Pre-pregnancy and early pregnancy dietary behavior in relation to maternal and newborn health in the Norwegian Fit for Delivery study – a post hoc observational analysis

  • Elisabet R. Hillesund
  • Elling Bere
  • Linda R. Sagedal
  • Ingvild Vistad
  • Hilde L. Seiler
  • Monica K. Torstveit
  • Nina C. Øverby
Keywords: Key words: diet; neonatal health; diet score; preconception; preconception diet; pregnancy complications; pregnancy health; preeclampsia; preterm birth; gestational weight gain


Background: Randomized controlled trials targeting maternal dietary and physical activity behaviors during
pregnancy have generally failed to accomplish reductions in the prevalence of adverse maternal and neonatal
outcomes. Interventions carried out during pregnancy could thus be missing the mark in maximizing intervention health benefit.

Objective: To investigate whether pre-pregnancy and early pregnancy dietary behavior as reported at inclusion into the Norwegian Fit for Delivery (NFFD) trial was associated with maternal and neonatal outcomes irrespective of subsequent randomization assignment.

Design: The study is a post-hoc observational analysis of data from a randomized controlled lifestyle intervention. We constructed two diet scores from participant responses to a 43-item questionnaire that addresseddietary behavior in retrospect (pre-pregnancy diet score) and dietary behavior at inclusion (early pregnancy diet score), respectively. The diet scores ranged from 0 to 10, with higher score reflecting healthier dietary behavior. Associations between diet scores and maternal and neonatal health outcomes were estimated in multivariate logistic regression models.

Results: A total of 591 women were eligible for analysis. A one-point increase in pre-pregnancy diet score
was associated with lower odds of excessive gestational weight gain (GWG) (odds ratio [OR]adj: 0.92; 95%
confidence interval [CI]: 0.84–1.00, p = 0.050), preterm delivery (ORadj: 0.81; 95% CI: 0.68–0.97, p = 0.019),
and birthweight ≥ 4,000 g (ORadj: 0.88; 95% CI: 0.78–0.99, p = 0.038). A one-point increase in early pregnancy
diet score was associated with lower odds of excessive GWG (ORadj: 0.88; 95% CI: 0.79–0.97, p = 0.009), preterm
delivery (ORadj: 0.82; 95% CI: 0.67–0.99, p = 0.038), and preeclampsia (ORadj: 0.78; 95% CI: 0.62–0.99,
p = 0.038).

Discussion: Higher diet score either pre-pregnancy or in early pregnancy was protectively associated with excessive GWG and preterm delivery, whereas the protective association with high birthweight was confined to
pre-pregnancy diet and with preeclampsia to early pregnancy diet.

Conclusions: Both pre-pregnancy and early pregnancy dietary behavior was associated with important maternal and neonatal health outcomes in the NFFD dataset.


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  1. Rasmussen KM, Yaktine AL, eds. Weight gain during pregnancy: reexamining the guidelines. Washington, DC: The National Academies Press; 2009.

  2. Sagedal LR, Overby NC, Bere E, Torstveit MK, Lohne-Seiler H, Smastuen M, et al. Lifestyle intervention to limit gestational weight gain: the Norwegian Fit for Delivery randomised controlled trial. BJOG 2017; 124(1): 97–109.

  3. Vinter CA, Jensen DM, Ovesen P, Beck-Nielsen H, Jørgensen JS. The LiP (Lifestyle in Pregnancy) study: a randomized controlled trial of lifestyle intervention in 360 obese pregnant women. Diabetes Care 2011; 34(12): 2502–7.

  4. Dodd JM, Turnbull D, McPhee AJ, Deussen AR, Grivell RM, Yelland LN, et al. Antenatal lifestyle advice for women who are overweight or obese: LIMIT randomised trial. BMJ 2014; 348(7948): 11.

  5. Poston L, Bell R, Croker H, Flynn AC, Godfrey KM, Goff L, et al. Effect of a behavioural intervention in obese pregnant women (the UPBEAT study): a multicentre, randomised controlled trial. Lancet Diabetes Endocrinol 2015; 3(10): 767–77.

