Bookshelf NBK578487

Dietary Patterns during Pregnancy and
Gestational Weight Gain: A Systematic

Review
Sharon Donovan, PhD, RD,a Kathryn Dewey, PhD,b Rachel Novotny,
PhD, RDN, LD,c Jamie Stang, PhD, MPH, RD,d Elsie Taveras, MD, MPH,e
Ronald Kleinman, MD,f Ramkripa Raghavan, DrPH, MPH, MSc,g Julie
Nevins, PhD,g Sara Scinto-Madonich, MS,g Julia H. Kim, PhD, MPH, RD,g
Nancy Terry, MS, MLS,h Gisela Butera, MLIS, MEd,i Julie Obbagy, PhD,
RDj
a
Chair, Pregnancy and Lactation Subcommittee, 2020 Dietary Guidelines Advisory Committee; University of Illinois, Urbana-Champaign
b
Member, Pregnancy and Lactation Subcommittee, 2020 Dietary Guidelines Advisory Committee; University of California, Davis
c
Member, Pregnancy and Lactation Subcommittee, 2020 Dietary Guidelines Advisory Committee; University of Hawaii
d
Member, Pregnancy and Lactation Subcommittee, 2020 Dietary Guidelines Advisory Committee; University of Minnesota
e
Member, Pregnancy and Lactation Subcommittee, 2020 Dietary Guidelines Advisory Committee; Massachusetts General Hospital, Harvard Medical
School, and Harvard T.H. Chan School of Public Health
f Vice-Chair, 2020 Dietary Guidelines Advisory Committee; Massachusetts General Hospital, Harvard Medical School
g Systematic review analyst, Nutrition Evidence Systematic Review (NESR) team; Panum Group under contract with the Food and Nutrition Service
(FNS), U.S. Department of Agriculture (USDA)
h
Biomedical librarian, NESR team; National Institutes of Health Library, U.S. Department of Health and Human Services
i
Systematic review librarian, NESR team; Panum Group under contract with the FNS, USDA
j
Project Lead, NESR team; Nutrition Guidance and Analysis Division, Center for Nutrition Policy and Promotion, FNS, USDA
Suggested citation: Donovan S, Dewey K, Novotny R, Stang J, Taveras E, Kleinman R, Raghavan R, Nevins J, Scinto-Madonich S,
Kim JH, Terry N, Butera G, Obbagy J. Dietary Patterns during Pregnancy and Gestational Weight Gain: A Systematic Review. July
2020. U.S. Department of Agriculture, Food and Nutrition Service, Center for Nutrition Policy and Promotion, Nutrition Evidence
Systematic Review. Available at: https://doi.org/10.52570/NESR.DGAC2020.SR0201
Related citation: Dietary Guidelines Advisory Committee. Scientific Report of the 2020 Dietary Guidelines Advisory Committee:
Advisory Report to the Secretary of Agriculture and the Secretary of Health and Human Services. July 2020. U.S. Department of
Agriculture, Agricultural Research Service. Available at: https://doi.org/10.52570/DGAC2020
The contents of this document may be used and reprinted without permission. Endorsements by NESR, NGAD, CNPP, FNS, or USDA
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ACKNOWLEDGEMENTS
Pregnancy and Lactation Subcommittee:

 Sharon Donovan, PhD, RD, University of Illinois, Urbana-Champaign,
Subcommittee Chair
 Kathryn Dewey, PhD, University of California, Davis
 Rachel Novotny, PhD, RDN, LD, University of Hawaii
 Jamie Stang, PhD, MPH, RD, University of Minnesota
 Elsie Taveras, MD, MPH, Massachusetts General Hospital, Harvard Medical
School, and Harvard T.H. Chan School of Public Health
 Ronald Kleinman, MD, Massachusetts General Hospital, Harvard Medical
School, Vice-Chair of the 2020 Dietary Guidelines Advisory Committee
Nutrition Evidence Systematic Review (NESR) Team:
• Ramkripa Raghavan, DrPH, MPH, MSc, Analyst, Panum Groupi
• Julie Nevins, PhD, Analyst, Panum Groupi
• Sara Scinto-Madonich, MS, Analyst, Panum Groupi
• Julia H. Kim, PhD, MPH, RD, Analyst, Panum Groupi
• Nancy Terry, MS, MLS, Biomedical Librarian, National Institutes of Health (NIH)
Library, U.S. Department of Health and Human Services (HHS)
• Gisela Butera, MLIS, MEd, Systematic Review Librarian, Panum Groupi
• Julie Obbagy, PhD, RD, Project Lead, Nutrition Guidance and Analysis Division
(NGAD), Center for Nutrition Policy and Promotion (CNPP), Food and Nutrition
Service (FNS), U.S. Department of Agriculture (USDA)
Federal Liaisons:
• Jean Altman, MS, NGAD, CNPP, FNS, USDA
• Meghan Adler, MS, RDN, NGAD, CNPP, FNS, USDA
• Jenna Fahle, MSPH, RDN, NGAD, CNPP, FNS, USDA (08/2019-11/2019)
Project Leadership:
• Eve Stoody, PhD, Designated Federal Officer and Director, NGAD, CNPP,
FNS, USDA
• Janet de Jesus, MS, RD, Nutrition Advisor, Office of Disease Prevention and
Health Promotion, Office of the Assistant Secretary for Health, HHS
USDA and HHS implemented a process to identify topics and scientific questions to be
examined by the 2020 Dietary Guidelines Advisory Committee. The Committee
conducted its review of evidence in subcommittees for discussion by the full
Committee during its public meetings. The role of the Committee members involved
establishing all aspects of the protocol, which presented the plan for how they would
examine the scientific evidence, including the inclusion and exclusion criteria;
i
Under contract with the Food and Nutrition Service, United States Department of
Agriculture.
3
reviewing all studies that met the criteria they set; deliberating on the body of evidence
for each question; and writing and grading the conclusion statements to be included in
the scientific report the 2020 Committee submitted to USDA and HHS. The NESR
team with assistance from Federal Liaisons and Project Leadership, supported the
Committee by facilitating, executing, and documenting the work necessary to ensure
the reviews were completed in accordance with NESR methodology. More information
about the 2020 Dietary Guidelines Advisory Committee, including the process used to
identify topics and questions, can be found at www.DietaryGuidelines.gov. More
information about NESR can be found at NESR.usda.gov.
The Committee and NESR staff thank USDA’s Agricultural Research Service for
coordinating the peer review of this systematic review, and the Federal scientist peer
reviewers for their time and expertise.
FUNDING SOURCE: United States Department of Agriculture, Food and Nutrition

Service, Center for Nutrition Policy and Promotion, Alexandria, VA
4
TABLE OF CONTENTS
Acknowledgements.............................................................................................................. 3
Table of Contents ................................................................................................................ 5
Introduction .......................................................................................................................... 7
What is the relationship between dietary patterns consumed during pregnancy and
gestational weight gain? .................................................................................................... 10
Plain language summary ................................................................................................ 10
Technical abstract .......................................................................................................... 12
Full review ...................................................................................................................... 14
Systematic review question ........................................................................................ 14
Conclusion statement and grade ................................................................................ 14
Summary of the evidence ........................................................................................... 14
Description of the evidence ........................................................................................ 15
Evidence synthesis ..................................................................................................... 26
Research recommendations ....................................................................................... 41
Included articles.......................................................................................................... 42
Methodology ...................................................................................................................... 95
Analytic framework ......................................................................................................... 95
Literature search and screening plan ............................................................................. 97
Inclusion and exclusion criteria ................................................................................... 97
Electronic databases and search terms .................................................................... 100
Literature search and screening results ....................................................................... 105
Excluded articles ...................................................................................................... 107
Table 1. Included trials and cohorts ................................................................................... 16

Table 2. Dietary pattern components ................................................................................. 19
Table 3. Description of evidence on the relationship between dietary patterns during
pregnancy and gestational weight gain.............................................................................. 45
Table 4. Description of evidence on the relationship between diets based on macronutrient
distribution during pregnancy and gestational weight gain ................................................ 90
Table 5. Risk of bias for randomized controlled trials examining dietary patterns during
pregnancy and gestational weight gain ............................................................................. 93
Table 6. Risk of bias for observational studies examining dietary patterns during pregnancy
and gestational weight gain ............................................................................................... 93
Table 7. Inclusion and exclusion criteria ............................................................................ 97
Table 8. Articles excluded after full text screening with rationale for exclusion ................ 107
5
Figure 1: Analytic framework ............................................................................................. 96
Figure 2: Flow chart of literature search and screening results........................................ 106
6
INTRODUCTION
This document describes a systematic review conducted to answer the following question:
gestational weight gain? This systematic review was conducted by the 2020 Dietary
Guidelines Advisory Committee, supported by USDA’s Nutrition Evidence Systematic
Review (NESR).
More information about the 2020 Dietary Guidelines Advisory Committee is available at the
following website: www.DietaryGuidelines.gov.
NESR specializes in conducting food- and nutrition-related systematic reviews using a

rigorous, protocol-driven methodology. More information about NESR is available at the
following website: NESR.usda.gov.
NESR’s systematic review methodology involves developing a protocol, searching for and
selecting studies, extracting data from and assessing the risk of bias of each included
study, synthesizing the evidence, developing conclusion statements, grading the evidence
underlying the conclusion statements, and recommending future research. A detailed
description of the systematic reviews conducted for the 2020 Dietary Guidelines Advisory
Committee, including information about methodology, is available on the NESR website:
https://nesr.usda.gov/2020-dietary-guidelines-advisory-committee-systematic-reviews. In
addition, starting on page 95, this document describes the final protocol as it was applied
in the systematic review. A description of and rationale for modifications made to the
protocol are described in the 2020 Dietary Guidelines Advisory Committee Report, Part D:
Chapter 2. Food, Beverage, and Nutrient Consumption During Pregnancy.
7
List of abbreviations
Abbreviation Full name
AHEI Alternative Healthy Eating Index
AMDR Acceptable Macronutrient Distribution Range
DASH Dietary Approaches to Stop Hypertension
DII Dietary Inflammatory Index
DP Dietary pattern
EVOO Extra virgin olive oil
FFQ Food frequency questionnaire
GDM Gestational diabetes mellitus

GWG Gestational weight gain
HDI Human Development Index
HEI Healthy Eating Index
HFII Healthy Food Intake Index
HHS Department of Health and Human Services
IOM Institute of Medicine
MDA Mediterranean Diet Adherence
MDQS Maternal Diet Quality Score
MED Mediterranean
NESR Nutrition Evidence Systematic Review
NFFD Norwegian Fit for Delivery Diet

NND New Nordic Diet
PCA Principal component analysis
PPWL Postpartum weight loss
PUFA Polyunsaturated fatty acid
RCT Randomized controlled trial
rMED Relative Mediterranean Diet
8
Abbreviation Full name
RoB Risk of bias
SES Socioeconomic status
USDA United States Department of Agriculture
9
WHAT IS THE RELATIONSHIP BETWEEN DIETARY PATTERNS
CONSUMED DURING PREGNANCY AND GESTATIONAL WEIGHT GAIN?
PLAIN LANGUAGE SUMMARY

What is the question?
 The question is: What is the relationship between dietary patterns consumed
during pregnancy and gestational weight gain?
What is the answer to the question?
 Limited evidence suggests that certain dietary patterns during pregnancy are
associated with a lower risk of excessive gestational weight gain during pregnancy.
These patterns are higher in vegetables, fruits, nuts, legumes, fish, and lower in
added sugar, and red and processed meat.
Why was this question asked?
 This important public health question was identified by the U.S. Departments of
Agriculture (USDA) and Health and Human Services (HHS) to be examined by the
2020 Dietary Guidelines Advisory Committee.
How was this question answered?
 The 2020 Dietary Guidelines Advisory Committee, Pregnancy and Lactation
Subcommittee conducted a systematic review to answer this question with support
from the Nutrition Evidence Systematic Review (NESR) team.
 Dietary patterns were defined as the quantities, proportions, variety, or combination
of different foods, drinks, and nutrients (when available) in diets, and the frequency
with which they are habitually consumed.
 Diets based on macronutrient distribution were examined when at least one
macronutrient proportion was outside of the acceptable macronutrient distribution
range (AMDR) for carbohydrate, fat, and/or protein, whether or not the foods/food
groups consumed were provided.
What is the population of interest?
 The population of interest is generally healthy, pregnant women.
What evidence was found?
 This review includes 26 articles published between 2009 and 2019.
 Many studies showed that “beneficial” dietary patterns were related to less weight
gain during pregnancy.
 Dietary patterns that were consistently related to less weight gain during pregnancy
were:
o higher in vegetables, fruits, nuts, legumes, fish, and
o lower in added sugar, red and processed meat.
 The body of evidence is limited in several ways:
o Studies were mostly observational and cause-effect relationships between
diet and weight gain during pregnancy were therefore difficult to determine.
10
o There was little racial/ethnic, socioeconomic, and age diversity in these
studies.
o It was difficult to compare studies due to inconsistencies in how diets were
measured.
o There were concerns about potential bias of the studies.
o Many studies were not designed to study the relationship between dietary
patterns and weight gain during pregnancy.
How up-to-date is this systematic review?
 This review searched for studies from January 2000 to November 2019.
11
TECHNICAL ABSTRACT
Background
 This important public health question was identified by the U.S. Departments of
Agriculture (USDA) and Health and Human Services (HHS) to be examined by the
2020 Dietary Guidelines Advisory Committee.
 The 2020 Dietary Guidelines Advisory Committee, Pregnancy and Lactation
Subcommittee conducted a systematic review to answer this question with support
from the Nutrition Evidence Systematic Review (NESR) team.
 The goal of this systematic review was to examine the following question: What is
the relationship between dietary patterns consumed during pregnancy and
gestational weight gain?
Conclusion statement and grade
 Limited evidence suggests that certain dietary patterns during pregnancy are
These patterns are higher in vegetables, fruits, nuts, legumes, fish, and lower in
added sugar, and red and processed meat. (Grade: Limited)
Methods
 A literature search was conducted using four databases (PubMed, Cochrane,
Embase, and CINAHL) to identify articles that evaluated the intervention/exposure
of dietary patterns during pregnancy and the outcome of gestational weight gain. A
manual search was conducted to identify articles that may not have been included
in the electronic databases searched. Articles were screened by two NESR analysts
independently for inclusion based on pre-determined criteria.
 Data extraction and risk of bias assessment were conducted for each included
study, and both were checked for accuracy. The Committee qualitatively
synthesized the body of evidence to inform development of a conclusion
statement(s), and graded the strength of evidence using pre-established criteria for
risk of bias, consistency, directness, precision, and generalizability.
Summary of the evidence
 This systematic review includes 26 articles, including five from four randomized
controlled trials (RCTs) and 21 from 19 prospective cohort studies published
between 2009 and 2019.
 Articles included in this review assessed one of the following
interventions/exposures during pregnancy:
o Dietary patterns (DPs) (24 studies).
o Diets based on macronutrient distributions outside of the acceptable
macronutrient distribution range (AMDR) (2 studies).
 Eight of the 15 articles that assessed maternal DPs using an index/score method
showed an association with gestational weight gain (GWG).
o Five of the eight articles showed that greater adherence to a DP (identified
as beneficial by the study) was associated with lower GWG.
o Three articles showed that greater adherence to a DP (identified as
12
beneficial by the study) was associated with greater GWG in all participants
or only women with obesity.
 Four of the five articles that assessed maternal DPs using a factor or cluster
analysis showed one or more associations between adherence to DPs and GWG.
o One article showed that greater adherence to a DP (identified as beneficial
by the study) was associated with lower GWG.
o Four articles showed that greater adherence to a DP (identified as
detrimental by the study) was associated with higher GWG.
 One study that assessed maternal DPs using reduced rank regression showed that
greater adherence to a DP was associated with higher GWG.
 Two RCTs showed that participants randomized to a DP (identified as beneficial by
the study) had lower GWG.
 One RCT and one prospective cohort study showed no association between
maternal consumption of a diet higher in fat (i.e. >35 percent of total energy from
fat, which is greater than the AMDR) and GWG.
 Although the DPs examined were characterized by combinations of different foods
and beverages, the patterns that were consistently shown to be associated with
lower risk of excessive GWG were: higher in vegetables, fruits, nuts, legumes, and
fish and lower in added sugar and red and processed meat.
o Not all foods were part of the same DP. The evidence did not show a
consistent association between grains or dairy and GWG.
 The ability to draw strong conclusions was limited by the following issues:
o There were few RCTs and thus data were primarily observational in nature,
limiting the ability to determine causal effects of DPs on GWG.
o Key confounders were not consistently controlled for in most of the studies.
o Studies had risk-of-bias issues, including exposure misclassification, self-
reported outcomes, and selection bias.
o Most of the studies were not designed to assess the association between
DPs and GWG.
o People with lower SES, adolescents, and racially and ethnically diverse
populations were underrepresented in the body of evidence.
13
FULL REVIEW
Systematic review question

gestational weight gain?
Conclusion statement and grade
Limited evidence suggests that certain dietary patterns during pregnancy are
These patterns are higher in vegetables, fruits, nuts, legumes, fish, and lower in added
sugar, and red and processed meat. (Grade: Limited)
Summary of the evidence
 This systematic review includes 26 articles,1-26 including five articles from four
randomized controlled trials (RCTs) and 21 articles from 19 prospective cohort
studies published between 2009 and 2019.
 Articles included in this review assessed one of the following
interventions/exposures during pregnancy:
o Dietary patterns (DP) (24 studies).
o Diets based on macronutrient distributions outside of the acceptable
macronutrient distribution range (AMDR) (2 studies).
 Eight of the 15 articles that assessed maternal DPs using an index/score
method showed an association with gestational weight gain (GWG):
o Five of the eight articles showed that greater adherence to a DP
(identified as beneficial by the study) was associated with lower GWG.
o Three articles showed that greater adherence to a DP (identified as
beneficial by the study) was associated with greater GWG in all
participants or only women with obesity.
 Four of the five articles that assessed maternal DPs using a factor or cluster
analysis showed one or more associations between adherence to DPs and
GWG.
o One article showed that greater adherence to a DP (identified as
beneficial by the study) was associated with lower GWG.
o Four articles showed that greater adherence to a DP (identified as
detrimental by the study) was associated with higher GWG.
 One study that assessed maternal DPs using reduced rank regression showed
that greater adherence to a DP was associated with higher GWG.
 Two RCTs showed that participants randomized to a DP (identified as beneficial
by the study) had lower GWG
 One RCT and one prospective cohort study showed no association between
maternal consumption of a diet higher in fat (i.e., >35 percent of total energy
from fat, which is greater than the AMDR) and GWG
 Although the DPs examined were characterized by combinations of different
foods and beverages, the patterns that were consistently shown to be
associated with lower risk of excessive GWG were: higher in vegetables, fruits,
nuts, legumes, and fish and lower in added sugar and red and processed meat.
o Not all foods were part of the same DP. The evidence did not show a
14
consistent association between grains or dairy and GWG.
 The ability to draw strong conclusions was limited by the following issues:
o There were few RCTs and thus data were primarily observational in
nature, limiting the ability to determine causal effects of DPs on GWG.
o Key confounders were not consistently controlled for in most of the
studies.
o Studies had risk-of-bias issues, including exposure misclassification, self-
reported outcomes, and selection bias.
o Most of the studies were not designed to assess the association between
DPs and GWG.
o People with lower SES, adolescents, and racially and ethnically diverse
populations were underrepresented in the body of evidence.
Description of the evidence
This systematic review included articles that address the relationship between dietary
patterns and/or diets based on macronutrient distributions outside of the AMDR during
pregnancy and gestational weight gain (GWG). The search included articles from high
and very high Human Development Indexii countries and the search time frame
spanned between January 2000 and November 2019. Studies considered in this body
of evidence included pregnant women who were generally healthy. The following study
designs were included: randomized controlled trials (RCTs), non-randomized
controlled trials, prospective and retrospective cohort studies, and nested case-control
studies.
This body of evidence includes 26 articles, including five from four RCTs22-26 and 21 from
19 prospective cohort studies.1-21 A total of 23 distinct trials/cohort studies are represented
in this body of evidence. References are included for each study in Table 1 with trial/cohort
names or locations when names were unavailable. Six studies were conducted in the
U.S.6,7,9,11-13,16,25 In addition, three studies were conducted in Spain,1,2,23,26 two each in the
U.K.,22,24 Norway,5,21 and Japan3,4; and one each in Mexico,18 Italy,19 Poland,17 Iceland,14
Finland,10 the Netherlands,8 China,15 and Malaysia.20
ii
The Human Development classification was based on the Human Development Index (HDI) ranking
from the year the study intervention occurred or data were collected (UN Development Program. HDI
1990-2017 HDRO calculations based on data from UNDESA (2017a), UNESCO Institute for Statistics
(2018), United Nations Statistics Division (2018b), World Bank (2018b), Barro and Lee (2016) and IMF
(2018). Available from: http://hdr.undp.org/en/data). If the study did not report the year in which the
intervention occurred or data were collected, the HDI classification for the year of publication was
applied. HDI values are available from 1980, and then from 1990 to present. If a study was conducted
prior to 1990, the HDI classification from 1990 was applied. When a country was not included in the HDI
ranking, the current country classification from the World Bank was used instead (The World Bank.
World Bank country and lending groups. Available from:
https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world- country-and-lending-groups).
15
Table 1. Included trials and cohorts
Trial/Cohort name Reference number(s)
Randomized Controlled Trials

22
Effect of Simple, Targeted Diet in Pregnant Women With Metabolic
Risk Factors on Pregnancy Outcomes (ESTEEM) trial
23,26
St. Carlos GDM prevention study
25
Maternal Offspring Metabolics Family Intervention Trial (MOMFIT)
24
U.K. Pregnancies Better Eating and Activity Trial (UPBEAT)
Prospective Cohort Studies

19
Mamma & Bambino
3
Osaka Maternal and Child Health Study (OMCHS)
8
Generation R Study
15
Born in Guangzhou Cohort Study (BIGCS)
17
Polish Mother and Child Cohort
18
Pregnancy Research on Inflammation, Nutrition and City
Environments: Systematic Analyses (PRINCESA)
13
New Hampshire Birth Cohort Study (NHBCS)
1
INfancia y Medio Ambiente (INMA)
6,9,12
Project Viva
2
Mérida Cohort
21
Norwegian Fit for Delivery (NFFD)
5
Norwegian Mother and Child Cohort Study (MoBa)
14
PREgnant Women of Iceland (PREWICE)
10
Control arm of RADIEL trial
7
Infant Feeding Practices Study II (IFPSII)
20
Seremben Cohort Study (SECOST)
16
Pregnancy Environment and Lifestyle Study (PETALS)
11
Healthy Start
16
Trial/Cohort name Reference number(s)
4
Tokyo (Japan)
Subject characteristics:
 Sample sizes of the studies ranged from 352 to 66,5975 participants.
 Almost all of the studies were conducted in adult women (18-45 y) who had
singleton pregnancies. Of note, Fulay et al12 and Wedolowska et al17 enrolled
mothers as young as 15 y and 17 y, respectively.
 Health characteristics:
o Prepregnancy BMI: Seven studies enrolled predominantly or exclusively
overweight or obese women.7,10,11,16,18,24,25 In addition, Al Wattar et al
enrolled women with metabolic risk factors, including women with
obesity.22
o Diabetes: 10 studies excluded women with a previous diagnosis of type 1
and/or 2 diabetes mellitus (as defined by the studies).5,9-12,16,17,19,21,22,25
Two studies excluded women with one or more of the following
conditions: gestational diabetes, hypertension, and preeclampsia.18,19 In
an RCT conducted in Spain, the authors noted that approximately 25
percent of the participants had a family history of type 2 diabetes
mellitus.23,26
 Race/ethnicity: Thirteen of the 26 articles noted that the participants were
predominantly or exclusively White (defined as ≥50 percent of the
participants).2,6-9,11-13,21,23-26 Nine studies did not report
race/ethnicity.1,3,5,10,14,15,17-19 Yong et al20 reported that 89 percent of the
participants were Malay and Tajima et al4 noted that 100 percent of their
participants were Japanese. Zhu et al16 reported that the participants were
predominantly Hispanic (approximately 41.3 percent) and Al Wattar et al22 noted
that the participants were predominantly Asian (approximately 43.7 percent).
 Socio-economic status:
o Maternal education:
 A majority of the studies reported that the participants had some
college education.6-9,11-16,23,25,26 When studies reported the years
of education, most noted that a majority of the participants had
≥12 y of education.3,17,20,21 Maugeri et al19 noted that < 20 percent
of the participants had low-medium education (defined as ≤ 8 y of
education), but did not give other details. Similarly, Gesteiro et al2
reported that 83 percent of the participants had medium or high
education (but did not categorize education further).
 However, the following were exceptions: Ancira-Moreno et al
noted that >50 percent of the participants had < 9 y of education.18
Fernandez-Barres et al1 reported that 63.6 percent of the
participants had secondary education or less.
 Four studies did not report maternal education.4,5,22,24
(Note: Fulay et al,12 who used Project Viva data, reported that
approximately 32 percent of their participants had a college education,
17
whereas Rifas-Shiman et al6 and Sen et al,9 who also used Project
Viva data with a similar sample size as Fulay et al, reported that
approximately 69 percent had college degrees).
o Income: In the 17 articles that reported household income and/or
participant employment status, the majority of women were employed
and/or from middle-to-high income households.1,3,6-9,12,15-17,19,21,23,25,26
Two studies20,24 reported that the majority of participants were from low
SES backgrounds.
Interventions/Exposures
Dietary Patterns
Dietary pattern (DP) was defined as the quantities, proportions, variety, or combination
of different foods, drinks, and nutrients (when available) in diets, and the frequency
with which they were habitually consumed. At minimum, there had to be a description
of the foods and beverages in the pattern. Dietary patterns may have been measured
or derived using a variety of approaches, such as adherence to a priori patterns
(indices/scores), data driven patterns (factor or cluster analysis), reduced rank
regression, or other methods, including clinical trials.
Dietary patterns were assessed using 1) index/score analysis, 2) factor analysis and
principal component analysis (PCA), 3) experimental diet, and 4) reduced rank
regression. A description of the studies categorized by the method used to measure
dietary patterns is included below:
Index/Score Analysis
Fifteen articles included in this review used one or more of the following indices/scores
summarized below:
 Maternal Diet Quality Score (MDQS)18
 Alternative Healthy Eating Index (AHEI) and its modifications6,7,13
 Healthy Eating Index (HEI)2,16,20
 relative Mediterranean Diet (rMED) score1
 Dietary Approaches to Stop Hypertension (DASH) and its modifications12
 Mediterranean Diet Adherence (MDA)2
 New Nordic Diet (NND)5
 Norwegian Fit for Delivery (NFFD) Diet21
 Dietary risk scores14
 Healthy Food Intake Index (HFII)10
 Dietary Inflammatory Index (DII)9
 Dutch Healthy Diet Index8
Factor analysis and PCA
Five studies included in this review assessed dietary patterns using factor analysis or
PCA.3,8,15,17,19
Experimental Diet
Three RCTs22,23,25,26 in this review assigned participants to an experimental diet (i.e.
Mediterranean diet, DASH diet) or a control diet.
18
Reduced Rank Regression
One study11 assessed adherence to DPs (patterns 1 and 2) derived using reduced
rank regression.
Table 2. Dietary pattern componentsiii
Reference Dietary pattern Dietary components
Index/Score Analysis
Ancira-Moreno et al18 MDQS Vegetables and fruits; legumes; low-fat dairy

products; PUFAs (positive)
Red meat; added sugars; foods high in saturated
fat or added sugar (negative)
Emond et al13 AHEI-2010 Vegetables; fruits; whole grains; nuts and

legumes; long-chain (n-3) fats; PUFAs (positive)
Red and processed meats; sugar-sweetened
beverages and fruit juice; trans fats; sodium
(negative)
Alcohol component excluded
Fernández-Barrés et al1 rMED Vegetables; fruits and nuts; cereals; legumes; fish;
olive oil (positive)
Meat; dairy (negative)
Fulay et al12 DASH Vegetables; fruits; whole grains; nuts and

legumes; low-fat dairy (positive)
Red and processed meat; sugar-sweetened
beverages; sodium (negative)
DASH OMNI Vegetables; fruits; whole grains; nuts and

legumes; low-fat dairy; PUFAs; MUFAs (positive)
Red and processed meat; sugar-sweetened
beverages; sodium (negative)
Gesteiro et al2 HEI Vegetables; fruits; cereals, grains, and legumes;

meat, eggs, and fish; milk and dairy products;
dietary variety
Total fats; SFAs; cholesterol; sodium
iii
EVOO: extra virgin olive oil, MUFA: monounsaturated fatty acid, OMNI: optimal macronutrient intake,
PCA: principal component analysis, PUFA: polyunsaturated fatty acid, SFA: saturated fatty acid
19
MDA Total vegetables; raw vegetables; fruits (including

natural fruit juices); legumes; nuts (including
peanuts); chicken, turkey, or rabbit meat; fish or
shellfish; olive oil; dishes seasoned with sofrito
(positive)
Red meat, veal, hamburger, or sausage; butter,
margarine or cream; sweet or carbonated
beverages; commercial sweets or pastries
(negative)
Hillesund et al 20145 NND Root vegetables; cabbages; potatoes relative to

rice and pasta; Nordic fruits; foods from the wild
countryside (game, ﬁsh, seafood, and native
berries); whole grain breads relative to refined
breads; oatmeal porridge; unsweetened milk
relative to fruit juice; water relative to sweetened
beverages; meal frequency (positive)
Hillesund et al 201821 NFFD diet Vegetables with dinner; fruits or vegetables as

snacks; water relative to other beverages; small
portion size of one or more unhealthy food items
(soda, salty crisps, or chocolate); meal frequency;
never eating sweets and snacks without
appreciation; reading nutrition labels (positive)
Sugar-rich food items; fast-foods, snacks, or other
salty food; eating beyond satiety (negative)
Hrolfsdottir et al14 Dietary risk score Low intake of vegetables and fruits; whole grains;
(13 risk factors) beans, nuts, and seeds; dairy; fish; vitamin D
Low dietary variety
High intake of processed meat; french fries and
fried potatoes; dairy; sweets, ice cream, cakes,
and cookies; sugar and artificially sweetened
beverages; butter relative to oil
Dietary risk score (6 Low intake of vegetables and fruits; whole grains;
risk factors) dairy
Low dietary variety
High intake of dairy; sugar and artificially
sweetened beverages
20
Dietary risk score (4 Low intake of whole grains; dairy

risk factors) High intake of dairy; sugar and artificially
sweetened beverages
Meinila et al10 HFII Vegetables; fruits and berries; high-fiber grains;

fish; low-fat milk; low-fat cheese; vegetable oils as
cooking fat; oil-based fat spreads (positive)
Sugar-sweetened beverages (including juice); fast
food; snacks with added sugar or salt (negative)
Poon et al7 AHEI-P Vegetables; whole fruit; whole grains; nuts and
legumes; long-chain (n-3) fats; PUFAs; calcium;
folate; iron (positive)
Red and processed meats; sugar-sweetened
beverages; trans fats; sodium (negative)
Rifas-Shiman et al6 AHEI-P Vegetables (includes tofu and soybeans); fruits;

ratio of white (poultry, fish) to red meat (beef, pork,
lamb, processed); ratio of PUFAs to SFAs; fiber;
calcium; folate; iron (positive)
Trans fats (negative)
Alcohol and nut components excluded
Sen et al9 DII Vegetables; fruits; whole grains; fish and seafood;
whole eggs (positive)
Red and processed meat; sugar-sweetened soda
(negative)
Tielemans et al8 Dutch Healthy Diet Vegetables; fruits; fish; fiber (positive)
Index SFAs; sodium (negative)
Alcohol, acidic food and drink, and trans fat
components excluded
Yong et al20 Modified HEI for Vegetables; fruits; cereals and grains; legumes;
Malaysians poultry, meat, and eggs; fish and seafood; milk
and milk products; total fats; sodium (negative)
Zhu et al16 HEI-2010 Total vegetables; beans and greens; total fruit;
whole fruit; whole grains; total protein foods;
seafood and plant proteins; dairy; ratio of PUFAs
and MUFAs to SFAs (positive)
21
Refined grains; calories from solid fats and added
sugars; sodium (negative)
Factor Analysis and PCAiv
Maugeri et al19 Western High intake of red meat, fries, dipping sauces,
salty snacks and alcoholic drinks
Prudent High intake of boiled potatoes, cooked vegetables,

legumes, pizza and soup
Okubo et al3 Meat and eggs High intake of beef and pork, processed meat,
chicken, eggs, butter, and dairy products
Wheat products High intake of bread, confectioneries, fruit and

vegetable juice, and soft drinks
Rice, fish, and High intake of rice, potatoes, nuts, pulses, fruits,
vegetables green and yellow vegetables, white vegetables,
mushrooms, seaweeds, Japanese and Chinese
tea, fish, shellfish, sea products, miso soup, and
salt-containing seasoning
Tielemans et al8 Vegetable, Oil and High intake of vegetables, oil, and fish
Fish
Nuts, High-Fiber High intake of nuts, high-fiber cereals, and soy

