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Hospitalaria

Trabajo Original Pediatría

The influence of obesity and diet quality on fetal growth and perinatal outcome
Influencia de la obesidad y la calidad de la dieta en el crecimiento fetal y resultados perinatales
Montserrat Comas Rovira, Anna Moreno Baró, Núria Burgaya Guiu, Laura Toledo Mesa, Cristina Lesmes Heredia, Silvia Pina Pérez,
María Grimau Gallego, Laia Martí Malgosa, Belen Cochs Cosme, Jordi Costa Pueyo
Maternal-Fetal Unit. Department of Obstetrics and Gynecology. Hospital Universitario Parc Taulí. Sabadell, Barcelona. Spain

Abstract
Background: maternal obesity is associated with an increase of both maternal and fetal complications as macrosomia.
Aim: to assess the quality of diet in a cohort of pregnant women in terms of Mediterranean diet (MD) adherence and to examine the association
between diet quality, obesity, weight gain and fetal growth and perinatal complications.
Methods: Mediterranean Diet Adherence Screener (MEDAS) was applied to assess diet quality in 542 pregnant women. Fetal biometric meas-
urements at third-trimester ultrasound were collected and perinatal outcomes were recorded.
Results: only 35 % of pregnant women presented a good quality of diet, in terms of adherence to MD. Diet quality significantly increased with
lower values of body mass index (BMI) and higher maternal age. Higher BMI was significantly associated with a higher abdominal circumference
and estimated fetal weight at the third trimester, a higher risk of hypertension disorder, induction of labor and a higher birthweight. A statistically
Keywords: significant association between diet quality and ultranosographic measures or perinatal outcome was not found. However, a higher weight gain
across gestation was significantly associated with a higher risk of gestational diabetes, a higher gestational age at delivery and a higher birthweight.
Fetal growth.
Mediterranean diet. Conclusion: most of our pregnant women did not showed a great diet quality, but there was no evidence that diet quality affected pregnancy
Obesity. Pregnancy. complications. On the contrary, pre-pregnancy BMI was related to fetal and neonatal growth and obstetric outcomes, similarly to weight gain
Gestational diabetes. across gestation.

Resumen
Introducción: la obesidad materna se asocia con un aumento de complicaciones maternas y fetales, como la macrosomía.
Objetivo: evaluar la calidad de la dieta en una cohorte de mujeres embarazadas en términos de adherencia a la dieta mediterránea (DM) y
examinar la asociación entre la calidad de la dieta, la obesidad, el aumento de peso y el crecimiento fetal y las complicaciones perinatales.
Métodos: se aplicó el Mediterranean Diet Adherence Screener (MEDAS) para evaluar la calidad de la dieta en 542 mujeres embarazadas. Se
recogieron las medidas biométricas fetales en la ecografía del tercer trimestre y se registraron los resultados perinatales.
Resultados: solo el 35 % de las gestantes presentó una buena calidad de alimentación en términos de adherencia a la DM. La calidad de la
dieta aumentó significativamente con valores más bajos de índice de masa corporal (IMC) y mayor edad materna. Un IMC más alto se asoció
significativamente con una mayor circunferencia abdominal y peso fetal estimado en el tercer trimestre, un mayor riesgo de trastorno hipertensivo,
inducción del parto y mayor peso al nacer. No se encontró una asociación estadísticamente significativa entre la calidad de la dieta y las medidas
Palabras clave: ecográficas o el resultado perinatal. Sin embargo, un mayor aumento de peso durante la gestación se asoció significativamente con un mayor
riesgo de diabetes gestacional, mayor edad gestacional al momento del parto y mayor peso al nacer.
Crecimiento fetal. Dieta
mediterránea. Obesidad. Conclusiones: la mayoría de nuestras gestantes no mostró una buena calidad de la dieta, pero no hubo evidencia de que la calidad de la dieta
Embarazo. Diabetes afectara las complicaciones del embarazo. Por el contrario, el IMC pregestacional se relacionó con el crecimiento fetal y neonatal y los resultados
gestacional. obstétricos, de manera similar al aumento de peso durante la gestación.

