Article

The Dietary Composition of Women Who Delivered Healthy Full-Term Infants, Preterm Infants, and Full-Term Infants Who Were Small for Gestational Age

Biological Research for Nursing 2015, Vol. 17(5) 495-502 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1099800414556529 brn.sagepub.com

Rafał Bobin´ski, PhD1, Monika Mikulska, MD1, Hanna Mojska, PhD2, and Izabela Ulman-Włodarz, MD1

Abstract The impact of diet on the health of pregnant women remains an unresolved clinical issue. The aim of this study was to determine and compare the dietary intake of mothers who gave birth to full-term infants whose sizes were appropriate for gestational age (AGA), preterm birth (PTB) infants, and full-term infants who were small for gestational age (SGA). Of the 103 women who participated, 50 gave birth to AGA infants, 30 gave birth to PTB infants, and 23 gave birth to SGA infants. The composition of each woman’s diet was analyzed using a questionnaire completed 3 days postchildbirth. Findings revealed a number of differences between the groups. The percentage of energy obtained from fat and the calcium and lactose intake was all highest in Group AGA. The largest number of differences in intake of fatty acids (FAs) was observed among short- and medium-chain FAs. Lower levels of C4:0, C6:0, C8:0, C10:0, and C14:0 were observed in the diets of women in Group PTB than in Group AGA. C18:0 intake was also lower in Group PTB than in Group AGA. The reduced short-, medium-, and long-chain FA intake by women in Group PTB also affected the total saturated FA intake, which was lowest in that group. These findings suggest that, even in mothers giving birth to children with only slight deviations from normal birth weight or normal gestational duration, differences in diet can be identified, particularly regarding FA content, which may affect the health of the newborn. Keywords mother’s diet, fatty acids, preterm, low birth weight

Pregnancy is characterized by changes in a woman’s lifestyle, eating habits, and diet. The mother’s dietary intake has a crucial impact on the intrauterine development of her child. An adequate intake (AI) will quantitatively and qualitatively meet the needs of both mother and the developing fetus for nutrients and energy components. The most important dietary components for pregnant women and fetuses include proteins, carbohydrates, vitamins, microelements, and fats, of which fatty acids (FAs) are the most crucial. The average human diet contains a very large number of FAs, which have different functions involving building, metabolism, and energy (Cetin, Alvino, & Cardellicchio, 2009; Koletzko et al., 2001). The functions each FA performs depend on the length of the carbon chain, the number of double bonds, and the location of these bonds, which determines the categorization of long-chain polyunsaturated FAs (LCPUFAs) into the n-3 and n-6 families. Saturated medium-chain FAs (MCFAs) and long-chain FAs (LCFAs) are used primarily in the mitochondrial energy production process, that is, adenosine triphosphate (ATP) biosynthesis (Bobin´ski & Mikulska, 2012a, 2012b). LCPUFAs of both the n-3 and n-6 families, such as

docosahexaenoic acid (22:6 n-3) and arachidonic acid (20:4 n-6), are responsible for processes such as development of the brain and nervous system and involved in the biosynthesis of prostaglandins, thromboxanes, and leukotrienes, which are fundamental components of immune responses (Duttaroy, 2009; Haggarty, 2002; Magnusson, Waterman, Wennergren, Jansson, & Powell, 2004; Smithers, Markrides, & Gibson, 2010; Xiang, Lei, Li, & Zetterstro¨m, 1999). Studies have shown that an inadequate supply of the necessary FAs in a mother’s diet can cause health problems in her children. The most frequently cited problems include impaired development of the nervous system

1

Faculty of Health Sciences, Department of Nursing, University of BielskoBiala, Bielsko-Biała, Poland 2 National Food and Nutrition Institute, Chemical Safety of Food Laboratory, Warsaw, Poland Corresponding Author: Rafał Bobin´ski, PhD, Faculty of Health Science, University of Bielsko-Biala, ul. Willowa 2, 43-309 Bielsko-Biala, Poland. Email: [email protected]

