Journal of Dietary Supplements, 11(2):155–165, 2014 C 2014 by Informa Healthcare USA, Inc. Available online at www.informahealthcare.com/jds DOI: 10.3109/19390211.2013.859210
ARTICLE
Greek Pregnant Women Demonstrate Inadequate Micronutrient Intake Despite Supplement Use Konstantina Hatzopoulou, RD, Vlasios Filis, RD, Maria G. Grammatikopoulou, MSc, PhD, Charalambos Kotzamanidis, MSc, PhD, & Maria Tsigga, DEA, PhD Department of Human Nutrition & Dietetics, Alexander Technological Educational Institute, GR-57400 Thessaloniki, Greece
ABSTRACT. Background/Aim: Maternal diet is important in the outcome of pregnancy and the health of the children. The present cross-sectional study aimed to assess the use of dietary supplements during pregnancy and define the maternal characteristics associated with supplement use. Methods: The diet of 100 childbearing women was recorded for three consecutive days and micronutrient supplementation was added to the dietary intake and the median values were used in the analyses. Results: The majority of the participants (92%) consumed at least one supplement. Supplementation of folic acid (FA) was significantly lower during the third trimester compared to the second (p ≤ .007). Higher intake of Ca and Fe supplements was observed in the second trimester (p ≤ .001). The use of supplements contributed to an attenuated consumption of all reported micronutrients (Mg, Ca, FA, and Fe, p ≤ .001). The principal components analysis revealed that the most important factor contributing to supplementation was primiparity. Conclusions: Overall, a high prevalence of micronutrient supplementation during pregnancy was observed without ensuring adequacy in the micronutrient intake. The increased rates of supplement users might be the result of an act for balancing diet in unplanned pregnancies. KEYWORDS. calcium, diet, folic acid, healthy eating index, iron, pregnancy, supplementation
INTRODUCTION Since the majority of pregnancies are unplanned, women do not have adequate time to adapt to the new dietary recommendations promptly (Inskip et al., 2009). In parallel, there is evidence that the diet of childbearing women changes very little compared to the preconceptional period, despite the need for a more adequate nutritional intake (Crozier, Robinson, Godfrey, Cooper, & Inskip, 2009). The U.S. Institute of Medicine (Institute of Medicine, 2003) recommends an increased dietary intake for the majority of micronutrients during pregnancy, Address correspondence to: Maria Tsigga, Department of Human Nutrition & Dietetics, Alexander Technological Educational Institute, PO Box 141, GR-57400 Thessaloniki, Greece (E-mail: [email protected]) (Received 6 March 2013; revised 12 August 2013; accepted 10 September 2013)
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however, nutritional inadequacy appears to prevail even in westernized countries (Okubo et al., 2001). The most prevalent nutritional inadequacies in Europe concern folate and iron (Derbyshire, Davies, Costarelli, & Dettmar, 2009; Franke et al., 2008; Ortiz-Andrellucchi, Snchez-Villegas, Ramrez-Garca, & Serra-Majem, 2009; Tsigga, Filis, Hatzopoulou, Kotzamanidis, & Grammatikopoulou, 2011), two nutrients important for the neurological development of the fetus as well as for the prevention of iron deficiency anemia and adverse birth outcomes (Wolff et al., 2009; Bnhidy, Acs, Puh, & Czeizel, 2011). Despite the recorded nutritional inadequacies and the evidence for improved birth outcomes through supplementation, rates of folic acid (FA, the synthetic form of folate) supplementation appear to be low (de Jong-van den Berg, 2008; Rasmussen & Clemmensen, 2010). According to a recent systematic review, in order to delineate gestational nutritional inadequacies, the consumption of dietary supplements should be included in the dietary assessment methods (Ortiz-Andrellucchi, Doreste-Alonso, Henrquez-Snchez, Cetin, & Serra-Majem, 2009); however, supplement use during pregnancy is not adequately documented in literature (Picciano & McGuire, 2009). The present cross-sectional study aimed to estimate nutritional inadequacies in a sample of Greek pregnant women through dietary assessment record including the use of supplements and define sociodemographic characteristics associated with supplement use and micronutrient inadequacies. MATERIALS AND METHODS Sample The sample consisted of 100 adult pregnant women, aged 18-42 years, all inhabitants of Athens, Greece, recruited from private clinics in Athens. All childbearing women who were outpatients at the collaborating private clinics during the recruitment period were selected for the study, irrespectively of the gestation trimester. The participants were not diagnosed with any disorder that affects body weight and/or appetite neither did they follow any specific dietary program. The study’s protocol was approved by our