Most women thinking about having a baby know that they need to make lifestyle changes before and while they are pregnant for a safe and healthy pregnancy. They ask their doctor or midwife for recommendations about caffeine intake, exercise, alcohol consumption, the best foods to eat and what to avoid, and are particularly receptive to changing their health behaviour1.
Many researchers have sought to establish the effectiveness of lifestyle interventions during pregnancy such as diet or physical activity programmes, with the aim to produce evidence based approaches that will influence clinical practice and healthcare policies. Studies on maternal diet before and during pregnancy have reported long-term implications for both the mother’s and baby’s health, from placental development2, risk of developing gestational diabetes3, birth complications4 and birth weight5.
Other studies have explored whether eating healthily can improve clinically important pregnancy outcomes. A 2014 Norwegian study showed that women with a balanced diet including vegetables, fruit, whole grains, and fish were at lower risk of preterm delivery6. Similarly, a 2016 Australian study demonstrated that a high-quality diet (vegetables, fruits, whole grains, nuts and legumes, dairy and lean animal proteins) before and during pregnancy may reduce the risk of gestational hypertension for the mother7.
More recently focus has shifted on the Mediterranean diet in particular, as it is widely recognised as one to follow for a healthy dietary pattern as it includes: a high intake of fruits, vegetables, whole grain cereals, legumes, fish and nuts, low-to-moderate consumption of dairy products and limited amounts of red meat and red wine. It is low in saturated fats and high in antioxidants, fibre and fatty acids mainly derived from extra virgin olive oil and oily fish. Researchers have demonstrated its beneficial effects for disease prevention making the Mediterranean diet the most evidence-based approach to healthy eating8,9.
Additionally, studies have also confirmed the benefits of following a Mediterranean diet for pregnant women. A 2019 study in the UK found that having a Mediterranean-style diet (including a high intake of nuts, extra virgin olive oil, fruit, vegetables, non-refined grains and legumes, and moderate to high consumption of fish) led to a 35% lower risk of developing diabetes in pregnancy10. The diet also resulted in less weight gain during pregnancy (on average 1.25kg less weight gain). Similar results were reported in a Spanish study, where early dietary intervention in pregnant women with a Mediterranean Diet proved to have a lower risk of developing gestational diabetes11.
Mind–body interventions have also emerged as non-pharmacological therapies. These interventions are based on several practices designed to facilitate the mind’s positive impact on the body. Mindfulness-based stress reduction in particular has been extensively used for stress-related diseases12.
In pregnancy, studies have reported that mindfulness-based interventions played a significant positive role in reducing stress for most types of pregnant women and were associated with lower levels of anxiety, depression and perceived stress13,14. However, no studies have evaluated the effect of these interventions on pregnancy outcomes.
A new study published in JAMA evaluated whether lifestyle interventions based on either Mediterranean diet or mindfulness-based stress reduction when pregnant could help those at risk of having a small baby deliver a child at a healthy weight15.
The clinical trial was carried out by researchers from BCNatal (Hospital Clínic-IDIBAPS and Hospital Sant Joan de Déu in Barcelona) with the support of Cerebra and focused on low birth weight babies. Low birth weight (which accounts for 10% of all births) reflects growth restriction in foetal life. It is one of the most important causes of perinatal mortality worldwide and poor neurodevelopment in childhood.
1,200 women at risk of delivering babies with a low birth weight were randomly divided into three groups: one in which they had visits with a nutritionist in order to follow a Mediterranean diet, a second group in which they followed a mindfulness programme to reduce stress, and a control group with standard care.
The Mediterranean group were given olive oil and walnuts and were encouraged to eat fresh fruit, whole grains, vegetables and dairy products, as well as consuming a diet rich in legumes, fish and white meat. The mindfulness group were encouraged to attend sessions of mindfulness every week for two months and follow daily meditation sessions at home. Among those following the Mediterranean diet there was a 36% reduction of low birth weight prevalence when compared to women receiving standard care, while the mindfulness programme group demonstrated a 29% reduction.
The study demonstrated for the first time, that a Mediterranean diet or mindfulness during pregnancy reduces the percentage of low birth weight and improves complications in pregnancy for which no previous treatment had previously demonstrated positive effects, such as preeclampsia or perinatal death, when used in a structured, guided manner.
Although further studies are required to validate these findings, the study provides important evidence for the effectiveness of structured lifestyle interventions in pregnant women and the impact to their health. It not only reinforces the importance of providing early nutritional education to pregnant women, but highlights the effectiveness of mindfulness-based programmes for improving pregnancy outcomes.
