Effect of Dietary Patterns and, or Nutrition Strategies Reducing Risk in Adverse Maternal Health Occurrences during Pregnancy: A Systematic Review

Dietary patterns and nutrition strategies are essential to maintain optimal maternal health during pregnancy to prevent and minimize conditions that lead to complications. Previous studies found nutrition education and counseling effect on food habit modification, beneficial during pregnancy. In promoting health and reducing adverse maternal conditions during pregnancy, need increasing knowledge on diversities of dietary pattern consumption, modify attitude and practice. The present review conducted on effect of dietary patterns and/or nutrition interventions on health risks such as hypertension disorders in pregnancy or gestational hypertension or high blood pressure related to obesity or overweight, low haemoglobin, undernutrition and anaemia. Eighteen eligible studies identified. Studies on dietary patterns: Mediterranean or DASH diets, DASH diet vs Western diet with dietary counseling, combined nutrition counseling, advice and healthy diet. Healthy diet vs Western, Traditional or high-energy-foo; 2 healthy diets rich in fruit and vegetables. Two healthy diets combined with dietary counseling, nutrition messages compared with high-energy-food. The remaining 5 studies were nutrition education and health promotion model, dietary counseling and knowledge, attitude and practice with healthy diet, nutrition education with or without diet plan, then guided counseling with planned behaviour model. The studies reported positive impact on reduction of maternal adverse conditions, improved anthropometric, haemoglobin, undernutrition or malnutrition status. Study designs were 5 randomized controlled interventions, 11 prospective or longitudinal cohort studies and 2 systematic review. Abstract Dietary patterns and nutrition strategies are essential to maintain optimal maternal health during pregnancy to prevent and minimize conditions that lead to complications. Previous studies found nutrition education and counseling effect on food habit modification, beneficial during pregnancy. In promoting health and reducing adverse maternal conditions during pregnancy, need increasing knowledge on diversities of dietary pattern consumption, modify attitude and practice. The present review conducted on effect of dietary patterns and/or nutrition interventions on health risks such as hypertension disorders in pregnancy or gestational hypertension or high blood pressure related to obesity or overweight, low haemoglobin, undernutrition and anaemia. Eighteen eligible studies identified. Studies on dietary patterns: Mediterranean or DASH diets, DASH diet vs Western diet with dietary counseling, combined nutrition counseling, advice and healthy diet. Healthy diet vs Western, Traditional or high-energy-foo; 2 healthy diets rich in fruit and vegetables. Two healthy diets combined with dietary counseling, nutrition messages compared with high-energy-food. The remaining 5 studies were nutrition education and health promotion model, dietary counseling and knowledge, attitude and practice with healthy diet, nutrition education with or without diet plan, then guided counseling with planned behaviour model. The studies reported positive impact on reduction of maternal adverse conditions, improved anthropometric, haemoglobin, undernutrition or malnutrition status. Study designs were 5 randomized controlled interventions, 11 prospective or longitudinal cohort studies and 2 systematic review. Effect of Dietary Patterns and, or Nutrition Strategies Health Occurrences during Pregnancy: Systematic Review Eligible studies investigated were 18. All the studies measured significant in in intervention and control The review investigated a decreased in 9 5 with dietary and 4 nutrition promoted Studies conducted in 4 developing countries, two systematics and 12 from developed nations, communities and facilities showed specific effect of dietary patterns or nutrition strategies. Reported nine studies on healthy dietary patterns improved maternal health status while other 9 studies on nutrition strategies modified food habit, improved knowledge and practices to maintain healthy lifestyle. One study found that DASH diet had no association with HDP, gestational diabetes, premature delivery or birth size but a positive effect on weight reduction related to obesity. 28 Individual weekly reinforcement on dietary practices, nutrition education or counseling showed beneficial effect on health during pregnancy. Studies on dietary practices and nutrition strategies showed effective reduction in excessive gestational weight gain that could decreased poor birth outcomes. 30, 31, 32 Dietary counseling and nutrition education served as preventive measures in medicine: protecting, promoting and maintaining healthy lifestyle and well-being. Therefore, implementation of dietary counseling with health promotion could modify understanding for healthy living and effective behavioural change during pregnancy. A Cochrane systematic review and meta-analysis supported that healthy dietary patterns decrease HDP, gestational diabetes mellitus, premature birth and low birth weight et al., 2018).This systematic reviewed showed significant effect of dietary patterns or nutrition strategies on maternal health problems with P-value<0.001 to < 0.05 which is a strong scientific evidence. Further investigation needed for how food portions intake could have impacts on pregnancy outcomes. Most of the studies conducted in developed countries related to well-educated people could not be generalized. Further research need investigation into situations in developing countries to understand effect of inadequate resources and food insecurity on dietary intake and adverse pregnancy or birth outcomes. showed the need for further research to establish universal nutrition strategies on healthy dietary intake to improve women’s health and pregnancy outcome. Studies showed healthy dietary patterns reduced high blood pressure, pregnancy induced hypertension, excessive weight gain, anaemia and improved weight gain in underweight pregnant women while energy-food diets increased health risk in pregnancy and birth complications. This systematic review revealed the relevance to adopt dietary management and nutrition strategies in clinical practices as public health concern. A Cochrane database systematic review suggested that dietary patterns implementation in clinical management of pregnant women is essential.