Cereals, and Soy
Margarine, Sugar, High intake of margarine, sugar, and snacks

and Snacks
Wei et al15 Cereals Richer in cereals
Vegetables Richer in vegetables
Meats Richer in meats
Fruits Richer in fruits
Fish, beans, nuts, Richer in fish, beans, nuts, and yogurt

and yogurt
Milk and milk Richer in milk and milk powder

powder
iv
Author-derived dietary pattern
22
Wesolowska et al17 Western High intake of refined grains, processed meat,

potatoes, and very low intake of whole grains
Mixed Intake between Western and Prudent
Prudent High intake of fruit, vegetables, legumes, whole

grains, poultry, and low-fat dairy products
Experimental Diet
Al Wattar et al22 MED-style Diet High consumption of nuts, extra virgin olive oil,
fruits, vegetables, non-refined grains, and
legumes; moderate-to-high consumption of fish;
low-to-moderate amounts of poultry and dairy
products, such as yogurt and cheese; low
consumption of red meat and processed meat;
avoidance of sugary drinks, fast food, and foods
rich in animal fat. Mixed nuts (walnuts, hazelnuts,
and almonds) and EVOO provided by
investigators.
Control Diet recommended as per U.K. national

recommendations for antenatal care
Assaf-Balut et al23,26 Control Mediterranean Diet: High consumption of

vegetables, fruit (avoiding juices), skimmed dairy
products, whole grain cereals, and legumes;
moderate-to-high consumption of fish; low
consumption of red and processed meat;
avoidance of refined grains, processed baked
goods, pre-sliced bread, soft drinks and fresh
juices, fast foods, and precooked meals; restriction
of dietary fat, including EVOO and nuts
Intervention Mediterranean Diet plus EVOO and pistachios

provided by investigators
Van Horn et al 25 Mama-DASH Encouraged consumption of low-fat dairy products,

fish, skinless poultry, lean meat and vegetable
protein, unsaturated fats, fiber-rich whole grains,
fruits, vegetables, and legumes; discouraged
consumption of sugar-sweetened beverages,
sweets, and non-nutrient-dense snack foods;
avoidance of fish considered higher in mercury;
inclusion of calcium-rich, vitamin D−enriched dairy,
or calcium-fortified non-dairy products
23
Control Usual care, including bi-weekly newsletters and

publicly available maternity website links
Reduced Rank Regressionv
Starling et al11 Pattern 1 Higher consumption of poultry, nuts, cheese, fruits,

whole grains, added sugars, and solid fats
Pattern 2 Higher consumption of eggs, starchy vegetables,

solid fats, fruits, and non-whole grains and a lower
consumption of dairy foods, dark-green
vegetables, and whole grains
v
Author-derived dietary pattern
24
Diets based on Macronutrient Distribution
Studies assessing diets based on macronutrient distributions outside of the acceptable
macronutrient distribution range (AMDR) had to specify the distribution of
carbohydrate, fat, and protein in the diet to be considered for this review.
Macronutrient proportions outside of the AMDR are as follows:
 Carbohydrate for all age groups: < 45 or > 65 percent of energy;
 Protein for ≥ 19 years: < 10 or > 35 percent of energy;
 Fat for ≥ 19 years: < 20 or > 35 percent of energy
One RCT and one prospective cohort study4,24 in this review assessed macronutrient
proportions and reported the percentage of total energy from fat was higher than the
AMDR for one of the groups.
Time point of exposure
The RCTs22-26 randomized women during the late first trimester23,26 or early second
trimester22,24,25 and followed them to the end of the second trimester.22-26
Most of the cohort studies administered food frequency questionnaires (FFQ) or 24
hour recalls toward the end of the first trimester or early in the second.2,6,8-10,12,14,16,19-21
Investigators typically collected retrospective dietary data reflecting early pregnancy
intake (i.e. first trimester). In a few studies, maternal dietary data were collected in the
second trimester3,5,13,15,17 or third trimester,1,7 reflecting intake in the past week,15
month,3,7 or the entire pregnancy until that point.13,17 In a few cohorts, dietary data
were collected at multiple time points and assessed at individual time points (e.g. by
trimester) or combined in the analysis.6,9,11,20
Outcome
The outcome considered in this review was gestational weight gain (GWG), reported in
a number of ways, including total GWG,2,3,7,11,12,15,16,19,22,25 GWG for a specified time
period 23,24,26 or trimester,10 GWG rate,1,4,8,15,18,20 and GWG adequacy.5,6,8,9,13-15,17-
21,23,25
The studies that assessed GWG adequacy classified GWG as inadequate,
adequate, or excessive according to the Institute of Medicine (2009) guidelinesvi, with
the exception of Rifas-Shiman et al,6 who used Institute of Medicine (1990)
guidelinesvii, Hrolfsdottir et al,14 who used Icelandic recommendations (no reference
provided), and Assaf-Balut et al,23 who had cited a previous publicationviii.
vi
Institute of Medicine (US) and National Research Council (US) Committee to Reexamine IOM
Pregnancy Weight Guidelines. Weight Gain During Pregnancy: Reexamining the Guidelines.
(Rasmussen KM, Yaktine AL, eds.). Washington (DC): National Academies Press (US); 2009
vii
Institute of Medicine (US) Committee on Nutritional Status During Pregnancy and Lactation. Nutrition
During Pregnancy: Part I Weight Gain. Washington (DC): National Academies Press (US); 1990
viii
Hutcheon JA, Platt RW, Abrams B, Himes KP, Simhan HN, Bodnar LM. Pregnancy weight gain charts
for obese and overweight women. Obesity. 2015; 23(3): 532-535. doi: 10.1002/oby.21011.
25
Evidence synthesis
With 26 articles, there is a substantial body of evidence available to examine the
association between DPs during pregnancy and GWG (Table 3, Table 4). However,
there is heterogeneity in the methods used to define and assess DPs and how
outcomes were reported, which made it difficult to compare results across studies.
Furthermore, the time period of dietary assessment and the duration of the recall also
varied across studies.
Dietary patterns assessed via index/score
Fifteen articles used indices/scores to assess DPs and the findings are described
below:
 Ancira-Moreno et al18 assessed the association between adherence to the
Maternal Diet Quality Score (MDQS) and GWG trajectories (baseline n=660) in
Mexican participants. The MDQS was based on the Mexican Dietary Guidelines
and international recommendations for specific foods and was characterized by
higher intake of PUFAs, fruits and vegetables, legumes, and low-fat dairy
products; lower in foods higher in saturated fat, added sugars, and red meat.
The study accounted for key confounders including age, SES, physical activity,
prepregnancy BMI, GDM, hypertension, and parity. Anciro-Moreno et al also
adjusted for energy intake (kilocalories per day) in the model when assessing
whether diet quality was independent of total energy. The study noted the
following findings:
o Medium and high adherence throughout pregnancy were associated with
lower risk of inadequate weight gain, but only high adherence was
associated with lower risk of excessive weight gain.
o When the investigators assessed specific time periods during pregnancy
they noted that:
 Medium adherence to the MDQS was associated with significantly
lower rate of weight gain during middle pregnancy (20-30 weeks).
 In late pregnancy (30-40 weeks), medium and higher adherence
were positively associated with the rate of GWG.
 When looking at weight gain beyond 40 weeks (defined by authors
as prolonged pregnancy), higher adherence was associated with
lower rate of weight gain.
 Emond et al13 examined maternal adherence to the Alternative Healthy Eating
Index-2010 (AHEI) and GWG in a U.S.-based cohort (baseline n=1,140). The
AHEI-2010 was characterized by higher intake of six ‘healthful’ components,
including: fruits, vegetables, whole grains, nuts and legumes, long-chain n–3
fatty acids from foods and supplements, and PUFAs; and lower intake of four
components, including: sugar-sweetened beverages and fruit juice, red and
processed meats, trans fatty acids, and sodium. The primary objective of this
study was to assess the association between the AHEI-2010 and infant
outcomes. The study reported that there were no significant differences in GWG
adequacy (i.e., insufficient, adequate, excessive) based on different levels of
26
adherence to the AHEI-2010. None of the key confounders were accounted for
in the analysis.
 In a Spain-based cohort study with a baseline sample size of 2,195 participants,
Fernandez-Barres et al1 assessed maternal adherence to the relative
Mediterranean Diet (rMED) score, which was constructed by taking into account
the consumption of vegetables, fruits and nuts, cereals, legumes, fish, olive oil,
meat, and dairy products. The scoring for meat and dairy products was reversed.
Although GWG was assessed, the study was designed to examine the
association between the rMED and the child’s longitudinal BMI and
cardiometabolic risk. The study reported that highest adherence to the rMED DP
was associated with significantly lower mean GWG (kilogram per week). The
study did not account for any of the key confounders.
 In the U.S.-based Project Viva study (baseline n=2,128), Fulay et al12 examined
the association between the DASH diet and GWG, in addition to other
pregnancy outcomes. The authors noted that the DASH diet was similar to the
Mediterranean diet in that both are rich in fruits, vegetables, legumes, whole
grains, and healthy fats, with limited amounts of poultry, red meat, and dairy. In
addition, the DASH diet emphasized reduced intake of sodium, saturated fat,
total fat, and cholesterol, and higher intake of fiber and protein. As a variation of
DASH, the authors also assessed the association between the DASH OMNI
(supplemented by higher unsaturated fat intake) and GWG. After adjusting for
total energy intake and key confounders (including age, race/ethnicity, SES,
prepregnancy BMI, smoking and parity) in a statistical model, the authors
reported that greater adherence to the DASH and DASH OMNI diets was
associated with greater subsequent GWG. This was primarily observed among
women who were obese during prepregnancy (≥ 30 kg/m2) and not in those who
were overweight, normal weight or underweight.
 Gesteiro et al2 examined the association between maternal Mediterranean Diet
Adherence (MDA), the Healthy Eating Index (HEI), and GWG, in a Spanish
cohort study (baseline n=35).
o High MDA (≥ 7) was characterized by the use of olive oil as the main
dietary fat, higher intakes of vegetables, raw vegetables, fruits, fish or
shellfish, nuts (including peanuts), legumes, chicken, turkey or rabbit
meat, and dishes seasoned with sofrito, sauce made with tomato, onion,
leek or garlic, and simmered with olive oil, and lower intakes of red meat,
veal, pork, hamburger or sausage, butter, margarine or cream, sweet or
carbonated beverages, and commercial sweets or pastries.
o The HEI was characterized by intake of cereals, grains and legumes,
vegetables, fruits, milk and dairy products, meat, eggs and fish, total fat,
saturated fat, cholesterol (milligrams per day), and sodium (grams per
day). HEI also accounted for the intake of total fat, saturated fat, sodium
and dietary variety.
The primary objective of this study was to assess the association between first
trimester diet quality, measured by the HEI and MDA, and insulin
sensitivity/resistance biomarkers at birth. The study accounted for key
27
confounders, including race/ethnicity, smoking, and GDM. The investigators
noted that women with higher MDA (≥ 7) had significantly higher total GWG,
when compared to those with lower MDA (< 7). There were no significant
differences in GWG between women with adequate vs. inadequate HEI
adherence.
o Hillesund et al5 examined the association between the New Nordic Diet (NND)
and GWG and fetal growth in this Norwegian cohort study (baseline n=66,597).
The NND measured the frequency of eating of the following foods: Nordic fruits
(apples, pears, plums, strawberries), root vegetables (carrots, rutabaga and
various types of onions), cabbages (kale, cauliflower, broccoli and Brussels
sprouts), potatoes, whole grain breads, oatmeal porridge, foods from the wild
countryside (wild fish, seafood, game and wild berries), milk, and water. There
were significant differences in GWG adequacy between groups, depending on
the extent of NND adherence. Specifically, the proportion of women with
excessive GWG was higher in the low adherence group compared to the
medium or high adherence groups. When stratified by prepregnancy BMI, these
results were consistent for women with a healthy prepregnancy BMI (BMI < 25.0
kg/m2), and marginally significant for those who were overweight or obese (BMI
≥ 25 kg/m2) prior to pregnancy (p=0.076). None of the key confounders were
adjusted for in the analysis.
o Hillesund et al21 assessed maternal adherence to the Norwegian Fit for Delivery
(NFFD) Diet in this Norwegian cohort study (based on the Norwegian Fit for
Delivery trial) with a baseline sample size of 606. The NFFD diet was
characterized by ≥ 24 main meals per week, water for ≥ 44 percent of drinking
events, vegetables with dinner ≥ 5 per week, fruits or vegetables as snacks ≥ 3
per week, < 1 per day sugar-rich food items, <1 per day fast-foods, snacks, or
other salty food, never eating sweets and snacks without appreciation, buying
small portion size of ≥ 1 unhealthy food items, eating beyond satiety < 1 per
week, and reading nutrition labels on foods sometimes or often. The main
objective of the study was to assess the association between the NFFD diet and
a number of maternal and neonatal outcomes, including GWG. After accounting
for the key confounders, including age, SES, prepregnancy BMI, smoking and
parity, there was a statistically significant inverse association between early
pregnancy NFFD diet score and the odds of excessive GWG. This association
remained significant even after adjusting for physical activity, in addition to other
key confounders. There was no association between diet scores and inadequate
GWG.
o Hrolsdottir et al,14 an Icelandic cohort study (baseline n=1,326), assessed the
association between dietary risk scores and excessive GWG. A high dietary risk
score was characterized by a non-varied diet, non-adequate frequency of
consumption of fruits/vegetables, dairy, and whole grain intake, and excessive
intake of sugar/artificially sweetened beverages and dairy. After accounting for
the key confounders, including age, SES, prepregnancy BMI, smoking, parity
and GDM (only in a sub-analysis), the study showed that a higher dietary risk
score (which included 6 dietary risk factors - a non-varied diet, vegetables and
fruits < 5 times per day, dairy intake < 2 times per day, whole grain products < 2
times per day, sugar- and artificially sweetened beverages ≥ 5 times per week,
28
dairy intake ≥ 5 times per day) was associated with excessive GWG. Similarly
higher dietary risk score with three foods (sugar- and artificially sweetened
beverages ≥ 5 times per week, whole grain products < 2 times per day and dairy
intake ≥ 5 times per day) was associated with the risk of excessive GWG;
however, there was no association between dietary risk score when 13 foods
were considered (not eating a varied diet, vegetables and fruits < 5 times per
day, fish intake < 2 times per day, dairy intake < 2 times per day, whole grain
products < 2 times per day, beans, nuts, seeds < 3.5 times per week, D-vitamin
< 5 times per week, quality of fat - using butter rather than oil (≥ 50%) French
fries and fried potatoes ≥ 1 times per week, sweets, ice cream, cakes, cookies ≥
2.5 times per week, sugar- and artificially sweetened beverages ≥ 5 times per
week, dairy intake ≥ 5 times per day, processed meat products ≥ 1 times per
week).
o Meinila et al,10 a Finnish prospective cohort study (based on the control arm of
the RADIEL trial), assessed the association between the Healthy Food Intake
Index (HFII) and GWG (baseline n=137). The primary objective of this study,
however, was to assess the association between the HFII and GDM. A higher
HFII score was indicative of higher adherence to the Nordic Nutrition
Recommendations (NNR), characterized by the following: 1) increased
consumption of vegetables, fruits, fish and seafood, nuts and seeds; 2)
substituting whole grains for refined grains, vegetable oils for butter, oil-based fat
instead of butter-based spread and low-fat dairy instead of full-fat dairy; and 3)
limiting beverages and foods with added sugar or salt, including snacks, sugar-
sweetened drinks/juice, fast foods, and red and processed meat. Adherence to
the HFII was not associated with GWG from the first to the second trimester.
None of the key confounders were accounted for in the analysis.
o Poon et al7 assessed adherence to the Alternate Healthy Eating Index for
Pregnancy (AHEI-P) and its association with GWG in a U.S.-based cohort study
(baseline n=893). The primary objective of this study was to examine the impact
of the maternal DP on the incidence of SGA and LGA. The AHEI-P was
characterized by higher intake of vegetables, whole fruit, whole grains, nuts and
legumes, long-chain (n-3) fatty acids, PUFAs, folate, calcium, and iron, and
lower intake of sugar-sweetened beverages, red and processed meat, trans fat,
and sodium. The authors reported no significant difference in GWG across
different levels of adherence to the AHEI-P. None of the key confounders were
accounted for in the analysis.
o Rifas-Shiman et al6 also used a modified AHEI called AHEI-P, characterized by
the intake of vegetables (including tofu or soybean), fruit, ratio of white-to-red
meat, fiber, trans fat, ratio of polyunsaturated-to-saturated fatty acids, and folate,
calcium, and iron from foods. The authors made some changes to the AHEI by
excluding alcohol and nuts and including folate, calcium and iron intake.
Although the AHEI-P indices assessed by Poon et al7 and Rifas-Shiman et al6
are similar, they are not the same. The main objective of this U.S.-based study
(baseline n=1,777), which used Project Viva data, was to assess the maternal
characteristics associated with the AHEI-P score, with GWG measured as a
secondary outcome. After adjusting for the key confounders, including age,
race/ethnicity, SES and prepregnancy BMI, the study found that greater
29
adherence to the AHEI-P was not associated with altered risk for inadequate or
excessive GWG.
o Sen et al9 also used Project Viva data to assess the association between
prenatal Dietary Inflammatory Index (DII) and a number of perinatal outcomes,
including GWG (baseline n=1,808). Lower DII is characterized by higher intakes
of vegetables, fruit, whole-grain foods, fish/seafood, and whole eggs, and lower
intakes of red or processed meats and sugar-sweetened soda. After accounting
for the key confounders, including age, race/ethnicity, SES, prepregnancy BMI,
smoking and parity, the study found no association between consuming a lower
DII diet and GWG.
o Tielemans et al8 used the Netherlands-based Generation R study data to assess
the association between an a priori and an a posteriori DP and GWG (baseline
n=4,097). The latter findings are discussed in the next section. The Dutch
Healthy Diet Index (a priori DP) consisted of 6 components, including
vegetables, fruit, dietary fiber, fish, saturated fatty acids, and sodium. After
accounting for the key confounders, including, age, race/ethnicity, SES,
prepregnancy BMI, smoking, GDM, hypertension and parity, the study found no
significant association between the Dutch Health Diet Index and GWG.
o Yong et al20 examined the association between diet quality and GWG in a
Malaysia-based Seremben Cohort Study (baseline n=480). Specifically, the
study used a modified HEI for Malaysians, which measured adherence to the
seven food groups, including 1) cereals and grains, 2) vegetables, 3) fruits, 4)
milk and milk products, 5) poultry, meat and egg, 6) fish and seafood, and 7)
legumes. After adjusting for the key confounders, including, age, SES, physical
activity, prepregnancy BMI and parity, the authors reported that a higher HEI
score in the third trimester was associated with excessive GWG, irrespective of
prepregnancy BMI. However, during the second trimester, the association
between the HEI and GWG varied based on prepregnancy BMI. In women with a
prepregnancy BMI (18.50–24.99 kg/m2), higher HEI was associated with lower
odds of inadequate GWG. In women who were overweight or obese during
prepregnancy, higher HEI was associated with increased odds of excessive
GWG.
o Zhu et al,16 using the U.S.-based PETALS cohort, investigated the association
between the HEI-2010 and GWG, although the primary objective of this study
was to investigate whether maternal diet quality affected fetal growth (baseline
n=2,269). The HEI-2010 included 12 components: total fruit, whole fruit, total
vegetables, greens and beans, whole grains, dairy, total protein foods, seafood
and plant proteins, fatty acids, refined grains, sodium, and empty calories from
solid fats, alcohol and added sugars. However, for this study, alcohol intake was
excluded from the empty calories component. The study reported that total GWG
did not differ among women across different levels of adherence to the HEI-
2010. None of the key confounders were accounted for in the analysis.
Summary: Of the 15 articles that assessed maternal DPs using an index/score
method, eight showed an association with GWG.1,2,5,12,14,18,20,21 Four of the eight
showed that greater adherence to a beneficial DP was either associated with a: 1)
lower risk of excessive GWG, 5,21 2) lower rate of GWG,18 or 3) lower mean GWG.1 An
30
additional study showed that greater adherence to a ‘detrimental’ DP was associated
with excessive GWG.14 However, three studies showed that higher adherence to a
beneficial DP (i.e. DASH, DASH OMNI, Mediterranean Diet, HEI) was associated with
higher GWG, either in all participants2 or only in obese women.12,20 Six of the eight
articles2,12,14,18,20,21 that showed an association adjusted for one or more of the key
confounders.
Among the seven articles that did not show an association,6-10,13,16 four did not adjust
for any of the key confounders, nor were they primarily designed to address the
association between DP and GWG.7,10,13,16 In two of these, the timing of exposure
assessment was also different, with one assessing maternal diet at the end of the
second trimester13 and the other during the third trimester.7 Two other articles that did
not show an association were both conducted with the same cohort (Project Viva).6,9
Dietary patterns assessed via factor or principal components analysis
Five studies3,8,15,17,19 used data-driven methods (i.e. PCA, exploratory factor analysis,
and cluster analysis) to assess dietary patterns:
o Maugeri et al19 used PCA to generate the following dietary patterns:
o Western pattern characterized by high intake of red meat, fries, dipping
sauces, salty snacks, and alcoholic drinks
o Prudent pattern characterized by high intake of boiled potatoes, cooked
vegetables, legumes, pizza, and soup
The primary objective of this Italian study (baseline n=232) was to assess the
association between maternal DPs and total GWG. In a statistical model, the analysis
adjusted for total energy intake and key confounders, including, age, SES, smoking,
GDM, hypertension, and parity. The study reported a positive trend of GWG across
tertiles of a Western DP and this was more prominent in women who were obese prior
to pregnancy. On the other hand, adherence to a prudent DP was positively
associated with GWG among women who were underweight before pregnancy and
negatively associated with GWG among women who were overweight and obese
women before pregnancy.
o In a Japanese prospective cohort study (baseline n=803), Okubo et al3 used a
cluster analysis to create the following dietary patterns:
o Meat and eggs pattern characterized by high intake of beef and pork,
processed meat, chicken, eggs, butter, and dairy products
o Wheat products pattern characterized by high intake of bread,
confectioneries, fruit and vegetable juice, and soft drinks
o Rice, fish, and vegetables pattern characterized by high intake of rice,
potatoes, nuts, pulses, fruits, green and yellow vegetables, white
vegetables, mushrooms, seaweeds, Japanese and Chinese tea, fish,
shellfish, sea products, miso soup, and salt-containing seasoning
The primary objective of the study was to assess the association between maternal
diet and neonatal anthropometric measurements at birth. The study noted that greater
adherence to the wheat products DP was associated with significantly higher mean
GWG when compared to the rice, fish, and vegetable DP. None of the key
31
confounders were adjusted for in the analysis.
o In a Dutch cohort study with a baseline n=4,097, Tielemans et al8 used a PCA to
generate the DPs described below:
o Vegetable, Oil, and Fish pattern characterized by higher intake of
vegetables, high fat dairy products, cereals (both low and high fiber), fish
and shellfish, eggs and egg products, vegetable oils, coffee and tea,
alcoholic beverages, and legumes
o Nuts, High-Fiber Cereals, and Soy pattern characterized by higher intake
of potatoes and other tubers, fruits, high and low fat dairy products, high
fiber cereals, meat and meat products, fish and shellfish, coffee and tea,
sugar-containing beverages, light soft drinks, nuts, seeds and olives, and
soy products
o Margarine, Sugar, and Snacks pattern characterized by higher intake of
potatoes and other tubers, high fat dairy products, low and high fiber
cereals, meat and meat products, margarine and butter, sugar and
confectionary and cakes, snacks, sugar-containing beverages,
condiments and sauces, nuts, seeds and olives
The primary objective of the study was to investigate the association between DPs and
GWG. After accounting for the key confounders, including age, race/ethnicity, SES,
prepregnancy BMI, smoking and parity, none of the DPs were associated with rate of
GWG (grams per week) (mid- and late-pregnancy) in normal weight or overweight
women. The findings were consistent after adjusting for total energy intake in a
sensitivity analysis. Similarly, none of the DPs were associated with inadequate GWG.
However, greater adherence to the margarine, sugar, and snacks DP was associated
with increased odds of excessive GWG compared to the lowest adherence, although
per standard deviation (SD) increase in DP score was not statistically significantly
associated with GWG. Tielemans et al8 also assessed the association between the
Dutch Healthy Diet Index and GWG and the results were discussed in the previous
section.
o In a Chinese prospective cohort study (baseline n=5,733), Wei et al15 used
cluster analysis to generate the following DPs according to the food groups that
were predominant in each cluster:
o Richer in cereals characterized by higher intake of cereals (rice, pasta,
porridge) and eggs (fresh and preserved)
o Richer in vegetables characterized by higher intake of leafy and
cruciferous vegetables (dark green leafy vegetables, white leafy
vegetables, broccoli, cauliflower)
o Richer in meats characterized by higher intake of meats (red meat,
including pork, beef, and mutton, and processed meat)
o Richer in fruits characterized by higher intake of fruits
(cherry/grapefruit/plum/apple/pear/peach, banana/oranges/grape,
Watermelon/pineapple/mango/litchi/longan/durian and others) and
Cantonese desserts
32
o Richer in fish, beans, nuts, and yogurt characterized by higher intake of
cereals (noodles, bread), poultry, animal organ meat (animal liver, other
animal innards, animal brain and animal blood), fish (freshwater fish,
seawater fish, other seafood including prawn/crab, shell fish/squid,
others), bean products (soybean, other dry beans, soybean milk and bean
curd), nuts (oil nuts, starchy nuts, melon), vegetables (including
pumpkin/tomato/capsicums/eggplant, root vegetables including carrot,
potatoes/radishes/lotus root, bean vegetables, mushrooms, sea
vegetables and processed vegetables), and yogurt (snack including
biscuit, cornmeal, cake/fried dough twist, confectionaries including honey,
candy/chocolate, other confectionaries, sweet beverage and puffed food)
o Richer in milk and milk powder characterized by higher intake of fresh
milk, pasteurized milk, formula milk powder, fat free milk powder, whole
milk powder, and others
The primary objective of this Chinese study was to assess the association between
maternal DPs and GWG. The study accounted for some of the key confounders,
including age, SES, prepregnancy BMI and parity. Among Chinese pregnant women
with a healthy prepregnancy BMI, a DP richer in fruits (compared to a DP richer in
cereals) was positively associated with total GWG and GWG rate. A DP richer in fruits
was also associated with an increased risk for excessive GWG. A DP richer in fish,
beans, nuts and yogurt, compared to a DP richer in cereals, was positively associated
with GWG rate in the second trimester and was associated with a reduced risk for
inadequate GWG.
o In a Polish prospective cohort study (baseline n=1,306), Wesolowska et al,17
used an exploratory factor analysis to generate three DPs:
o Western pattern characterized by higher intake of refined grains,
processed meat, potatoes, and low intake of whole grains
o Mixed pattern characterized by intakes in between Western and Prudent
patterns
o Prudent pattern characterized by high consumption of fruits, vegetables,
legumes, whole grains, poultry, and both low-fat and high-fat dairy
products
The primary objective of the study was to evaluate sociodemographic, lifestyle,
environmental, and pregnancy-related determinants of DPs during pregnancy. The
study reported no significant differences between the proportions of participants that
gained recommended vs. low vs. high GWG across the DPs. None of the key
confounders were adjusted for in the analysis.
Summary: Of the five studies that assessed maternal DPs using factor analysis or
PCA, four3,8,15,19 showed significant associations between a maternal DP and GWG.
One study showed that greater adherence to a beneficial DP was associated with
lower GWG,19 while the same study and three others showed that greater adherence
to a non-beneficial DP was associated with higher GWG.3,8,15,19 Three of the four
studies that showed an association adjusted for some of the key confounders.8,15,19
The only study17 that showed no association between DP and GWG did not adjust for
33
any of the key confounders.
Dietary patterns assessed using an experimental diet in an RCT