Received: 14/02/2022 • Accepted: 05/06/2022

Conflict of interest: the authors declare no conflict of interest.

Acknowledgments: the authors would like to thank Manuel Corona, Judit Lleberia and Montserrat Mestre,
for the work performing scans on study patients.
Correspondence:
Comas Rovira M, Moreno Baró A, Burgaya Guiu N, Toledo Mesa L, Lesmes Heredia C, Pina Pérez S, Montserrat Comas. Maternal-Fetal Unit. Department of
Grimau Gallego M, Martí Malgosa L, Cochs Cosme B, Costa Pueyo J. The influence of obesity and diet Obstetrics and Gynecology. Hospital Universitario Parc
quality on fetal growth and perinatal outcome. Nutr Hosp 2022;39(6):1205-1211     Taulí. C/ Parc Taulí, s/n. 08208 Sabadell, Barcelona.
Spain
DOI: http://dx.doi.org/10.20960/nh.04076 e-mail: [email protected]
©
Copyright 2022 SENPE y ©Arán Ediciones S.L. Este es un artículo Open Access bajo la licencia CC BY-NC-SA (http://creativecommons.org/licenses/by-nc-sa/4.0/).
1206 M.   Comas Rovira et al.

INTRODUCTION terms of Mediterranean diet (MD) adherence (8). The compli-

ance of each item provides +1 points and MEDAS score ranges
Obesity is a disease that affects nearly every organ in our body from 0 to 14 points. As consumption of alcohol is not recom-
and its prevalence is rising worldwide, becoming the most com- mended during pregnancy, this item was removed and score ≥ 8
mon medical condition in women of reproductive age (1). was considered as high adherence (9,10). The test was assessed
In pregnancy, obesity is associated with an increase of both after second-trimester ultrasound if women met the inclusion cri-
maternal and fetal complications (2). A higher risk of occult teria, had no exclusion criteria, and the consent form was signed.
type 2 diabetes, gestational diabetes (GD) and pregnancy-related At that moment, information about maternal characteristics was
hypertension disorders has been documented. At delivery, sev- recorded from the medical history. Parity, last menstrual date,
eral studies have described a higher rate of induction of labor, maternal age, pre-gestational weight and height were collected.
longer and more failed inductions and a higher rate of cesarean Body mass index (BMI) was calculated as weight in kilograms/
delivery (3). Regarding fetal complications, it exists a higher dif- height in m2. Obesity was defined as pregestational BMI ≥ 30. In
ficulty in measuring biometric parameters at fetal scans and in addition, obstetric history, chronic diseases and medication use
detecting fetal malformations, due to poor scans quality in obese were collected.
women. Furthermore, some studies suggest an increased risk of
macrosomia (4,5). In addition, there is an increasing evidence
that maternal obesity and macrosomia may produce, through STUDY OUTCOMES
epigenetic mechanisms, long-term consequences for the new-
born at childhood and adult life, including obesity, diabetes and The main outcome was the quality of diet in a cohort of preg-
cardiovascular diseases (6). nant women of our center at the second trimester of pregnancy,
The preconception period is an ideal time to assess condi- in terms of MD adherence. Secondary outcomes included fetal
tions that could influence health of the mother and the fetus. growth and pregnancy complications as GD or hypertension dis-
Pregnancy guidelines recommend a preconception visit in obese orders, as well as labor induction, type of delivery, gestational
women to inform about obesity-related pregnancy complications, age (GA) at delivery and neonatal weight.
give dietetic counsel and promote physical activity (7). While the
preconception period represents a key time point for weight op-
timization, during pregnancy the objective should be acquiring DATA COLLECTION
an appropriate weight gain and nutritional status. This can be
reached by following a healthy diet and practicing exercise. Maternal outcomes were obtained after delivery, through the
The primary objective of our study was to test the quality of medical and obstetric record. Fetal biometric measurements,
diet in obese and non-obese pregnant women followed in our estimated fetal weight (EFW) and percentile at third-trimes-
institution and, secondly, to examine the association between ter ultrasound were also collected. Fetal percentile had been
quality of diet, obesity and pregnancy common complications calculated using national reference curves (11). GD was de-
related to obesity. fined as either fasting glucose > 125 mg/dl (7.0 mmol/l) or
two abnormal values following a 100-g oral glucose toler-
ance test (fasting glucose ≥ 105 mg/dl [5,8 mmol/l], 190 mg/
MATERIAL AND METHODS dl [10,6 mmol/l] at one hour, 165 mg/dl [9,2 mmol/l] at two
hours, 145 mg/dl [8,1 mmol/l] at three hours), as per National
STUDY DESIGN AND PARTICIPANTS Diabetes Data Group. Hypertension-related pregnancy disorders
included gestational hypertension and preeclampsia. Gestation-
This is a prospective observational study performed in our in- al hypertension was defined as de novo blood pressure eleva-
stitution from January 1st 2019 to December 31st 2019. Pregnant tions (> 140/90 mmHg) after 20 weeks of gestation without
women who were referred from the Primary Care center to attend other organ system dysfunction. Preeclampsia was defined as
second-trimester ultrasound and who met the inclusion criteria de novo blood pressure elevation after 20 weeks of gestation
were invited to participate. Inclusion criteria were pregnant wom- coupled with proteinuria or other end‐organ dysfunction. In-
en between 19 and 24 weeks, single gestation and agreement to duction or spontaneous delivery, mode of delivery and birth-
sign the informed consent. Exclusion criteria were GD diagnosed weight (BW) were recorded.
on first trimester of pregnancy or pre-gestational diabetes, pres-
ence of major fetal malformations and multiple pregnancy.
STATISTICAL ANALYSIS