Introduction
It is evident that nutrition education, counseling and advice with nutritional support promote healthy state during pregnancy. 1,2 Poor diet intakes and lifestyle affect physiological functions causing hypertension, malnutrition, undernutrition, anaemia, high body mass index, overweight and obesity in pregnancy. Severe maternal conditions can lead to premature delivery, low birth weight, maternal -foetal deaths. 3,4 Aside inadequate nutrient intake affecting health, the biological utilization, physiological and pathological status of the individual is considered. Pregnant women consuming inadequate nutritious diet could develop health issues. The health problems resulting in pregnancy may attributing to inaccessibility, unaffordability, unacceptability and seasonal changes of food items leading to insecurity. Evidences are that diversities of dietary patterns and nutrition strategies reduce adverse maternal health conditions and prevent complications. 5,6,7 In order to address most public health issues, behavioural counseling on dietary practices and nutrition education for females in reproductive age becomes necessary. Creating awareness on maternal-fetal risks relating to pre-pregnancy overweight that is potential for excessive gestational weight gain must need effective implementation to change individual's lifestyle. 35 There is a need to focusing on individual's knowledge level, attitude and practices through motivation to achieve better food choice. Globally, gestational hypertension and pre-eclampsia represent 5-15 % and 8-10% respectively, which is due to hormonal changes causing increase blood pressure that lead to maternal mortality. 8,6 Mostly, hypertension during pregnancy is diagnosed as blood pressure above 140/90mmHg after 20 weeks gestation without protein in urine and oedema. 9, 6   1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60  61  62  63  64  65 In Sub-Saharan Africa, pregnant women suffer from deficiencies of folate and iron because of inadequate nutritious diet leading to anaemia in pregnancy, morbidity, mortality and infections. 10 World Health Organization (WHO) recommends nutrition education and counseling (NEC) adoption to increase healthy diets with fruit and vegetables to reduce health risks. (WHO, 2018).
Fruit and vegetables contain minerals and vitamins that aid to reduce adverse conditions during pregnancy and birth outcomes. 11,12 In order to upgrade knowledge of the inhabitants' in Iran, focusing on nutrition education campaign enable improvement in F&V consumption to reduce nutrition-related-problems. 13 World Health Organization and other studies improving knowledge on diet planning on food diversities, create awareness on sources of iron, folate, plant and animal food to reduce anaemia during pregnancy. 14,15 It is evident, pregnant women with excessive vomiting or bleeding after 24 weeks gestation, may develop undernutrition, weight loss and anaemia. These conditions could cause premature delivery and low birth weight but intake of diversities of nutritious diet could improve their haemoglobin above 10.5g/dl and gain weight. 16 Moreover, high-energy diets intake among African women in urban areas, contribute to obesity and overweight before becoming pregnant. This cause excessive weight gain during 1 st trimester. Women need encouragement to take diets rich in F&V to reduce weight and complications in pregnancy. 17 WHO recommends that health caregivers in clinics and communities implement effective nutrition advice, education and counseling in the antenatal management. 1 Implementation of NEC in developing countries during antenatal care is inadequate or irregular. Therefore, reinforcing NEC and dietary interventions effectively could reduce health risks during pregnancy. 18,19 Committing to dietary pattern and nutrition interventions as measures to reduce or prevent health risks in pregnancies need further investigation. 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60  61  62  63 64 65

Literature Search Method
Literature searched from PubMed, Google Scholar and other similar reviewed studies conducted on dietary patterns, nutrition strategies and health risks during pregnancy. Selected study designs were randomized control trails (RCTs), cohort observational or prospective, quantitative and qualitative variables. Effect of randomized control trials on dietary approaches took minimum of 3 months, maximum less than one year and cohort observation took less than one year or more.
Searched on dietary patterns interventions of DASH or Mediterranean, healthy diet with F&V and related factors of overweight, high body mass index, hypertension, anaemia, undernutrition and malnutrition selected. Nutrition education and counseling interventions promoting healthy diet to reduce health problems were included. The search was restricted to articles published in English language. Titles, abstracts and full text relevant to the study reviewed with other cross-references screened for further search.

Eligibility Criteria
This was based on dietary patterns and, or nutrition strategy reducing health risk during pregnancy with birth outcomes. Studies included randomize control trial, quasi-experiment and prospective, longitudinal or observational cohort. Target population included pregnant women at 16 years or above aged 18, gestational age below 20 weeks and above, with problems such as hypertension, anaemia, obesity or overweight, low haemoglobin, undernutrition and malnutrition. High blood pressure defined above 140/90 mmHg. Obesity and overweight definition according to WHO is measurement from 40kg/m 2 . Dietary patterns captured healthy diet, Mediterranean, DASH and traditional diet with fruit and vegetables.