  6. Rogozinska E, Marlin N, Jackson L, Rayanagoudar G, Ruifrok AE, Dodds J, et al. Effects of antenatal diet and physical activity on maternal and fetal outcomes: individual patient data meta-analysis and health economic evaluation. Health Technol Assess 2017; 21(41): 1–158.

  7. Brantsaeter AL, Haugen M, Samuelsen SO, Torjusen H, Trogstad L, Alexander J, et al. A dietary pattern characterized by high intake of vegetables, fruits, and vegetable oils is associated with reduced risk of preeclampsia in nulliparous pregnant Norwegian women. J Nutr 2009; 139(6): 1162–8.

  8. Hillesund ER, Øverby NC, Engel SM, Klungsøyr K, Harmon QE, Haugen M, et al. Associations of adherence to the New Nordic Diet with risk of preeclampsia and preterm delivery in the Norwegian Mother and Child Cohort Study (MoBa). Eur J Epidemiol 2014; 29(10): 753–65.

  9. Englund-Ogge L, Brantsaeter AL, Sengpiel V, Haugen M, Birgisdottir BE, Myhre R, et al. Maternal dietary patterns and preterm delivery: results from large prospective cohort study. BMJ 2014; 348: g1446.

  10. Englund-Ogge L, Birgisdottir BE, Sengpiel V, Brantsaeter AL, Haugen M, Myhre R, et al. Meal frequency patterns and glycemic properties of maternal diet in relation to preterm delivery: results from a large prospective cohort study. PLoS One 2017; 12(3): e0172896.

  11. Chia A-R, de Seymour JV, Colega M, Chen L-W, Chan Y-H, Aris IM, et al. A vegetable, fruit, and white rice dietary pattern during pregnancy is associated with a lower risk of preterm birth and larger birth size in a multiethnic Asian cohort: the Growing Up in Singapore Towards healthy Outcomes (GUSTO) cohort study. Am J Clin Nutr 2016; 104(5): 1416–23.

  12. Martin CL, Sotres-Alvarez D, Siega-Riz AM. Maternal dietary patterns during the second trimester are associated with preterm birth. J Nutr 2015; 145(8): 1857–64.

  13. Meinila J, Valkama A, Koivusalo SB, Stach-Lempinen B, Rono K, Lindstrom J, et al. Is improvement in the Healthy Food Intake Index (HFII) related to a lower risk for gestational diabetes? Br J Nutr 2017; 117(8): 1103–9.

  14. Willett WC. Nutritional epidemiology. 3rd edn. New York, NY, USA: Oxford University Press; 2013.

  15. Hanson MA, Gluckman PD. Early developmental conditioning of later health and disease: physiology or pathophysiology? Physiol Rev 2014; 94(4): 1027–76.

  16. Ferrero DM, Larson J, Jacobsson B, Di Renzo GC, Norman JE, Martin JN, Jr., et al. Cross-country individual participant analysis of 4.1 million singleton births in 5 countries with very high human development index confirms known associations but provides no biologic explanation for 2/3 of all preterm births. PLoS One 2016; 11(9):e0162506.

  17. Sagedal LR, Overby NC, Lohne-Seiler H, Bere E, Torstveit MK, Henriksen T, et al. Study protocol: fit for delivery – can a lifestyle intervention in pregnancy result in measurable health benefits for mothers and newborns? A randomized controlled trial. BMC Public Health 2013; 13: 132.

  18. Sagedal LR, Sanda B, Overby NC, Bere E, Torstveit MK, Lohne-Seiler H, et al. The effect of prenatal lifestyle intervention on weight retention 12 months postpartum: results of the Norwegian Fit for Delivery randomised controlled trial. BJOG 2017; 124(1): 111–21.

  19. Hillesund ER, Bere E, Sagedal LR, Vistad I, Øverby NC. Effect of a diet intervention during pregnancy on dietary behavior in the randomized controlled Norwegian fit for delivery study. J Dev Orig Health Dis 2016; 7(5): 538–47.