Four articles from three RCTs assessed the relationship between an intervention and
GWG:
 Al Wattar et al,22 in a multicenter U.K.-based trial (baseline n=1,252),
randomized pregnant women with metabolic risk factors such as obesity, chronic
hypertension, or hypertriglyceridemia to a Mediterranean-style diet or a control
diet.
o Those randomized to the Mediterranean-style diet were encouraged to
consume higher amounts of nuts, extra virgin olive oil, fruits, vegetables, non-
refined grains, and legumes; moderate-to-high amounts of fish; low-to-
moderate amounts of poultry and dairy products, such as yogurt and cheese;
low amounts of red meat and processed meat; and to avoid sugary drinks,
fast food, and foods rich in animal fat. Investigators provided mixed nuts (30
grams per day walnuts, hazelnuts, and almonds) and EVOO (0.5 liter per
week) to the participants.
o The control group received usual care and antenatal advice as per U.K.
national recommendations for antenatal care.
The primary outcomes were: 1) a composite maternal outcome that combined
GDM and preeclampsia, and 2) a composite infant outcome that combined
stillbirth and SGA or admission to neonatal care unit. GWG was considered a
secondary maternal outcome. The study showed that metabolically at-risk
women randomized to a Mediterranean-style dietary pattern had lower GWG
when compared to the control group.
 In a single center, clinic-based RCT in Spain (baseline n=1,000), Assaf-Balut et
al23,26 randomized pregnant women to one of the following groups:
o The control group was advised to follow a Mediterranean Diet with ≥ 2
servings vegetables per day, ≥ 3 servings of fruits per day (avoiding juices), 3
servings skimmed dairy products per day, 3 servings wholegrain cereals per
day, and 2-3 servings of legumes per week, moderate-to-high consumption
of fish, low consumption of red and processed meat, avoidance of refined
grains, processed baked goods, pre-sliced bread, soft drinks and fresh
juices, fast foods, and precooked meals. However, they were advised to
restrict the consumption of dietary fat, including EVOO and nuts.
o The intervention group was advised to follow the same Mediterranean Diet as
the control group, and were advised to also consume 40 mL per day of
EVOO and 25-30 grams per day pistachios. Investigators provided 10 liters
of EVOO and 2 kilograms of roasted pistachios to the participants.
The primary outcome of this RCT26 was to assess the effect of the intervention
diet on GDM incidence, with GWG as a secondary outcome. When compared to
the control group, the intervention DP resulted in lower GWG between 12 to 24-
28 weeks gestation in women with a prepregnancy BMI < 25 kg/m2 (p=0.052)
34
and overweight women (BMI ≥ 25 to ≤ 29.9 kg/m2) (p=0.076). These findings
were marginally significant. However, no significant differences in GWG between
the intervention and control groups were noted in women who were obese prior
to pregnancy (≥ 30 kg/m2).
When considering GWG from 12 to 36-38 weeks, the total GWG was not
different between the intervention and control groups. Although non-significant,
the directionality of the findings changed. In all women, the intervention group
gained more total GWG than the control group between the beginning of the
second trimester to the end of the third trimester (p=0.12). Among women with a
prepregnancy BMI < 25 kg/m2, the intervention group tended to gain more
weight than the control group (p=0.096), whereas among obese women there
was no significant difference between groups (p=0.77), and among overweight
women, those assigned to the control group tended to gain more weight than the
intervention group (p=0.066).
In a sub-analysis of the St. Carlos GDM Prevention Study23 with normoglycemic
women, there were no significant differences in GWG from 12 weeks to 36-38
weeks between the control and intervention groups. Also, the study did not
report significant differences in weight gain between the intervention and control
groups after stratifying by adequacy of weight gain (i.e. excessive, adequate,
inadequate).
 In a U.S.-based RCT (baseline n=281), Van Horn et al25 randomized women
who were overweight or obese (prepregnancy BMI 25-40 kg/m2) to a DASH diet
and lifestyle intervention or a usual-care group, as described below:
o The intervention group was assigned to a slightly modified DASH diet (called
Mama-DASH) and women were encouraged to consume a diet with low-fat
dairy products, fish, skinless poultry, lean meat and vegetable protein,
unsaturated fats, fiber-rich whole grains, fruits, vegetables, and legumes.
They were also advised not to consume sugar-sweetened beverages,
sweets, and non-nutrient-dense snack foods. Mama-DASH was designed to
calorically suit the restricted weight gain recommendations (based on IOM)
and to enable pregnant women to follow the nutrition guidelines specific for
this population including avoidance of fish considered higher in mercury, and
inclusion of calcium-rich, vitamin D−enriched dairy, or calcium-fortified non-
dairy products.
o The control group received the usual care that included bi-weekly newsletters
and publicly available maternity website links.
In addition to the diet, all participants were encouraged to engage in at least 30
minutes of activity or walking > 10,000 steps per day. The primary outcome of
this study was GWG at 35 weeks. The study noted that pregnant women (with a
prepregnancy BMI between 25-40 kg/m2) randomized to the intervention group
gained significantly less weight when compared to their counterparts in the
control group. Most participants in both groups exceeded the IOM’s
recommended weight gain, although it was less common in the intervention
group (69 percent) compared to the control group (85 percent) (p=0.004).
Physical activity goals were not achieved by the majority of participants.
35
Summary: Of the three RCTs that assessed the relationship between Mediterranean
(vs usual care),22 Mediterranean+EVOO (vs Mediterranean diet),23,26 or modified
DASH (vs usual care)25 diets, two trials22,25 showed that the women in the intervention
group had significantly lower GWG than their counterparts in the control groups. The
third trial by Assaf-Balut et al23,26 showed that women assigned to the Mediterranean
Diet+EVOO tended to have lower GWG only until the end of the second trimester
(p=0.052). Both studies that showed an effect were conducted in either metabolically
at-risk women22 or women who were overweight or obese prior to pregnancy.25
Consistent with these findings, Assaf-Balut et al26 showed that among overweight
women, those in the intervention group tended to have lower GWG than those in the
control group (p=0.076) from 12 to 24 weeks; however, this difference was not
observed in women who were obese prepregnancy. When considering GWG from 12
to 36-38 weeks, the total GWG was not different between the intervention and control
groups. Although non-significant, there was a change in directionality for certain sub-
groups (i.e. normal weight, obese women) with women randomized to the intervention
group gaining more weight than the control group from 12 to 36-38 weeks.26 As part of
the same trial, a sub-analysis that was restricted only to normoglycemic women
showed that there was no difference in GWG from 12 to 36-38 weeks between the
intervention and control groups.23
Dietary patterns assessed via reduced rank regression
In a U.S.-based study (baseline n=764), Starling et al11 arrived at DPs by “entering the
residual intakes from each food group into a reduced–rank regression model.” Two
DPs were determined using this approach:
o Pattern 1 was characterized by a higher consumption of poultry, nuts, cheese,
fruits, whole grains, added sugars, and solid fats.
o Pattern 2 was characterized by a higher consumption of eggs, starchy
vegetables, solid fats, fruits, and non-whole grains and a lower consumption of
dairy foods, dark-green vegetables, and whole grains.
The primary objective of this study was to assess the association between maternal
DPs and newborn fat mass and adiposity, with maternal GWG as the intermediate
variable. The study showed that women with greater adherence to pattern 1 (tertile 3)
had significantly greater GWG (p for trend < 0.001). Similarly, women with greater
adherence to pattern 2 (tertile 2 and tertile 3) had significantly greater GWG (p for
trend=0.03). However, none of the key confounders were adjusted for in the analysis.
Diets based on macronutrient distributions
As described below, one RCT24 and one prospective cohort study4 assessed the
association between diets based on macronutrient distributions and GWG.
o In a U.K.-based RCT (baseline n=183), Poston et al24 randomized obese women
(BMI ≥ 30 kg/m2) to an intervention of dietary advice and physical activity
delivered by health trainers vs. standard care. The primary outcome of the study
was to assess the impact of the intervention on maternal (GDM) and neonatal
(LGA) outcomes, with GWG reported as a secondary outcome. The dietary
advice in the intervention group focused on increasing the consumption of foods
with a low dietary glycemic index (GI), including replacing sugar-sweetened
36
beverages with low GI alternatives and reducing saturated fat consumption and
replacing with mono- and polyunsaturated fatty acids. At the end of the
intervention, there were significant differences in total fat intake between the
groups, with the control group consuming an average of 35.9 percent of total
energy from fat (which is outside of the AMDR), while the intervention group
consumed an average of 32.5 percent of total energy from fat. The study
reported that there was no significant difference in GWG between the
intervention and control groups. Physical activity was a co-intervention in the
study but the authors reported no difference in physical activity between the
intervention and control groups.
o Tajima et al,4 in a Japanese prospective cohort study (baseline n=325),
assessed the association between tertiles of carbohydrate intake and glucose
tolerance test. Based on 3-d dietary records collected from participants, the
investigators assessed the average carbohydrate, protein, total fat, and
saturated fatty acid intake, and calculated the percentage of total energy intake
for each component. Carbohydrate intake was calculated by subtracting the
percent total energy from fat and protein intake from 100 percent and
participants were categorized into tertiles based on their carbohydrate intake.
The study reported that women in different tertiles of carbohydrate intake also
differed significantly on percent energy from total fat intake (p<0.001). That is,
women in the ‘bottom’ tertile for carbohydrate had 35.1 percent energy from total
fat (which is outside of the AMDR); those in the ‘middle’ and ‘top’ tertiles for
carbohydrate intake had 30.3 percent and 24.6 percent energy from total fat
intake, respectively. The study also reported GWG across tertiles of
carbohydrate intake (i.e., ‘bottom’, ‘middle’ and ‘top’) and noted that the mean
weight gain per week was not significantly different across the groups. None of
the key confounders were adjusted for in the analysis.
Summary: Two studies included in this body of evidence reported no significant
difference in GWG24 or rate of GWG4 based on varying percentages of total energy
intake from fat. Of note, neither the RCT nor the prospective cohort study manipulated
percentage of energy from fat. Further, these studies were not designed to assess the
relationship between macronutrient proportions and GWG. In the U.K. based trial, the
control group consumed a greater percentage of total energy from fat (which was
above the AMDR) when compared to the intervention group. GWG was measured as a
secondary objective. While the U.K. trial did not deliberately manipulate percentage of
energy from total fat, the investigators recommended replacing saturated fats with
mono- and poly-unsaturated fatty acids for the intervention group, whereas routine
care was recommended for the control group. The Japanese cohort study presented
tertiles of carbohydrate intake and stratified GWG into categories. Women with
‘bottom’, ‘middle’ and ‘top’ carbohydrate intake also differed on percentage of total
energy from fat. The study reported no difference in rate of GWG among these tertiles.
Assessment of the evidenceix
ix
A detailed description of the methodology used for grading the strength of the evidence is available on
the NESR website: https://nesr.usda.gov/2020-dietary-guidelines-advisory-committee-systematic-
37
The following conclusion statement was supported by three RCTs and 19 prospective
cohort studies and was graded “limited.” The individual grading elements are
discussed below and summarized in Table 5 and Table 6.
“Limited evidence suggests that certain dietary patterns during pregnancy are
These patterns are higher in vegetables, fruits, nuts, legumes, fish, and lower in added
sugar, and red and processed meat”
The DPs examined were characterized by combinations of different foods and
beverages. The patterns that were consistently shown to be associated with lower risk
of excessive GWG commonly included the foods highlighted in the conclusion
statement (i.e. higher in vegetables, fruits, nuts, legumes, fish and lower in added
sugar, red and processed meat), although not all foods were part of the same pattern.
Grains and dairy products were included in a number of studies; however, the
association between these foods and GWG was inconsistent. Specifically, in the 10
articles that included dairy products in a DP, some recommended consuming low-fat
dairy products, while others recommended dairy consumption in moderation (without
specifying percent fat), and a few other articles reverse coded it as they considered it
to be detrimental. Similarly, five articles included whole/non-refined grains in a DP, of
which four included it as part of a beneficial DP (meaning the DP that included whole
grains was associated with a lower risk of excessive GWG). One additional article
noted that avoidance of refined grains was beneficial. In three articles, it was unclear
whether the participants consumed whole or refined grains and two other articles
reported that participants consumed both whole and refined grains. Because of these
inconsistencies, it was difficult to determine the relationship between grains or dairy
and GWG.
Risk of bias was graded as limited for both RCTs and cohort studies.
 Most of the RCTs included in this body of evidence had notable flaws, as
described below:
o In a RCT conducted in Spain,23,26 women randomized to both intervention
and control groups received nutritional guidance to reduce the calorie
content of their diet, individualized based on GWG in the first trimester
BMI. In addition, women diagnosed with GDM in both the intervention and
control group received treatment with insulin and/or diet. However,
significantly more women in the control group were diagnosed with GDM.
In the sub-analysis, 23 the investigators excluded participants with
gestational diabetes and assessed the effect of the diet on GWG only in
normoglycemic women. Since the selection of participants into this sub-
analysis was based on post intervention status, this sub-analysis was
treated as a “per-protocol analysis,” rather than an “intention-to-treat
analysis.”
reviews and in Part C of the following reference: Dietary Guidelines Advisory Committee. 2020.
Scientific Report of the 2020 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary
of Agriculture and the Secretary of Health and Human Services. U.S. Department of Agriculture,
Agricultural Research Service, Washington, DC
38
o In the U.S.-based RCT,25 there were issues with adherence, which was
different between the intervention and control groups.
o Outcome assessment methods were not specified in at least one RCT.
 Similar to the RCTs, the cohort studies had serious flaws in the design and
conduct of the studies:
o No studies accounted for all the key confounders. Seven studies had
potentially critical bias as none of the key confounders were accounted
for.
o More than half of the studies had selection bias issues because selection
of the participants was related to characteristics observed after the start of
the exposure.
o Dietary data reflected dietary intake at a single time point during
pregnancy. The exposure data were self-reported (typically collected
around the end of the first trimester or later), and thus it is possible that
classification of exposure status may have been impacted by the
knowledge of the outcome.
o Many studies reported co-exposures which were unbalanced across
treatment groups.
o Outcome data were self-reported and in a few studies reporting of
outcome data may have been influenced by the knowledge of the
exposure received.
o None of the studies reported having a pre-registered data analysis plan.
Consistency was graded limited for both RCTs and cohort studies.
 Among the articles that assessed DPs using an index/score method, five
showed that greater adherence to a beneficial DP was associated with a lower
risk of excessive GWG. 1,5,14,18,21 However, three other articles showed that
greater adherence to a beneficial DP was associated with excessive GWG.2,12,20
Seven other articles showed no association between DPs and GWG.6-10,13,16
 Four of the five cohort studies3,8,15,19 that assessed DPs using factor/cluster
analysis showed an association with GWG, whereas one other study found no
association between DPs and GWG.17
 One of the studies that assessed DP using reduced rank regression was
associated with GWG.11
 Two RCTs showed that the intervention diet resulted in lower GWG.22,25
 Neither of the studies that assessed the relationship between a maternal high-fat
diet (>35 percent total energy from fat) and GWG showed an association.4,24
Even among studies that found similar associations, the strength of the association
could not be adequately assessed because of differences in study methods, including
exposure and outcome assessment methodology.
The inconsistency in findings may be explained by the following:
39
 Key confounders: Many of the studies that reported null findings did not adjust
for any of the key confounders. This can at least partly be attributed to the fact
that the studies were not designed to assess the association, but rather
presented the data because they assessed GWG as a secondary outcome or a
mediator in the study.
 Exposure assessment: There was heterogeneity in exposure assessment
methods. Studies used different approaches to generate DPs. The foods
included in each DP were also different, thus making it difficult to compare
exposures across studies.
 The inconsistencies in findings between RCTs may have been due to
differences in study populations. The two RCTs that found an effect only
included overweight/obese women, or metabolically at-risk women. On the other
hand, the RCT that showed no effect recruited healthy women, which might
partly explain the inconsistency in study findings.
Directness was graded as limited for both RCTs and prospective cohort studies. Only
half of the studies in this body of evidence were designed to assess the association
between DPs and GWG. For the rest, GWG was a secondary measure and thus the
objectives of these studies did not necessarily align with the systematic review
question. Often this also meant that most or all of the key confounders were not
accounted for in the analysis.
Precision was graded as limited for both RCTs and prospective cohort studies. Most
of the studies, except RCTs, did not report power analyses or sample size
calculations. Even among the RCTs, two trials conducted power calculations for
outcomes other than GWG and thus precision with respect to the present review is
difficult to evaluate. Studies included in this body of evidence generally had moderate
analytic sample sizes to investigate the relationship between maternal DPs and GWG.
None of the studies unduly influenced the findings of this systematic review and
removing a single study from this body of evidence would not likely change the
conclusions.
Generalizability was graded as limited for both RCTs and prospective cohort studies.
About one-fourth of the included studies (n=6), including only one RCT, were
conducted in the U.S. Minority women were generally underrepresented in this body of
evidence. Thirteen articles reported that their participants were predominantly White
and nine others did not report race/ethnicity of the participants. With regard to SES,
most women in the studies had at least some college education and participants were
generally from mid-high income households. Participants were primarily adult women
and none of the studies focused on adolescent mothers. Two RCTs recruited only
women who were overweight/obese or had other metabolic risk factors. For the
reasons stated above, it is unclear if the findings from this systematic review would be
applicable to a more diverse U.S. population.
Publication bias is definitely a consideration for the systematic reviews. However, it
may not be a serious concern for this body of evidence because at least a third of the
studies reported non-significant findings while the others report significant findings or a
mix of significant and non-significant findings.
40
Research recommendations
 Include diverse populations with varying age groups and different racial/ethnic
and socioeconomic backgrounds.
 Foster collaborative efforts to score dietary patterns consistently, so that they
can be compared and reproduced across studies.
 Adjust for key confounding factors in observational studies, including age,
race/ethnicity, SES, physical activity, anthropometry (prepregnancy BMI),
smoking, history/diagnosis of gestational diabetes and gestational hypertension,
and parity.
 Develop a standardized recommendation of what constitutes a ‘high-fat’ or ‘low-
carbohydrate’ dietary pattern.
41
Included articles
1. Fernandez-Barres S, Vrijheid M, Manzano-Salgado CB, et al. The association
of Mediterranean diet during pregnancy with longitudinal body mass index
trajectories and cardiometabolic risk in early childhood. J Pediatr.
2019;206:119-127 e116. doi:10.1016/j.jpeds.2018.10.005
2. Gesteiro E, Rodriguez Bernal B, Bastida S, Sanchez-Muniz FJ. Maternal diets
with low healthy eating index or Mediterranean diet adherence scores are
associated with high cord-blood insulin levels and insulin resistance markers at
birth. Eur J Clin Nutr. 2012;66(9):1008-1015. doi:10.1038/ejcn.2012.92
3. Okubo H, Miyake Y, Sasaki S, et al. Maternal dietary patterns in pregnancy and
fetal growth in Japan: the Osaka Maternal and Child Health Study. Br J Nutr.
2012;107(10):1526-1533. doi:10.1017/S0007114511004636
4. Tajima R, Yachi Y, Tanaka Y, et al. Carbohydrate intake during early pregnancy
is inversely associated with abnormal glucose challenge test results in
Japanese pregnant women. Diabetes Metab Res Rev. 2017;33(6).
doi:10.1002/dmrr.2898
5. Hillesund ER, Bere E, Haugen M, Overby 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):1909-1918. doi:10.1017/S1368980014000421
6. Rifas-Shiman SL, Rich-Edwards JW, Kleinman KP, Oken E, Gillman MW.
Dietary quality during pregnancy varies by maternal characteristics in Project
Viva: a US cohort. J Am Diet Assoc. 2009;109(6):1004-1011.
doi:10.1016/j.jada.2009.03.001
7. Poon AK, Yeung E, Boghossian N, Albert PS, Zhang C. Maternal dietary
patterns during third trimester in association with birthweight characteristics and
early infant growth. Scientifica (Cairo). 2013;2013:786409.
doi:10.1155/2013/786409
8. Tielemans MJ, Erler NS, Leermakers ET, et al. A priori and a posteriori dietary
patterns during pregnancy and gestational weight gain: The Generation R
study. Nutrients. 2015;7(11):9383-9399. doi:10.3390/nu7115476
9. Sen S, Rifas-Shiman SL, Shivappa N, et al. Dietary inflammatory potential
during pregnancy is associated with lower fetal growth and breastfeeding
failure: results from Project Viva. J Nutr. 2016;146(4):728-736.
doi:10.3945/jn.115.225581
10. Meinila J, Valkama A, Koivusalo SB, et al. Association between diet quality
measured by the Healthy Food Intake Index and later risk of gestational
diabetes-a secondary analysis of the RADIEL trial. Eur J Clin Nutr.
2017;71(4):555-557. doi:10.1038/ejcn.2016.275
11. Starling AP, Sauder KA, Kaar JL, Shapiro AL, Siega-Riz AM, Dabelea D.
Maternal dietary patterns during pregnancy are associated with newborn body
composition. J Nutr. 2017;147(7):1334-1339. doi:10.3945/jn.117.248948
12. Fulay AP, Rifas-Shiman SL, Oken E, Perng W. Associations of the dietary
approaches to stop hypertension (DASH) diet with pregnancy complications in
Project Viva. Eur J Clin Nutr. 2018;72(10):1385-1395. doi:10.1038/s41430-017-
0068-8
13. Emond JA, Karagas MR, Baker ER, Gilbert-Diamond D. Better diet quality
during pregnancy is associated with a reduced likelihood of an infant born small
42
for gestational age: an analysis of the prospective New Hampshire birth cohort
study. J Nutr. 2018;148(1):22-30. doi:10.1093/jn/nxx005
14. Hrolfsdottir L, Halldorsson TI, Birgisdottir BE, Hreidarsdottir IT, Hardardottir H,
Gunnarsdottir I. Development of a dietary screening questionnaire to predict
excessive weight gain in pregnancy. Matern Child Nutr. 2019;15(1):e12639.
doi:10.1111/mcn.12639
15. Wei X, He JR, Lin Y, et al. The influence of maternal dietary patterns on
gestational weight gain: A large prospective cohort study in China. Nutrition.
2019;59:90-95. doi:10.1016/j.nut.2018.07.113
16. Zhu Y, Hedderson MM, Sridhar S, Xu F, Feng J, Ferrara A. Poor diet quality in
pregnancy is associated with increased risk of excess fetal growth: a
prospective multi-racial/ethnic cohort study. Int J Epidemiol. 2019;48(2):423-
432. doi:10.1093/ije/dyy285
17. Wesolowska E, Jankowska A, Trafalska E, et al. Sociodemographic, lifestyle,
environmental and pregnancy-related determinants of dietary patterns during
pregnancy. Int J Environ Res Public Health. 2019;16(5).
doi:10.3390/ijerph16050754
18. Ancira-Moreno M, Vadillo-Ortega F, Rivera-Dommarco JA, et al. Gestational
weight gain trajectories over pregnancy and their association with maternal diet
quality: Results from the PRINCESA cohort. Nutrition. 2019;65:158-166.
doi:10.1016/j.nut.2019.02.002
19. Maugeri A, Barchitta M, Favara G, et al. Maternal dietary patterns are
associated with pre-pregnancy body mass index and gestational weight gain:
results from the "Mamma & Bambino" cohort. Nutrients. 2019;11(6).
doi:10.3390/nu11061308
20. Yong HY, Mohd Shariff Z, Mohd Yusof BN, et al. Pre-Pregnancy BMI influences
the association of dietary quality and gestational weight gain: The SECOST
study. Int J Environ Res Public Health. 2019;16(19).
doi:10.3390/ijerph16193735
21. Hillesund ER, Bere E, Sagedal LR, et al. 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 Nutr Res. 2018;62.
doi:10.29219/fnr.v62.1273
22. Al Wattar BH, Dodds J, Placzek A, et al. Mediterranean-style diet in pregnant
women with metabolic risk factors (ESTEEM): A pragmatic multicentre
randomised trial. PLoS Med. 2019;16(7):e1002857.
doi:10.1371/journal.pmed.1002857
23. Assaf-Balut C, Garcia de la Torre N, Duran A, et al. A Mediterranean diet with
an enhanced consumption of extra virgin olive oil and pistachios improves
pregnancy outcomes in women without gestational diabetes mellitus: a sub-
analysis of the St. Carlos gestational diabetes mellitus prevention study. Ann
Nutr Metab. 2019;74(1):69-79. doi:10.1159/000495793
24. Poston L, Briley AL, Barr S, et al. Developing a complex intervention for diet
and activity behaviour change in obese pregnant women (the UPBEAT trial);
assessment of behavioural change and process evaluation in a pilot
randomised controlled trial. BMC Pregnancy Childbirth. 2013;13:148.
doi:10.1186/1471-2393-13-148
43
25. Van Horn L, Peaceman A, Kwasny M, et al. Dietary approaches to stop
hypertension diet and activity to limit gestational weight: maternal offspring
metabolics family intervention trial, a technology enhanced randomized trial. Am
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26. Assaf-Balut C, Garcia de la Torre N, Duran A, et al. A Mediterranean diet with
additional extra virgin olive oil and pistachios reduces the incidence of
gestational diabetes mellitus (GDM): A randomized controlled trial: The St.
Carlos GDM prevention study. PLoS One. 2017;12(10):e0185873.
doi:10.1371/journal.pone.0185873
27. Meinila J, Valkama A, Koivusalo SB, et al. Association between diet quality
measured by the Healthy Food Intake Index and later risk of gestational
diabetes-a secondary analysis of the RADIEL trial. Eur J Clin Nutr.
2017;71(7):913. doi:10.1038/ejcn.2017.66
44
Table 3. Description of evidence on the relationship between dietary patterns during pregnancy and gestational weight
gainx
Study and Participant Confounding, Study Limitations, and
Intervention/Exposure and Outcomes Results
Characteristicsxi Summary of Findings
Randomized Controlled Trials

Index/Score
Al Wattar, 201922; U.K. Dietary Pattern(s): Significant: Key confounders accounted for:
RCT, ESTEEM trial  Control: Received usual care and antenatal GWG (kg), P=0.03 Age Race/ethnicity, Prepregnancy BMI, GDM,
dietary advice as per U.K. national  Control: 8.3± 6.4 Parity
recommendations (Ref, n=625)  Intervention: 6.8± 5.6
Baseline N=1252 Analytic N=468  Intervention:
(Attrition: 63%)  aOR: −1.2 , 95% CI=(−2.2, - Limitations:
o High intake of nuts, EVOO, fruit, 0.2)
vegetables, nonrefined grains, and  Self-reported adherence
n=~1190 for all participant legumes  Dietary intake info for ~40% of participants;
characteristics o Moderate to high consumption of fish Non-significant: change in diet based on intervention reported
o Low to moderate intake of poultry and only for a sub-set of the women that were
 Age: ~31.1y dairy products originally recruited
 Race/Ethnicity: o Low consumption of red meat and  Unclear how gestational weight gain was
o White: ~36.0% processed meat assessed and the window in which it was
o Asian: ~43.7% assessed
o Black: ~16.8%
x
ACOG: American College of Obstetricians and Gynecologists, AHEI: alternative healthy eating index, aOR: adjustd odds ration, aRR: adjusted risk ratio,
BIGCS: Born in Guangzhou Cohort Study, BMI: body mass index, BW: birth weight, CI: confidence interval, d: day, DASH: Dietary Approaches to Stop
Hypertension, DHQ: diet history questionnaire, DII: Dietary Inflammation Index, DP: dietary pattern, ESTEEM: Effect of Simple, Targeted Diet in Pregnant
Women With Metabolic Risk Factors on Pregnancy Outcomes, EVOO: extra virgin olive oil, FFQ: food frequency questionnaire, g: gram(s), GDM:
gestational diabetes mellitus, GWG: gestational weight gain, HEI: Healthy Eating Index, HFII: Healthy Food Intake Index, hr: hour, HTN: hypertension,
IFPSII: Infant Feeding Practices Study II, INMA: INfancia y Medio Ambiente, IOM: Institute of Medicine, IQR: interquartile range, kcal: kilocalories, kg:
kilogram(s), MDA: Mediterranean Diet Adherence, MDQS: Maternal Diet Quality Score, Med: Mediterranean, MET: metabolic equivalent of task, mo:
month, MOMFIT: Maternal Offspring Metabolics Family Intervention Trial, MoBa: Mothers and Babies cohort, MUFA: monounsaturated fatty acid, NFFD:
Norwegian Fit for Delivery, NHBCS: New Hampshire Birth Cohort Study, NHS: National Health Service, NND: New Nordic Diet, NR: not reported, NS: non-
significant, OMCHS: Osaka Maternal and Child Health Study, OMNI: optimal macronutrient intake, OR: odds ratio, PA: physical activity, PCA: principal
component analysis, PCS: prospective cohort study, PE: preeclampsia, PETALS: Pregnancy Environment and Lifestyle Study, PRINCESA: Pregnancy
Research on Inflammation, Nutrition and City Environments: Systematic Analyses, PREWICE: PREgnant Women of Iceland, PUFA: polyunsaturated fatty
acid, Q#: quartile, Ref: reference, RCT: randomized controlled trial, rMED: relative Mediterranean Diet, SD: standard deviation, SE: standard error,
SECOST: Seremben Cohort Study, SES: socioeconomic status, SFA: saturated fatty acid, T#: tertile, wk: week(s), y: year(s)
xi
± indicates values of Mean± SD unless otherwise noted
45
o Other: ~3.5% o Avoidance of sugary drinks, fast food, and  Metabolically at risk participants, so the
 Physical Activity (n=1205): MET: food rich in animal fat findings may not be generalizable
~2,584 min/wk o Participants provided with 30 g/d of mixed  Weight gain was collapsed into one group and
 Anthropometry: nuts and 0.5 L/wk of EVOO (n=627) was not stratified by prepregnancy BMI
o Normal BMI: ~13.9% at ~18 wk gestation
o Overweight: ~16.7%
o Obese: ~69.4% Summary:
 GDM: History: ~3.2% Dietary assessment methods: A simple, individualized, Mediterranean-style
 Gestational HTN: History of PE: 24-hr recall used to identify changes needed DP supplemented with mixed nuts and EVOO
~4.3% in the intervention group to follow a moderately reduced GWG in metabolically at
 Parity: Mediterranean-style pattern. Validated short risk women.
o Primigravida: ~27.4% questionnaire (ESTEEM Q) used to assess
o Multigravida: ~72.6% dietary intake at 20, 24, 28, 32, and 36wk
Outcome & assessment methods:

