Nutrition
Study identified seven dietary patterns via principal compo-
nents analysis [32]. Third trimester diet was captured from a
validated FFQ administered 3 months post-partum, and body
Curr Nutr Rep
weight at prepregnancy and time of delivery was also self-
reported at this time. Significantly higher rates of GWG (kg/
week) were observed for the “fast food” pattern (p for trend<
0.0001) and the “traditional bread” pattern (p for trend=
0.0002). The “fast food” pattern included items such as fast
food, sweets and desserts, fried potatoes, soft drinks and fruit
juices, white bread, and processed meats, while the “tradition-
al bread” pattern included pastries, breads, cheeses, potatoes,
breakfast cereals, meats, butter and milk, nuts and seeds, and
berries. A significantly lower rate of GWG was observed for
adherence to the “alcohol and butter” score (p for trend=
0.014). This pattern included alcoholic beverages, butter, sal-
ad dressing, and soft drinks, with negative loading for marga-
rine, fruit and fruit juice, breakfast cereal, and high fat milk.
The “healthy” (vegetables, fruits, fish, roots, berries, poultry,
low-fat dairy, etc.), “traditional meat” (meats, potatoes, etc),
“low-fat” (low-fat dairy, processed meat, light soft drinks, low
in high-fat dairy, etc), and “coffee” patterns were not associ-
ated with GWG in this cohort. The “traditional bread” pattern
was no longer significant after adjustment for total energy
intake, but the other patterns remained unchanged.
The sparse literature currently does not provide strong
evidence for specific dietary patterns at this time.
Caloric Restriction and Monitoring
Restriction of caloric intake for weight management in preg-
nancy is a complex recommendation, given concerns for low
birth weight and other health outcomes associated with under-
nutrition and inadequate weight gain [15, 59–61]. Recent
randomized trials have evaluated the role of hypocaloric die-
tary interventions in pregnant populations, with most conduct-
ed among high–risk, overweight and obese participants.
Wolff et al [62] compared the effects of a low calorie diet
versus no dietary intervention among 50 obese pregnant
Danish women, with the aim of 6 – 7 kg GWG. Women in
the intervention group gain a total of 6.6 kg on average
compared with 13.3 kg in the control group (p=0.002). In a
trial among 124 obese women with gestational diabetes, ran-
domization late in pregnancy (prior to 35 weeks gestational
age) to a diabetic diet with or without caloric restriction did
not improve weight gain outcomes [63]. Total GWG did not
differ between groups (calorie-restricted = 11.6 kg, not
calorie-restricted = 9.7; p=0.2), nor did weight gain from the
start of the dietary intervention through the end of pregnancy
(calorie-restricted = 0.24 kg, not calorie-restricted = 0.91 kg;
p=0.3). A dietary intervention trial among obese pregnant
women compared the effects of a physical activity interven-
tion with and without a hypocaloric Mediterranean diet of
1,200 – 1,675 kcal/day with a GWG goal of <5 kg [64].
Although both interventions (exercise + diet, exercise only)
led to significantly less weight gain than the control group, the
addition of a dietary component did not lead to weight gain
benefits above and beyond what was seen in the physical
activity only group (exercise+diet=8.6 kg, exercise only =
9.4 kg; p=0.6).
Two additional studies evaluated dietary interventions with
“balanced” nutritional guidelines anchored around individu-
alized energy intake levels to achieve weight gain goals versus
no-intervention control groups [65, 66]. Results among the
232 US obese pregnant women (total GWG: intervention vs.
control p<0.001) [65], and the 154 low-risk antenatal Italian
women (total GWG: intervention = 8.2 kg, control = 13.4 kg;
p<0.001) [66], indicated significant benefits of dietary inter-
ventions that included the monitoring of caloric intake. For the
latter study, 95 % of intervention participants, versus 41 % of
control participants, gained within the recommended GWG.
Evidence suggests that energy restriction may benefit
GWG outcomes among obese women. However, one study
among women with gestational diabetes found no benefit for
an intervention beginning in mid-to-late pregnancy. Two trials
evaluating interventions to monitor energy intake without
major calorie restrictions also observed improved GWG
versus control groups, suggesting that prescriptions for strict
hypocaloric diets may not be necessary to achieve modest yet
effective reductions in participants’ caloric intake.
Conclusions and Considerations for Future Research
Based on our review of the current literature, the role of
nutrition in GWG is largely unknown. Numerous clinical
trials and observational studies have been published in recent
years, but heterogeneity in study design, dietary factors eval-
uated, outcomes, and patient characteristics hinder between-
study comparisons and the pooling of evidence.