Pregnancy presents a unique opportunity to promote lifestyle changes as women. Research such as this can provide healthcare professionals with new relevant evidence-based resources that they might have not consider but can ultimately help pregnant women manage a number of pregnancy-related factors.
References
1. Olander, E.K., Smith, D.M. and Darwin, Z. Health behaviour and pregnancy: a time for change. Journal of Reproductive and Infant Psychology. 2018, 36(1), pp.1-3.
2. Reijnders, I.F., Mulders, A.G.M.G.J., van der Windt, M., Steegers, E.A.P. and Steegers-Theunissen, R.P.M. The impact of periconceptional maternal lifestyle on clinical features and biomarkers of placental development and function: a systematic review. Human Reproduction Update. 2019, 25(1), pp.72-94.
3. Kampmann, U., Madsen, L.R., Skajaa, G.O., Iversen, D.S., Moeller, N. and Ovesen, P. Gestational diabetes: A clinical update. World J Diabetes. 2015, 6(8), pp.1065-1072.
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5. Zerfu, T.A., Pinto, E. and Baye, K. Consumption of dairy, fruits and dark green leafy vegetables is associated with lower risk of adverse pregnancy outcomes (APO): a prospective cohort study in rural Ethiopia. Nutrition & Diabetes. 2018, 8(1), p.52.
6. Englund-Ögge, L., Brantsæter, A.L., Sengpiel, V., Haugen, M., Birgisdottir, B.E., Myhre, R., Meltzer, H.M. and Jacobsson, B. Maternal dietary patterns and preterm delivery: results from large prospective cohort study. BMJ : British Medical Journal. 2014, 348, p.g1446.
7. Gresham, E., Collins, C.E., Mishra, G.D., Byles, J.E. and Hure, A.J. Diet quality before or during pregnancy and the relationship with pregnancy and birth outcomes: the Australian Longitudinal Study on Women’s Health. Public Health Nutrition. 2016, 19(16), pp.2975-2983.
8. Sofi, F., Abbate, R., Gensini, G.F. and Casini, A. Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. The American Journal of Clinical Nutrition. 2010, 92(5), pp.1189-1196.
9. Widmer, R.J., Flammer, A.J., Lerman, L.O. and Lerman, A. The Mediterranean Diet, its Components, and Cardiovascular Disease. The American Journal of Medicine. 2015, 128(3), pp.229-238.
10. H. Al Wattar, B., Dodds, J., Placzek, A., Beresford, L., Spyreli, E., Moore, A., Gonzalez Carreras, F.J., Austin, F., Murugesu, N., Roseboom, T.J., Bes-Rastrollo, M., Hitman, G.A., Hooper, R., Khan, K.S., Thangaratinam, S. and for the, E.s.g. Mediterranean-style diet in pregnant women with metabolic risk factors (ESTEEM): A pragmatic multicentre randomised trial. PLOS Medicine. 2019, 16(7), p.e1002857.
11. Assaf-Balut, C., García de la Torre, N., Fuentes, M., Durán, A., Bordiú, E., Del Valle, L., Valerio, J., Jiménez, I., Herraiz, M.A., Izquierdo, N., Torrejón, M.J., De Miguel, M.P., Barabash, A., Cuesta, M., Rubio, M.A. and Calle-Pascual, A.L. A High Adherence to Six Food Targets of the Mediterranean Diet in the Late First Trimester is Associated with a Reduction in the Risk of Materno-Foetal Outcomes: The St. Carlos Gestational Diabetes Mellitus Prevention Study. Nutrients. 2019, 11(1).
12. Ludwig, D.S. and Kabat-Zinn, J. Mindfulness in Medicine. JAMA. 2008, 300(11), pp.1350-1352.
13. Guo, P., Zhang, X., Liu, N., Wang, J., Chen, D., Sun, W., Li, P. and Zhang, W. Mind–body interventions on stress management in pregnant women: A systematic review and meta-analysis of randomized controlled trials. Journal of Advanced Nursing. 2021, 77(1), pp.125-146.
14. Dhillon, A., Sparkes, E. and Duarte, R.V. Mindfulness-Based Interventions During Pregnancy: a Systematic Review and Meta-analysis. Mindfulness. 2017, 8(6), pp.1421-1437.
15. Crovetto, F., Crispi, F., Casas, R., Martín-Asuero, A., Borràs, R., Vieta, E., Estruch, R., Gratacós, E. and Investigators, I.B.T. Effects of Mediterranean Diet or Mindfulness-Based Stress Reduction on Prevention of Small-for-Gestational Age Birth Weights in Newborns Born to At-Risk Pregnant Individuals: The IMPACT BCN Randomized Clinical Trial. JAMA. 2021, 326(21), pp.2150-2160.