GWG: Methods NR
26
Assaf-Balut, 2017 ; Spain Dietary Pattern(s): Significant: Key confounders accounted for:
RCT  MedDiet: Recommended diet (servings) GWG (kg) 12wk to 24–28wk Age, Race/ethnicity, SES, PA, Prepregnancy
(Ref, n=440): gestation BMI, Smoking, GDM, HTN, Parity
o ≥2/d vegetables, ≥3/d fruit (avoiding  Women with prepregnancy
Baseline N=1000 Analytic N=874 juices), 3/d skimmed dairy products, 3/d
(Attrition: 13%) BMI <25, P=0.003 Limitations:
wholegrain cereals, and 2-3/wk legumes o MedDiet (n=330): 5.8± 2.7
o Moderate to high consumption of fish o MedDiet + EVOO and  The findings reported in the table are
 Age: ~33.0 y o Low consumption of red and processed Pistachios (n=329): 5.4± inconsistent with what is reported in the text.
 Race/Ethnicity:
meat, avoidance of refined grains, 2.2  After GDM diagnosis (24-28wks), women in
processed baked goods, pre-sliced bread,  **Authors write: Overall both intervention and control groups received
o Caucasian: 68.4%
soft drinks and fresh juices, fast foods, and treatment with insulin and/or diet. Thus,
o Hispanic: 28.5% GWG was significantly
precooked meals women in the control group diagnosed with
o Other: 3.1% lower in EVOO and
o Recommended to walk ≥30 min/d for both GDM (103/440 (23.4%)) may have changed
 SES: Pistachio group vs controls
groups their diet post GDM-diagnosis. Note: there
 Education: o Advised to restrict consumption of dietary
at 24–28 GW and at 36–38
GW (P = 0.022 and 0.037, was increased olive oil intake in the control
 Elementary: 8.8% fat, including EVOO and nuts group (P-trend: 0.02).
 Secondary: 39.8% respectively). At 24–28
 MedDiet + EVOO and Pistachios (n=434): GW, the GWG was  Women in both groups received
 University degree: 50.3%
o In addition to MedDiet, recommended 40 individualized recommendations based on
 Employed: 76.6% mL/d EVOO and 25-30g/d pistachios;
significantly lower in all the
three groups of women
46
 Physical Activity: Score (Walking study provided 1L/wk EVOO and 150g/wk stratified by BMI (<25, 25– their first trimester BMI to reduce calorie
>5d/wk: Score 0: ≥30 min/d, +1: >60 roasted pistachios throughout the 29.9 and ≥30). content, when GWG goal is exceeded.
min/d, -1: <30 min/d; Climbing stairs pregnancy.
>5d/wk: Score 0: 4-16 floors/d, +1: at 12-14 wks
>16 floors/d, -1: <4 floors/d): -1.4 Non-significant: Summary:
 Anthropometry: Prepregnancy BMI: GWG (kg) 12wk to 24–28wk Consuming a MedDiet with EVOO and
23.1 Dietary assessment methods: gestation Pistachios vs MedDiet alone resulted in less
 Smoking status: Current: 8.3% Participants randomized to either MedDiet or  Total Sample, P=0.052 GWG at 24-28wk, particularly among women
 GDM: MedDiet + EVOO and Pistachios at 8-12wk o MedDiet: 5.6± 2.8 with prepregnancy BMI <25. There were no
o GDM history: 2.8% gestation o MedDiet + EVOO and statistically signficant differences in GWG
o Family history of Type 2 DM: 25.2% Pistachios: 5.2± 2.5 between groups at 36-38wk.
 Parity:  Women with prepregnancy
o Primiparous: 44.3% Outcome & assessment methods: BMI 25–29.9, P=0.076
o Second pregnancy: 32% Pregestational body weight was self-reported o MedDiet (n=88): 5.1± 3.0
o >2: 23.7% and registered at 12-14 wks (Visit 1). Weight o MedDiet + EVOO and
measured at each visit (1,2 and 3). GWG Pistachios (n=85): 4.7 ±
evaluated at 24–28 and 36–38wk gestation 3.4
(in relation to weight at Visit 1).  Women with prepregnancy
BMI ≥30,P= NS
GWG (kg) 12wk to 36–38wk

gestation
 Total Sample, P=NS
 Women with prepregnancy
BMI <25, P=0.096
o MedDiet (n=300): 9.9± 3.9
o MedDiet + EVOO and
Pistachios (n=329): 10.6±
4.0
 Women with prepregnancy
BMI 25–29.9, P=0.066
o MedDiet (n=88): 8.8± 4.5
Pistachios (n=85): 8.3± 6.5
47
Women with prepregnancy

BMI ≥30, P=NS
Assaf-Balut, 201923; Spain Dietary Pattern(s): Significant: Key confounders accounted for:
RCT  MedDiet: Recommended diet (servings) Age, Race/ethnicity, SES, PA, Prepregnancy
(Ref, n=337): BMI, Smoking, GDM, Parity
o ≥2/d vegetables, ≥3/d fruit (avoiding
Baseline N=1000 Analytic N=697 juices), 3/d skimmed dairy products, 3/d Non-significant:
wholegrain cereals, and 2-3/wk legumes GWG (kg) 12wk to 36–38wk Limitations:
o Moderate to high consumption of fish gestation, P=NS  Women in both groups received
 Age: ~33.0y
 Race/Ethnicity:
o Low consumption of red and processed  MedDiet (n=337): 10.29± individualized recommendations based on
meat, avoidance of refined grains, 3.97 their first trimester BMI to reduce calorie
o Caucasian: 67.5%
o Hispanic: 29.7%
processed baked goods, pre-sliced bread,  MedDiet + EVOO and content, when GWG goal is exceeded.
o Other: 2.8%
soft drinks and fresh juices, fast foods, and Pistachios (n=360): 10.68±  Risk of selective reporting
precooked meals 4.63
 SES:
o Recommended to walk ≥30 min/d for both
 Education: groups Summary:
 University degree: 50.8% o Advised to restrict consumption of dietary Consuming a MedDiet with EVOO and
 Employed: 77.3% fat, including EVOO and nuts
GWG adequacy, P=NS
Pistachios vs MedDiet alone resulted in no
 Physical Activity Score >0 (Walking  MedDiet + EVOO and Pistachios (n=360):  Excessive difference in GWG or GWG adequacy,
>5d/wk: Score 0: ≥30 min/d, +1: >60 o In addition to MedDiet, recommended 40 o MedDiet (n=337): 26.7% particularly among normoglycemic women.
min/d, -1: <30 min/d; Climbing stairs mL/d EVOO and 25-30g/d pistachios; o MedDiet + EVOO and
>5d/wk: Score 0: 4-16 floors/d, +1: study provided 1L/wk EVOO and 150g/wk Pistachios (n=360): 27.5%
>16 floors/d, -1: <4 floors/d): 11.6% roasted pistachios throughout the
 Anthropometry: Prepregnancy BMI:  Adequate
pregnancy.
22.6 o MedDiet (n=337): 70.9%
 Smoking status: Current: 7.9% at 12-14 wks
 GDM: Pistachios (n=360): 69.2%
o GDM history: 2.2% Dietary assessment methods:  Inadequate
o Family history of Type 2 DM: 4.2%
o 0% GDM Participants randomized to either MedDiet or o MedDiet (n=337): 2.4%
MedDiet + EVOO and Pistachios at 8-12wk o MedDiet + EVOO and
 Parity:
gestation Pistachios (n=360): 3.3%
o Primiparous: 43.2%
o Second pregnancy: 32.3%
o >2: 24.5% Outcome & assessment methods:
Prepregnancy weight self-reported at
baseline (12-14wk gestation). Weight
48
evaluated at 12–14, 24–28 and 36–38wks (or
last weight recorded before delivery). GWG
reported at 36-38wk in relation to baseline.
Adequate GWG defined according to
prepregnancy BMI: <25: 9 kg, 25–29: 9.6 kg,
30–34.9: 3 kg, and ≥35: 0 kg. Weight gain 3
kg below designated target categorized as
insufficient. Weight gain 3 kg above
designated target categorized as excessive.
Van Horn, 201825; U.S. Dietary Pattern(s): Significant: Key confounders accounted for:
RCT, MOMFIT  Control: Received usual-care, including GWG (kg), P=0.02 Age, Race/ethnicity, Prepregnancy BMI
biweekly newsletters and publicly available  Control: 12± 6
maternity website links via email (Ref,  Intervention: 10± 6
Baseline N=281 Analytic N=280 n=140) Limitations:
(Attrition: 0%)  Intervention: Mama-DASH diet  Self-reported diet and exercise
o Encouraged low-fat dairy products, fish, Exceeded GWG guidelines,  Lower adherence to intervention than
 Age: ~33.6y skinless poultry, lean meat and vegetable P=0.004 expected
 Race/Ethnicity: protein, unsaturated fats, fiber-rich whole
 Control: 84.4%  Analyses differ between protocol and
grains, fruits, vegetables, and legumes publication
o Hispanic: ~21.4%  Intervention: 68.6%
o White: ~63.3% o Discouraged sugar-sweetened beverages,
o Black/African American: ~19.2% sweets, and non-nutrient-dense snack
foods GWG (kg), P=0.01 Summary:
o Other: ~17.4%
o Calorically suited to restricted GWG  Prepregnancy BMI >30 The MOMFIT intervention, including adherence
 SES:
recommendations and followed nutrition o Control: 26± 14 to the Mama-DASH DP, significantly reduced
o Education:
guidelines for pregnant women, including o Intervention: 20± 12 GWG in obese women.
 ≤High school diploma/GED: ~4.6%
avoidance of fish considered higher in
 1−3 years’ college: ~15.7%
mercury, inclusion of calcium-rich, vitamin
 College degree: ~39.1%
D−enriched dairy, or calcium-fortified non- Exceeded GWG guidelines,
 Postgraduate work: ~40.2%
dairy products P=0.001
o Marital status:
o Received 3 individual and 6 group diet and  Prepregnancy BMI >30
 Married: ~83.3%
physical activity counseling sessions by o Control: 83%
 Living with significant other: 9.6%
phone and webinar (n=140) o Intervention: 60%
 Not married: ~7.1%
o Total family income: at 15wk gestation
 <$20,000: ~4.6%
 ≥$200,000: ~17.4% Non-significant:
Dietary assessment methods:
 Physical Activity (Median time/wk):
49
o Moderate activities (3-6 METs): Two self-reported 24-hour recalls collected GWG (kg), stratified by
~4.5 hr prior to randomization and at 35wks using the prepregnancy BMI, Median
o Vigorous activities (7-12 METs): ASA24 system. Nutrient and food group (IQR), P=0.49
~0.55 hr intakes averaged at each time point with and
 Anthropometry:  Prepregnancy BMI >25-30,
without vitamin/mineral supplements, and P=NS
o Prepregnancy BMI: ~31 then further averaged for group means by
o Prepregnancy obesity: ~54.8% randomization status. Adherence to DASH
 Smoking status: 0% diet scored 0-9 and 8-40 using different Exceeded GWG guidelines,
 Parity: Nulliparous: 47.0% methodologies. Diet quality also assessed Median (IQR), P=0.33
 Sleep duration >7 hrs: ~50.5% using the HEI-2010, with scores ranging from
Prepregnancy BMI
0-100.
Overweight, P=NS
All participants received the 2008 Physical
Activity Guidelines for Americans and
recommendations from the ACOG.

GWG calculated as difference between self-
reported prepregnancy weight and weight
measured by blinded, trained staff at 35wk
(weight closest to this time extracted from
clinic charts or taken from previous study
visits if no 35wk measure available). GWG
adequcy determined by IOM 2009
recommendations.
Prospective Cohort Studies
Factor Analysis and PCA
Maugeri, 201919; Italy Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, Mamma & Bambino  Prudent dietary pattern characterized by a GWG (kg), All women: Age, SES, Smoking, GDM, HTN, Parity
high intake of boiled potatoes, cooked  Western Diet
vegetables, legumes, pizza and soup o T1: Ref
Baseline N=232 Analytic N=232  Western dietary pattern characterized by Limitations:
(Attrition: 0%) o Trend T1 to T3: β=1.217,
high intake of red meat, fries, dipping SE=0.487, P=0.013  Accounted for total energy intake
sauces, salty snacks and alcoholic drinks.
50
 Median Age: ~37.3y at ~16wk gestation GWG (kg), Prepregnancy BMI  Could not investigate the effect of DP on
 Race/Ethnicity: NR Underweight GWG trajectories
 SES:  Limited sample size in underweight and obese
Dietary assessment methods:  Prudent Diet groups
o ≤8y of school: ~19.4% o Trend T1 to T3: β= 4.127,
o Working: ~58.3% Dietary assessment performed at ~16wk  PCA-derived dietary patterns only explained
SE=1.722, P=0.048 15.55% of total variance among food groups
 Anthropometry: Prepregnancy BMI: gestation using a validated 95-item semi-
~22.6 quantitative FFQ, which referred to the  Selection into the analysis was related to
 Smoking status: ~18.1% previous month. Items from the FFQ were GWG (kg), Prepregnancy BMI exposure and outcome and not adjusted for in
classified into 39 predefined food groups the analysis; Start of follow up and exposure
 GDM: 0% Overweight
using PCA did not coincide and a potentially important
 Gestational HTN: 0%  Prudent Diet amount of follow-up time is missing from
o T1: Ref analyses
o T2: β= −7.975, SE=2.672,
Outcome & assessment methods:  Dietary data reflected first trimester intake,
P=0.010 when mothers may have been prone to
GWG (kg) calculated by subtracting self- o T3: β= −9.736, SE=4.302,
reported prepregnancy weight from weight morning sickness
P=0.037
measured at delivery  Outcome measure was subjective and
o Trend T1 to T3: β= −4.209,
assessed by participants
SE=1.635, P=0.016
 No pre-registered data analysis plan
GWG (kg), Prepregnancy BMI

Summary:
Obese
Adherence to a Western DP is positively
 Prudent Diet
associated with GWG, especially among obese
o Trend T1 to T3: β= −7.356,
women. Adherence to a prudent DP is positively
SE=2.304, P=0.031
associated with GWG among underweight
 Western Diet
women and negatively associated with GWG
o T1: Ref
among overweight and obese women.
o T3: β=13.701, SE=0.887,
P=0.041
o Trend T1 to T3: β=7.363,
SE=1.808, P=0.005
Non-significant:
GWG (kg), All women,
P=0.830
 Prudent Diet, P=NS
51
 Western Diet, Median
(IQR), P=0.056
o T1: 11.5 (7.2)
o T2: 13.0 (7.0)
o T3: 13.0 (9.0)
GWG Adequacy
 Prudent Diet, P=0.823
o No difference in the
prevalence of inadequate,
adequate, and excessive
GWG among tertiles of
adherence
 Western Diet, P=0.162
o No difference in the
prevalence of inadequate,
adequate, and excessive
GWG among tertiles of
adherence
GWG (kg) among all women,

and those with Prepregnancy
underweight or normal
weight:
 Prudent Diet
o No association with T2 or
T3 (vs T1) adherence and
GWG, and no significant
trend.
 Western Diet
trend.
52

Overweight
 Western Diet
trend.

Obese
 Prudent Diet
o T1: Ref
o T2 vs T1, P=NS
o T3: β= −10.730, SE=4.156,
P=0.061
 Western Diet
o T1: Ref
o T2 vs T1, P=NS
Okubo, 20123; Japan Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, OMCHS  Meat and eggs pattern: high intake of beef GWG (kg), Mean (95% CI), None
and pork, processed meat, chicken, eggs, P=0.01
butter and dairy products (n=326)  Meat and eggs: 10.0 (9.7,
Baseline N=803 Analytic N=803  Wheat products pattern: high intake of Limitations:
(Attrition: 0%) 10.3)
bread, confectioneries, fruit and vegetable  Wheat products: 10.2 (9.8,  Questionnaire not validated in pregnant
juice, and soft drinks (n=303) 10.6) women and may not reflect total food and
 Age:  Rice, fish, and vegetables pattern: high  Rice, fish and vegetables: nutrient intake
o <29y: ~37.1% intake of rice, potatoes, nuts, pulses, fruits, 9.3 (8.8, 9.7)  Self-administered questionnaire used to
o 29-31y: ~30.4% green and yellow vegetables, white o Meat and eggs vs. wheat assess potential confounders were developed
o ≥32y: ~32.5% vegetables, mushrooms, seaweeds, products: NS for this study not validated
 Race/Ethnicity: NR Japanese and Chinese tea, fish, shellfish, o Meat and eggs vs. rice,  Self-reported outcome data collected 2-9 mo
 SES: sea products, miso soup and salt- fish and veg.: NS postpartum
o Education: containing seasoning (n=174)  Supplement intake: Sig higher in rice, fish and
vegetables (~29% vs. ~19% in other groups)
53
 <13y: ~28.8% at ~18.0wk, Range: 5 to 39wk gestation o Wheat vs. rice, fish and  Follow-up time varied (potentially widely)
 13-14y: ~42.8% veg: P<0.05 across participants
 ≥15y: ~28.4%  Important co-exposures imbalanced across
o Household income (yen/y): Dietary assessment methods: groups and could have likely to impacted the
 <4,000,000: ~28.6% Non-significant: outcome
Self-administered, comprehensive, 150-item
 ≥6,000,000: ~31.1% diet history questionnaire (DHQ), validated in  Missingness by exposure NR
 Anthropometry: Prepregnancy BMI: Japanese men and women (not specifically  No pre-registered data analysis plan
~20.2 pregnant women) (see Sasaki, 2000 and
 Parity: ≥1: ~51.7% Sasaki, 1998)
 Smoking: Summary:
Patterns identified by Κ-means cluster
o Never: ~71.6% Adherence to a wheat products dietary patterns
analysis
o Former: ~12.2% was associated with significantly greater weight
o Current: ~16.2% gain when compared to rice, fish, and
 Physical Activity: Outcome & assessment methods: vegetables DPs
o Low: ~58.9%
Maternal weight gain was obtained using a
o Moderate or High: ~41.1%
survey collected 2-9 mo postpartum
Tielemans, 20158; Netherlands Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, Generation R Study  Vegetable, Oil and Fish Pattern: higher Weekly GWG adequacy Age, Race/ethnicity, SES, Prepregnancy BMI,
intake of vegetables, high fat dairy  Inadequate (n=437, Ref: Smoking, Parity
products, cereals (both low and high fiber), Adequate, n=753)
Baseline N=3374 Analytic N=2748 fish and shellfish, eggs and egg products,
(Attrition: 33%) o Margarine, Sugar, and Limitations:
vegetable oils, coffee and tea, alcoholic Snacks Pattern Q4 vs Q1:
Women excluded due to missing diet beverages and legumes OR=1.49, 95% CI=(1.05,  Accounted for total energy intake
data (n = 538), weight data (n=5),  Nuts, High-Fiber Cereals and Soy Pattern: 2.11)  Start of follow up and start of exposure did not
multiple pregnancy (n=53), induced higher intake of potatoes and other tubers,  Excessive (n=1555, Ref: coincide
abortion (n=8), intrauterine fetal death fruits, high and low fat dairy products, high Adequate, n=753)  Self-reported diet, prepregnancy weight, and
(n=16), loss-to-follow up (n=3), fiber cereals, meat and meat products, fish o Margarine, Sugar, and maximum pregnancy weight
prepregnancy underweight (n = 100), and shellfish, coffee and tea, sugar- Snacks Pattern Q4 vs Q1:  No pre-registered data analysis plan
leaving 3374 women for the current containing beverages, light soft drinks, nuts, OR=1.32, 95% CI=(1.01,
analysis. seeds and olives, and soy products 1.720
 Margarine, Sugar and Snacks Pattern: Summary:
higher intake of potatoes and other tubers, None of the a posteriori-derived DPs were
n=3374 for participant characteristics Non-significant:
high fat dairy products, low and high fiber associated with GWG.
 Age: ~31.3y cereals, meat and meat products,
54
 Race/Ethnicity: 100% of Dutch margarine and butter, sugar and Mid-Pregnancy Weight Gain
ancestry confectionary and cakes, snacks, sugar- (g/wk)
 SES: containing beverages, condiments and
o Education: sauces, nuts, seeds and olives  Prepregnancy Normal
 Low and midlow: ~18.2% Weight (n=2079)
at ~13.4wk gestation o Vegetable, Oil, and Fish
 Midhigh: ~51.5%
 High: ~30.4% Higher adherence to each pattern indicates a Pattern, P=NS per SD
o Household income <2200 Euro/mo: diet characterized by higher intake of those increase in DP score
~28.3% food groups. o Nuts, High-Fiber Cereals
 Anthropometry: Prepregnancy BMI: and Soy Pattern, P=NS
~24.7 o Margarine, Sugar and
Dietary assessment methods: Snacks Pattern, P=NS
 Smoking status:
Dietary intake assessed at ~13.4wk gestation
o Never in pregnancy: ~74.4%
o Until pregnancy known: ~8.3%
using a validated, 293-item FFQ that covered  Prepregnancy Overweight
dietary intake over the previous 3 months. A Women (n=669)
o During pregnancy: ~17.4%
posteriori-derived dietary patterns identified o Vegetable, Oil, and Fish
 Parity:
using PCA with Varimax rotation. Adherence Pattern, P=NS per SD
o 0: ~59.8%
scores for each participant and each pattern increase in DP score
o ≥1: ~40.2%
calculated by individual sum of the intake of o Nuts, High-Fiber Cereals
 Alcohol: the 23 food groups, weighted with their factor and Soy Pattern, P=NS
o Never in pregnancy: ~36.6% loadings and standardizing those weighted o Margarine, Sugar and
o Until pregnancy known: ~16.5% sums to have mean zero and standard Snacks Pattern, P=NS
o During pregnancy: ~46.9% deviation one.
Late-Pregnancy Weight Gain

Outcome & assessment methods: (g/wk)
Self-reported prepregnancy weight collected  Prepregnancy Normal
at enrollment. Staff measured weight at 3 Weight Women (n=2384)
study visits: ~12.9wk (first visit), ~20.4wk o Vegetable, Oil, and Fish
(second visit), and ~30.2wk (third visit). At Pattern, P=NS per SD
6wk postpartum, women self-reported increase in DP score
maximum weight during pregnancy. o Nuts, High-Fiber Cereals
GWG in different phases of pregnancy was and Soy, P=NS
calculated mid-pregnancy GWG (weight at o Margarine, Sugar and
the second visit minus weight the first visit, Snacks Pattern, P=NS
divided by follow-up duration (g/week), n =
2748), late-pregnancy GWG (weight at the  Prepregnancy Overweight
third visit minus weight at the second visit, Women (n=774)
55
divided by follow-up duration (g/week), n = o Vegetable, Oil, and Fish
3158), and GWG until early-third trimester Pattern, P=NS per SD
(weight at the third visit minus prepregnancy increase in DP score
weight, divided by follow up duration o Nuts, High-Fiber Cereals
(g/week), n = 2815). and Soy, P=NS
Women’s total GWG (maximum pregnancy o Margarine, Sugar and
weight minus prepregnancy weight, n = 1917) Snacks Pattern, P=NS
and GWG rate between visits 1 and 3 was
used to classify their GWG into inadequate, GWG adequacy:
adequate, or excessive GWG according to
IOM (2009) recommendations.  Inadequate GWG (n=459,
Ref: Adequate, n=632)
o Vegetable, Oil and Fish
Pattern, P=NS per SD
increase in DP score
o Nuts, High-Fiber Cereals
and Soy Pattern, P=NS
o Margarine, Sugar and
Snacks Pattern, P=NS
 Excessive GWG (n=826,

Ref: Adequate, n=632)
Weekly GWG adequacy

 Inadequate (n=437, Ref:
Adequate, n=753)
o Vegetable, Oil, and Fish
56
o Margarine, Sugar, and
 Excessive (n=1555, Ref:
Adequate. N=753)
o Vegetable, Oil, and Fish
Margarine, Sugar, and
Tielemans, 2015 continued Tielemans, 2015 continued Significant: Key confounders accounted for:
Sensitivity Analysis (excludes Age, Race/ethnicity, SES, Prepregnancy BMI,
women with GDM or Smoking, GDM, HTN, Parity
hypertensive disorders of
pregnancy)
Summary:
GWG until early-third
trimester (g/wk) Among women with normal prepregnancy
weight, higher adherence to the Vegetable, Oil
 Prepregnancy Normal and Fish Pattern was associated with greater
Weight Women (n=1937) GWG.
Pattern, P<0.01 per SD
 Q1: Ref
 Q2: β=20, 95% CI: (3,
36), P<0.05
 Q3: β=7, 95% CI: (−10,
23)
 Q4: β=27, 95% CI: (11,
44), P<0.05
Non-significant:
57
Sensitivity Analysis (excludes

women with GDM or
hypertensive disorders of
pregnancy)
GWG until early-third
trimester (g/wk)
 Prepregnancy Normal
Weight Women (n=1937)
and Soy, P=NS per SD
o Margarine, Sugar, and
Snacks, P=NS
 Prepregnancy Overweight
Women (n=532)
Wei, 201915; China Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, BIGCS Six dietary patterns were generated GWG (kg), P=0.007 Age, SES, Prepregnancy BMI, Parity
according to the food groups predominant in  Cereals: Ref
each cluster.
Baseline N=5,733 Analytic N=5,733  Fruits: β=0.592, 95% CI: Limitations:
 Cereals (n=872) (0.166, 1.018)
 Vegetables (n=1147)  Food quantity and portion size not
 Age: ~29.1y  Meats (n=927) documented in the FFQ
 Race/Ethnicity: NR  Fruits (n=640) GWG rate (kg/wk), P=0.007  Adjusted for post-exposure variables
 SES:  Fish, beans, nuts, and yogurt (n=1130)  Cereals: Ref  Selection into analysis related to outcome
o Educational level:  Milk and milk powder (n=817)
58
 High school or below: 8.0% at 24-27wk gestation  Fruits: β=0.015, 95% CI:  Start of follow up and exposure did not
 Vocational/technical college: (0.004, 0.026) coincide and a potentially important amount of
23.6% follow-up time is missing from analyses
 Undergraduate: 55.5% Dietary assessment methods:  Proportions of missing participants differed
 Postgraduate: 12.9% Second Trimester GWG rate substantially across exposure groups and was
A validated, 64-item FFQ used to assess diet (kg/wk), P<0.05
o Income (Yuan/mo; n=5605): Individual food items were combined into 30 not accounted for in the analyses
 ≤1500: 9.3% groups by similar nutrient profile or culinary  Cereals: Ref, n=821  No pre-registered data analysis plan
 ≥9001: 16.9% use. Contribution (%) of every food group  Fish, beans, nuts, and  High risk of selective reporting from among
 Anthropometry: Prepregnancy BMI: was calculated for each participant. Cluster yogurt: β=0.024, 95% CI: multiple analyses
20.4± 2.6 analysis with K-means method was (0.001, 0.048), n=658
 Smoker: 29.7% conducted to generate six dietary patterns
 Parity: Primiparous: 88.2% based on foods highly consumed and
Summary:
GWG adequacy Among Chinese pregnant women with healthy
distribution of foods within clusters.
 Inadequate GWG BMI, the dietary pattern richer in fruits was
o Cereals: Ref positively associated with total GWG, GWG
Outcome & assessment methods: o Fish, beans, nuts, and rate, and an increased risk for excessive GWG.
Prepregnancy weight self-reported, while yogurt: OR=0.797, 95% CI: The richer in fish, beans, nuts and yogurt
weight during pregnancy extracted from (0.638, 0.997) pattern was positively associated with GWG
medical records. Total GWG (kg) calculated rate in the second trimester and related to a
as difference in weight between reduced risk for inadequate GWG.
prepregnancy and delivery. Total GWG rate  Excessive GWG
(kg/wk) calculated by dividing total GWG by o Cereals: Ref
total gestational wks. Second trimester GWG o Fruits: OR=1.393, 95% CI:
rate (kg/wk) calculated as difference in weight (1.101, 1.763)
before 28wk and weight after 13wk, divided
by wks between the two measures. Third Non-significant:
trimester GWG rate (kg/wk) calculated as
difference between pre-delivery weight and GWG (kg), P=NS
weight at 28wk, divided by wks between the  Cereals: Ref
two measures.  Vegetables
 Meats
 Fish, beans, nuts, and
yogurt: β=0.341, 95% CI: (-
0.017, 0.699), P=0.062
 Milk and milk powder
GWG rate (kg/wk), P=NS

59
 Cereals: Ref
 Vegetables:
 Meats:
yogurt: β=0.009, 95% CI:
(0.000, 0.018), P=0.060
 Milk and milk powder
Second Trimester GWG rate

(kg/wk), P=NS
 Cereals: Ref, n=821
 Vegetables: n=682
 Meats: n=493
 Fruits: n=968
 Milk and milk powder:
n=645
Third Trimester GWG rate

(kg/wk) , P=NS
 Cereals: Ref, n=830
 Vegetables: n=708
 Meats: n=517
 Fruits: n=993
yogurt: n=679
n=669
GWG adequacy (Ref:

Adequate GWG, Cereals DP)
, P=NS
 Inadequate
 Excessive
60
Wei, 2019 continued Wei, 2019 continued Significant: Key confounders accounted for:
GWG (kg), P<0.01 None
 Cereals: 14.5± 4.3
 Vegetables: 14.5± 4.4
Summary:
 Meats: 14.3± 4.3
 Fruits: 15.1± 4.4 Among Chinese pregnant women with healthy
 Fish, beans, nuts, and BMI, the dietary pattern richer in fruits was
yogurt: 14.7± 4.1 positively associated with total GWG, GWG
 Milk and milk powder: 14.6 rate, and an increased risk for excessive GWG.
± 4.4 The richer in fish, beans, nuts and yogurt
pattern was positively associated with GWG
rate in the second trimester and related to a
GWG rate (kg/wk), P=0.01 reduced risk for inadequate GWG.
 Cereals: 0.37± 0.11
 Vegetables: 0.37± 0.1
 Meats: 0.39± 0.11
 Fruits: 0.38± 0.10
yogurt: 0.38± 0.11
0.37± 0.11
GWG Adequacy, P<0.01