  20. Sagedal LR, Vistad I, Overby NC, Bere E, Torstveit MK, Lohne-Seiler H, et al. The effect of a prenatal lifestyle intervention on glucose metabolism: results of the Norwegian fit for delivery randomized controlled trial. BMC Pregnancy Childbirth 2017; 17(1): 167.

  21. Haakstad LA, Sanda B, Vistad I, Sagedal LR, Seiler HL, Torstveit MK. Evaluation of implementing a community-based exercise intervention during pregnancy. Midwifery 2017; 46: 45–51.

  22. Øverby NC, Hillesund ER, Sagedal LR, Vistad I, Bere E. The fit for delivery study: rationale for the recommendations and test-retest reliability of a dietary score measuring adherence to 10 specific recommendations for prevention of excessive weight gain during pregnancy. Matern Child Nutr 2015; 11(1): 20–32.

  23. World Health Organization. Definition and diagnosis of diabetes mellitus and intermediate hyperglycaemia: report of a WHO/IDF consultation. Geneva, Switzerland: World Health Organization; 2006.

  24. Klungsøyr K, Morken NH, Irgens L, Vollset SE, Skjærven R. Secular trends in the epidemiology of pre-eclampsia throughout 40 years in Norway: prevalence, risk factors and perinatal survival. Paediatr Perinat Epidemiol 2012; 26(3): 190–8.

  25. Boulet SL, Alexander GR, Salihu HM, Pass M. Macrosomic births in the united states: determinants, outcomes, and proposed grades of risk. Am J Obstet Gynecol 2003; 188(5): 1372–8.

  26. Skjaerven R, Gjessing HK, Bakketeig LS. Birthweight by gestational age in Norway. Acta Obstet Gynecol Scand 2000; 79(6): 440–9.

  27. Craig CL, Marshall AL, Sjostrom M, Bauman AE, Booth ML, Ainsworth BE, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc 2003; 35(8): 1381–95.

  28. Sanda B, Vistad I, Haakstad LAH, Berntsen S, Sagedal LR, Lohne-Seiler H, et al. Reliability and concurrent validity of the International Physical Activity Questionnaire short form among pregnant women. BMC Sports Sci Med Rehabil 2017; 9: 7.

  29. Veierød M, Lydersen S, Laake P, eds. Logistic regression. In: Hosmer DW, Lemeshow S. Medical statistics in clinical and epidemiological research. Oslo, Norway: Gyldendal Akademisk; 2012, pp. 90–126.

  30. Skreden M, Bere E, Sagedal LR, Vistad I, Overby NC. Changes in beverage consumption from pre-pregnancy to early pregnancy in the Norwegian Fit for Delivery study. Public Health Nutr 2015; 18(7): 1187–96.

  31. Skreden M, Bere E, Sagedal LR, Vistad I, Overby NC. Changes in fruit and vegetable consumption habits from pre-pregnancy to early pregnancy among Norwegian women. BMC Pregnancy Childbirth 2017; 17(1): 107.

  32. Koutelidakis AE, Alexatou O, Kousaiti S, Gkretsi E, Vasios G, Sampani A, et al. Higher adherence to Mediterranean diet prior to pregnancy is associated with decreased risk for deviation from the maternal recommended gestational weight gain. Int J Food Sci Nutr 2018; 69(1): 84–92.

  33. Hillesund ER, Bere E, Haugen M, Øverby NC. Development of a New Nordic Diet score and its association with gestational weight gain and fetal growth – a study performed in the Norwegian Mother and Child Cohort Study (MoBa). Public Health Nutr 2014; 17(9): 1909–18.

  34. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet 2008; 371(9606): 75–84.

  35. Hibbard JU, Wilkins I, Sun L, Gregory K, Haberman S, Hoffman M, et al. Respiratory morbidity in late preterm births. JAMA 2010; 304(4): 419–25.

  36. Rasmussen MA, Maslova E, Halldorsson TI, Olsen SF. Characterization of dietary patterns in the Danish national birth cohort in relation to preterm birth. PLoS One 2014; 9(4): e93644.