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and the brain (including a reduction in the IQ), impaired development of the retina, and development of metabolic and cardiovascular diseases (Auestad et al., 2003; Gale et al., 2008; Haggarty, 2002; Helland, Smith, Saarem, Saugstad, & Drevon, 2003; Jensen, 1996; Jensen et al., 2005). An inadequate supply of FAs in the diet of pregnant women may also contribute to abnormalities in fetal development leading to preterm births (PTBs), intrauterine growth restriction (IUGR), or neonates who are small for gestational age (SGA) (Bahrami & Rahimi, 2005; Bokor, Koletzko, & Decsi, 2007; Food and Agriculture Organization of the United Nations, 2010; Genzel-Borovicz´eny, Wahle, & Koletzko, 1997; Lo´pez-Lo´pez, Lo´pez-Sabater, CampoyFolgoso, Rivero-Urgell, & Castellote-Bargallo, 2002; Merino, Ma, & Mutch, 2010; Molto´-Puigmartı´, Castellote, CarbonellEstrany, & Lo´pez-Sabater, 2011). PTB is becoming more and more common in the Polish population (Central and Eastern Europe). Currently, PTBs constitute about 7% of all births, but this percentage has been increasing (Bojar, Owoc, Humeniuk, Wierzba, & Fronczak, 2012; Goryn´ski, Kopczyn´ski, Radiukiewicz, Wojtyniak, & Woynarowska, 1996). The main reasons for the rise in the PTB rate are thought to be environmental factors and the mothers’ poor diets, which are characteristics of the rapid socioeconomic changes that have taken place in recent years in Poland. These changes have contributed to an increase in the consumption of foods, specifically highly processed foods, that do not fully meet the FA requirements of the developing fetus or the levels of specific vitamins and microelements required for the metabolism of FAs (Urbaniak, Klejewski, Pisarska, & Kostecka, 2012; Wojtyła et al., 2011). Research has only provided a thorough understanding of the roles of a few of the FAs from the mother’s diet in the development of the fetus, primarily selected LCPUFAs. Little is known about the roles of short-, medium-, and long-chain saturated FAs and monounsaturated FAs. The goal of this study was to investigate noticeable differences in the maternal diet, including the full range of FAs, that might lead to slight differences in the developing fetus and result in a slightly PTB or SGA neonate. Our primary aim was to determine and compare the dietary FA profiles of three groups of pregnant women, that is, those who gave birth slightly prematurely, those who gave birth at term but whose infants were slightly SGA, and those who gave birth to full-term infants whose size was appropriate for gestational age (AGA). For a better understanding of the relationships between the components of the diet and the duration of pregnancy and infant’s birth weight, we also analyzed the maternal dietary protein, vitamin, carbohydrate, and microelement content. Our assumption in selecting our study population was that studying the diets of mothers who gave birth to infants who were only slightly premature or SGA would give us a better picture of possible developmental changes attributable to maternal diet than would studying the diets of mothers who gave birth to neonates with IUGR or who were very preterm, who could have been affected to a large extent by factors other than maternal diet, such as, for example, functioning of the placenta (Herrera, 2000; Herrera, Amusquivar, LopezSoldado, & Ortega, 2006).

Method and Material We conducted this cross-sectional study among 1,856 women who gave birth at a hospital in Tychy, Poland, between 2007 and 2008. Pregnant women were recruited for the study during their first visit to the hospital. Of the original number of women approached, 103 met the inclusion criteria and were included in the study. The study was approved by the Bioethics Review Board of the Silesian University of Medicine in Katowice, Poland (L.dz.NN-6501-183/I/07), which is in accordance with the Declaration of Helsinki. To obtain a homogeneous group of women, we applied the following inclusion criteria: 1. Polish nationality (excluding naturalized Polish citizens), single pregnancy, parity 1–3. 2. Stable socioeconomic status based on factors such as income, marital status, education, and place of residence. Women eligible for the study were married, had good housing conditions, had a secondary or higher education, lived in a highly industrialized urban region, and, along with their husbands, had a steady job. 3. Followed a diet typical of the Polish population. Women accepted into the study were neither vegetarians nor followed any other special diets; their diets had not been modified in any way during pregnancy for medical or health reasons. The following exclusion criteria were applied: 1. Diagnosis of a chronic disease prior to pregnancy such as chronic hypertension or pregestational diabetes, pathologies during the course of pregnancy such as gestational high blood pressure or infections during pregnancy (any kind of infection in the perinatal period, such as fever, respiratory infections, urinary infections, etc.), miscarriages, and/or premature birth resulting in the death of the child or developmental anomalies in the fetus. 2. Diagnosis of AIDS or other sexually transmitted diseases. 3. Adherence to a vegetarian, Mediterranean, or other special diet. Women who participated in the research program provided written informed consent and were classified into three groups according to the following criteria: (1) Group AGA (n ¼ 50) comprised healthy mothers with routine, uneventful pregnancies and full-term neonates whose weight fell in the 10th–90th percentile; (2) Group PTB (n ¼ 30) comprised mothers who gave birth prematurely at 35–37 weeks’ gestation to neonates whose weight fell in the 10th–90th percentile; and (3) Group SGA (n ¼ 23) comprised mothers who gave birth to full-term but SGA neonates (neonatal weight < 10th percentile). Women eligible for the study underwent three ultrasound examinations (between the 12th and 14th weeks of gestation, between the 20th and 22nd weeks, and between the 32nd and