 Cereals:
o Inadequate: 23.5%
o Adequate: 47.6%
o Excessive: 28.9%
 Vegetables:
o Inadequate: 23.6%
o Adequate: 44.9%
o Excessive: 31.5%
 Meats:
o Inadequate: 22.4%
61
o Adequate: 49.9%
o Excessive: 27.6%
 Fruits:
o Inadequate: 19.2%
o Adequate: 43.6%
o Excessive: 37.2%

yogurt:
o Inadequate: 19.6%
o Adequate: 48.9%
o Excessive: 31.5%

o Inadequate: 20.2%
o Adequate: 46.9%
o Excessive: 32.9%
Wesolowska, 201917; Poland Dietary Pattern(s): Significant: Key confounders accounted for:
PCS  Western: High intake of refined grains, None
Baseline N=1306 Analytic N=1158 processed meat, potatoes, and low intake Non-significant:
(Attrition: 34%) of whole grains
 Mixed: Intakes in between Western and GWG Adequacy (Pearson’s Limitations:
Prudent chi squared test across all  Selection into the study related to exposure
GWG and diet categories),
N=1306 for participant characteristics  Prudent: High consumption of fruits, and outcome
P=NS
 Age: 17-30y: ~65.2%, >30y: ~34.8% vegetables, legumes, whole grains, poultry,  Some missing outcome data, reasons NR
 Race/Ethnicity: NR and low-fat and high-fat dairy products  Unclear if outcome was self-reported or
 SES: at 20-24wk gestation assessed objectively. Start of follow up and
o Marital Status: Married: ~80.0% exposure did not coincide and a potentially
o Education: important amount of follow-up time was
 ≤9y: ~2.3% Dietary assessment methods: missing from analyses
 10-12y: ~27.9% Modified version of validated FFQ  Important co-exposures not balanced across
 >12y: ~69.8% administered by trained personnel at 20- groups that were likely to impact the outcome,
o SES: 24wks gestation. Food items grouped into 14
62
 Low: ~7.4% predefined food groups: Refined grains, and no adjustment techniques were used to
 Middle: ~67.9% Whole grains, Low–fat dairy, High–fat dairy, correct for the issues
 High: ~24.7% Butter, Red meat, Poultry, Processed meat,  No information on how weight was measured
 Physical Activity: Yes: ~68.8% Fish/Seafood, Fruits, Vegetables, Potatoes,  No pre-registered data analysis plan
 Anthropometry: Prepregnancy BMI: Legumes, Sweets. 3 dietary patterns derived
o <18.5: ~8.9% using exploratory factor analysis.
o 18.5-24.99: ~72.6% Summary:
o ≥25: ~18.6% No association was found between GWG and
 Smoking status: Cotinine level >10 Western, Mixed, or Prudent dietary patterns
ng/mL: ~11.1% GWG calculated as difference between latest during pregnancy.
 Parity: weight before delivery and prepregnancy
o 0: ~52.0% weight. GWG adequacy determined by IOM
o ≥1: ~48.0% 2009 recommendations.
 Alcohol consumption: ~6.4%
 Perceived Stress Scale (0-38 pts):
≥17 points (higher stress): ~52.6%
Index/Score
Ancira-Moreno, 201918; Mexico Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, PRINCESA Maternal Diet Quality Score (MDQS) based GWG rate (kg/wk) Age, SES, PA, Prepregnancy BMI, GDM, HTN,
on Mexican Dietary Guidelines and  Middle pregnancy (≥20 and Parity
international recommendations for specific <30wk)
Baseline N=660 Analytic N=660 foods and nutrients.
(Attrition: 0%) o Low: Ref Limitations:
 Low adherence (Score 0-2) o Medium: β= -0.0266, 95%
 Medium adherence (Score 3-4) CI: (-0.0496, -0.0037),  Accounted for total energy intake
 Age: ~24.9y  High adherence (Score ≥5) P=0.023  Lack of weight measurement at each visit
 Race/Ethnicity: NR  Recall bias and other biases related to a priori
Higher adherence characterized by:
 SES:  Late pregnancy (30-40wk) DP; could not capture day-to-day variability in
o Married/partnered: ~73.9%  PUFAS >6% of energy intake o Low: Ref dietary intake
o >9y education: ~14.2%  Added sugars <10% of energy intake o Medium: β=0.0256, 95%  Participants who developed HTN or GDM
 Anthropometry: Prepregnancy BMI:  Fruits and vegetables >400 g/d CI: (0.0077, 0.0436), excluded from final analysis
~25.7  Red meat <500 g/wk P=0.005  Selection into analysis related to exposure
 GDM: 0%  2 servings/d low fat dairy products o High: β=0.0472, 95% CI: and outcome and not adjusted for
 Gestational HTN: 0%  2 servings/d legumes (0.0222, 0.0723), P<0.001  Start of follow up and exposure do not
 Parity:  Foods high in SFAs or added sugar <10% coincide and a potentially important amount of
o Nulliparous: ~48.0% of energy intake follow-up time missing from analyses
63
o 1-2: ~28.3% early-mid pregnancy (0-20 wk), middle  Prolonged pregnancy  Multiple 24HR recalls collected, but unclear if
o ≥3: ~23.3% pregnancy (≥20 and <30wk), late pregnancy (≥40wk) analysis was cross-sectional
 Term birth: ~88.0% (30-40wk), and prolonged pregnancy (≥40wk)  Low: Ref  No pre-registered data analysis plan
 High: β=-0.182, 95% CI: (-  High risk of selective reporting from among
0.360, -0.00450), P=0.044 multiple analyses
Dietary assessment methods:  Baseline differences in maternal age and
Dietitian collected data on maternal diet via a GWG rate adequacy education
multiple-step 24-h dietary recall at each
 Inadequate
prenatal visit.
o Low: Ref Summary:
Value of 1 assigned if recommendation met o Medium: OR=0.742, 95% Higher adherence to maternal dietary quality
and 0 if recommendation not met. Values CI: (0.555, 0.991), recommendations was protective against
summed with maximum score of 7 and P=0.044 inadequate and excessive GWG throughout
minimum score of 0. Three categories of o High: OR=0.630, 95% CI: pregnancy, associated with slower GWG in
adherence defined: low (0-2 points), medium (0.417, 0.953), P=0.031 middle and prolonged late pregnancy, and
(3-4 points), and high (≥5 points).
associated with a faster GWG in early and late
 Excessive pregnancy.
o Low: Ref
o High: OR=0.623, 95% CI:
Weight measured at first and consecutive (0.411, 0.942), P=0.025
visits by trained staff using standardized
methods. Prepregnancy weight self-reported.
Rate of GWG (kg/wk) calculated as weight at GWG rate adequacy,
current visit minus weight from previous visit, Prepregnancy BMI <25
divided by follow-up duration. First GWG rate  Inadequate
estimated using prepregnancy weight. o Low: Ref
Adequacy of GWG rate based on IOM (2009) o Medium: OR=0.426, 95%
recommendations. CI: (0.184, 0.985),
P=0.046
o High: OR=0.295, 95% CI:
(0.092, 0.946), P=0.040
 Excessive
o Low: Ref
o Medium: OR=0.347, 95%
CI: (0.126, 0.952),
P=0.040
64
o High: OR=0.242, 95% CI:
(0.059, 0.989), P=0.048
GWG rate adequacy,

Prepregnancy BMI ≥25
 Inadequate
o Low: Ref
o Medium: OR=0.095, 95%
CI: (0.010, 0.906),
P=0.044
o High: OR= 0.033, 95% CI:
(0.002, 0.442), P=0.010
 Excessive
o Low: Ref
o Medium: OR= 0.084, 95%
CI: (0.126, 0.918),
P=0.042
o High: OR=0.077, 95% CI:
(0.059, 0.999), P=0.05
Non-significant:
GWG rate (kg/wk)
 Early-mid pregnancy (0-
20wk)
o Low: Ref
o Medium: β=0.0162, 95%
CI: (-0.0005, 0.0333),
P=0.058
o High, P=NS
 Middle pregnancy (≥20 and

<30wk)
o Low: Ref
65
o High: β= -0.0363, 95% CI:
(-0.076, 0.0037), P=0.076
 Prolonged pregnancy
(≥40wk)
o Low: Ref
o Medium, P=NS
GWG rate adequacy:

 Excessive
o Low: Ref
o Medium: OR=0.773, 95%
CI: (0.572, 1.044),
P=0.094
Emond, 201813; U.S. Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, NHBCS Adherence to AHEI-2010 diet, by quartile None
 Q1: n=215 Non-significant:
Baseline N=1140 Analytic N=862  Q2: n=215  GWG Adequacy, P=NS Limitations:
 Q3: n=216 o Insufficient GWG
Participants excluded due to  Power analysis NR for this secondary analysis
 Q4: Highest intake of fruits, vegetables, o Adequate GWG
unrealistic/missing dietary data (n=64),
whole grains, nuts and legumes, long-chain  Selection into study may have been related to
missing key covariates (n=89), o Excessive GWG exposure and outcome, without adjustment
n–3 FAs, and PUFAs; Lowest intake of
underweight prepregnancy BMI
sugar-sweetened beverages and fruit juice,  Self-reported exposure & prepregnancy BMI
(n=20), incomplete/ unrealistic infant
red and processed meats, trans fatty acids,  Unclear sample size at enrollment
birth data (n=62), or missing urinary  No preregistered data analysis plan
and sodium (n=216)
arsenic data (n=43)  Baseline imbalances in multiple key
at 24-28wk gestation
confounders
N=862 for all participant  No correction for multiple comparisons
characteristics Dietary assessment methods:
 Age: ~31.2y Women completed a validated FFQ at 24– Summary:
 Race/Ethnicity: White, non-Hispanic: 28wk gestation), reflecting usual dietary
Adherence to the AHEI-2010 diet at 24-28wk
96.8% intake during pregnancy.
gestation was not associated with GWG.
 SES: Diet quality assessed as adherence to a
o High school graduate or less: modified AHEI-2010 for pregnant women,
26.8% including 10 dietary components: 6 healthful
66
o Some college: 24.1% components to encourage (vegetables, fruits,
o College graduate or more: 49.1% whole grains, nuts/legumes, long-chain n–3
 Physical Activity: Regular exercise FAs from foods and supplements,
during pregnancy: 60.6% polyunsaturated fats) and 4 components to
 Anthropometry: Prepregnancy BMI: reduce (sugary beverages, red and
o 18.5-24.9: 54.5% processed meats, trans fatty acids, and
o 25.0-29.9: 26.3% sodium). All components are scored from 0 to
o ≥30: 19.3% 10 for a total score of 0-100 such that a
 Smoking status: Smoker: 5.5% higher score indicates a healthier intake.
 GDM: 7.1%
o History of DM: 5.9%
 Gestational HTN: PE: 6.7%
o History of HTN: 1.9% GWG computed using self-reported
 Parity: Nulliparous: 41.0% prepregnancy weight and the last recorded
prenatal weight from prenatal medical
records. Adequacy of GWG defined
according to IOM 2009 recommendations.
Fernández-Barrés, 20191; Spain Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, INMA  Adherence to Relative Mediterranean Diet GWG (kg/wk), P=0.017 None
(rMED) score: consumption of vegetables,  T1: 0.35± 0.13
fruits and nuts, cereals, legumes, fish, olive  T2: 0.35± 0.12
Baseline N=2195 Analytic N=2127 oil, meat, and dairy products. Alcohol not Limitations:
 T3: 0.34± 0.13
Participants excluded from analysis if scored.  Start of follow up and exposure did not
no dietary data at 3rd trimester (n =  T1: low rMED (Score 0-7), n=925 coincide and potentially important amount of
319) or no BMI measured (n = 248);  T2: medium rMED (Score 8-9), n=631 Non-significant: follow-up time was missing from analyses
Those lost to follow-up were younger,  T3: high rMED (Score 10-15), n=639  Important co-exposures were not balanced
smoked more, and had lower  *highest score differs btw 15 and 16 across groups that were likely to impact the
socioeconomic and education levels. throughout the paper outcome, and no adjustment techniques were
used to correct for the issues
at 12wk and 32wk gestation
 No pre-registered data analysis plan
 Age: 30.9y
 Race/Ethnicity: NR
 SES: Summary:
o Social class: 101-item validated FFQ at 12 and 32wk
 I+II: ~23.2% gestation measured diet in the first trimester
67
 III: ~27.1% and 12-32wk. Adherence to the Higher adherence to the Mediterranean diet
 IV+V: ~49.7% Mediterranean diet assessed using the rMED. during pregnancy is associated with lower
o Education level: Values of 0, 1, and 2 assigned to intake GWG.
 Primary or less: ~22.1% tertiles, positively scoring higher intakes for
 Secondary: ~41.5% the 6 components that fit into the
 University: ~36.4% Mediterranean diet (vegetables, fruits and
 Physical Activity: METs(hr/d): ~37.4 nuts, cereals, legumes, fish, olive oil). Scoring
 Anthropometry: Prepregnancy BMI: reversed for meat and dairy. Scores summed
~23.5 for each component, for a total score ranging
 Smoking status: During pregnancy: from 0 to 16.
~16.6%
 GDM: ~4.1%
o History of GDM: ~0.3%
 Parity: GWG extracted from prenatal visit records;
o Primiparous: ~57.0% timing NR
o Multiparous: ~43.0%
Fulay, 201812; U.S. Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, Project Viva  Adherence to DASH diet Subsequent GWG (kg) per Age, Race/ethnicity, SES, Pre-preg BMI,
o Higher adherence characterized by higher unit 1st trimester DASH score Smoking, Parity
intakes of fruits, vegetables, whole grains,  Prepregnancy obese
Baseline N=2128 Analytic N=1756 nuts/legumes, and low-fat dairy, and lower
(Attrition: 17%) (n=244) Limitations:
intakes of sodium, sugar-sweetened o β=0.31, 95% CI: 0.08, 0.53
Participants excluded due to Type 1 or beverages, and red and/or processed  Accounted for total energy intake
2 Diabetes Mellitus (n=16), missing meats.  Power analysis NR for this exploratory study
outcomes data (n=7) or dietary data  Adherence to DASH OMNI diet at 11wk Subsequent GWG (kg) per based on secondary analysis of existing data
(n=345) gestation. unit 1st trimester DASH OMNI  Adjusted for potential mediator (early GWG)
o Higher adherence characterized by higher score  Start of follow up and start of exposure did not
intakes of fruits, vegetables, whole grains,  Prepregnancy obese coincide
n=~1760 for all participant
characteristics
nuts/legumes, low-fat dairy, and MUFAs (n=244)  Unclear proportions/reasons for missing
and PUFAs, and lower intakes of sodium, o β=0.34, 95% CI: (0.09, exposure data
 Age: sugar-sweetened beverages, and red 0.58)  Self-reported diet and prepregnancy weight
o 15-24y: 7.4% and/or processed meats.  No pre-registered data analysis plan
o 25-34y: 63.9% at 11wk gestation
o 35-44y: 28.8% Non-significant:
 Race/Ethnicity: Summary:
68
o Black: 12.3% Dietary assessment methods: Subsequent GWG (kg) per Among women with prepregnancy obesity,
o Hispanic: 6.5% unit 1st trimester DASH higher adherence to a DASH or DASH OMNI
o White: 72% Semi-quantitative, validated, 140-item FFQ
based on NHS, administered at enrollment score, P=NS diet is associated with higher GWG from 1st
o Asian: 5.6% trimester through delivery. This association was
o Other: 3.6% (11.1wk gestation).DASH score calculated as  Prepregnancy underweight
weighted sum of frequency of intake/day for (n=68) not statistically significant among women with
 SES: prepregnancy BMI <30.
o Annual household income the following components, with increasingly  Prepregnancy normal
 <$20,000: 2.9% postitive scores for higher quintiles of intake weight (n=1068)
 >$70,000: 59.6% for fruits, vegetables, whole grains,  Prepregnancy overweight
o Married/cohabiting: 93.3% nuts/legumes, and low-fat dairy, and for lower (n=376)
o Education quintiles of intake for sodium, sugar-
 Primary: 9.4% sweetened beverages, and red and/or
processed meats. Total score range: 8- Subsequent GWG (kg) per
 Secondary: 58.6%
40.The DASH diet is rich in fruits, unit 1st trimester DASH OMNI
 ≥College: 32.0%
vegetables, legumes, whole grains, and score, P=NS
 Anthropometry: Prepregnancy BMI:
o <18.5: 3.9% healthy fats, with limited amounts of poultry,  Prepregnancy underweight
o 18.5-24.9: 60.7% red meat, and dairy. The DASH diet also (n=68)
o 25.0-29.9: 21.4% focuses on intake of foods high in macro- and  Prepregnancy normal
o ≥30: 12.7% micronutrients that have been specifically weight (n=1068)
demonstrated to be effective in reducing risk  Prepregnancy overweight
 Smoking status: During pregnancy:
of hypertension: reduced amounts of (n=376)
10.9%
saturated fat, total fat, and cholesterol; and
 GDM: 5.2%
high levels of potassium, magnesium,
 Gestational HTN: History before calcium, fiber, and protein, with ≤3 g/d
pregnancy: 4.5% sodium.
 Parity:
o 0: 49.3% DASH OMNI score calculated similarly to
o 1: 35.3% DASH score, with the additional component
o ≥2: 15.4% of increasingly postitive scores for higher
quintiles of intake of MUFAs and PUFAs.
Total score range: 9-45.

GWG from time of FFQ in first trimester to
delivery. Derived via linear interpolation
between the two measures of weight
assessed in closest temporal proximity to the
date of FFQ administration and calculated the
69
difference between the last clinically-
measured weight prior to self-reported
prepregnancy weight.
Gesteiro, 20122; Spain Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, Mérida Cohort Mediterranean Diet Adherence (MDA) GWG (kg), Mean± SE (95% Race/ethnicity, Smoking, GDM
 Low MDA (n=13) CI), P= 0.017
Baseline N=35 Analytic N=35  High MDA: olive oil as main culinary fat,  Low MDA: 7.9± 1.8 (4.1, Limitations:
higher intakes of vegetables, raw 11.8)
vegetables, fruits, fish or shellfish, nuts  High MDA: 11.5± 0.6 (10.1,  Study powered to detect differences in insulin
n=35 for all participant characteristics (including peanuts), legumes, chicken, 12.8) resistance in infants.
turkey or rabbit meat, and dishes seasoned  No information on group differences in
 Age: exclusion due to GDM (a potential mediator)
o Mean± SE: 30.4± 0.9y with sofrito, sauce made with tomato, onion,
leek or garlic and simmered with olive oil, Non-significant:  No pre-registered data analysis plan
o <35y: 54%
o ≥35y: 46% and lower intakes of red meat, veal, pork,
 Race/Ethnicity: All infants were hamburger or sausage, butter, margarine or
Summary:
Caucasian cream, sweet or carbonated beverages,
and commercial sweets or pastries (n=22) Higher vs lower adherence to a Mediterranean
 SES: diet at 12-15wk gestation was associated with
o Education degree: at 12-15wk gestation
greater GWG.
 Low: 17%
 Medium: 63%
 High: 20% Dietary assessment methods:
 Anthropometry: Prepregnancy BMI: Dietary intake assessed via a validated, 169-
23.0± 0.6 item FFQ, conducted by a trained dietician,
 Smoking status: 0% and included photographs of sample portions
 GDM: 0% to estimate the serving size and volumes
o Positive O'Sullivan glucose consumed.
tolerance test at 24-28wk gestation: Dietary pattern adherence assessed with the
77% Mediterranean Diet, modified to remove red
 Parity: wine consumption (PERIMED study). 1pt
o Primiparous: 37% awarded for each of the following 13
o Multiparous: 63% components: Use of olive oil as main culinary
 Full-term: 100% fat; ≥4 TBSP/d olive oil; ≥2 servings/d
 Alcohol consumption: 0% vegetables, including ≥1 raw or as salad; ≥3
units of fruits, including juices; <1 serving/d
red meat; <1 serving/d butter, margarine or
cream; <1 sweet or carbonated beverage/d;
70
≥3 servings/wk legumes; ≥3 servings/wk fish
or shellfish; <3 commercial (not home-made)
sweets or pastries; ≥3 servings/wk nuts
(including peanuts); Consumption of chicken,
turkey or rabbit meat instead of veal, pork,
hamburger or sausage; 2 servings/wk
vegetables, pasta, rice or dishes seasoned
with sofrito, sauce made with tomato, onion,
leek or garlic and simmered with olive oil
Low Mediterranean Diet adherence (MDA)
defined as score <7, and high MDA defined
as scores ≥7.

Anthropometrical measurements were taken
by trained personnel following hospital’s
standard procedures. GWG data obtained
from hospital records
Gesteiro, 2012 continued Dietary Pattern(s): Significant: Key confounders accounted for:
Adherence to Healthy Eating Index Race/ethnicity, Smoking, GDM
 Inadequate HEI (n=19) Non-significant:
 Adequate HEI (n=16) GWG (kg), Mean, P=NS Summary:
 Perfect HEI adherence encourages 6-10
Adequate vs inadequate adherence to a
servings/d Cereals, grains, and legumes; 3-
Healthy Eating Index was not associated with
5 servings/d Vegetables; 2-4 servings/d
differential GWG.
Fruits; 2-3 serving/d Milk and dairy
products; 2-3 servings/d Meat, eggs and
fish; ≤30% FAT; ≤10% SFA; <300mg/d
Cholesterol; <2,400 mg/d Sodium; 16
different food items diet variety over 3d
at 12-15 wk gestation
71
Dietary pattern assessed with the Healthy

Eating Index (HEI), modified for the Spanish
population (Kennedy et al), based on a 10-
component, 100-point scale, taking into
account recommended energy intakes of for
1600, 2200 and 2800 kcal and the required
servings. Diets with HEI scores of ≤70 were
labelled ‘inadequate’, vs ‘adequate’ (scores
>70).
Dietary components included 10 groups (by
1600, 2200 and 2800 kcal/d
recommendations): Cereals, grains, and
legumes (0=0 servings, 10=6, 8, 10 servings);
Vegetables (0=0 servings, 10=3, 4, 5
servings); Fruits (0=0 servings, 10=2, 3, 4
servings); Milk and dairy products (0=0
servings, 10=2-3 servings) ; Meat, eggs and
fish (0=0 servings, 10=2-3 servings); % FAT
(0=≥45%, 10=≤30%); % SFA (0=≥15%,
10=≤10%); Cholesterol (0=≥450mg/d, 10=
<300mg/d); Sodium (0=≥ 4,800 mg/d,
10=<2,400 mg/d); Diet variety over 3d (0=≤6
different food items, 10=16 different food
items)
Hillesund, 201821; Norway Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, NFFD  Adherence to the Norwegian Fit for Delivery GWG Adequacy, per 1pt Age, SES, PA (subanalyses), Pre-preg BMI,
(NFFD) diet, NFFD score Smoking, Parity
 Low (Score 0-3), n=151  Excessive (Ref: Optimal
Baseline N=606 Analytic N=524
 Medium (Score 4-5), n=204 GWG), n=528, P=0.024
Twelve women withdrew due to Limitations:
 High (Score 6-10), n=236 o aOR=0.90, 95% CI: (0.83,
miscarriage (n=6), twin pregnancy  Models adjusted for randomization
(n=2), and moving away (n=4), very  Higher scores characterized by 0.99)
eating/drinking: ≥24 main meals/wk, water assignment, but residual confounding could
low BMI (n=1), and personal reasons remain
(n=2), leaving 591 eligible for the for ≥44% of drinking events, vegetables
with dinner ≥5x/wk, fruits or vegetables as Subanalysis additionally  The study was restricted to nulliparous
present analyses. adjusting for PA
snacks ≥3x/wk, <1x/d sugar-rich food women, so the findings may not be
items, <1x/d fast-foods, snacks, or other generalizable
72
n=~591 for participant characteristics salty food, never eating sweets and snacks GWG Adequacy, per 1pt  Diet score showed test–retest reproducibility
without appreciation, buying small portion NFFD score but this was not validated against other
 Age: 28.0± 4.4 y (range 18–44y) size of ≥1 unhealthy food items, eating methods of operationalizing dietary behavior
o <25y: 25.2%, beyond satiety <1/wk, and reading nutrition  Excessive (Ref: Optimal  Not all participants who would have been
o 25-29y: 46.2% labels on foods sometimes or often. GWG, Low adherence), eligible for the target trial were included in the
o 30-34y: 21.8% n=418, P=0.009 study
at 15 wk gestation
o ≥35y: 6.8%  aOR=0.88, 95% CI: (0.79,  Single FFQ did not address full diet
 Race/Ethnicity: "predominantly 0.97)  Smoking status varied by diet score, but
White, European" Dietary assessment methods: included in models
 SES: Education:  May not have accounted for all effects of co-
43-item FFQ, including questions about Non-significant:
o ≤12y: 31.8% exposures across groups
selected aspects of current diet and dietary
o 13-15y: 32.7% GWG Adequacy, per 1pt
behavior, mainly those targeted in NFFD.  Total missingness similar across groups, but
o ≥16y: 35.5% NFFD score
unclear proportions for different reasons for
 Occupation: The subscales could be single variables or
 Inadequate (Ref: Optimal missingness
o Work outside home: 84.2% sum scores constructed from relevant
questionnaire responses. Each subscale was
GWG, Low adherence),  The outcome measure may be influenced by
o Student: 8.7% n=524, P=NS
dichotomized with the sample median as knowledge of the exposure received by study
o Unempoyed: 3.9%
cutoff, and participants with the healthier participants
o Sick leave/disabled: 1.9%
behavior were assigned ‘1’ in each subscale,  No pre-registered data analysis plan
o Homemaker: 1.4% Sub-analysis additionally
 Income (NOK): whereas the other half of the sample was adjusting for PA
o ≤400,000: 31.2% assigned ‘0’. Individual diet scoring ranged Summary:
from 0 to 10, with higher score indicating GWG Adequacy, per 1pt
o >700,000: 34.4% NFFD score
healthier behavior. Higher adherence to NFFD diet at 15wk
o Refrain from response: 6.6%
Inadequate (Ref: Optimal gestation is associated with lower odds of
 Marital Status:
GWG, Low adherence), excessive GWG at term, regardless of dietary
o Married/boyfriend/partner: 96.2% Outcome & assessment methods: (n=414) , P=NS and exercise intervention.
 PA: The intervention also included
supervised exercise classes (2/wk), GWG calculated as final measured weight
including strength training and within 2wk of delivery among women at term
cardiovascular exercise at moderate (≥37wk gestation) minus self-reported
intensity prepregnancy weight. GWG adequacy
 PA level in early pregnancy: defined by 2009 IOM recommendations.
o Low activity: 26.4%
o Medium activity: 58.2%
o High activity: 15.4%
 Anthropometry: Pre-preg BMI: 23.7±
3.9
o <19: 0%
73
o <25: 72.2 %
o 25-29.9: 20.2 %
o ≥30: 7.6%
 Smoking status: Current: 3.9%
 GDM: ~9.1%
 Gestational HTN: PE: ~4.3%
 Parity: Nulliparous: 100%
Hillesund, 20145; Norway Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, MoBa Adherence to New Nordic Diet (NND) GWG (kg) None
 Low, n=17802  Overall: 15.0± 5.9
Baseline N=66,597 Analytic N=56629  Medium, n=23558  Inadequate: 6.8± 3.9 Limitations:
(Attrition: 15%)  High, n=25237  Optimal: 12.8± 2.5
 Limited generalizability due to homogenous
 Higher scores characterized by  Excessive: 19.3± 4.7
sample
eating/drinking: ≥24 main meals/wk, Nordic
 Age: 30.1± 4.6y fruits ≥5/wk, root vegetables ≥5/wk,  Potential selection bias because of excluding
GWG adequacy (%) preterm and post-term infants
 Race/Ethnicity: NR cabbage ≥2/wk, potatoes at least one-third
 SES: of total occasions of eating potatoes, rice or  All Women, P<0.001  Start of follow up and start of exposure did not
o Education pasta, whole grain bread more often than o Low: coincide
 ≤12y: ~33.3% refined bread, oatmeal ≥1/mo,  Inadequate: 18.7  Self-reported outcome
 13-16y: ~33.3% fish/game/berries ~2/wk, milk more often  Optimal: 33.0  Unclear why the sample size in table 4 was
 ≥17y: ~33.3% than juice, ≥6 times as much water as  Excessive: 48.3 smaller than other tables
 Anthropometry: Prepregnancy BMI: sugar-sweetened beverages o Medium:  Energy intake was potentially on the causal
24.0± 4.2  Inadequate: 18.4 pathway, but was still adjusted for in the
at 22wk gestation  Optimal: 34.6
 Smoking: During pregnancy: ~7.2% multivariable regression model
 Physical Activity: Exercise:  Excessive: 47.1
o Rarely: ~37.4% Dietary assessment methods: o High:
 Inadequate: 18.6 Summary:
o 1-2 times/wk: ~32.1% Self-administered, semi-quantitative FFQ
o ≥3 times/wk: ~30.5%  Optimal: 35.9 Greater adherence to the NND during
validated for use in MoBa (see Brantsaeter,  Excessive: 45.4
 GDM: History of DM: 0% pregnancy may facilitate optimal GWG,
2008)  Prepregnancy BMI <25,
 Parity: especially among with healthy prepregnancy
P=0.008 BMI
o 0: ~52.7%
Outcome & assessment methods: o Low:
o 1: ~30.2%
 Inadequate: 21.8
o 2: ~13.4% GWG, difference between prepregnancy  Optimal: 39.1
o ≥3: ~3.7% body weight and body weight at birth, as
74
reported in questionnaires at 17wk gestation  Excessive: 39.1
and 6 mo postpartum. o Medium:
GWG categorized into inadequate, optimal  Inadequate: 21.7
and excessive (2009 IOM recommendations)  Optimal: 40.2
 Excessive: 38.1
o High:
 Optimal: 41.6
 Excessive: 36.6
Non-significant:
GWG adequacy (%)
 Prepregnancy BMI ≥25,
P=0.07
o Low:
 Optimal: 21.4
 Excessive: 65.9
o Medium:
 Optimal: 21.9
 Excessive: 67.2
o High:
 Optimal: 20.8
 Excessive: 69.0
Hillesund, 2014 continued Hillesund, 2014 continued Significant: Key confounders accounted for:
Inadequate GWG (Ref: Age, SES, Pre-preg BMI, Smoking, PA, GDM,
Optimal GWG, Low NND), Parity
aOR (95% CI)
 Prepregnancy BMI ≥25
Summary:
o Medium: 0.86 (0.74, 0.99),
P=0.038 Greater adherence to the NND during
pregnancy may facilitate optimal GWG,
75
Excessive GWG (Ref: especially among with healthy prepregnancy

Optimal GWG, Low NND), BMI
aOR (95% CI)
 Prepregnancy BMI <25
o High: 0.93 (0.87, 0.99),
P=0.024
Non-significant:
Inadequate GWG (Ref:
Optimal GWG, Low NND),
aOR (95% CI)
o Medium, P=NS
o High, P=NS
o High, P=NS
Excessive GWG (Ref:

