Professional Documents
Culture Documents
Original Communication: Diet During Pregnancy in Relation To Maternal Weight Gain and Birth Size
Original Communication: Diet During Pregnancy in Relation To Maternal Weight Gain and Birth Size
& 2004 Nature Publishing Group All rights reserved 0954-3007/04 $25.00
www.nature.com/ejcn
ORIGINAL COMMUNICATION
Diet during pregnancy in relation to maternal weight
gain and birth size
P Lagiou1,2, RM Tamimi2, LA Mucci2, H-O Adami2,3, C-C Hsieh2,4 and D Trichopoulos1,2*
1
Department of Hygiene and Epidemiology, School of Medicine, University of Athens, Greece; 2Department of Epidemiology, Harvard
School of Public Health, Boston, MA, USA; 3Department of Medical Epidemiology, Karolinska Institutet, Stockholm, Sweden; and
4
University of Massachusetts Cancer Center, Worcester, MA, USA
Objective: Maternal weight gain has been consistently linked to birth weight but, beyond maternal energy intake, no
macronutrient has been associated with either of them. We have examined whether maternal energy-adjusted intake of
macronutrients is associated with either maternal weight gain or birth-size parameters.
Design: Cohort study.
Setting: University hospital in Boston, USA.
Subjects: A total of 224 pregnant women coming for their first routine prenatal visit. The women were followed through
delivery.
Interventions: None. Pregnant women’s dietary intake during the second trimester was ascertained at the 27th week of
pregnancy through a food frequency questionnaire.
Results: Intake of neither energy nor any of the energy-generating nutrients was significantly associated with birth size. In
contrast, maternal weight gain by the end of the second trimester of pregnancy was significantly associated with energy intake
( þ 0.9 kg/s.d. of intake; PB0.006) as well as energy-adjusted intake of protein ( þ 3.1 kg/s.d. of intake; Po10-4), lipids of animal
origin ( þ 2.6 kg/s.d. of intake; Po104) and carbohydrates (5.2 kg/s.d. of intake; Po104).
Conclusions: Although maternal weight gain is strongly associated with birth size, the indicated nutritional associations with
weight gain are not reflected in similar associations with birth-size parameters. The pattern is reminiscent of the sequence linking
diet to coronary heart disease (CHD) through cholesterol: diet has been conclusively linked to blood cholesterol levels and
cholesterol levels are conclusively linked to this disease, even though the association of diet with CHD has been inconclusive and
controversial.
Sponsorship: This study was supported in part by Grant No. CA54220 from the National Institutes of Health
European Journal of Clinical Nutrition (2004) 58, 231–237. doi:10.1038/sj.ejcn.1601771
Table 1 Birth weight, birth length and head circumference of babies born to 224 nonpre-eclamptic Caucasian womena in Boston USA (1994–1995)
after gestation lasting from 37 to 42 weeks, inclusive, according to maternal characteristics
Maternal education
High school graduate 36 3583 (77) 36 50.30 (0.42) 36 34.66 (0.24)
College graduate 92 3635 (48) 92 51.05 (0.24) 90 34.70 (0.16)
Higher 94 3490 (49) 94 50.32 (0.23) 93 34.46 (0.19)
Parity
1 138 3569 (40) 138 50.67 (0.20) 135 34.68 (0.13)
2 86 3558 (50) 86 50.56 (0.25) 86 34.44 (0.20)
Height (cm)
159 50 3473 (71) 50 50.26 (0.31) 50 34.18 (0.19)
160–164 53 3526 (71) 53 50.53 (0.28) 52 34.53 (0.20)
165–169 63 3599 (54) 63 50.70 (0.33) 62 34.70 (0.18)
170+ 56 3646 (58) 56 50.94 (0.32) 55 34.75 (0.30)
Smoking in pregnancy
Yes 11 3555 (192) 11 49.55 (1.11) 11 33.82 (0.41)
No 211 3566 (32) 211 50.67 (0.15) 208 34.64 (0.11)
Gender of offspring
Male 114 3629 (40) 114 51.14 (0.22) 112 34.74 (0.17)
Female 110 3498 (48) 110 50.07 (0.21) 109 34.42 (0.14)
a
The numbers do not always add up because of missing values.