Effect of Dietary Patterns and, or Nutrition Strategies Reducing Risk in Adverse Maternal Health Occurrences during Pregnancy: A Systematic Review
Study interventions included healthy diets vs western foods, nutrition education and counseling, nutrition education or dietary counseling, diet planned and behaviour change model. Exclusion were non-pregnant women, pregnant teenagers, chronic diseases, non-intervention or intervention studies of dietary supplements or placebo (e.g. vitamin C, vitamin E, calcium, potassium, garlic, soy protein), or energy foods less than 600 kcal/day, exercise as co-intervention, study designs of case control, retrospective cohort and clinical trials.

Evaluation of Studies Results
Reported study outcomes based on the following distinctions: i) difference between intervention and control groups with change from baseline to endline; ii) difference within groups from baseline to follow-up. iii) Differences between groups that considered change in values from baseline and endline adjusting cofounding characteristics to give meaningful comparison results. Differences considered as significant if the P-value less than 0.05.

Effect of Dietary Patterns and, or Nutrition Strategies Reducing Risk in Adverse Maternal Health Occurrences during Pregnancy: A Systematic Review
and 24 months. Literature searched 25 articles, excluded 7 for undetailed information on titles and abstract or chronic conditions and rejected 4 duplicates of dietary patterns on hypertension with diabetes during pregnancy or food supplements. The relevant articles were 18, comprised of dietary patterns or nutrition strategies. For an overview of the screening criteria, see Figure 1.

Data Extraction and Selection Process
Rejected Articles:

Effect of Dietary Patterns and, or Nutrition Strategies Reducing Risk in Adverse Maternal Health Occurrences during Pregnancy: A Systematic Review
Eligible studies investigated were 18. All the studies measured significant improvement in specific health problem in intervention and control groups. The review investigated a decreased in health risks with 9 dietary patterns, 5 nutrition strategies with dietary pattern and 4 nutrition strategies promoted healthy diet. Studies conducted in 4 developing countries, two systematics and 12 from developed nations, communities and health facilities showed specific effect of dietary patterns or nutrition strategies.

Effect of Dietary Patterns and Counseling on Anthropometric Status
Interventional effect of nutrition education or dietary counseling on dietary practices improved weight and reduced excessive weight or BMI. One study increased knowledge on daily food quantity. 29 The remaining respectively reduced excessive gestational weight gain by 42.7% and 13.9%, with mean weight reduction of 51.05±7.26kg while another improved haemoglobin and reduced anaemia in intervention vs control group. 15,30,32 A study found that DASH diet intake was ineffective in early pregnancy against HDP, but had a decreased effect on obesity before pregnancy and subsequent gestational weight gain. 28 A metaanalysis on effective combination of NEC with nutritional support found an improved weight gain during pregnancy. 31

Effect of Nutritional Education-Counseling on Dietary Intake and Practices
Three studies conducted on dietary counseling and nutrition education among pregnant women during antenatal visits, enabled upgrading of knowledge on nutrition health benefits and modified dietary practices. 7,15,30 One study showed impact of nutrition education with health promotion model to improving dietary practices on intake of food diversities among pregnant women.
Systematic reviewed studies conducted on nutrition education messages and counseling found promoting effective dietary practices to improve weight gain and reduced risk of anaemia. 29, 31

Effect on Haemoglobin Level, Anaemia and Undernutrition
A study reported on significant beneficial effect of nutrition education messages and counseling on food quality, quantity and undernutrition. This showed mean body weight of 51.05±7.26kg, haemoglobin status at 9.65±0.97 and 7.85±1.58 with reduction in anaemia prevalence from In addition, a nutrition education on source of iron food and diet planned respectively found significant mean haemoglobin level of 0.56±0.40gm/dl and 0.16±0.82/dl in intervention and control groups. 15 The study also improved knowledge by 8.26±4.57 and 1.05±6.59 respectively and anaemia from 40gm/dl to 82gm/dl, p-value <0.002. 15 Another study reported on undernutrition at base-line prevalence of 47.3% and adopting guided counseling with theory of planned behaviour reduced to 30.6% at endline. 27 This also showed a changed of 16.7% in intervention than 43.8% to 39.8% in control group. 27

Relevance and Limitations of Literature Review
Reported nine studies on healthy dietary patterns improved maternal health status while other 9 studies on nutrition strategies modified food habit, improved knowledge and practices to maintain healthy lifestyle. One study found that DASH diet had no association with HDP, gestational diabetes, premature delivery or birth size but a positive effect on weight reduction related to obesity. 28 Individual weekly reinforcement on dietary practices, nutrition education or counseling showed beneficial effect on health during pregnancy. Studies on dietary practices and nutrition strategies showed effective reduction in excessive gestational weight gain that could decreased poor birth outcomes. 30,31,32 Dietary counseling and nutrition education served as preventive measures in medicine: protecting, promoting and maintaining healthy lifestyle and well-being.
Therefore, implementation of dietary counseling with health promotion could modify understanding for healthy living and effective behavioural change during pregnancy. A Cochrane systematic review and meta-analysis supported that healthy dietary patterns decrease HDP, gestational diabetes mellitus, premature birth and low birth weight (Kibret, et al., 2018).This systematic reviewed showed significant effect of dietary patterns or nutrition strategies on maternal health problems with P-value<0.001 to < 0.05 which is a strong scientific evidence.