Optimal GWG, Low NND),
aOR (95% CI)
o Medium, P=NS
Medium, P=NS
Hrolfsdottir, 201914; Iceland Dietary Pattern(s): Significant: Key confounders accounted for: Age, SES,
PCS, PREWICE  Low risk diet score (≤2 pt), n=305 Excessive GWG Pre-preg BMI, Smoking, GDM (in subanalyses),
Parity
 Medium risk diet score (3 pt), n=632  Per unit increase in score:
 High risk diet score (≥4 pt), n=389 aRR: 1.10 (1.01, 1.19)
Baseline N=1326 Analytic N=1326
 Higher risk score (out of 5) characterized  Per SD increase in score: Limitations:
by: Not eating a varied diet, <5/d aRR: 1.08, 95% CI: (1.01,  Power analysis NR
n=1326 for all participant fruits/vegetable , <2/d dairy, <2/d whole 1.15), P<0.05  Self‐reported diet, prepregnancy weight and
characteristics height
76
 Age: 30.2± 5.2y grain products, ≥5/wk sugar/artificially  Low risk diet score:  Potential differential exposure time between
sweetened beverages, and ≥5/d dairy. Cases=99 (32%) groups
 Race/Ethnicity: NR
 SES: at 11-14wk gestation  High risk diet score: Cases  Unclear whether analyses accounted for
o Married status: Single: 6% n=160 (41%) group differences in missing data
o Education: o aRR vs Low risk scores:  Unclear systematic errors in outcome
Dietary assessment methods: 1.23, 95% CI: (1.002, measurement by exposure
 Elementary: 13%
 High & technical school: 29% Risk factors for inadequate diet assessed 1.50), P<0.05  No pre-registered data analyses
 University: 35% from 40-item FFQ. Women reported diet in
 Higher academic: 24% the previous 4wk, corresponding to the first
Summary:
 Anthropometry: Pre-preg BMI: 24.1± trimester (enrolled in 11–14 week of
6.5 pregnancy). This information was converted Non-significant: A higher dietary risk score, including a
o <18.5: 4% to frequency/wk for all food groups, which Excessive GWG nonvaried diet, a nonadequate intake of
o 18.5–24.9: 55% was then transformed into 13 predefined fruits/vegetables, dairy, and whole grain, as well
 Low risk diet score: Cases as an excessive intake of sugar/artificially
o ≥25.0–30.0: 24% dietary risk factors for inadequate diet, based
n=99 (32%) sweetened beverages and dairy, was
o ≥30.0: 18% on the Icelandic Food‐Based Dietary
 Medium risk diet score: associated with a higher risk of excessive
 Smoking status: Recommendations, which are based on the
Cases n=217 (34%)
o Before preg: 16% Nordic Nutrition Recommendations (2014). If GWG, but the association disappeared after
o aRR vs Low scores: 1.04, removing GDM cases.
o During preg: 7% the women excluded/avoided any of the main
food groups (cereal, vegetables/ fruits, fish, 95% CI: (0.86, 1.26),
 GDM: 19.9% P=NS
 Parity: Nulliparous: 39% meat, eggs, high‐fat foods, or dairy), they
were categorized to the group not eating a
varied diet. Analyses excluding 264 GDM
After logistic regression modeling to predict cases:
excessive GWG, the six dietary risk factors Excessive GWG
(predictors) were included in the final model.
To construct a total dietary risk score, each  Per one unit increase in
participant got 1 for fulfilling the risk criteria score: aRR: 1.09, 95% CI:
and 0 for not fulfilling the risk criteria. The (1.00, 1.19), P=NS
scores of the six dietary risk factors were then
summed up, ranging from scores of 0 to 5 as  Low risk diet score: Cases
it was not possible to be in both milk risk n=89/266 (34%)
groups (too low/too high).  Medium risk diet score:
Cases n=184/533 (35%)
o aRR vs Low scores: 1.01,
Outcome & assessment methods: 95% CI: (0.82, 1.23),
Excessive GWG: >18 kg in women with P=NS
normal pre-pregnant weight and >12 kg in
77
women with pre-pregnant overweight and  High risk diet score: Cases
obesity n=136/326 (42%)
GWG retrieved from the maternal hospital o aRR vs Low scores: 1.19 ,
records as women were weighed in antenatal 95% CI: (0.96, 1.47),
visits. Total GWG calculated as the difference P=NS
between the highest recorded weight (≥36wk)
and prepregnancy weight.
Hrolfsdottir, 2019 continued Dietary Pattern(s): Significant: Key confounders accounted for:
 Score based on three dietary risk factors Excessive GWG Pre-preg BMI, Smoking, GDM (in subanalyses),
most strongly associated with excessive Per SD increase in score Parity
GWG in the multivariable model. Higher
dietary risk scores characterized by ≥ 5/wk aRR: 1.08, 95% CI: (1.002, Summary:
sugar- and artificially sweetened beverages, 1.15), P<0.05 A higher dietary risk score, including excessive
<2/d whole grain products, and ≥5/d dairy intake of sugar- and artificially sweetened
at 11-14wk gestation Non-significant: beverages, inadequate intake of whole grains,
and nonadequate intake of dairy was
associated with a higher risk of excessive
GWG.
Hrolfsdottir, 2019 continued Dietary Pattern(s): Significant: Key confounders accounted for:
 Diet score based on 13 dietary risk factors. Pre-preg BMI, Smoking, GDM (in subanalyses),
Higher dietary risk scores characterized by: Non-significant: Parity
not eating a varied diet, <5/d vegetables
and fruits, <2/d fish, <2/d dairy, <2/d whole Excessive GWG: Summary:
grain products, <3.5/wk beans, nuts, seeds, Per SD increase in score, A higher dietary risk score including 13 dietary
<5/wk D-vitamin, using butter rather than oil P=NS risk factors (as described in the exposure) was
(≥50%), ≥ 1/wk french fries and fried not associated with the risk of excessive GWG.
potatoes, ≥ 2.5/wk sweets, ice cream,
cakes, cookies, ≥ 5/wk sugar- and artificially
sweetened beverages, ≥ 5/d dairy intake,
≥1/wk processed meat products
Meinila, 201727; Finland Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, Control arm of RADIEL trial Healthy Food Intake Index (HFII) adherence None
78
 HFII score 0-7 (n=24) Non-significant:

Baseline N=137 Analytic N=137  HFII score 8-12 (n=84) GWG from first to second Limitations:
 HFII score 13-17 (n=29) trimester (kg), P=NS  The study enrolled only those women who
 Higher scores are indicative of higher
 Age: ~32y were at risk of GDM (i.e. women with a history
adherence to the Nordic Nutrition
 Race/Ethnicity: NR of GDM and/or prepregnancy BMI ≥30). The
Recommendations (NNR), characterized by
findings, therefore, may not be generalizable
 SES: Education: ~14.3y higher consumption of fruits, vegetables,
 Potential selection bias due to exclusion after
 PA: Leisure-time physical activity: whole-grains, and fish and poultry, and
lower intakes of red and processed meat, first trimester OGTT
~78.3 min/wk
 Women diagnosed with GDM may have
 Anthropometry: BMI at 12.0-14.6wk: and refined grains.
altered their diet in an unbalanced way
~31.7 at first trimester (~13wk)  Potential differential exposure time between
 100% ≥30 BMI or with history of
groups
GDM
 Reasons for/characteristics of women with
 GDM: ~40.1% Dietary assessment methods:
missing outcome data NR
 Parity: Nulliparous: ~37.2% Diet assessed during the first trimester via  Total GWG not measured
FFQ. The HFII comprised the following
 No pre-registered data analysis plan.
components: snacks, low-fat cheese, fish,
low-fat milk, vegetables, fruits and berries,
sugar-sweetened beverages, high-fiber Summary:
grains, fast food, fat spread, and cooking fat.
Adherence to the Healthy Food Intake Index
The HFII scores were divided into three during the first trimester was not associated with
categories by setting z cut-off limits at ± 1 SD GWG from first to second trimester.
from the mean.

Weight measured by a study nurse. GWG
from 12.0-14.6wk through 22.4-24.1wk
gestation.
Poon, 20137; U.S. Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, IFPSII Alternative Healthy Eating Index for None
Pregnancy (AHEI-P): Non-significant:
Baseline N=893 Analytic N=893  T1: (n=285) GWG (kg), P=NS Limitations:
(Attrition: 0%)  T2: (n=286) T1: 13.4± 6.4
 T3: (n=282)
79
 Age: 29.1± 5.4y Based on a 130-point scale with 0–10 points T2: 14± 6.1  Baseline differences in BMI between groups
T3: 14.4± 5.8
 Race/Ethnicity: White: 87.4% awarded for optimal intake of 13 types of and it is possible that the rate of weight gain
 SES: foods and nutrients might have differed based on their baseline
o Education:  Positively-scored components: vegetables, BMI, but not discussed or accounted for
 High school or less: 18.0% whole fruit, whole grains, nuts and legumes,  GWG is self-reported
 Some college: 39.3% long-chain (n-3) fats, PUFAs, folate,
 Associate or BA: 31.7% calcium, and iron
 Master or more: 10.9% Summary:
 Negatively-scored components: sugar-
o Poverty index ratio: sweetened beverages, red and processed There was no association between adherence
 <185%: 37.5% meat, trans fat, and sodium to the AHEI-P and GWG
 ≥350%: 23.7%
 Anthropometry: Prepregnancy BMI: at 28-36wk gestation
26.1± 6.4
 Smoking Status: Yes: 8.3% Dietary assessment methods:
Modified version of the Diet History
Questionnaire (DHQ) previously developed
and validated by the National Cancer Institute
(see Subar, 2001a; Subar, 2001b;
Thompson, 2002a; Thompson, 2002b)

GWG at postpartum using neonatal
questionnaire
Rifas-Shiman, 20096; U.S. Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, Project Viva Adherence to Alternate Healthy Eating Index Age, Race/Ethnicity, SES, Pre-preg BMI
for Pregnancy (AHEI-P) Non-significant:
Baseline N=1777 Analytic N=1666  Based on 9 components: vegetables; fruit; 50% experienced excessive Limitations:
ratio of white to red meat; fiber; trans fat; weight gain
2,670 enrolled, then excluded 329 due ratio of polyunsaturated to saturated fatty  Unclear whether those who did not complete
to subsequent ineligibility. Additional acids; and folate, calcium, and iron from FFQ in round 2 were different from those that
women withdrew (n=195), or were lost foods (each 10 points, with a total of 90 GWG Adequacy for each 5 completed first FFQ.
to follow-up (n=18). 1777 completed points) point increase in AHEI-P  Follow-up time varied across participants
first FFQ, 1666 completed second score (Ref: Adequate)  Reasons for exposure missingness NR
FFQ  First trimester (n=1,777)  Pre-registered data analysis plan NR
80
 Changes made to original AHEI: Alcohol, o Inadequate, P=NS
nuts excluded; folate, calcium and iron o Excessive, P=NS Summary:
 Age: 32.4± 4.9y included
 Race/Ethnicity:  Second trimester (n=1,666) AHEI-P is not associated with pregnancy weight
o White: 72% at first trimester (~11wk) and second gain
trimester (~26-28wk) o Inadequate, P=NS
o Black/African American: 12%
o Other, > 1 race: 16% Excessive, P=NS
 SES: Dietary assessment methods:
o Education:
 ≤High school diploma: 9% 166-item validated semiquantitative FFQ,
 Some college/tech school: 21% slightly modified for use in pregnancy
 College graduate: 69% (Based on extensively validated Willett FFQ
o Household income <$40,000/y: used in the Nurses’ Health Study and
13% calibrated against blood levels) (see Fawzi,
2004)
24.6± 5.3
 Parity Outcome & assessment methods:
o Nulliparous: 49%
Self-reported prepregnancy weight at
o 1: 36%
baseline.
o ≥2: 15%
Last clinical prenatal weight recorded - self-
reported prepregnancy weight
GWG adequacy based on IOM 1990
recommendations
Sen, 20169; U.S. Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, Project Viva Dietary inflammatory index (DII) score: Age, Race/ethnicity, SES, Pre-preg BMI,
 Lower scores indicate lower dietary Non-significant: Smoking, Parity
Baseline N=1808 Analytic N=1808 inflammation, characterized by higher GWG adequacy per unit of
intakes of vegetables, fruit, whole-grain DII (Ref: Adequate): Limitations:
foods, fish/seafood, and whole eggs, and
n=~1808 for most participant lower intakes of red or processed meats  All women (n=1808)  Data collected at the end of 2nd trimester may
characteristics and sugar-sweetened soda. o Inadequate, P=NS be influenced by GDM knowledge
o Excessive, P=NS  Start of follow up and start of exposure may
 Age: 32.2± 5.0y mean score from ~9.9wk and ~27.9wk  Prepregnancy BMI 18.5- not coincide
 Race/Ethnicity: gestation <25 (n=1141)  Self-reported diet and prepregnancy weight
o Black: 13.9% o Inadequate, P=NS
o Hispanic: 6.8% o Excessive, P=NS
81
o Asian: 5.0% Dietary assessment methods:  Prepregnancy BMI 25-<30  Important co-exposures were not balanced
o White: 70.6% (n=406) across groups, and adjustment techniques
o Other: 3.8% Mothers completed self-administered FFQs at o Inadequate, P=NS were used to correct for the issues.
 SES: median 9.9wk and 27.9wk gestation., o Excessive, P=NS  No information on reasons for missingness or
o Graduated college: 68.6% assessing diet intake during the first and  Prepregnancy BMI ≥30 proportions across groups
o Household income ≤$70,000: second trimesters. (n=261)  Any error in measuring the outcome is only
36.5% Dietary data used to estimate a standard o Inadequate, P=NS minimally related to exposure status
 Anthropometry: Prepregnancy BMI: global mean for the 28 food parameters o Excessive, P=NS  No pre-registered data analysis plan
24.9± 5.2 included in the DII, then converted to a
o 18.5-<25: 63.1% centered percentile score, multiplied by the
o 25-<30: 22.5% literature-derived respective food parameter Summary:
o ≥30: 14.4% effect score to obtain a food parameter– Consumption of a low DII diet during the first
 Smoking status: specific DII score, which were all summed to and second trimesters was not associated with
o Never: 67.8% create the overall DII score for each GWG.
o Former: 21.0% participant. A higher DII score indicates a
o During pregnancy: 11.2% more proinflammatory diet, whereas a more
 GDM: 5.4% negative score represents a more anti-
 Gestational HTN: 6.9% inflammatory diet.
o Chronic HTN: 1.4%
o PE: 3.5%
 Parity: Nulliparous: 48.6%
GWG (kg) calculated as the difference
between the last recorded clinical weight
before delivery and self-reported
prepregnancy weight reported at the first
study visit (9,9wk gestation). GWG adequacy
categorized by IOM (2009)
recommendations.
Tielemans, 20158; Netherlands Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, Generation R Study  Adherence to standardized Dutch Healthy Age, Race/ethnicity, SES, Pre-preg BMI,
Diet Index. Higher scores indicate better Non-significant: Smoking, GDM, HTN, Parity
adherence and higher intake of vegetables,
Baseline N=4097 Analytic N=2748 fruits, fiber, and fish, and lower intake of Sensitivity Analysis (excludes
(Attrition: 33%) saturated fat and sodium. women with GDM or Limitations:
hypertensive disorders of  Self-reported diet, prepregnancy weight, and
at ~13.4wk pregnancy)
 Age: ~31.3y maximum pregnancy weight
82
 Race/Ethnicity: 100% of Dutch Dietary assessment methods: GWG until early-third
ancestry trimester (g/wk)
 SES: The Dutch HDI was modified to align with Summary:
o Education: pregnancy recommendations and available  Prepregnancy Normal Adherence to Dutch HDI the was not associated
 Low and midlow: ~18.2 data, and consisted of 6 components: Weight Women (n=1937) with GWG.
 Midhigh: ~51.5 vegetable, fruit, dietary fiber, fish, saturated o Dutch HDI Pattern, P=0.06
 High: ~30.4 fatty acids, and sodium. The score of each per SD increase in DP
o Household income <2200 Euro/mo: component ranged between 0 and 10 points, score
~28.3 resulting in a total score ranging from 0 to 60  Q1: Ref
points.  Q2: β=-13, 95% CI: (−29,
~24.7 3)
 Q3: β=-4, 95% CI: (−20,
 Smoking status: Outcome & assessment methods: 12)
o Never in pregnancy: ~74.4
Self-reported prepregnancy weight collected  Q4: β=-16, 95% CI: (−33,
o Until pregnancy known: ~8.3
at enrollment. Staff measured weight at 3 1)
o During pregnancy: ~17.4
study visits: ~12.9wk (first visit), ~20.4wk
 Alcohol:
(second visit), and ~30.2wk (third visit). At  Prepregnancy Overweight
o Never in pregnancy: ~36.6
6wk postpartum, women self-reported Women (n=532)
o Until pregnancy known: ~16.5
maximum weight during pregnancy. Dutch HDI Pattern, P=NS per
o During pregnancy: ~46.9
GWG in different phases of pregnancy was SD increase in DP score
calculated mid-pregnancy GWG (weight at
the second visit minus weight the first visit,
2748), late-pregnancy GWG (weight at the
third visit minus weight at the second visit,
3158), and GWG until early-third trimester
(weight at the third visit minus prepregnancy
weight, divided by follow up duration
(g/week), n = 2815).
Women’s total GWG (maximum pregnancy
weight minus prepregnancy weight, n = 1917)
was used to classify their GWG into
inadequate, adequate, or excessive GWG
according to IOM (2009) recommendations.
Tielemans, 2015 continued Tielemans, 2015 continued Significant: Key confounders accounted for:
83
Non-significant: Age, Race/ethnicity, SES, Pre-preg BMI,

Mid-Pregnancy Weight Gain Smoking, Parity
(g/wk)
 Prepregnancy Normal Summary:
Weight Women (n=2079) Adherence to Dutch HDI the was not associated
o Dutch HDI Pattern, P=0.76 with GWG.
per SD
Women (n=669)
o Dutch HDI Pattern, P=0.88
per SD
Late-Pregnancy Weight Gain

(g/wk)
 Prepregnancy Normal
Weight Women (n=2384)
per SD
Women (n=774)
per SD
GWG adequacy:
 Inadequate GWG (n=459,
Ref: Adequate intake,
n=632)
Excessive GWG (n=826, Ref:
Adequate intake, n=632)
Yong, 201920; Malaysia Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, SECOST  Modified HEI for Malaysians comprised of 9 GWG adequacy by HEI in Age, SES, PA, Pre-preg BMI, Parity
components, each with max score of 10 each trimester
84
Baseline N=480 Analytic N=480 and min score of 0. Higher score indicates  All women Limitations:
(Attrition: 0%) intake closer to recommended range. o 2nd trimester:
o Adherence with the 7 major food groups  Respondents were not representative of the
 Inadequate: OR=0.98, general population of pregnant women in
recommended by Malaysian Dietary 95% CI=(0.96, 0.98),
 Age: 30.16± 4.51y Guidelines 2010 (MDG): Malaysia.
P=0.03  Self-reported dietary data; single 24-h dietary
 Race/Ethnicity:  Cereals and grains o 3rd trimester:
o Malay: 89.0%  Vegetables recall might not represent the usual intake
 Excessive: OR=1.04,
o Non-Malay: 11.0%  Fruits  Third trimester results may be cross-
95% CI=(1.01, 1.06),
 SES:  Milk and milk products P=0.01
sectional—unclear timing of third FFQ
o Education level: 12.95± 2.41y  Poultry, meat and egg,  Start of follow up and start of exposure did not
 Secondary and lower: 46.0%  Fish and seafood coincide and a potentially important amount of
 Non-oveweight/obese
 STPM/matric/diploma/certificate:  Legumes follow-up time is missing from analyses
(n=304):
32.7% o Adherence with MDG recommendations  Co-exposures and reasons for missingness
o 2nd trimester:
 Tertiary and above: 21.3% for %E from fat and sodium intake. between groups NR
 Inadequate: OR=0.97,
o Occupation status: Employed: once during each trimester 95% CI=(0.95, 0.99),  High risk of selective reporting from among
69.2% P=0.01 multiple analyses
o Monthly household income: RM o 3rd trimester:  Information on missingness NR
3698.30± 2034.20 Dietary assessment methods:  Excessive: OR=1.04,  No pre-registered data analysis plan
 Low: 63.5% 24-hr recall conducted each trimester. Dietary 95% CI=(1.01, 1.07)
 Middle: 33.5% data analyzed using Nutritionist Pro Diet P=0.03
 High: 2.9% Summary:
Analysis software: Version 1.5.
o Household size: 3.78± 1.63  Overweight/obese (n=176): Women who were not overweight or obese
Score for each HEI component calculated
 ≤2: 24.2% o 2nd trimester: prepregnancy with a higher total HEI score in
using formula: (Actual serving consumed
 3–4: 50.0%  Excessive: OR=1.04, the second trimester were at a lower risk for
based on respondent’s diet
 ≥5: 25.8% 95% CI=(1.01, 1.07), inadequate GWG, while women who were
recall/recommended serving size based on
 Physical Activity: MET hrs/week: P=0.02 overweight or obese prepregnancy with a higher
MDG) and multiplied by 10. If an individual
o 2nd trimester 264.58± 118.06 o 3rd trimester: total HEI score in the second trimester were at a
consumed less than the recommended
o 3rd trimester: 249.56± 107.36  Excessive: OR=1.04, higher risk for excessive GWG. Women with a
amount of servings, score was calculated
 Anthropometry: with the formula: 10 × (the consumed amount 95% CI=(1.01–1.08), higher total HEI score in the third trimester were
o Pre-preg weight (kg): 59.11± 13.57 P=0.02 at higher risk for excessive GWG, regardless of
of servings)/ (the lower limit of the
o Pre-preg BMI: 24.10± 5.06 prepregnancy BMI.
recommended serving). If an individual
o Underweight: 10.2% consumed more than the recommended
o Normal: 53.1% Non-significant:
amount of servings, the score was calculated
o Overweight: 22.3% with the formula: 10–10 × [(the consumed GWG adequacy by HEI in
o Obese: 14.4% servings) − (the upper limit of the each trimester
 GDM: History: 7.5% recommended servings)]/(the upper limit of  All women
 Parity: 1.22± 1.29 the recommended serving). Each score o 1st trimester:
85
o 0: 36.7% rounded off to nearest whole number. When  Inadequate, P=NS
o 1–2: 47.7% calculation produced a negative score  Excessive, P=NS
o ≥3: 15.6% because of excess servings, score converted o 2nd trimester:
to 0.  Excessive, P=NS
o 3rd trimester:
 Inadequate, P=NS
Prepregnancy weight self-reported. Weight  Non-oveweight/obese
measured at 10–13wks, 24–32wks, and 34– (n=304):
38wks using standard instrument and o 1st trimester:
procedures. GWG calculated as difference  Inadequate, P=NS
between measured weight at last visit and  Excessive , P=NS
prepregnancy weight. o 2nd trimester:
 Excessive, P=NS
o 3rd trimester:
 Overweight/obese (n=176):
o 1st trimester:
 Excessive, P=NS
o 2nd trimester:
o 3rd trimester:
Inadequate, P=NS
16
Zhu, 2019 ; U.S. Dietary Pattern(s): Significant: Key confounders accounted for:
PCS, PETALS  Healthy Eating Index (HEI) index measures None
adherence to the USDA Dietary Guidelines Non-significant:
for Americans. The HEI-2010 consists of 12
Baseline N=2269 Analytic N=2269 components (total fruit, whole fruit, total GWG (kg), P=0.69 Limitations:
Of 2525 enrolled, loss to follow-up due vegetables, greens and beans, whole  Q1: 13.2± 6.7  Participant characteristics not balanced
to pregnancy loss (n=37), moved grains, dairy, total protein foods, seafood  Q2: 13.2± 6.2 across groups
(n=7) or excluded due to missing data and plant proteins, fatty acids, refined  Q3: 12.9± 6.2  Selection into the study related to exposure
on child BW (n=94), FFQ (n=87), grains, sodium and empty calories from  Q4: 13.1± 6.0 and outcome and could not be adjusted for in
>6000 kcal/d reported (n=23), or due solid fats, alcohol and added sugars), with a the analyses
to FFQ after GDM diagnosis (n=8) maximum possible score of 100. Alcohol
86
intake was excluded from the empty  Start of follow up and exposure did not
calories component. coincide and a potentially important amount of
n=2269 for all participants  Q1: Score of 37.5-64.4 (n=567) follow-up time was missing from analyses
characteristics  Q2: Score of 64.5-71.7 (n=567)  Dietary intake self-reported from one FFQ
 Age:  Q3: Score of 71.8-78.6 (n=568)  Important co-exposures not balanced across
o 18-24: ~16.1%  Q4: Score of 78.7-94.2 (n=567) groups that were likely to impact the outcome
o 25-29: ~26.5% and no adjustment techniques were used to
o 30-34: ~35.8% correct for the issues
o ≥35: ~21.6%  Outcome assessment methods NR
 Race/Ethnicity: Dietary assessment methods:  No pre-registered data analysis plan
o Non-Hispanic White: ~22.3%
Validated, 147 item Block FFQ administered
o Hispanic: ~41.3%
at visit 1 (gestational wks 10–13). Nutrient Summary:
o African American: ~9.4%
intakes adjusted for total energy intake using
o Asian/Pacific Islander: ~23.6% Maternal diet quality as measured by the HEI-
the residual method. HEI-2010 score was
o Other: ~3.5% 2010 in early pregnancy was not associated
calculated to assess diet quality.
 SES: with GWG.
o Education:
 High School or less: ~13.8% Outcome & assessment methods:
 Some college: ~38.4%
NR
 College graduate or above:
~47.9%
o Household income ($):
 <50,000: ~32.7%
 ≥150,000: ~15.9%
 Physical Activity: ~152.1 METs/wk
 Anthropometry: Pre-preg BMI:
o <18.5: ~2.7%
o 18.5-24.9: ~40.3%
o 25.0-29.9: ~28.9%
o ≥30.0: ~28.1%
 Smoking status: 0.5%
 GDM: ~10.8%
 Gestational HTN: ~10.8%
 Parity: Nulliparity: ~44.1%
 Alcohol in pregnancy: ~15.0%
87
Reduced Rank Regression

Starling, 201711; U.S. Dietary Pattern(s): Significant: Key confounders accounted for:
PCS  Pattern 1: Higher consumption of healthy GWG (kg) None
protein sources (poultry, nuts, and seeds),  Pattern 1, Ptrend<0.001
whole grains, cheese, citrus fruits, melons o T1: 12.4± 6.6
Baseline N=764 Analytic N=764 and berries, and other fruits, as well as Limitations:
(Attrition: 0%) o T2: 14.7± 5.6
added sugars and discretionary solid fat o T3: 15.7± 5.7  GWG was not stratified by prepregnancy BMI
 Pattern 2: Higher consumption of eggs, and the analysis did not stratify weight gain by
 Age: ~28.6y potatoes, other starchy vegetables,  Pattern 2, Ptrend=0.03 inadequate, adequate and excess
 Race/Ethnicity: discretionary solid fat, citrus, melons and o T1: 13.5± 6.1  Co-exposures unbalanced between groups
o Non-Hispanic White: 60% berries, and non-whole grains and yogurt, o T2: 14.7± 5.6 and likely to impact the outcome
o Hispanic: 21% added sugars, soy products (tofu and meat o T3: 14.7± 6.5  Missingness by exposure NR
o Non-Hispanic Black: 12% analogs), dark-green vegetables, and whole  Unclear GDM prevalence
o Other: 6% grains  Pattern 1 correlated with  No pre-registered data analysis plan
 SES: at 17wk gestation greater GWG, P<0.01
o More than high school education: o r=0.22
Summary:
75.3%
Dietary assessment methods:  Pattern 2 correlated with
 Physical Activity: METs/wk: ~183 Women with greater adherence to pattern 1
 Anthropometry: Prepregnancy BMI: Dietary intake during pregnancy was greater GWG, P=0.02 (tertile 3) had significantly greater GWG
25.4± 5.9 assessed using the National Cancer o r=0.09 (ptrend<0.001). Similarly, women with greater
 Smoking status: : ~5.5% Institute's Automated Self-Administered adherence to pattern 2 (tertile 2 and tertile 3)
(ASA) 24h Recall. Analysis was restricted to had significantly greater GWG (ptrend=0.03)
Parity: Multiparous: 62.8% participants who completed ≥2 ASA24s Non-significant:

Maternal weight during pregnancy was
measured at each in-person study visit, and
all weights measured at clinic visits were
abstracted from the prenatal medical record
by study personnel. Maternal weight before
pregnancy was obtained either from medical
records (~90%) or from participant self-report
at the first study visit (~10%). GWG was
calculated by subtracting the prepregnancy
weight from the last recorded maternal weight
88
during pregnancy. Median number of days
between the last recorded weight and
delivery was 5 d (IQR 2–8 d).
89
Table 4. Description of evidence on the relationship between diets based on macronutrient distribution during pregnancy
and gestational weight gainxii