Table 2 Mean change and standard error (s.e.) in birth weight, birth length and head circumference by quartilea of intake of energy and energy-
generating nutrients
Q2 Q3 Q4
Q1 Mean change s.e. Mean change s.e. Mean change s.e. P-value trend
Birth weight(g)
Energy REF +149.0 87.9 17.1 87.9 +165.1 87.9 0.24
Animal lipids REF +132.3 88.4 4.9 88.4 +131.3 88.4 0.36
Vegetable lipids REF +65.1 88.9 4.2 88.9 +105.4 88.9 0.38
Carbohydrates REF +181.4 88.2 +51.3 88.2 +160.6 88.2 0.21
Protein REF +11.1 89.0 +79.7 89.0 +88.3 89.0 0.24
a
The 25th, 50th and 75th centiles were for energy 6386, 8345 and 10146 kJ, for animal lipids 27.4, 35.1 and 47.2 g, for vegetable lipids 16.9, 22.8 and 29.6 g, for
carbohydrates 208.2, 271.8 and 345.5 g and for protein 67.2, 86.3, and 113.4 g, respectively.
Data from 224 nonpre-eclamptic pregnancies lasting from 37 to 42 weeks, inclusive, in Boston USA, 1994–1995.
a
s.d. for energy 3371.9 kJ/day, for animal lipids 19.6 g/day, for vegetable lipids 10.8 g/day, for carbohydrates 127.3 g/day and for protein 40.7 g/day
b
Total of 224 singleton, nonpre-eclamptic pregnancies, lasting from 37 to 42 weeks inclusive. Boston, USA, 1994–1995.
c
Adjusted for energy intake only (except for energy).
d
Adjusted for energy intake (except for energy), maternal age, maternal education, parity, maternal height, prepregnancy BMI, pregravid OC use, smoking during
pregnancy, exact gestational age at delivery and gender of the baby.
Table 4 Mean change and s.e. in maternal weight gain by quartile of intake of energy and energy-generating nutrients
Q2 Q3 Q4
Q1 Mean change s.e. Mean change s.e. Mean change s.e. P-value trend
Data from 207 nonpre-eclamptic pregnancies lasting from 37 to 42 weeks, inclusive, in Boston USA, 1994–1995.
Discussion present paper, we found that neither energy intake nor the
In an earlier paper (Lagiou et al, in press), examining non- energy-adjusted intake of any of the energy-generating
nutritional factors in relation to birth weight, we found, as nutrients, as ascertained at the end of the second trimester
others have (Abrams & Selvin, 1995; Zhou & Olsen, 1997; of pregnancy, is significantly associated with any of the
Thorsdottir & Birgisdottir, 1998; Shapiro et al, 2000), that studied birth-size parameters after adjustment for confound-
maternal weight gain is positively associated with birth ing variables. In contrast, energy intake was significantly
weight. Among Caucasian women, an increase in maternal positively associated with maternal weight gain through the
weight gain by 2 kg was associated with an increase of 37.1 g end of the second trimester of pregnancy and, after
(standard error 13.2 g) in birth weight, after adjustment for controlling for energy intake, protein and lipids of animal
possible confounding variables (Lagiou et al, in press). In the origin were also significantly positively associated with
a
A total of 207 singleton, nonpre-eclamptic pregnancies, lasting from 37 to 42 weeks inclusive. Boston, USA, 1994–1995.
b
Adjusted for energy intake only (except for energy).
c
Adjusted for energy intake (except for energy), maternal age, maternal education, parity, maternal height, prepregnancy BMI, pregravid OC use, smoking during
pregnancy, exact gestational age at delivery and gender of the baby.