Institute. Dietary Intake and Supplement Use Dietary intake of the participants was recorded for three consecutive days with three noncontinuous 24 hr previous-day dietary recalls. Food Processor 7.4 computer software (ESHA, Portland, Oregon) was used for the dietary analysis. Energy and micronutrient intake (iron, FA, magnesium, and calcium) for each recorded day were calculated for each participant and the median intakes (from the recorded days) were selected as representative of the subjects’ habitual intake. In order to increase validity in the dietary record and identify adequate energy reporters, the cutoffs for the habitual energy intake (EI) of pregnant women were applied (20.0 MJ/day), as suggested by Hure and her associates (Hure, Young, Smith, & Collins, 2008). Participants self-reported the use of dietary supplements, a method found to be confirmed by biological markers (Brantsaeter et al., 2007). The amount of daily supplement intake of each participant was added to the dietary intake of the
Supplement Use by Pregnant Women
157
specific micronutrient as suggested by Ortiz-Andrellucchi et al. (Ortiz-Andrellucchi et al., 2009). For FA supplements, 1 Dietary Folate Equivalent (DFE) was calculated for the intake of 0.6 μg of FA as a supplement consumed in food (Institute of Medicine, 2003). Total habitual (median) micronutrient intake (sum of dietary and supplemental) was compared to the Dietary Reference Intakes (DRI) (Institute of Medicine, 2003) in order to assess adequacy/inadequacy in the consumption. The term “dietary supplement” was defined according to the U.S. Food and Drug Administration (Centre for Food Safety and Applied Nutrition, 2001) as a product meeting the three following criteria: (1) a product intended to supplement the diet or that contains one or more of the following: vitamin, mineral, herb, or other plant derived substance (e.g., ginseng or garlic), amino acid, concentrate, metabolite, constituent, or extract, (2) a product intended for ingestion in pill, capsule, tablet, or liquid form, and (3) a product not represented for use as a conventional food or as the sole item of a meal/diet. The use of dietary supplements was compared with being underweight or overweight during the preconceptional period (Body Mass Index
ARTICLE
Greek Pregnant Women Demonstrate Inadequate Micronutrient Intake Despite Supplement Use Konstantina Hatzopoulou, RD, Vlasios Filis, RD, Maria G. Grammatikopoulou, MSc, PhD, Charalambos Kotzamanidis, MSc, PhD, & Maria Tsigga, DEA, PhD Department of Human Nutrition & Dietetics, Alexander Technological Educational Institute, GR-57400 Thessaloniki, Greece
ABSTRACT. Background/Aim: Maternal diet is important in the outcome of pregnancy and the health of the children. The present cross-sectional study aimed to assess the use of dietary supplements during pregnancy and define the maternal characteristics associated with supplement use. Methods: The diet of 100 childbearing women was recorded for three consecutive days and micronutrient supplementation was added to the dietary intake and the median values were used in the analyses. Results: The majority of the participants (92%) consumed at least one supplement. Supplementation of folic acid (FA) was significantly lower during the third trimester compared to the second (p ≤ .007). Higher intake of Ca and Fe supplements was observed in the second trimester (p ≤ .001). The use of supplements contributed to an attenuated consumption of all reported micronutrients (Mg, Ca, FA, and Fe, p ≤ .001). The principal components analysis revealed that the most important factor contributing to supplementation was primiparity. Conclusions: Overall, a high prevalence of micronutrient supplementation during pregnancy was observed without ensuring adequacy in the micronutrient intake. The increased rates of supplement users might be the result of an act for balancing diet in unplanned pregnancies. KEYWORDS. calcium, diet, folic acid, healthy eating index, iron, pregnancy, supplementation
INTRODUCTION Since the majority of pregnancies are unplanned, women do not have adequate time to adapt to the new dietary recommendations promptly (Inskip et al., 2009). In parallel, there is evidence that the diet of childbearing women changes very little compared to the preconceptional period, despite the need for a more adequate nutritional intake (Crozier, Robinson, Godfrey, Cooper, & Inskip, 2009). The U.S. Institute of Medicine (Institute of Medicine, 2003) recommends an increased dietary intake for the majority of micronutrients during pregnancy, Address correspondence to: Maria Tsigga, Department of Human Nutrition & Dietetics, Alexander Technological Educational Institute, PO Box 141, GR-57400 Thessaloniki, Greece (E-mail: [email protected]) (Received 6 March 2013; revised 12 August 2013; accepted 10 September 2013)
155
156
Hatzopoulou et al.