Characteristicsxiii Summary of findings
Poston, 201324; U.K. Macronutrient Proportions: Significant: Key confounders accounted for:
RCT, UPBEAT  Control: 35.9% FAT, 48.2% CHO, 15.5% Age, Race/ethnicity, SES, PA, GDM,
PRO (n=69) Parity
 Intervention: 32.5% FAT, 50.0% CHO, Non-significant:
Baseline N=183 Analytic N=140 17.1% PRO (n=71), also received PA  Weight at 17wk (kg), Mean± SD
(Attrition: 23%) intervention, to no effect o Control: 96.8± 16.2 Limitations:
o Intervention: 97.8± 12.7  Exploratory study, no power calculation
from 17wk to 28wk gestation  GWG at 28wk between groups, P=NS
 Age: ~30.5y for GWG
o Data NR  Deviations from intended intervention
 Race/Ethnicity:
o White: ~56% Dietary assessment methods: unbalanced between groups and likely
o Black: ~38% Women randomized to intervention of dietary to have affected the outcome
o Asian: ~2% and physical activity advice delivered by  Unclear how weight was assessed and
o Other: ~4% health trainers vs standard care. GWG was calculated
 SES:  No pre-registered data analysis plan
Diet assessed via repeated, triple pass,
o Most deprived: ~56% interviewer-led 24 hr recall data obtained at
o Single: ~46% baseline (randomization) and 28wk gestation. Summary:
 Living arrangements (%): Diet evaluated twice, one week apart in both
o With partner: ~74 Consuming a diet with >35% FAT versus
the intervention and control group.
o With parents: ~11 a diet with <35% FAT during send
 Housing (%): trimester in obese women did not affect
o Owned: ~26 Outcomes & assessment methods: GWG.
 Physical Activity (n=140): GWG: Weight measured at baseline and
o Sedentary (min/d): ~1169, 28wk
Active: 221, Light: 181,
MVPA: 41
 Anthropometry: BMI at ~17wk:
~36.3
xii
BMI: body mass index, CHO: carbohydrate, d: day, GDM: gestational diabetes mellitus, g: gram, GWG: gestational weight gain, hr: hour, kg: kilogram(s),
kJ: kilojoule(s), min: minute(s), MVPA: moderate to vigorous physical activity, PA: physical activity, PRO: protein, SES: socioeconomic status, UPBEAT:
U.K. Pregnancies Better Eating and Activity Trial, wk: week(s), y: year(s)
xiii
± indicates values of Mean± SD unless otherwise noted
90
 Smoking status: Never: 68%,
Ex-smoker: 26%, Current: 7%,
 GDM: at 28wk: 30%
 Parity: 0: 44%, 1: 36%, ≥2:
21%
Tajima, 20174; Japan Macronutrient Proportions: Significant: Key confounders accounted for:
PCS  Bottom: 48.9% CHO, 35.1% FAT, 16.0% Race/ethnicity
PRO (n=108)
 Middle: 54.9% CHO, 30.3% FAT, 14.8% Non-significant:
Baseline N=325 Analytic N=325 PRO (n=109)  GWG per week (kg), P=0.22 Limitations:
 Top: 61.5% CHO, 24.6% FAT, 13.9% PRO o Bottom: 0.3± 0.1  Self‐reported dietary assessments
(n=108) o Middle: 0.3± 0.1 during first trimester, when women may
 Age: ~33.5y o Top: 0.3± 0.1
 Race/Ethnicity: 100% at <16wk gestation be prone to nausea
Japanese  Start of follow up and exposure did not
 SES: NR coincide and a potentially important
Dietary assessment methods: amount of follow-up time is missing from
 Anthropometry: BMI at first
Data grouped by tertile of CHO intake analyses
prenatal visit: ~19.7
o <18.5: 28.9% (bottom, middle, and top).  Methods used to define exposure status
o ≥23: 5.5% are not clearly described and likely to
3‐d weighed dietary record on 2 weekdays result in some degree of random
 GDM: 4% (n=540), and 1 weekend day, consecutive or misclassification
Prepregnancy diabetes: 0% nonconsecutive. Calories from each  GWG not stratified by prepregnancy
 Parity: Primiparous: ~67.1% macronutrient calculated by multiplying g of BMI and unclear if it varied among
macronutrients by calories/g (16.7 kJ/g for underweight vs. healthy vs. overweight
protein; 37.7 kJ/g for fat). Percentage of participants
carbohydrate intake calculated by subtracting  GWG available for a small window (~7-
percentages of protein and fat intake from 28 wks) and weight gain during first
100%. trimester may have been minimal
 Generalizability to U.S. population may
Outcomes & assessment methods: be questionable given that ~1/3 of the
participants were underwight
GWG: Weight measured by a registered
 No information on whether the
nurse at the first prenatal visit and at 28wk.
proportion of participants and reasons
Rate of GWG/wk calculated from 1st prenatal
for missing data are similar across
visit to 28 wks of gestation.
exposure groups
91
Summary:
GWG per week is not significantly
different between tertiles of %CHO
among Japanese pregnant women.
92
Table 5. Risk of bias for randomized controlled trials examining dietary patterns during pregnancy and gestational weight
gainxiv xv
Randomization Deviations from Missing Outcome Selection of the
intended outcome data measurement reported result
interventions
Al Wattar, 201922 Low Low Low Some concerns Low
26
Assaf-Balut, 2017 Low High Low Low Low
25
Van Horn, 2018 Low High Low Low Low
24
Poston, 2013 Low High Low Some concerns Some concerns
23
Assaf-Balut, 2019 Low High Low Low High
Table 6. Risk of bias for observational studies examining dietary patterns during pregnancy and gestational weight gainxvi
Confounding Selection of Classification Deviations Missing data Outcome Selection of
participants of exposures from intended measurement the reported
exposures result
Maugeri, 201919 Serious Serious Low Low Low Moderate Serious
Okubo, 20123 Serious Serious Serious Serious Moderate Serious Serious
8
Tielemans, 2015 Serious Moderate Moderate Low Low Serious Serious
15
Wei, 2019 Serious Serious Serious No information Serious Moderate Serious
17
Wesolowska, 2019 Critical Serious Moderate Serious Moderate No information Serious
18
Ancira-Moreno, 2019 Serious Serious Serious Low Moderate Moderate Serious
13
Emond, 2018 Serious Serious Moderate Low No information Low Serious
xiv
A detailed description of the methodology used for assessing risk of bias is available on the NESR website: https://nesr.usda.gov/2020-dietary-guidelines-
advisory-committee-systematic-reviews and in Part C of the following reference: Dietary Guidelines Advisory Committee. 2020. Scientific Report of the 2020
Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Agriculture and the Secretary of Health and Human Services. U.S. Department of
Agriculture, Agricultural Research Service, Washington, DC.
xv
Possible ratings of low, some concerns, or high determined using the "Cochrane Risk-of-bias 2.0" (RoB 2.0) (August 2016 version)” (Higgins JPT, Sterne
JAC, Savović J, Page MJ, Hróbjartsson A, Boutron I, Reeves B, Eldridge S. A revised tool for assessing risk of bias in randomized trials In: Chandler J,
McKenzie J, Boutron I, Welch V (editors). Cochrane Methods. Cochrane Database of Systematic Reviews 2016, Issue 10 (Suppl 1).
dx.doi.org/10.1002/14651858.CD201601.)
xvi
Possible ratings of low, moderate, serious, critical, or no information determined using the "Risk of Bias for Nutrition Observational Studies" tool (RoB-
NObs) (Dietary Guidelines Advisory Committee. 2020. Scientific Report of the 2020 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary
of Agriculture and the Secretary of Health and Human Services. U.S. Department of Agriculture, Agricultural Research Service, Washington, DC.)
93
Confounding Selection of Classification Deviations Missing data Outcome Selection of
participants of exposures from intended measurement the reported
exposures result
Fernández-Barrés,
Critical Serious Serious Serious Moderate Moderate Serious
20191
Fulay, 201812 Serious Moderate Moderate Low Moderate Moderate Serious
2
Gesteiro, 2012 Serious Serious Serious Low Moderate Low Serious
21
Hillesund, 2018 Serious Moderate Serious Moderate Serious Moderate Serious
5
Hillesund, 2014 Serious Serious Moderate Moderate Moderate Serious Serious
Hrolfsdottir, 201914 Serious Moderate Moderate Low Moderate Moderate Serious
27
Meinila, 2017 Critical Serious Moderate Moderate No information Moderate Serious
7
Poon, 2013 Critical Serious Serious Serious Moderate Serious Serious
6
Rifas-Shiman, 2009 Serious Serious Moderate Moderate Moderate Moderate Serious
9
Sen, 2016 Serious Moderate Moderate Moderate Moderate Moderate Serious
20
Yong, 2019 Serious Serious Moderate No information No information Moderate Serious
16
Zhu, 2019 Critical Moderate Moderate Low Low No information Serious
11
Starling, 2017 Critical Moderate Moderate Moderate Moderate Moderate Serious
Tajima, 20174 Critical Moderate Serious Moderate No information Low Serious
94
METHODOLOGY
The NESR team used its rigorous, protocol-driven methodology to support the 2020 Dietary
Guidelines Advisory Committee in conducting this systematic review.
NESR’s systematic review methodology involves:
 Developing a protocol,
 Searching for and selecting studies,
 Extracting data from and assessing the risk of bias of each included study,
 Synthesizing the evidence,
 Developing conclusion statements,
 Grading the evidence underlying the conclusion statements, and
 Recommending future research.
A detailed description of the methodology used in conducting this systematic review is available on
the NESR website: https://nesr.usda.gov/2020-dietary-guidelines-advisory-committee-systematic-
reviews, and can be found in the 2020 Dietary Guidelines Advisory Committee Report, Part C:
Methodology.xvii Additional information about this systematic review, including a description of and
rationale for any modifications made to the protocol can be found in the 2020 Dietary Guidelines
Advisory Committee Report, Chapter 2. Food, Beverage, and Nutrient Consumption During
Pregnancy.
Below are details of the final protocol for the systematic review described herein, including the:
 Analytic framework
 Literature search and screening plan
 Literature search and screening results
ANALYTIC FRAMEWORK
The analytic framework (Figure 1) illustrates the overall scope of the systematic review, including the
population, the interventions and/or exposures, comparators, and outcomes of interest. It also
includes definitions of key terms and identifies key confounders considered in the systematic review.
The inclusion and exclusion criteria that follow provide additional information about how parts of the
analytic framework were defined and operationalized for the review.
xvii
Dietary Guidelines Advisory Committee. 2020. Scientific Report of the 2020 Dietary Guidelines Advisory
Committee: Advisory Report to the Secretary of Agriculture and the Secretary of Health and Human Services. U.S.
Department of Agriculture, Agricultural Research Service, Washington, DC.
95
Figure 1: Analytic framework
96
LITERATURE SEARCH AND SCREENING PLAN
Inclusion and exclusion criteria

This table provides the inclusion and exclusion criteria for the systematic review. The inclusion
and exclusion criteria are a set of characteristics used to determine which articles identified in the
literature search were included in or excluded from the systematic review.
Table 7. Inclusion and exclusion criteria
Category Inclusion Criteria Exclusion Criteria
Study  Randomized controlled trials  Uncontrolled trials

design
 Non-randomized controlled trials  Case-control studies
including quasi-experimental and
 Cross-sectional studies
controlled before-and-after studies
 Uncontrolled before-and-after
 Prospective cohort studies
studies
 Retrospective cohort studies
 Narrative reviews
 Nested case-control studies
 Systematic reviews
 Meta-analyses
Intervention/  Studies that examine consumption of  Studies that

exposure and/or adherence to a 1a. Do not provide a description
1. Dietary pattern [i.e., the of the dietary pattern, which at
quantities, proportions, variety, or minimum, must include the foods
combination of different foods, and beverages in the pattern
drinks, and nutrients (when (i.e., studies that examine a
available) in diets, and the labeled dietary pattern, but do
frequency with which they are not describe the foods and
habitually consumed] including, at beverages consumed)
a minimum, a description of the
foods and beverages in the
pattern
and/or
2. Diet based on macronutrient 2a. Examine consumption of
distribution outside of the AMDR and/or adherence to a diet based
and on macronutrient proportion in
which all macronutrients are
 Include the macronutrient
within the AMDR
distribution of carbohydrate,
fat, and protein of the diet, and 2b. Do not describe the entire
macronutrient distribution of the
 Include at least one
diet (i.e., studies that only
macronutrient outside of the
examine a single macronutrient
in relation to outcomes)
97
acceptable macronutrient
distribution range (AMDRxviii)
Comparator Dietary patterns described by foods and  No comparator

beverages consumed:
 Macronutrient proportion(s) of
 Consumption of and/or adherence to interest also outside the AMDR
a different dietary pattern
 Different levels of consumption of
and/or adherence to a dietary pattern
Diets described by macronutrient
distribution:
 Different macronutrient distribution of
carbohydrate, fat, and protein
Outcomes  Change in maternal body weight  Changes in weight from any point
from baseline (before or during during pre-pregnancy or
pregnancy) to a later time point pregnancy to postpartum period
during pregnancy and/or right before
delivery
 Weight gain in relationship to weight
gain recommendations, based on
pre-pregnancy BMI
Date of  January 2000-November 2019  Articles published before January

publication 2000 or after November 2019
Publication  Articles that have been peer-  Articles that have not been peer-
status reviewed reviewed and are not published
in peer-reviewed journals,
including unpublished data,
manuscripts, reports, abstracts,
and conference proceedings
Language of  Articles published in English  Articles published in languages

publication other than English
xviii
Macronutrient percent of energy outside of the AMDR are as follows:
 Carbohydrate for all age groups: < 45 or > 65 percent of energy;
 Protein (age 19 years and older): < 10 or > 35 percent of energy;
 Fat (age 19 years and older): < 20 or > 35 percent of energy.
Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein,
and Amino Acids. Washington, DC: The National Academies Press; 2002.
98
Countryxix  Studies conducted in countries  Studies conducted in countries

ranked as high or very high human ranked as medium or lower
development human development
Study  Women during pregnancy  Animal and in vitro models

participants
 Pregnancies conceived ONLY
using Assisted Reproductive
Technologies
 Studies that exclusively enroll
multiple gestation pregnancies
 Studies that enroll both singleton
and multiple pregnancies and do
not account for singleton and
multiple gestation in the design
or analyses and only present
aggregate findings
Health  Studies that enroll mothers who are  Studies that ONLY enroll
status of healthy and/or at risk for chronic mothers who gave birth to
study disease preterm (< 37 weeks)
participants
 Studies that enroll some mothers  Studies that ONLY enroll
diagnosed with a disease mothers diagnosed with a
disease, including severe
 Studies that enroll some mothers
undernutrition or hospitalized
who were severely undernourished
with an illness or injury
prior to pregnancy

 Studies that enroll some or all
mothers classified as underweight, or
obese prior to pregnancy
Temporality  Studies that assess exposure prior to  Studies that assess outcome
outcome prior to exposure
xix
The Human Development classification was based on the Human Development Index (HDI) ranking from the year
the study intervention occurred or data were collected (UN Development Program. HDI 1990-2017 HDRO
calculations based on data from UNDESA (2017a), UNESCO Institute for Statistics (2018), United Nations Statistics
Division (2018b), World Bank (2018b), Barro and Lee (2016) and IMF (2018). Available from:
http://hdr.undp.org/en/data). If the study did not report the year in which the intervention occurred or data were
collected, the HDI classification for the year of publication was applied. HDI values are available from 1980, and then
from 1990 to present. If a study was conducted prior to 1990, the HDI classification from 1990 was applied. When a
country was not included in the HDI ranking, the current country classification from the World Bank was used instead
(The World Bank. World Bank country and lending groups. Available from:
https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world- country-and-lending-groups).
99
Electronic databases and search terms
PubMed
 Provider: U.S. National Library of Medicine
 Date(s) searched: June 26, 2019, Update: November 7, 2019
 Date range searched: January 1, 2000 – June 26, 2019; Update: January 1, 2000 –
November 7, 2019
 Search terms:
#1 - dietary pattern* OR diet pattern* OR eating pattern* OR food pattern* OR diet quality[tiab]
OR eating habit*[tiab] OR dietary habit* OR diet habit* OR food habit* OR “Feeding
Behavior”[Mesh] OR feeding behavior*[tiab] OR beverage consumption[tiab] OR beverage
habit*[tiab] OR beverage intake*[tiab] OR dietary profile* OR food profile[tiab] OR diet profile*
OR eating profile* OR dietary guideline* OR dietary recommendation* OR dietary intake[tiab] OR
food intake[tiab] OR food consumption[tiab] OR dietary consumption[tiab] OR eating frequenc*
OR food frequenc*[tiab] OR eating style*[tiab] OR dietary change*[tiab] OR dietary choice*[tiab]
OR food choice*[tiab] OR "Diet, Mediterranean"[Mesh] OR Mediterranean Diet*[tiab] OR "Dietary
Approaches To Stop Hypertension"[Mesh] OR Dietary Approaches To Stop Hypertension Diet*
OR DASH diet* OR "Diet, Gluten-Free"[Mesh] OR Gluten Free diet* OR prudent diet* OR "Diet,
Paleolithic"[Mesh] OR Paleolithic Diet* OR "Diet, Vegetarian"[Mesh] OR vegetarian diet*[tiab]
OR vegan diet* OR "Healthy Diet"[Mesh] OR plant based diet* OR "Diet, Western"[Mesh] OR
western diet* OR "Diet, Carbohydrate-Restricted"[Mesh] OR low-carbohydrate diet* OR high
carbohydrate diet* OR Ketogenic Diet* OR Nordic Diet* OR "Diet, Fat-Restricted"[Mesh] OR
"Diet, High-Fat"[Mesh] OR "Diet, High-Protein"[Mesh] OR high protein diet*[tiab] OR high‐fat
diet* [tiab] OR low fat diet*[tiab] OR "Diet, Protein-Restricted"[Mesh] OR low protein diet* OR
"Diet, Sodium-Restricted"[Mesh] OR low-sodium diet* OR low salt diet* OR (("Dietary
Proteins"[Mesh] OR dietary protein*[tiab] OR "Dietary Carbohydrates"[Mesh] OR dietary
carbohydrate*[tiab] OR "Dietary Fats"[Mesh] OR dietary fat*[tiab] OR hypocaloric OR hypo-
caloric) AND (diet[tiab] OR diets[tiab] OR consumption[tiab] OR intake[tiab] OR
supplement*[tiab])) OR (“Guideline Adherence"[Mesh] AND (diet[tiab] OR dietary[tiab] OR
food[tiab] OR beverage[tiab])) OR (diet score* OR diet quality score* OR diet quality index* OR
dietary habits score* OR kidmed OR diet index* OR dietary index* OR Food-based Index* OR
diet quality index* OR food index* OR food score* OR Mediterranean diet score* OR
MedDietScore OR healthy eating index[tiab] OR food frequency questionnaire* OR food
frequency survey* OR “Nutrition Surveys”[Mesh] OR nutrition survey*[tiab] OR diet survey*[tiab]
OR food survey* OR dietary questionnaire[tiab]) OR ((pattern[tiab] OR patterns[tiab] OR
consumption[tiab] OR habit*[tiab]) AND (“Diet"[Mesh:NoExp] OR diet[tiab] OR diets[tiab] OR
dietary[tiab] OR "Food"[Mesh] OR food[tiab] OR foods[tiab] OR "Beverages"[Mesh] OR
beverage[tiab] OR beverages[tiab]))
#2 - "Pregnancy"[Mesh] OR “Pregnancy Complications”[Mesh] OR “Prenatal Exposure Delayed
Effects”[Mesh] OR “Maternal Exposure”[Mesh] OR “pregnant women”[Mesh] OR pregnan*[tiab]
OR pre-pregnancy[tiab] OR prenatal[tiab] OR pre-natal[tiab] OR maternal[tiab] OR mother[tiab]
OR mothers[tiab] OR “Mothers”[Mesh] OR postpartum[tiab] OR perinatal[tiab] OR peri-natal[tiab]
OR pre-conception[tiab] OR preconception[tiab] OR peri-conception[tiab] OR
periconception[tiab] OR "Peripartum Period"[Mesh] OR peripartum[tiab] OR peri-partum[tiab] OR
gestation*[tiab] OR natal[tiab] OR antenatal[tiab] OR ante-natal[tiab] OR puerperium[tiab] OR
100
"Maternal Nutritional Physiological Phenomena"[Mesh] OR "Postpartum Period"[Mesh] OR
postpartum[tiab] OR post‐partum[tiab] OR perinatal OR peri-natal OR puerperium[tiab] OR
postpartal OR post‐partal OR postnatal OR post delivery[tiab] OR after birth[tiab] OR
"Lactation"[Mesh] OR lactation[tiab] OR lactating[tiab] OR "Breast Feeding"[Mesh] OR
breastfeeding[tiab] OR breast‐feeding[tiab] OR breast feed* OR breast-feed*[tiab] OR
breastfed[tiab] OR breast-fed[tiab] OR breastfeed* OR "Milk, Human"[Mesh] OR human
milk[tiab] OR nursing women[tiab]
#3 - "Gestational Weight Gain"[Mesh] OR gestational weight gain[tiab] OR "Weight
Gain"[Mesh:NoExp] OR weight gain[tiab] OR "Obesity"[Mesh] OR obesity[tiab] OR obese[tiab]
OR overweight[tiab] OR "body size"[tiab] OR "Body Size"[Mesh] OR overnutrition[tiab] OR
"Overnutrition"[Mesh:NoExp] OR adipos*[tiab] OR anthropometry[tiab] OR anthropometric*[tiab]
OR "Adiposity"[Mesh] OR adipose[tiab] OR body weight[tiab] OR "Body Weight"[Mesh] OR
"Body Composition"[Mesh] OR body fat[tiab] OR weight[ti] OR "Body Mass Index"[Mesh] OR
body mass index[tiab] OR BMI[tiab] OR weight status[tiab] OR "Adipose Tissue"[Mesh] OR
healthy weight[tiab] OR body fat mass[tiab] OR weight change[tiab] OR weight changes[tiab] OR
"Weight Loss"[Mesh] OR weight loss*[tiab] OR weight reduc*[tiab] OR body weight[tiab] OR
"Weight Reduction Programs"[Mesh] OR "Body-Weight Trajectory"[Mesh] OR weight maint* OR
"Diet, Reducing"[Mesh] OR diet reduc*[tiab] OR weight cycling[tiab] OR weight decreas*[tiab]
OR weight watch*[tiab] OR weight control*[tiab] OR weight retention[tiab] OR (weight[tiab] AND
(reduction OR reduced OR reducing OR loss OR losses OR maintenanc* OR maintain*[tiab] OR
decreas*[tiab] OR watch OR control*[tiab] OR change*[tiab] OR gain[tiab]))
#4 - #1 AND #2 AND #3
#5 - #4 NOT ("Animals"[Mesh] NOT ("Animals"[Mesh] AND "Humans"[Mesh])) NOT
(editorial[ptyp] OR comment[ptyp] OR news[ptyp] OR letter[ptyp] OR review[ptyp] OR systematic
review[ptyp] OR systematic review[ti] OR meta-analysis[ptyp] OR meta-analysis[ti] OR meta-
analyses[ti] OR retracted publication[ptyp] OR retraction of publication[ptyp] OR retraction of
publication[tiab] OR retraction notice[ti]) Filters: Publication date from 2000/01/01 to 2019/06/26;
English, Update: Filters: Publication date from 2000/01/01 to 2019/11/07; English
Cochrane Central Register of Controlled Trials (CENTRAL)

 Provider: John Wiley & Sons
 Date(s) searched: June 26, 2019; Update: November 7, 2019
November 7, 2019
 Search terms:
#1 - “dietary pattern*” OR “diet pattern*” OR “eating pattern*” OR “food pattern*” OR “diet
quality” OR “eating habit*” OR “dietary habit*” OR “diet habit*” OR “food habit*” OR [mh
“Feeding Behavior”] OR “feeding behavior*” OR “beverage consumption” OR “beverage habit*”
OR “beverage intake*” OR “dietary profile*” OR “food profile” OR “diet profile*” OR “eating
profile*” OR “dietary guideline*” OR “dietary recommendation*” OR “dietary intake” OR “food
intake” OR “food consumption” OR “dietary consumption” OR “eating frequenc*” OR “food
frequenc*” OR “eating style*” OR “dietary change*” OR “dietary choice*” OR “food choice*” OR
[mh "Diet, Mediterranean"] OR “Mediterranean Diet*” OR [mh "Dietary Approaches To Stop
Hypertension"] OR “Dietary Approaches To Stop Hypertension Diet*” OR “DASH diet*” OR [mh
"Diet, Gluten-Free"] OR “Gluten Free diet*” OR “prudent diet*” OR [mh "Diet, Paleolithic"] OR
101
“Paleolithic Diet*” OR [mh "Diet, Vegetarian"] OR “vegetarian diet*” OR “vegan diet*” OR [mh
"Healthy Diet"] OR “plant based diet*” OR [mh "Diet, Western"] OR “western diet*” OR [mh
"Diet, Carbohydrate-Restricted"] OR “low-carbohydrate diet*” OR “high carbohydrate diet*” OR
“Ketogenic Diet*” OR “Nordic Diet*” OR [mh "Diet, Fat-Restricted"] OR [mh "Diet, High-Fat"]
OR [mh "Diet, High-Protein"] OR “high protein diet*” OR “high‐fat diet*” OR “low fat diet*” OR
[mh "Diet, Protein-Restricted"] OR “low protein diet*” OR [mh "Diet, Sodium-Restricted"] OR
“low-sodium diet*” OR “low salt diet*”OR (([mh "Dietary Proteins"] OR “dietary protein*” OR
[mh "Dietary Carbohydrates"] OR “dietary carbohydrate*” OR [mh "Dietary Fats"] OR “dietary
fat*” OR hypocaloric OR hypo-caloric) NEAR (diet OR diets OR consumption OR intake OR
supplement*)) OR ("guideline adherence") NEAR (diet OR dietary OR food OR beverage)) OR
(“diet score” OR “diet scores” OR “diet quality score” OR “diet quality scores” OR “diet quality
index” OR “dietary habits score” OR kidmed OR “diet index” OR “dietary index” OR “Food-
based Index” OR “diet quality index” OR “food index” OR “food score” OR “food scores” OR
“Mediterranean diet score” OR MedDietScore OR “healthy eating index” OR “food frequency
questionnaire” OR “food frequency questionnaires” OR “food frequency survey” OR “food
frequency surveys” OR [mh “Nutrition Surveys”] OR “nutrition survey” OR “nutrition surveys”
OR “diet survey” OR “diet surveys” OR “food survey” OR “food surveys” OR “dietary
questionnaire”):ti,ab,kw OR ((pattern OR patterns OR consumption OR habit*) NEAR ([mh
^Diet] OR diet OR diets OR dietary OR [mh Food] OR food OR foods OR [mh Beverages] OR
beverage OR beverages)):ti,ab,kw
#2 - [mh "Pregnancy"] OR [mh "Pregnancy Complications"] OR [mh "Prenatal Exposure
Delayed Effects"] OR [mh "Maternal Exposure"] OR [mh "Pregnant Women"] OR [mh
"Mothers"] OR [mh "Peripartum Period"] OR [mh "Maternal Nutritional Physiological
Phenomena"] OR [mh "Postpartum Period"] OR [mh Lactation] OR [mh "Breast Feeding"] OR
[mh "Milk, Human"] OR (pregnancy OR pre-pregnancy OR prenatal OR pre-natal OR maternal
OR mother OR mothers OR postpartum OR perinatal OR peri-natal OR pre-conception OR
preconception OR peri-conception OR periconception OR peripartum OR peri-partum OR
gestation* OR natal OR antenatal OR ante-natal OR puerperium OR postpartum OR post‐
partum OR perinatal OR peri-natal OR puerperium OR postpartal OR post‐partal OR postnatal
OR “post delivery” OR “after birth” OR lactation OR lactating OR breastfeeding OR breast‐
feeding OR breast feed* OR breast-feed* OR breastfed OR breast-fed OR breastfeed OR
“human milk” OR “nursing women”):ti,ab,kw
#3 - (weight NEAR/4 (reduction OR reduced OR reducing OR loss OR losses OR maintenanc*
OR maintain* OR decreas* OR watch OR control* OR change* OR gain)):ti,ab,kw OR
(“gestational weight gain” OR “weight gain” OR obesity OR obese OR overweight OR "body
size" OR overnutrition OR adipos* OR anthropometry OR anthropometric* OR adipose OR
“body weight” OR “body fat” OR weight OR “body mass index” OR BMI OR “weight status” OR
“healthy weight” OR “body fat mass” OR “weight change” OR “weight changes” OR “weight
loss*” OR “weight reduct*” OR “body weight” OR “weight maint*” OR “diet reduc*” OR “weight
cycling” OR “weight decreas*” OR “weight watch*” OR “weight control*” OR “weight
retention”):ti,ab,kw OR [mh "Gestational Weight Gain"] OR [mh ^"Weight Gain"] OR [mh
Obesity] OR [mh "Body Size"] OR [mh ^Overnutrition] OR [mh Adiposity] OR [mh "body
weight"] OR [mh "Body Composition"] OR [mh "Body Mass Index"] OR [mh "Adipose Tissue"]
OR [mh "Weight Loss"] OR [mh "Weight Reduction Programs"] OR [mh "Body-Weight
Trajectory"] OR [mh "Diet, Reducing"]
#4 - #1 AND #2 AND #3
Filters: publication year from 2000 to 2019, Trials
102
Embase
 Provider: Elsevier
 Date(s) searched: June 26, 2019, Update: November 7, 2019
November 7, 2019
 Search terms:
#1 - 'feeding behavior'/exp OR 'mediterranean diet'/de OR 'dash diet'/de OR 'gluten free
diet'/exp OR 'paleolithic diet'/de OR 'vegetarian diet'/exp OR 'healthy diet'/de OR 'western
diet'/de OR 'low carbohydrate diet'/exp OR 'low fat diet'/de OR 'lipid diet'/exp OR 'protein
diet'/exp OR 'protein restriction'/de OR 'sodium restriction'/de OR 'dietary pattern*':ab,ti OR
'diet pattern*':ab,ti OR 'eating pattern*':ab,ti OR 'food pattern*':ab,ti OR 'diet quality':ab,ti OR
'eating habit*':ab,ti OR 'dietary habit*':ab,ti OR 'diet habit*':ab,ti OR 'food habit*':ab,ti OR
'feeding behavior*':ab,ti OR 'beverage consumption':ab,ti OR 'beverage habit*':ab,ti OR
'beverage intake*':ab,ti OR 'dietary profile*':ab,ti OR 'food profile':ab,ti OR 'diet profile*':ab,ti
OR 'eating profile*':ab,ti OR 'dietary guideline*':ab,ti OR 'dietary recommendation*':ab,ti OR
'dietary intake':ab,ti OR 'food intake':ab,ti OR 'food consumption':ab,ti OR 'dietary
consumption':ab,ti OR 'eating frequenc*':ab,ti OR 'food frequenc*':ab,ti OR 'eating style*':ab,ti
OR 'dietary change*':ab,ti OR 'dietary choice*':ab,ti OR 'food choice*':ab,ti OR 'mediterranean
diet*':ab,ti OR 'dietary approaches to stop hypertension diet*':ab,ti OR 'dash diet*':ab,ti OR
'gluten free diet*':ab,ti OR 'prudent diet*':ab,ti OR 'paleolithic diet*':ab,ti OR 'vegetarian
diet*':ab,ti OR 'vegan diet*':ab,ti OR 'plant based diet*':ab,ti OR 'western diet*':ab,ti OR 'low-
carbohydrate diet*':ab,ti OR 'high carbohydrate diet*':ab,ti OR 'ketogenic diet*':ab,ti OR 'nordic
diet*':ab,ti OR 'high protein diet*':ab,ti OR 'high‐fat diet*':ab,ti OR 'low fat diet*':ab,ti OR 'low
protein diet*':ab,ti OR 'low-sodium diet*':ab,ti OR 'low salt diet*':ab,ti OR ((('dietary protein*'
OR 'dietary carbohydrate*' OR 'dietary fat*' OR hypocaloric OR 'hypo caloric') NEAR/6 (diet
OR diets OR consumption OR intake OR supplement*)):ab,ti)* OR (('guideline adherence'
NEAR/6 (diet OR dietary OR food OR beverage)):ab,ti) OR 'diet score*':ab,ti OR 'diet quality
score*':ab,ti OR 'dietary habits score*':ab,ti OR kidmed:ab,ti OR 'diet index*':ab,ti OR 'dietary
index*':ab,ti OR 'food-based index*':ab,ti OR 'diet quality index*':ab,ti OR 'food index*':ab,ti OR
'food score*':ab,ti OR 'mediterranean diet score*':ab,ti OR meddietscore:ab,ti OR 'healthy
eating index':ab,ti OR 'food frequency questionnaire*':ab,ti OR 'food frequency survey*':ab,ti
OR 'nutrition survey*':ab,ti OR 'diet survey*':ab,ti OR 'food survey*':ab,ti OR 'dietary
questionnaire':ab,ti OR ((pattern OR patterns OR consumption OR habit*) NEAR/6 (diet OR
diets OR dietary OR food OR foods OR beverage OR beverages)):ab,ti)
#2 - pregnancy:ab,ti OR 'pre pregnancy':ab,ti OR prenatal:ab,ti OR 'pre natal':ab,ti OR
maternal:ab,ti OR mother:ab,ti OR mothers:ab,ti OR 'pre conception':ab,ti OR
preconception:ab,ti OR 'peri conception':ab,ti OR periconception:ab,ti OR peripartum:ab,ti OR
'peri partum':ab,ti OR gestation*:ab,ti OR natal:ab,ti OR antenatal:ab,ti OR 'ante natal':ab,ti
OR postpartum:ab,ti OR post‐partum:ab,ti OR perinatal:ab,ti OR 'peri natal':ab,ti OR
puerperium:ab,ti OR postpartal:ab,ti OR post‐partal:ab,ti OR postnatal:ab,ti OR 'post
delivery':ab,ti OR 'after birth':ab,ti OR lactation:ab,ti OR lactating:ab,ti OR breastfeeding:ab,ti
OR breast‐feeding:ab,ti OR 'breast feed*':ab,ti OR breastfed:ab,ti OR 'breast fed':ab,ti OR
breastfeed:ab,ti OR 'human milk':ab,ti OR 'nursing women':ab,ti OR 'pregnancy'/exp/mj OR
'pregnancy complication'/exp/mj OR 'prenatal exposure'/mj OR 'maternal exposure'/mj OR
'pregnant woman'/mj OR 'mother'/mj OR 'puerperium'/exp/mj OR 'maternal nutrition'/mj OR
'lactation'/mj OR 'breast feeding'/exp/mj OR 'breast milk'/exp/mj
103
#3 - ((weight NEAR/4 (reduction OR reduced OR reducing OR loss OR losses OR
maintenanc* OR maintain* OR decreas* OR watch OR control* OR change* OR gain)):ab,ti)
OR 'gestational weight gain':ab,ti OR 'weight gain':ab,ti OR obesity:ab,ti OR obese:ab,ti OR
overweight:ab,ti OR 'body size':ab,ti OR overnutrition:ab,ti OR adipos*:ab,ti OR
anthropometry:ab,ti OR anthropometric*:ab,ti OR adipose:ab,ti OR 'body fat':ab,ti OR
weight:ab,ti OR 'body mass index':ab,ti OR bmi:ab,ti OR 'weight status':ab,ti OR 'healthy
weight':ab,ti OR 'body fat mass':ab,ti OR 'weight change':ab,ti OR 'weight changes':ab,ti OR
'weight loss*':ab,ti OR 'weight reduct*':ab,ti OR 'body weight':ab,ti OR 'weight maint*':ab,ti OR
'diet reduc*':ab,ti OR 'weight cycling':ab,ti OR 'weight decreas*':ab,ti OR 'weight watch*':ab,ti
OR 'weight control*':ab,ti OR 'weight retention':ab,ti OR 'gestational weight gain'/mj OR 'body
weight gain'/de OR 'obesity'/exp/mj OR 'body size'/mj OR 'overnutrition'/mj OR 'body
weight'/exp/mj OR 'body composition'/exp/mj OR 'body mass'/de OR 'adipose tissue'/exp/mj
OR 'body weight loss'/exp/mj OR 'weight loss program'/mj OR 'weight trajectory (body
weight)'/mj OR 'low calorie diet'/exp/mj
#4 - #1 AND #2 AND #3
#5 - #4 AND ([article]/lim OR [article in press]/lim) AND [humans]/lim AND [english]/lim AND
[2000-2019]/py NOT ([conference abstract]/lim OR [conference paper]/lim OR [editorial]/lim
OR [erratum]/lim OR [letter]/lim OR [note]/lim OR [review]/lim OR [systematic review]/lim OR
[meta analysis]/lim)
Cumulative Index of Nursing and Allied Health Literature (CINAHL Plus)