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33rd weeks). Fetuses with in-utero abdominal measurements below the 10th percentile of reference values were defined as SGA fetuses. SGA was confirmed at birth with a neonatal weight below the 10th percentile. All of the fetuses had normal karyotypes and no malformation at birth. The mothers did not receive any dietary supplementation during pregnancy. The mothers in PTB did not receive corticosteroids. Women whose infant’s weight exceeded the 90th percentile (large for gestational age [LGA]) were not included in the study. In accordance with Polish perinatology protocols, mothers and babies were admitted onto the maternity ward for 3 days following the delivery. The data on the course of pregnancy came from the pregnancy chart (i.e., the document recorded by the gynecologist caring for the woman). The gynecologist estimated the women’s body mass index (BMI) during the visit confirming the women’s pregnancy. The data concerning the birth and postpartum period, the newborn’s health status at birth, and the results of their physical examination were taken from the hospital medical record.

Procedures We analyzed participating women’s eating habits and dietary composition using a monthly dietary questionnaire designed by the National Food and Nutrition Institute in Warsaw, Poland. The questionnaire allowed the researchers to determine the women’s daily consumption of each particular dietary component (proteins, carbohydrates, fats, FAs, vitamins) as well as their calorie consumption over a 1-month period. A research team member administered the dietary questionnaire to each mother in the hospital 3 days postchildbirth, asking them to retrospectively describe their diet during the last month of their pregnancy. We clearly instructed each participant about how to report on their diet upon their enrollment in the study, offering them training on how to fill in the questionnaire as well as how to record the volume or mass of foods using standard household measures such as a spoonful, glass, and so on. We did not give the women any hints or tips on diet. Women referred to the Album of Photographs of Food Products and Dishes (Szponar, Wolnicka, & Rychlik, 2000) in filling out the questionnaire for support in specifying the quantity and quality of the food consumed. The portion size was verified by two nutritionists and a gynecologist trained at the National Food and Nutrition Institute, Warsaw, Poland. The questionnaire included a list of products grouped according to the following 22 food groups: milk and dairy products, eggs, meat, sausages, offal, fish, seafood, animal and vegetable fats, vegetables, fruit and fruit products, potatoes and potatobased products, seeds, legumes, cereals and cereal products, precooked ready-to-eat meals, salty snacks, nuts and grains, sugar and sweets, soft drinks, alcohol, soup concentrates, and sauces and spices. Study participants recorded how frequently they consumed each product, with the options being daily, several times a week, once a week, 2–3 times a month, or never. We used the DIETA FAO 2.0 software program (developed by the National

Table 1. Characteristics of the Study Population by Study Group. Characteristic Age, years BMI, kg/m2 Neonatal weight, g

AGA (n ¼ 50) PTB (n ¼ 30) SGA (n ¼ 23) 28.1 + 4.5 22.8 + 3.7 3,529.9 + 382.6

27.7+ 3.7 23.0 + 3.9 2,399 + 419.4

29.0 + 5.1 23.1 + 4.8 2,297 + 158.9

39 11 9–10

20 10 9–10

12 11 9–10

Mode of delivery, n NSVD CS 5-min Apgar score, range

Note. AGA ¼ mothers who gave birth to full-term neonates whose weights were appropriate for gestational age; BMI ¼ body mass index of women at the start of pregnancy; CS ¼ Cesarean section; NSVD ¼ normal spontaneous vaginal delivery; PTB ¼ mothers who gave birth slightly prematurely (35–37 weeks’ gestation) to neonates whose weights fell in the AGA range; SGA ¼ mothers who gave birth to full-term neonates who were small for gestational age (weight < 10th percentile). Results are mean + SD, unless otherwise indicated.