however, nutritional inadequacy appears to prevail even in westernized countries (Okubo et al., 2001). The most prevalent nutritional inadequacies in Europe concern folate and iron (Derbyshire, Davies, Costarelli, & Dettmar, 2009; Franke et al., 2008; Ortiz-Andrellucchi, Snchez-Villegas, Ramrez-Garca, & Serra-Majem, 2009; Tsigga, Filis, Hatzopoulou, Kotzamanidis, & Grammatikopoulou, 2011), two nutrients important for the neurological development of the fetus as well as for the prevention of iron deficiency anemia and adverse birth outcomes (Wolff et al., 2009; Bnhidy, Acs, Puh, & Czeizel, 2011). Despite the recorded nutritional inadequacies and the evidence for improved birth outcomes through supplementation, rates of folic acid (FA, the synthetic form of folate) supplementation appear to be low (de Jong-van den Berg, 2008; Rasmussen & Clemmensen, 2010). According to a recent systematic review, in order to delineate gestational nutritional inadequacies, the consumption of dietary supplements should be included in the dietary assessment methods (Ortiz-Andrellucchi, Doreste-Alonso, Henrquez-Snchez, Cetin, & Serra-Majem, 2009); however, supplement use during pregnancy is not adequately documented in literature (Picciano & McGuire, 2009). The present cross-sectional study aimed to estimate nutritional inadequacies in a sample of Greek pregnant women through dietary assessment record including the use of supplements and define sociodemographic characteristics associated with supplement use and micronutrient inadequacies. MATERIALS AND METHODS Sample The sample consisted of 100 adult pregnant women, aged 18-42 years, all inhabitants of Athens, Greece, recruited from private clinics in Athens. All childbearing women who were outpatients at the collaborating private clinics during the recruitment period were selected for the study, irrespectively of the gestation trimester. The participants were not diagnosed with any disorder that affects body weight and/or appetite neither did they follow any specific dietary program. The study’s protocol was approved by our Institute. Dietary Intake and Supplement Use Dietary intake of the participants was recorded for three consecutive days with three noncontinuous 24 hr previous-day dietary recalls. Food Processor 7.4 computer software (ESHA, Portland, Oregon) was used for the dietary analysis. Energy and micronutrient intake (iron, FA, magnesium, and calcium) for each recorded day were calculated for each participant and the median intakes (from the recorded days) were selected as representative of the subjects’ habitual intake. In order to increase validity in the dietary record and identify adequate energy reporters, the cutoffs for the habitual energy intake (EI) of pregnant women were applied (20.0 MJ/day), as suggested by Hure and her associates (Hure, Young, Smith, & Collins, 2008). Participants self-reported the use of dietary supplements, a method found to be confirmed by biological markers (Brantsaeter et al., 2007). The amount of daily supplement intake of each participant was added to the dietary intake of the
Supplement Use by Pregnant Women
157
specific micronutrient as suggested by Ortiz-Andrellucchi et al. (Ortiz-Andrellucchi et al., 2009). For FA supplements, 1 Dietary Folate Equivalent (DFE) was calculated for the intake of 0.6 μg of FA as a supplement consumed in food (Institute of Medicine, 2003). Total habitual (median) micronutrient intake (sum of dietary and supplemental) was compared to the Dietary Reference Intakes (DRI) (Institute of Medicine, 2003) in order to assess adequacy/inadequacy in the consumption. The term “dietary supplement” was defined according to the U.S. Food and Drug Administration (Centre for Food Safety and Applied Nutrition, 2001) as a product meeting the three following criteria: (1) a product intended to supplement the diet or that contains one or more of the following: vitamin, mineral, herb, or other plant derived substance (e.g., ginseng or garlic), amino acid, concentrate, metabolite, constituent, or extract, (2) a product intended for ingestion in pill, capsule, tablet, or liquid form, and (3) a product not represented for use as a conventional food or as the sole item of a meal/diet. The use of dietary supplements was compared with being underweight or overweight during the preconceptional period (Body Mass Index