 Provider: EBSCOhost
 Date(s) searched: June 26, 2019; Update: November 7, 2019
November 7, 2019
 Search terms:
#1 - “dietary pattern*” OR “diet pattern*” OR “eating pattern*” OR “food pattern*” OR “diet
quality” OR “eating habit*” OR “dietary habit*” OR “diet habit*” OR “food habit*” OR MH
"Eating Behavior+" OR “feeding behavior*” OR “beverage consumption” OR “beverage habit*”
OR “beverage intake*” OR “dietary profile*” OR “food profile*” OR “diet profile*” OR “eating
profile*” OR “dietary guideline*” OR “dietary recommendation*” OR “dietary intake*” OR “food
intake*” OR “food consumption” OR “dietary consumption” OR “eating frequenc*” OR “food
frequenc*” OR “eating style*” OR “dietary change*” OR “dietary choice*” OR food choice*” OR
MH "Diet, Mediterranean" OR “Mediterranean Diet*” OR MH "Dietary Approaches To Stop
Hypertension" OR “Dietary Approaches To Stop Hypertension Diet*” OR “DASH diet*” OR MH
"Diet, Gluten-Free" OR “Gluten Free diet*” OR “prudent diet*” OR MH "Diet, Paleolithic" OR
“Paleolithic Diet*” OR MH "Diet, Vegetarian" OR “vegetarian diet*” OR “vegan diet*” OR MH
"Healthy Diet" OR “plant based diet*” OR MH "Diet, Western" OR “western diet*” OR MH
"Diet, Carbohydrate-Restricted" OR “low-carbohydrate diet*” OR “high carbohydrate diet*” OR
“Ketogenic Diet*” OR “Nordic Diet*” OR MH "Diet, Fat-Restricted" OR MH "Diet, High-Fat" OR
MH "Diet, High-Protein" OR “high protein diet*” OR “high‐fat diet*” OR “low fat diet*” OR MH
"Diet, Protein-Restricted" OR “low protein diet*” OR MH "Diet, Sodium-Restricted" OR “low-
sodium diet*” OR “low salt diet*” OR ((MH "Dietary Proteins" OR “dietary protein*” OR MH
"Dietary Carbohydrates" OR “dietary carbohydrate*” OR MH "Dietary Fats" OR “dietary fat*”
OR hypocaloric OR hypo-caloric) AND (diet OR diets OR consumption OR intake OR
104
supplementation)) OR (MH “Guideline Adherence" AND (diet OR dietary OR food OR
beverage)) OR (“diet score*” OR “diet quality score*” OR “diet quality index*” OR “dietary
habits score*” OR kidmed OR “diet index*” OR “dietary index*” OR “Food-based Index*” OR
“diet quality index*” OR “food index*” OR “food score*” OR “Mediterranean diet score*” OR
MedDietScore OR “healthy eating index” OR “food frequency questionnaire*” OR “food
frequency survey*” OR MH “Nutrition Surveys” OR “nutrition survey*” OR “diet survey*” OR
“food survey*” OR “dietary questionnaire*”) OR ((pattern OR patterns OR consumption OR
habit*) AND (MH “Diet" OR diet OR diets OR dietary OR MH "Food" OR food OR foods OR
MH "Beverages" OR beverage OR beverages))
#2 - postpartum OR post-partum OR MH "Postpartum Period" OR postpartal OR post‐partal
OR postnatal OR post-natal OR "post deliver*" OR "after birth" OR MH pregnancy OR MH
“pregnancy complications” OR MH "Prenatal Exposure Delayed Effects" OR MH "Maternal
Exposure" OR MH "pregnant women" OR pregnan* OR pre-pregnancy OR prepregnancy OR
prenatal OR antenatal OR maternal OR mother OR mothers OR perinatal OR peri-natal OR
peri-conception OR periconception OR MH "Peripartum Period" OR peripartum OR peri-
partum OR gestation* OR natal OR puerperium OR MH "Maternal Nutritional Physiological
Phenomena" OR MH "Breast Feeding"OR breastfeeding OR breast‐feeding OR MH "Milk,
Human" OR “human milk” OR MH Lactation OR lactation OR lactating OR breastfeeding OR
“breast feed*” OR breast-feed* OR breastfed OR breast-fed OR breastfeed* OR "nursing
women" OR “nursing mother*”
#3 - MH "Gestational Weight Gain" OR MH "Weight Gain" OR MH Obesity OR MH "Body
Size" OR MH Overnutrition OR MH Adiposity OR MH "Body Weight” OR MH "Body
Composition" OR MH "Body Mass Index" OR MH "Adipose Tissue" OR MH "Weight Loss" OR
MH "Weight Reduction Programs" OR MH "Body-Weight Trajectory" OR MH "Diet, Reducing"
OR gestational weight gain OR weight gain OR obesity OR obese OR overweight OR "body
size" OR overnutrition OR adipos* OR anthropometry OR anthropometric* OR adipose OR
“body weight” OR “body fat” OR weight OR “body mass index” OR BMI OR “weight status” OR
“healthy weight” OR “body fat mass” OR “weight change” OR “weight changes” OR “weight
loss*” OR “weight reduc*” OR “body weight” OR MH "Body-Weight Trajectory" OR “weight
change*” OR “weight maint*” OR “diet reduc*” OR “weight cycling” OR “weight decreas*” OR
“weight watch*” OR “weight control*” OR “weight retention” OR (weight N4 (reduction OR
reduced OR reducing OR loss OR losses OR maintenanc* OR maintain* OR decreas* OR
watch OR control* OR change* OR gain ))
#4 - #1 AND #2 AND #3
#5 - #4 NOT (MH "Literature Review" OR MH "Meta Analysis" OR MH "Systematic Review"
OR MH "News" OR MH "Retracted Publication" OR MH "Retraction of Publication)
Filters: Published Date: 20000101 - 20190626; Update: Published Date: 20000101 -
20191107
LITERATURE SEARCH AND SCREENING RESULTS

The flow chart (Figure 2) below illustrates the literature search and screening results for
articles examining the systematic review questions on dietary patterns and gestational weight
gain (GWG), as well as dietary patterns and postpartum weight loss (PPWL). Articles on
dietary patterns and GWG and dietary patterns and PPWL were searched for and screened
105
together. This was done to leverage the overlap in topical areas and to improve efficiency.
After the initial electronic database search (January 2000-June 2019), an updated search was
conducted to also capture macronutrient distribution articles (January 2000-November 2019).
The results of both electronic database searches, after removal of duplicates, were screened
independently by two NESR analysts using a step-wise process by reviewing titles, abstracts,
and full-texts to determine which articles met the inclusion criteria for each systematic review
question depicted in the flow chart. Refer to Table 8 for the rationale for exclusion for each
excluded full-text article. A manual search was done to find articles that were not identified
when searching the electronic databases; all manually identified articles are also screened to
determine whether they meet criteria for inclusion.
Figure 2: Flow chart of literature search and screening results
106
Excluded articles
The table below lists the articles excluded after full-text screening, and includes columns for the categories of inclusion and
exclusion criteria (see Table 7) that studies were excluded based on. At least one reason for exclusion is provided for each article,
though this may not reflect all possible reasons for exclusion. Information about articles excluded after title and abstract screening
is available upon request.
Table 8. Articles excluded after full text screening with rationale for exclusion
Citation Rationale
1. Aaltonen, J, Ojala, T, Laitinen, K, Poussa, T, Ozanne, S, Isolauri, E. Impact of maternal Intervention/Exposure; Outcome
diet during pregnancy and breastfeeding on infant metabolic programming: a prospective
randomized controlled study. Eur J Clin Nutr. 2011. 65:10-9. doi:10.1038/ejcn.2010.225.
2. Abdel-Aziz, SB, Hegazy, IS, Mohamed, DA, Abu El Kasem, MMA, Hagag, SS. Effect of Intervention/Exposure
dietary counseling on preventing excessive weight gain during pregnancy. Public Health.
2018. 154:172-181. doi:10.1016/j.puhe.2017.10.014.
3. Abreu, S, Santos, PC, Montenegro, N, Mota, J. Relationship between dairy product intake Intervention/Exposure
during pregnancy and neonatal and maternal outcomes among Portuguese women. Obes
Res Clin Pract. 2017. 11:276-286. doi:10.1016/j.orcp.2016.07.001.
4. Adair, LS, Kuzawa, CW, Borja, J. Maternal energy stores and diet composition during Outcome
pregnancy program adolescent blood pressure. Circulation. 2001. 104:1034-9.
doi:10.1161/hc3401.095037.
5. Adherence to Canada's Food Guide Recommendations during Pregnancy: Nutritional Outcome
Epidemiology and Public Health. Curr Dev Nutr. 2017. 1:e000356.
doi:10.3945/cdn.116.000356.
6. Ainscough, K, Kennelly, MA, O'Sullivan, EJ, Lindsay, KL, Gibney, ER, McCarthy, M, Abstract
McAuliffe, FM. Impact of a smartphone app supporting a lifestyle intervention in
overweight and obese pregnancy on on maternal health and lifestyle outcomes. American
journal of obstetrics and gynecology. 2018. 218:S598‐S599.
7. Akbari, Z, Mansourian, M, Kelishadi, R. Relationship of the intake of different food groups Intervention/Exposure; Outcome
by pregnant mothers with the birth weight and gestational age: Need for public and
individual educational programs. J Educ Health Promot. 2015. 4:23. doi:10.4103/2277-
9531.154109.
8. Allman, BR, Diaz Fuentes, E, Williams, DK, Turner, DE, Andres, A, Borsheim, E. Obesity Intervention/Exposure; Outcome
Status Affects the Relationship Between Protein Intake and Insulin Sensitivity in Late
Pregnancy. Nutrients. 2019. 11. doi:10.3390/nu11092190.
107
Citation Rationale
9. Althuizen, E, van Poppel, MN, Seidell, JC, van Mechelen, W. Correlates of absolute and Intervention/Exposure
excessive weight gain during pregnancy. J Womens Health (Larchmt). 2009. 18:1559-66.
doi:10.1089/jwh.2008.1275.
10. Alves-Santos, NH, Cocate, PG, Benaim, C, Farias, DR, Emmett, PM, Kac, G. Outcome
Prepregnancy Dietary Patterns and Their Association with Perinatal Outcomes: A
Prospective Cohort Study. J Acad Nutr Diet. 2019. doi:10.1016/j.jand.2019.02.016.
11. Alves-Santos, NH, Cocate, PG, Eshriqui, I, Benaim, C, Barros, EG, Emmett, PM, Kac, G. Population
Dietary patterns and their association with adiponectin and leptin concentrations
throughout pregnancy: a prospective cohort. Br J Nutr. 2018. 119:320-329.
doi:10.1017/s0007114517003580.
12. Alves-Santos, NH, Eshriqui, I, Franco-Sena, AB, Cocate, PG, Freitas-Vilela, AA, Benaim, Intervention/Exposure; Outcome
C, Vaz Jdos, S, Castro, MB, Kac, G. Dietary intake variations from pre-conception to
gestational period according to the degree of industrial processing: A Brazilian cohort.
Appetite. 2016. 105:164-71. doi:10.1016/j.appet.2016.05.027.
13. Amezcua-Prieto, C, Martínez-Galiano, JM, Cano-Ibáñez, N, Olmedo-Requena, R, Bueno- Study Design
Cavanillas, A, Delgado-Rodríguez, M. Types of carbohydrates intake during pregnancy
and frequency of a small for gestational age newborn: A case-control study. Nutrients.
2019. 11. doi:10.3390/nu11030523.
14. Anand, SS, Gupta, M, Teo, KK, Schulze, KM, Desai, D, Abdalla, N, Zulyniak, M, de Souza, Intervention/Exposure; Outcome
R, Wahi, G, Shaikh, M, Beyene, J, de Villa, E, Morrison, K, McDonald, SD, Gerstein, H.
Causes and consequences of gestational diabetes in South Asians living in Canada:
results from a prospective cohort study. CMAJ Open. 2017. 5:E604-e611.
doi:10.9778/cmajo.20170027.
15. Anleu, E, Reyes, M, Araya, BM, Flores, M, Uauy, R, Garmendia, ML. Effectiveness of an Intervention/Exposure
Intervention of Dietary Counseling for Overweight and Obese Pregnant Women in the
Consumption of Sugars and Energy. Nutrients. 2019. 11. doi:10.3390/nu11020385.
16. Antal, M. Nutritional status of Hungarian pregnant women. Forum Nutr. 2003. 56:229-31. Intervention/Exposure; Outcome
17. Antonakou, A, Papoutsis, D, Panou, I, Chiou, A, Matalas, AL. Role of exclusive Intervention/Exposure
breastfeeding in energy balance and weight loss during the first six months postpartum.
Clin Exp Obstet Gynecol. 2013. 40:485-8.
18. Apolzan, JW, Myers, CA, Cowley, AD, Brady, H, Hsia, DS, Stewart, TM, Redman, LM, Intervention/Exposure
Martin, CK. Examination of the reliability and validity of the Mindful Eating Questionnaire
in pregnant women. Appetite. 2016. 100:142-51. doi:10.1016/j.appet.2016.02.025.
19. Arredondo, A, Torres, C, Orozco, E, Pacheco, S, Huang, F, Zambrano, E, Bolanos- Outcome
Jimenez, F. Socio-economic indicators, dietary patterns, and physical activity as
determinants of maternal obesity in middle-income countries: Evidences from a cohort
study in Mexico. Int J Health Plann Manage. 2019. 34:e713-e725. doi:10.1002/hpm.2684.
108
Citation Rationale
20. Artal, R, Catanzaro, RB, Gavard, JA, Mostello, DJ, Friganza, JC. A lifestyle intervention of Intervention/Exposure
weight-gain restriction: diet and exercise in obese women with gestational diabetes
mellitus. Appl Physiol Nutr Metab. 2007. 32:596-601. doi:10.1139/h07-024.
21. Arvizu, M, Afeiche, MC, Hansen, S, Halldorsson, TF, Olsen, SF, Chavarro, JE. Fat intake Outcome
during pregnancy and risk of preeclampsia: a prospective cohort study in Denmark.
European Journal of Clinical Nutrition. 2019. 73:1040-1048. doi:10.1038/s41430-018-
0290-z.
22. Arvizu, M, Stuart, J, Rich-Edwards, J, Gaskins, A, Rosner, B, Chavarro, J. Adherence to Abstract
Pre-pregnancy DASH Dietary Pattern and Diet Recommendations from the American
Heart Association and the Risk of Preeclampsia (OR35-06-19). Curr Dev Nutr. 2019. 3.
doi:10.1093/cdn/nzz048.OR35-06-19.
23. Asbjornsdottir, B, Ronneby, H, Vestgaard, M, Ringholm, L, Nichum, VL, Jensen, DM, Intervention/Exposure; Health Status
Raben, A, Damm, P, Mathiesen, ER. Lower daily carbohydrate consumption than
recommended by the Institute of Medicine is common among women with type 2 diabetes
in early pregnancy in Denmark. Diabetes Res Clin Pract. 2019. 152:88-95.
doi:10.1016/j.diabres.2019.05.012.
24. Asci, O, Rathfisch, G. Effect of lifestyle interventions of pregnant women on their dietary Intervention/Exposure
habits, lifestyle behaviors, and weight gain: a randomized controlled trial. J Health Popul
Nutr. 2016. 35:7. doi:10.1186/s41043-016-0044-2.
25. Asemi, Z, Samimi, M, Tabassi, Z, Esmaillzadeh, A. The effect of DASH diet on pregnancy Health Status
outcomes in gestational diabetes: a randomized controlled clinical trial. Eur J Clin Nutr.
2014. 68:490-5. doi:10.1038/ejcn.2013.296.
26. Asemi, Z, Samimi, M, Tabassi, Z, Sabihi, S, Esmaillzadeh, A. A randomized controlled Health Status
clinical trial investigating the effect of DASH diet on insulin resistance, inflammation, and
oxidative stress in gestational diabetes. Nutrition. 2013. 29:619-624.
doi:10.1016/j.nut.2012.11.020.
27. Ashman, AM, Collins, CE, Hure, AJ, Jensen, M, Oldmeadow, C. Maternal diet during early Outcome
childhood, but not pregnancy, predicts diet quality and fruit and vegetable acceptance in
offspring. Matern Child Nutr. 2016. 12:579-90. doi:10.1111/mcn.12151.
28. Ashman, AM, Collins, CE, Weatherall, L, Brown, LJ, Rollo, ME, Clausen, D, Blackwell, CC, Intervention/Exposure
Pringle, KG, Attia, J, Smith, R, Lumbers, ER, Rae, KM. A cohort of Indigenous Australian
women and their children through pregnancy and beyond: the Gomeroi gaaynggal study. J
Dev Orig Health Dis. 2016. 7:357-68. doi:10.1017/s204017441600009x.
109
Citation Rationale
29. Assaf-Balut, C, de la Torre, NG, Fuentes, M, Durán, A, Bordiú, E, Del Valle, L, Valerio, J, Study Design; Temporality
Jiménez, I, Herraiz, MA, Izquierdo, N, Torrejón, MJ, de Miguel, MP, Barabash, A, Cuesta,
M, Rubio, MA, Calle-Pascual, AL. 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. doi:10.3390/nu11010066.
30. Assaf-Balut, C, Garcia de la Torre, N, Duran, A, Fuentes, M, Bordiu, E, Del Valle, L, Intervention/Exposure; Outcome
Valerio, J, Familiar, C, Jimenez, I, Herraiz, MA, Izquierdo, N, Torrejon, MJ, Runkle, I, de
Miguel, MP, Moraga, I, Montanez, MC, Barabash, A, Cuesta, M, Rubio, MA, Calle-
Pascual, AL. Medical nutrition therapy for gestational diabetes mellitus based on
Mediterranean Diet principles: a subanalysis of the St Carlos GDM Prevention Study. BMJ
Open Diabetes Res Care. 2018. 6:e000550. doi:10.1136/bmjdrc-2018-000550.
31. Aydin, EK, Ozturk, S. Assessment of the Diets and Weights of Primiparous and Study Design; Intervention/Exposure
Multiparous Pregnant Women in the Last Trimester. International Journal of Caring
Sciences. 2016. 9:1033-1039.
32. Babaei, M, Banaem, LM. Nutritional status of pregnant women and urine calcium-to- Outcome
creatinine ratio during 24th-28th weeks of pregnancy and their relationship with the
incidence of hypertensive disorders during pregnancy. Journal of Kermanshah University
of Medical Sciences. 2018. 22. doi:10.5812/jkums.69638.
33. Badon, SE, Miller, RS, Qiu, C, Sorensen, TK, Williams, MA, Enquobahrie, DA. Maternal Outcome; Comparator
healthy lifestyle during early pregnancy and offspring birthweight: differences by offspring
sex. J Matern Fetal Neonatal Med. 2018. 31:1111-1117.
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34. Bao, W, Bowers, K, Tobias, DK, Olsen, SF, Chavarro, J, Vaag, A, Kiely, M, Zhang, C. Outcome
Prepregnancy low-carbohydrate dietary pattern and risk of gestational diabetes mellitus: a
prospective cohort study. Am J Clin Nutr. 2014. 99:1378-84.
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35. Bao, W. Comment on Koivusalo et al. Gestational diabetes mellitus can be prevented by Study Design
lifestyle intervention: the finnish gestational diabetes prevention study (RADIEL): a
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36. Bao, W, Tobias, DK, Hu, FB, Chavarro, J, Zhang, C. Pre-pregnancy potato consumption Outcome
and risk of gestational diabetes mellitus. BMJ: British Medical Journal. 2016. 352:h6898-
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37. Barbieri, MA, Portella, AK, Silveira, PP, Bettiol, H, Agranonik, M, Silva, AA, Goldani, MZ. Study Design; Outcome
Severe intrauterine growth restriction is associated with higher spontaneous carbohydrate
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38. Barebring, L, Brembeck, P, Lof, M, Brekke, HK, Winkvist, A, Augustin, H. Food intake and Study Design; Intervention/Exposure
gestational weight gain in Swedish women. Springerplus. 2016. 5:377.
doi:10.1186/s40064-016-2015-x.
39. Barnes, RA, Edghill, N, Mackenzie, J, Holters, G, Ross, GP, Jalaludin, BB, Flack, JR. Intervention/Exposure; Outcome
Predictors of large and small for gestational age birthweight in offspring of women with
gestational diabetes mellitus. Diabetic Medicine. 2013. 30:1040-1046.
doi:10.1111/dme.12207.
40. Bawadi, HA, Al-Kuran, O, Al-Bastoni, LA, Tayyem, RF, Jaradat, A, Tuuri, G, Al-Beitawi, Intervention/Exposure; Comparator
SN, Al-Mehaisen, LM. Gestational nutrition improves outcomes of vaginal deliveries in
Jordan: an epidemiologic screening. Nutr Res. 2010. 30:110-7.
doi:10.1016/j.nutres.2010.01.005.
41. Baykan, A, Yalcin, SS, Yurdakok, K. Does maternal iron supplementation during the Outcome
lactation period affect iron status of exclusively breast-fed infants? Turk J Pediatr. 2006.
48:301-7.
42. Beardsall, A, Perreault, M, Farncombe, T, Vanniyasingam, T, Thabane, L, Teo, KK, Intervention/Exposure; Outcome
Atkinson, SA. Maternal and child factors associated with bone length traits in children at
3years of age. Bone. 2019. 127:1-8. doi:10.1016/j.bone.2019.05.025.
43. Bechtel-Blackwell, DA. Computer-assisted self-interview and nutrition education in Intervention/Exposure
pregnant teens. Clin Nurs Res. 2002. 11:450-62. doi:10.1177/105477302237456.
44. Belan, M, Carranza-Mamane, B, AinMelk, Y, Pesant, MH, Duval, K, Jean-Denis, F, Conference abstract
Langlois, MF, Lavoie, H, Waddell, G, Baillargeon, JP. A lifestyle intervention targeting
women with obesity and infertility improves their fertility outcomes, especially in women
with PCOS: a randomized controlled trial. Fertility and sterility. 2019. 112:e40‐.
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Recommended Gestational Weight Gain in High-Risk Versus Low-Risk Pregnancies. Isr
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Bacha, T, Kac, G. Early pregnancy body mass index modifies the association of pre-
pregnancy dietary patterns with serum polyunsaturated fatty acid concentrations
throughout pregnancy in Brazilian women. Matern Child Nutr. 2018. 14.
doi:10.1111/mcn.12480.
47. Bennett, WL, Liu, SH, Yeh, HC, Nicholson, WK, Gunderson, EP, Lewis, CE, Clark, JM. Intervention/Exposure; Diet measured (well) before
Changes in weight and health behaviors after pregnancies complicated by gestational pregnancy
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48. Berkey, CS, Tamimi, RM, Willett, WC, Rosner, B, Hickey, M, Toriola, AT, Lindsay Frazier, Population; Outcome
A, Colditz, GA. Dietary intake from birth through adolescence in relation to risk of benign
breast disease in young women. Breast Cancer Res Treat. 2019. doi:10.1007/s10549-
019-05323-8.
49. Bertolotto, A, Volpe, L, Calianno, A, Pugliese, MC, Lencioni, C, Resi, V, Ghio, A, Corfini, Intervention/Exposure; No association between diet
M, Benzi, L, Del Prato, S, Di Cianni, G. Physical activity and dietary habits during and GWG examined
pregnancy: effects on glucose tolerance. J Matern Fetal Neonatal Med. 2010. 23:1310-4.
doi:10.3109/14767051003678150.
50. Bertz, F, Winkvist, A, Brekke, HK. Sustainable weight loss among overweight and obese Outcome
lactating women is achieved with an energy-reduced diet in line with dietary
recommendations: results from the LEVA randomized controlled trial. J Acad Nutr Diet.
2015. 115:78-86. doi:10.1016/j.jand.2014.05.017.
51. Black, MM, Papas, MA, Bentley, ME, Cureton, P, Saunders, A, Le, K, Anliker, J, Robinson, Population
N. Overweight adolescent African-American mothers gain weight in spite of intentions to
lose weight. J Am Diet Assoc. 2006. 106:80-7. doi:10.1016/j.jada.2005.09.049.
52. Blumfield, ML, Hure, AJ, MacDonald-Wicks, LK, Smith, R, Simpson, SJ, Giles, WB, Outcome; Comparator
Raubenheimer, D, Collins, CE. Dietary balance during pregnancy is associated with fetal
adiposity and fat distribution. Am J Clin Nutr. 2012. 96:1032-41.
doi:10.3945/ajcn.111.033241.
53. Blumfield, ML, Schreurs, M, Rollo, ME, MacDonald-Wicks, LK, Kokavec, A, Collins, CE. Intervention/Exposure; Outcome
The association between portion size, nutrient intake and gestational weight gain: a
secondary analysis in the WATCH study 2006/7. J Hum Nutr Diet. 2016. 29:271-80.
doi:10.1111/jhn.12330.
54. Bo, S, Menato, G, Lezo, A, Signorile, A, Bardelli, C, De Michieli, F, Massobrio, M, Pagano, Intervention/Exposure; Outcome
G. Dietary fat and gestational hyperglycaemia. Diabetologia. 2001. 44:972-8.
doi:10.1007/s001250100590.
55. Bobinski, R, Mikulska, M, Mojska, H, Ulman-Wodarz, I, Sodowska, P. Assessment of the Intervention/Exposure; Outcome
diet components of pregnant women as predictors of risk of preterm birth and born baby
with low birth weight. Ginekol Pol. 2015. 86:292-9.
56. Boghossian, NS, Yeung, EH, Lipsky, LM, Poon, AK, Albert, PS. Dietary patterns in Population
association with postpartum weight retention. Am J Clin Nutr. 2013. 97:1338-45.
doi:10.3945/ajcn.112.048702.
57. Bonakdar, SA, Dorosty Motlagh, AR, Bagherniya, M, Ranjbar, G, Daryabeygi- Study Design; Outcome
Khotbehsara, R, Mohajeri, SAR, Safarian, M. Pre-pregnancy Body Mass Index and
Maternal Nutrition in Relation to Infant Birth Size. Clin Nutr Res. 2019. 8:129-137.
doi:10.7762/cnr.2019.8.2.129.
112
Citation Rationale
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Dietary Patterns during Pregnancy and

Gestational Weight Gain: A Systematic

(2) fax: (202) 690-7442; or

(3) email: program.intake@usda.gov.

USDA is an equal opportunity provider, employer, and lender.

Pregnancy and Lactation Subcommittee:

FUNDING SOURCE: United States Department of Agriculture, Food and Nutrition

Table 1. Included trials and cohorts ................................................................................... 16

NESR specializes in conducting food- and nutrition-related systematic reviews using a

Abbreviation Full name

AHEI Alternative Healthy Eating Index

AMDR Acceptable Macronutrient Distribution Range

DASH Dietary Approaches to Stop Hypertension

DII Dietary Inflammatory Index

EVOO Extra virgin olive oil

FFQ Food frequency questionnaire

GDM Gestational diabetes mellitus

HDI Human Development Index

HEI Healthy Eating Index

HFII Healthy Food Intake Index

HHS Department of Health and Human Services

IOM Institute of Medicine

MDA Mediterranean Diet Adherence

MDQS Maternal Diet Quality Score

NESR Nutrition Evidence Systematic Review

NFFD Norwegian Fit for Delivery Diet

PCA Principal component analysis

PPWL Postpartum weight loss

PUFA Polyunsaturated fatty acid

RCT Randomized controlled trial

rMED Relative Mediterranean Diet

RoB Risk of bias

SES Socioeconomic status

USDA United States Department of Agriculture

PLAIN LANGUAGE SUMMARY

Systematic review question

Trial/Cohort name Reference number(s)

Randomized Controlled Trials

Prospective Cohort Studies

Table 2. Dietary pattern componentsiii

Reference Dietary pattern Dietary components

Ancira-Moreno et al18 MDQS Vegetables and fruits; legumes; low-fat dairy

Emond et al13 AHEI-2010 Vegetables; fruits; whole grains; nuts and

Fulay et al12 DASH Vegetables; fruits; whole grains; nuts and

DASH OMNI Vegetables; fruits; whole grains; nuts and

Gesteiro et al2 HEI Vegetables; fruits; cereals, grains, and legumes;

MDA Total vegetables; raw vegetables; fruits (including

Hillesund et al 20145 NND Root vegetables; cabbages; potatoes relative to

Hillesund et al 201821 NFFD diet Vegetables with dinner; fruits or vegetables as

Dietary risk score (4 Low intake of whole grains; dairy

Meinila et al10 HFII Vegetables; fruits and berries; high-fiber grains;

Rifas-Shiman et al6 AHEI-P Vegetables (includes tofu and soybeans); fruits;

Factor Analysis and PCAiv

Prudent High intake of boiled potatoes, cooked vegetables,

Wheat products High intake of bread, confectioneries, fruit and

Nuts, High-Fiber High intake of nuts, high-fiber cereals, and soy

Margarine, Sugar, High intake of margarine, sugar, and snacks

Wei et al15 Cereals Richer in cereals

Vegetables Richer in vegetables

Meats Richer in meats