For randomized clinical trials, improvements in the quality
of reporting of a study’s enrollment criteria, design, data
collection methods, and outcomes are needed. For example,
detailed descriptions of dietary interventions will be useful in
translating effective interventions into clinical practice.
Specifying an intervention as a “healthy diet” is an inadequate
description. Data collection methods should explicitly state
randomization scheme, blinding of study staff and partici-
pants, if applicable, participant withdrawals and reasons for
drop-outs, the timing of enrollment and timeframe in which
the intervention was followed [67]. The timing and data
source (e.g., participant recall, antenatal records) of body
weight change between two time-points should also be in-
cluded in the methods. It is also imperative that studies assess
and present results of adherence measures as well as descrip-
tive statistics for correlated lifestyle factors. These data are
useful in determining potential intermediates of an interven-
tion on the outcome (e.g., intervention to increase fruit and
vegetable intake also led to a decrease in sugar-sweetened

beverages). Multiple GWG outcomes should be considered,
including total GWG and % achieving excessive GWG. Fetal
and maternal safety outcomes should also be presented.
Future research from observational studies should include
prospectively collected and validated pregnancy dietary data
with technician-measured body weights. Prepregnancy body
weight measured by a technician, rather than self-reported by
the participant, may minimize bias due to differential recall.
Careful control for confounding factors, such as physical
activity, prepregnancy BMI, smoking status, correlated dietary
components, and other pregnancy characteristics is essential
to estimate the independent association of diet. These factors
should be assessed simultaneously with the dietary informa-
tion. Total energy intake has important implications as a
covariate in multivariable models, as a potential confounder
as well as an intermediate on the causal pathway between diet
and weight gain. It is recommended that authors present
results for multivariable models with and without the inclu-
sion of total energy intake. Models should avoid including
variables and pregnancy characteristics that may be conse-
quences of GWG. For example, offspring’s birthweight may
be in part a consequence of GWG [10], and its inclusion in the
model would represent an over-adjustment, potentially
underestimating the relationship between diet and GWG. A
hypothetical study design for a prospective observational
pregnancy cohort is depicted in Fig. 1. A prospective design,
assessment of diet and other lifestyle factors, and technician-
measured body weight prepregnancy and throughout pregnan-
cy will minimize measurement error and bias.
Randomized clinical trials are valuable for the body of
literature on pregnancy diet and outcomes of GWG. Free from
confounding by other lifestyle factors, randomized trials can
Fig. 1 This figure proposes a
hypothetical study design for a
prospective observational
pregnancy cohort study. Repeated
validated dietary measures, such
as food frequency questionnaires,
capture diet at multiple time
points during pregnancy.
Additional lifestyle characteristics
should be assessed at the same
time. Technician-measured body
weight will minimize
measurement error and recall bias
associated with retrospective
self-reported body weight
Curr Nutr Rep
test the efficacy and effectiveness of a single dietary component
or pattern on GWG. Observational studies contribute additional
valuable evidence, such that a single well-conducted prospec-
tive study can assess multiple aspects of diet. Well-powered
cohorts can examine wide ranges of dietary exposures that are
often beyond the feasibility for a randomized trial. Additionally,
the relatively short pregnancy period makes both trials and
observational studies of diet and GWG highly feasible. As
evidence accumulates, it will also be important to consider
the timing of the dietary assessment and time period of weight
gain. For example, first trimester weight gain may have differ-
ent risk factors than third trimester weight gain. Capturing
information on diet at multiple timepoints will allow re-
searchers to investigate this.
Numerous aspects of diet in pregnancy have been studied
in relation to GWG and excessive GWG; however, high
quality evidence for any one component is sparse.
Methodological limitations and inconsistent findings hinder
the ability to propose comprehensive evidence-based dietary
recommendations at this time. Inconsistent evidence was
found for macronutrients with GWG and data for individual
foods was sparse. Dietary patterns are largely under-studied in
pregnant populations and may offer a valuable tool for the
prevention of GWG. The role of caloric restriction and mon-
itoring of energy intake may be useful in certain populations,
although concerns for safety have not been adequately ad-
dressed. Identification of dietary risk factors and interventions
for excessive GWG will be essential to prevent health out-
comes and consequences in both the mother and offspring.
Comparable findings from both randomized trials and obser-
vational data will be valuable in shaping future directions for
dietary guidelines for pregnant women.
Curr Nutr Rep
Compliance with Ethics Guidelines
Conflict of Interest Deirdre Tobias and Wei Bao declare that they have
no conflict of interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
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Papers of particular interest, published recently, have been
highlighted as:
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