DIETARY ASSESSMENT Data collection has been carried out in specific sheet being
subsequently entered in database. Categorical variables were
The adapted form of the 14-point Mediterranean Diet Adher- described using absolute frequencies and percentages, while
ence Screener (MEDAS) was applied to evaluate diet quality in discrete variables were described with mean and standard devi-

[Nutr Hosp 2022;39(6):1205-1211]

The influence of obesity and diet quality on fetal growth and perinatal outcome 1207

ation. Association between discrete variables was analyzed using

lineal regression, while association with dichotomous variables
was analyzed using logistic regression. We used the Bonferroni
method to correct for multiple testing. All analyses were conduct-
ed with the version 15 of Stata.

ETHICAL ASPECTS

All the data were anonymized by the clinicians who acquired

them before being analyzed. All women signed an informed
consent. The research protocol was approved by the region-
al ethics committee (Ethics Committee for Clinical Research
of the Hospital Universitari Parc Taulí), with reference CEIC
2019/509. Figure 1.
Association between body mass index (BMI) and MEDAS score.

RESULTS

Data from 542 patients were collected. From the initial eligible
cohort, 32 pregnancies were excluded because perinatal results
could not be collected, and 510 women were included in the final
analysis. Their main characteristics can be seen in table I. Briefly,
35 % of pregnant women presented an appropriate quality of
diet (MEDAS ≥ 8). Obesity was present in 15 % of the popula-
tion. Regarding obstetric complications, the incidence of GD and
pregnancy-associated hypertension disorder was 11 % and 7 %,
respectively.
Differences in maternal characteristics depending on quality
of diet were observed. MEDAS score significantly increased with
lower values of BMI (p = 0.005) (Fig. 1). Moreover, MEDAS score
significantly increased with maternal age (p < 0.001) (Fig. 2).
However, quality of diet was not associated with parity (p = 0.51) Figure 2.
or foreign origin (p = 0.76). Association between maternal age and MEDAS score.

Table I. Characteristics of the 510 pregnant women included in the study

and comparison between non-obese and obese women
Overall population Non-obese Obese
p
n = 510 n = 435 n = 75
Maternal characteristics

Age (years), mean (SD) 32 (6) 32 (6) 31 (7) 0.29

Nuliparity, n (%) 219 (43) 239 (55) 46 (62) 0.26
Foreign origin, n (%) 76 (15) 74 (17) 15 0.9
Hypertension, n (%) 6 (1.2) 1 (0.2) 1 (1.4) 0.17
Hypothyroidism, n (%) 38 (7.4) 28 (6.5) 11.1 0.17
BMI (kg/m2), mean (SD) 26 (5.7) 23.8 (3.2) 34.2 (3.9) < 0.001
MEDAS, mean (SD) 6.8 (1.9) 6.9 (1.9) 6.4 (1.8) 0.02
MEDAS ≥ 8, n (%) 185 (35) 165 (38) 22 (29) 0.16

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1208 M.   Comas Rovira et al.