  37. Grieger JA, Grzeskowiak LE, Clifton VL. Preconception dietary patterns in human pregnancies are associated with preterm delivery. J Nutr 2014; 144(7): 1075–80.

  38. Sibai B, Dekker G, Kupferminc M. Pre-eclampsia. Lancet 2005; 365(9461): 785–99.

  39. Allen R, Rogozinska E, Sivarajasingam P, Khan KS, Thangaratinam S. Effect of diet- and lifestyle-based metabolic risk-modifying interventions on preeclampsia: a meta-analysis. Acta Obstet Gynecol Scand 2014; 93(10): 973–85.

  40. Schoenaker DAJM, Soedamah-Muthu SS, Callaway LK, Mishra GD. Prepregnancy dietary patterns and risk of developing hypertensive disorders of pregnancy: results from the Australian Longitudinal Study on Women’s Health. Am J Clin Nutr 2015; 102(1): 94–101.

  41. Haugen M, Brantsæter AL, Winkvist A, Lissner L, Alexander J, Oftedal B, et al. Associations of pre-pregnancy body mass index and gestational weight gain with pregnancy outcome and postpartum weight retention: a prospective observational cohort study. BMC Pregnancy Childbirth 2014; 14: 201.

  42. Kim SY, Sharma AJ, Sappenfield W, Wilson HG, Salihu HM. Association of maternal body mass index, excessive weight gain, and gestational diabetes mellitus with large-for-gestational-age births. Obstet Gynecol 2014; 123(4): 737–44.

  43. Brantsaeter AL, Haugen M, Myhre R, Sengpiel V, Englund-Øgge L, Nilsen RM, et al. Diet matters, particularly in pregnancy – results from MoBA studies of maternal diet and pregnancy outcomes. Norwegian J Epidemiol 2014; 24(1–2): 63–78.

  44. Schoenaker DAJM, Soedamah-Muthu SS, Callaway LK, Mishra GD. Pre-pregnancy dietary patterns and risk of gestational diabetes mellitus: results from an Australian population-based prospective cohort study. Diabetologia 2015; 58(12): 2726–35.

  45. Sagedal LR, Øverby NC, Bere E, Torstveit MK, Lohne-Seiler H, Småstuen M, et al. Lifestyle intervention to limit gestational weight gain: the Norwegian Fit for Delivery randomised controlled trial. BJOG 2017; 124(1): 97–109.

  46. Donazar-Ezcurra M, López-del Burgo C, Bes-Rastrollo M. Primary prevention of gestational diabetes mellitus through nutritional factors: a systematic review. BMC Pregnancy Childbirth 2017; 17: 1–5.

  47. Westerterp KR, Goris AH. Validity of the assessment of dietary intake: problems of misreporting. Curr Opin Clin Nutr Metab Care 2002; 5(5): 489–93.

  48. Savitz DA, Harmon Q, Siega-Riz AM, Herring AH, Dole N, Thorp JM, Jr. Behavioral influences on preterm birth: integrated analysis of the pregnancy, infection, and nutrition study. Matern Child Health J 2012; 16(6): 1151–63.

  49. Bach A, Serra-Majem L, Carrasco JL, Roman B, Ngo J, Bertomeu I, et al. The use of indexes evaluating the adherence to the Mediterranean diet in epidemiological studies: a review. Public Health Nutr 2006; 9(1A): 132–46.

  50. Nilsen RM, Vollset SE, Gjessing HK, Skjaerven R, Melve KK, Schreuder P, et al. Self-selection and bias in a large prospective pregnancy cohort in Norway. Paediatr Perinat Epidemiol 2009; 23(6): 597–608.

How to Cite
Hillesund E. R., Bere E., Sagedal L. R., Vistad I., Seiler H. L., Torstveit M. K., & Øverby N. C. (2018). Pre-pregnancy and early pregnancy dietary behavior in relation to maternal and newborn health in the Norwegian Fit for Delivery study – a post hoc observational analysis. Food & Nutrition Research, 62.
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