maternal weight gain, whereas carbohydrates were signifi- questionnaire. Weaknesses of the study include the moderate
cantly inversely associated with it. size and the focus on pregnancy weight gain during the first
The strong associations between four of the five studied two trimesters. However, several reports have indicated that
nutritional variables and maternal weight gain, in combina- maternal weight gain in the first and second trimester may
tion with the strong positive association of the latter variable be stronger determinants of newborn size than weight gain
with birth weight (and, indeed, birth length and birth head in the third trimester of pregnancy (Abrams & Selvin, 1995;
circumferenceFTable 1) would have led to the prediction of Brown et al, 2002; Guihard-Costa et al, 2002). In any case,
significant associations between the nutritional variables even if weight gain during the third trimester has its own
and birth-size parameters. The absence of such associations is determinants and consequences, this does not affect the
intriguing. There is a biological precedent, however, findings of the present study. Prepregnancy weight was self-
although in a different time scale. The relation of diet to reported, but there is evidence in the literature (Yu & Nagey,
coronary heart disease (CHD) has been weak in most 1992) that self-reported prepregnancy weight is highly
epidemiological investigations, even though cholesterol correlated (rB0.9) with the objective measurement. A high
levels (both high- and low-density lipoprotein cholesterol) proportion of women were excluded, but most of these
are powerful predictors of CHD and are clearly associated exclusions were imposed by technical or administrative
with diet (Willett, 1998). It appears that the effects of reasons that were unlikely to have introduced selection bias.
nutritional variables are diluted by those of other determi- The study group was not representative of the American
nants of birth-size parameters, so that they might only be population, but representativeness is not a prerequisite for
detected in very large studies. Nevertheless, such effects are validity in prospective cohort studies, the strength of which
likely to exist and, if they are dose-dependent and exposures stems from the lack of association between errors in exposure
are extreme, they could even have physiological implica- and outcome ascertainment.
tions. In conclusion, we have found evidence that, after adjust-
There have been earlier studies indicating that maternal ment for energy intake, intake of protein and lipids of
protein intake is positively associated with pregnancy weight animal origin is positively associated with weight gain
gain (Scholl et al, 1991; Kramer, 2000a) with birth weight through the end of the second trimester of pregnancy,
(Weigel et al, 1991; Godfrey et al, 1997) or both (Kramer, whereas intake of carbohydrates is inversely associated with
2000b). Other studies indicate that maternal intake of fat it. Although weight gain is strongly associated with birth-size
(Weigel et al, 1991) and carbohydrates (Godfrey et al, 1997) parameters, the indicated nutritional associations are not
is, respectively, positively and inversely associated with birth reflected in similar associations with birth-size variables. The
weight. A study in rats showed that protein intake during pattern is reminiscent of the sequence linking diet to CHD
pregnancy is positively associated with pregnancy weight through cholesterol and may be explained by the operation
gain and birth weight (Levy & Jackson, 1993). Finally, there of non-nutritional determinants of birth size.
have been many reports indicating that overt malnutrition
and reduction in maternal energy intake are associated with
reduced pregnancy weight gain and birth weight (Susser,
References
1991; Alexy et al, 1997; Bergmann et al, 1997; Rondo & Abrams B & Selvin S (1995): Maternal weight gain pattern and birth
Tomkins, 1999; Rush, 2001). Thus, the existing collective weight. Obstet. Gynecol. 86,163–169.
evidence is not incompatible with our findings, which, Alexy B, Nichols B, Heverly MA & Garzon L (1997): Prenatal factors
and birth outcomes in the public health service: a rural/urban
however, present a more integrated perspective.
comparison. Res. Nurs. Health 20, 61–70.
Among the advantages of our study are its prospective Bergmann MM, Flagg EW, Miracle-McMahill HL & Boeing H (1997):
nature and its reliance on a validated food frequency Energy intake and net weight gain in pregnant women according