Table I (Cont.). Characteristics of the 510 pregnant women included in the study
and comparison between non-obese and obese women
Overall population Non-obese Obese
p
n = 510 n = 435 n = 75
Ultrasonographic measures
GA at ultrasound (weeks), mean(SD) 34.4 (0.9) 34 (0.9) 34 (0.7) 0.86
CC (mm), mean (SD) 308 (18) 308 (35) 304 (35) 0.21
AC (mm), mean (SD) 301 (17) 300 (17) 303 (16) 0.25
EFW (g), mean (SD) 2,373 (309) 2,356 (291) 2,386 (269) 0.4
Fetal percentile, mean (SD) 60 (26) 58 (26) 63 (28) 0.13
Perinatal results
Weight gain (kg), mean (SD) 11.7 (5.7) 12.7 (5.1) 7.2 (5.7) < 0.001
Gestational diabetes, n (%) 56 (11) 35 (8) 19 (26) < 0.001
Pregnancy-associated hypertension disorders, n (%) 36 (7) 17 (4) 10 (14) < 0.001
GA at delivery (weeks), mean (SD) 39.1 (1.4) 39.2 (1.6) 39.1 (1.4) 0.76
Induction of labor, n (%) 239 (47) 191 (44) 46 (61) 0.014
Cesarean section, n (%) 92 (18) 70 (16) 14 (19) 0.57
Instrumental delivery, n (%) 44 (9) 39 (9) 7 (9) 0.73
Birthweight (g), mean (SD) 3,281 (487) 3,252 (486) 3,302 (441) 0.42
Birthweight percentile, mean (SD) 52 (30) 50 (30) 53 (30) 0.48
SGA, n (%) 55 (11) 52 (12) 7 (10) 0.59
Macrosomia (> 4,000 g), n (%) 52 (10) 35 (8) 7 (10) 0.69
AC: abdominal circumference; BMI: body mass index; CC: cranial circumference; EFW: estimated fetal weight; MEDAS: Mediterranean Diet Adherence score; GA:
gestational age; SD: standard deviation; SGA: small for gestational age.

ASSOCIATION BETWEEN BMI tion of labor, and increased values of BW (Fig. 4) and BW percen-
AND ULTRASONOGRAPHIC AND OBSTETRIC tile. An increased BMI was associated with decreased gestational
RESULTS weight gain (p < 0.001).

Association between BMI and ultrasonographic and perinatal

results is shown in table II. When the association between BMI ASSOCIATION BETWEEN DIET QUALITY
and ultrasonographic findings was analyzed, it was found that an AND ULTRASONOGRAPHIC AND OBSTETRIC
increased BMI was significantly associated with increased values RESULTS
of abdominal circumference (AC), EFW (Fig. 3) and fetal percentile.
Regarding perinatal outcomes, vaginal delivery, GA at delivery Association between MEDAS score and obstetric and perinatal
and GD were not associated with BMI (association between GD outcomes are shown in table II. We did not find any statistically sig-
and BMI lost statistical significance after correcting for multiple nificant association between MEDAS score and ultranosographic
comparisons). An increased BMI was associated with a higher measures or perinatal outcomes. Significant association between
risk of pregnancy-associated hypertension disorder and induc- MEDAS score and gestational weight gain was not observed either.

Table II. Relation between BMI, diet quality, weight gain and ultrasonographic
and perinatal results
Variables BMI Diet quality Weight gain
Result 95 % CI p Result 95 % CI p Result 95 % CI p
Ultrasound measures
AC coef 0.48 0.21-0.75 < 0.001 coef 0.33 -0.47-1.14 0.422 coef 0.11 -0.17-0.39 0.442
EFW coef 8.25 3.51-13.01 0.001 coef 4.56 -9.8-18.98 0.534 coef 2.24 -2.67-7.16 0.373
Fetal percentile coef 0.88 0.48-1.28 < 0.001 coef 0.14 -1.08-1.36 0.821 coef 0.2 -0.01-0.0051 0.192

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[Nutr Hosp 2022;39(6):1205-1211]

The influence of obesity and diet quality on fetal growth and perinatal outcome 1209

Table II (Cont.). Relation between BMI, diet quality, weight gain and ultrasonographic
and perinatal results
Variables BMI Diet quality Weight gain
Result 95 % CI p Result 95 % CI p Result 95 % CI p
Perinatal outcome
Gestational diabetes OR 1.06 1.01-1.11 0.011 OR 0.99 0.85-1.15 0.922 OR 0.9 0.85-0.94 < 0.001
Hypertension disorders OR 1.14 1.07-1.21 < 0.001 OR 0.91 0.74-1.11 0.354 OR 1.0 0.97-1.11 0.344
Vaginal delivery OR 0.97 0.92-1.02 0.214 OR 0.9 0.77-1.04 0.167 OR 0.97 0.92-1.03 0.327
Induction of labor OR 1.05 1.01-1.08 0.004 OR 1.06 0.97-1.16 0.191 OR 1.00 0.97-1.03 0.971
GA at delivery coef 0.003 -0.021-0.028 0.771 coef 0.02 -0.06-0.089 0.793 coef 0.036 0.01-0.06 0.006
Birthweight coef 14.60 7.21-21.99 < 0.001 coef 17.25 -4.82-39.82 0.125 coef 16.51 8.74-24.29 < 0.001
Birthweight percentile coef 0.77 0.31-1.23 < 0.001 coef 0.96 -0.042-2.34 0.176 coef 0.88 0.39-1.36 < 0.001
AC: abdominal circumference; BMI: body mass index; coef: linear regression coefficient; 95 % CI: 95 % confidence interval; EFW: estimated fetal weight; GA:
gestational age; OR: odds ratio.

Figure 4.
Association between body mass index (BMI) and birthweight.

ASSOCIATION BETWEEN WEIGHT GAIN

AND ULTRASONOGRAPHIC AND OBSTETRIC
RESULTS

Association between weight gain and obstetric and perinatal

outcomes is shown in table II. Any statistically significant asso-
ciation was found between weight gain and ultrasonographic
measures. A higher weight gain across gestation was significant-
ly associated with a higher risk of GD, a higher GA at delivery, a
higher BW and a higher BW percentile.

DISCUSSION
Figure 3.
Association between body mass index (BMI) and abdominal circumference and In this prospective study, it was observed that only about
estimated fetal weight. a third of our pregnant women followed a healthy diet and

[Nutr Hosp 2022;39(6):1205-1211]

1210 M.   Comas Rovira et al.

15 % presented obesity. Women with a better diet quality had a quality and weight at birth (10,22,23). However, there is agree-
lower BMI and were older. Higher BMI was significantly associ- ment in the literature at the highest risk of GD in case of poor MD
ated with a higher fetal growth and a worse perinatal outcome, adherence (22-26). Regarding hypertension disorders, previous
similarly to higher gestational weight gain. However, diet quality data are controversial. Schnoenaker et al. (27) found a nega-
and ultranosographic measures or perinatal outcome were not tive association between MD pre-pregnancy pattern and the risk
found to be associated. of developing hypertensive disorders of pregnancy in a cohort
In our series, only 35 % of pregnant women followed a healthy of 3,582 Australian women. However, the group of St. Carlos
diet, in terms of MD adherence. This percentage is low consid- Gestational Diabetes Mellitus Prevention Study (22,28) did not
ering that pregnancy is a life period when lifestyle habits usually find a reduced risk of gestational hypertension and preeclampsia
improve and diet is one of the modifiable behaviors that women in pregnant women with good MD adherence. The divergences
can be motivated to change. Other studies investigating diet pat- between our results and those reported by other authors could be
terns during pregnancy in different countries like Spain, United explained by the different moment when the food questionnaire
States or Australia have also found suboptimal dietary results, in was applied. In most of the reports, women were interviewed
general characterized by being higher in saturated fats and lower before pregnancy or at the first trimester while, in our study, we
in monounsaturated fatty acids, fiber, iron and folates (12-14). did it at 20-22 weeks of pregnancy. This suggests that the op-
Another remarkable finding of our study is that maternal age timization of diet has ideally to take place prior to pregnancy, as
was positively associated with adherence to MD. This could be ex- well as it happens with BMI. A recent meta-analysis (29) about
plained by a higher maturity and awareness on this issue with age. the effect of dietary interventions on pregnancy concluded that
However, better results were not observed in multiparous mothers, diet intervention does not reduce the risk of GD and hypertension
who might have improved their diet quality previously. Other stud- disorders. Women, specially the obese, should be encouraged
ies have shown similar maternal characteristics in women pre- to modify food habits prior to pregnancy, as well as to improve
senting a lower quality diet consumption, who were younger, less weight, decreasing the risk of obesity-related complications and
educated and had a higher pre-pregnancy BMI, while controversial improving fetal growth.
results have been reported regarding to parity (15,16). However, differences were observed regarding weight gain
The present study confirms previous results (4,5,17,18) sug- across gestation. Women with a higher weight gain presented a
gesting the association between maternal obesity and fetal over- higher BW and BW percentile, a higher GA at delivery and a high-
growth. A higher BMI was associated with higher EFW and fetal er risk of GD. These findings support the recent evidence that
percentile at the third trimester due to a higher AC, and leading gestational weight gain acts as an added independent factor for
to a higher BW and BW percentile. A meta-analysis by Gaudet et adverse obstetric outcome, which has a cumulative effect during
al. (4) described the association between maternal obesity and gestation (18,30). The importance of improving pre-gestational
macrosomia and large for gestational age (LGA) at birth. Rela- BMI is clear, but when a woman is already pregnant, a limited
tionship between obesity and fetal growth during gestation has weight gain during pregnancy should also be recommended. In
been less evaluated. Some authors have found positive associ- other words, in the course of pregnancy, it would be necessary
ation between BMI and biometric measures and EFW, starting to recommend a diet with good quality for its global advantages
at mid pregnancy and increasing with GA (5,18). The potential at any vital time of life, but also to ensure quantities that allow a
mechanism for increased fetal growth might be related to the correct weight gain.
greater insulin resistance in those women, resulting in higher One of the strengths of the present study was its prospective
fetal glucose exposure and insulin levels, which may lead to performance on a healthy sample of pregnant women at our in-
overnutrition and overgrowth of the fetus. Evidence from exper- stitution, which could be representative to Spanish low-risk preg-
imental studies has suggested that maternal obesity creates an nant population. Another strength is having used a great easy
intrauterine environment with higher levels of insulin resistance, questionnaire for global assessment of MD adherence, which
chronic inflammation and oxidative stress, which predispose allows one to capture diet as a whole and in a short time.
these fetuses to obesity and cardiometabolic disorders in later A number of limitations of the study should be considered.
life (19,20). A worse diet quality in these obese women, which First, the food questionnaire was completed by women them-
has been demonstrated in our study, might also play a role in the selves and could be biased by women’s answers. Secondly, the
process. questionnaire was the same for all women and diet character-
Our study confirms the association between BMI and common istics of women of other cultures were not taken into account;
pregnancy complications as hypertension disorders. Although some women could have a good quality of diet different than the
association between BMI and GD has been described in other MD, which was not represented by the punctuation of the test.
studies, it did not reach statistically significant association (21). However, although a considered part of our population was from
Contrary to BMI, in our sample, no differences were observed a foreign origin, the majority came from countries with a MD
depending on the diet quality, fetal growth and perinatal out- such as Morocco. In addition, differences in diet quality were not
comes. To the best of our knowledge, there are no studies eval- found regarding foreign origin. However, differences could ex-
uating the association between diet quality and fetal growth, but ist depending on sociocultural status, which was not registered.
several authors have reported a lack of association between diet Another limitation is that the questionnaire was assessed at the

[Nutr Hosp 2022;39(6):1205-1211]

The influence of obesity and diet quality on fetal growth and perinatal outcome 1211

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