Food and Nutrition Institute, Warsaw, Poland, and approved by the Food and Agriculture Organization of the United Nations), which includes data on 1,067 typical Polish dishes or food products, to estimate the monthly quantity consumed of the aforementioned nutritional components. The National Food and Nutrition Institute validated the monthly dietary consumption using the Food Intake Frequency Questionnaire, a 7-day nutritional survey. Participants in the validation study were asked to record their food and beverage intake each day for a period of 7 days. They were instructed to specify portion sizes in household measures such as spoonful or glass, and in the case of some products, where possible, in grams as well. Subsequently, the same participants were asked to fill out the monthly questionnaire retrospectively for a time period that included the 7 days covered in the Food Intake Frequency Questionnaire. Research personnel verified portion quantities via direct consultation with each participant for both questionnaires using the Album of Photographs of Food Products and Dishes (Szponar et al., 2000). Study findings revealed a positive correlation between the two questionnaires, thus validating the use of the monthly dietary questionnaire for determining nutrient intake.

Statistics We used the Kruskal–Wallis analysis of variance test to determine differences in food intake among the three groups. We chose this statistical test because of the high absolute values of the skewness and kurtosis of a large number of the variables. We also conducted a detailed post hoc analysis.

Results Maternal age, BMI, neonatal weight, mode of delivery, and Apgar scores are presented in Table 1. All women were of normal weight. We observed significant differences between groups only in neonatal weight. We analyzed the dietary intake

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45.00

*

40.00

Percent energy from fats [%]

35.00 30.00 25.00 20.00 15.00 10.00 5.00 0.00 AGA

PTB

SGA

Figure 1. Percentage of daily energy obtained from fats by mothers who gave birth to healthy, full-term infants (appropriate for gestational age [AGA]; n ¼ 50), mothers who gave birth prematurely (preterm birth [PTB]; n ¼ 30) to infants of normal weight, and mothers who gave birth to full-term infants who were small for gestational age (SGA; n ¼ 23). *p < .05.

2000.00 *

1800.00 1600.00 1400.00 Ca (mg/day)

of 67 elements (variables) in the mothers’ diets using participants’ responses on the monthly nutritional questionnaires. These variables included trace elements (sodium [Na], potassium [K], calcium [Ca], phosphorous [P], magnesium [Mg], iron [Fe], zinc [Zn], copper [Cu], and manganese [Mn]), vitamins (vitamin A, retinol, beta-carotene, vitamin E, thiamine, riboflavin, niacin, vitamin B6, vitamin C, and folic acid), carbohydrates (total carbohydrates, lactose, sucrose, starch, and cellulose), proteins (total protein, animal protein, vegetable protein), fats (fat, cholesterol, and FAs) as well as other variables (water, ash, waste, energy, and alcohol). Due to the large number of variables analyzed in this study, we have presented only those variables for which we detected statistically significant differences or which are most essential for normal intrauterine development of a child. Mothers in the AGA groups consumed an average of 2,885 kcal/day, those in the PTB group consumed an average of 2,657 kcal/day, and those in the SGA group consumed an average of 2,491 kcal/day. There were no statistical differences in kilocalories consumed per day between the groups. The percentages of energy obtained daily from protein and carbohydrates were as follows: 14.0% and 51.1% in Group AGA, 13.7% and 54.8% in Group PTB, and 13.4% and 53.3% in Group SGA, respectively. Again, there were no statistical differences in these parameters between the groups. The percentage of energy obtained from fat for each group was 34.7% (AGA), 31.4% (PTB), and 33.2% (SGA). For this parameter, the difference between Groups AGA and PTB was statistically significant (p < .05; Figure 1). The average daily intake of protein for each group was 95 g (AGA), 86 g (PTB), and 79 g (SGA). These values all meet the estimated average requirement (EAR) and the recommended dietary allowance (RDA), and none of the differences between groups were significant. The average dietary intakes of vitamin A, retinol, vitamin E, beta-carotene, riboflavin, niacin (vitamin PP), vitamin B6, and vitamin C also met the recommended requirements set out by the EAR, RDA, and AI guidelines. Average daily dietary intake of thiamine was slightly below the RDA in Group SGA but met the guidelines in all other groups. There were no statistical differences between the groups for any of these values (data not shown). Calcium was the only trace element that differed significantly in level between groups, with Group PTB having significantly lower levels compared with group AGA (p < .05). The daily dietary calcium intake of mothers was 1,235 mg in Group AGA, 955 mg in Group PTB, and 1,022 mg in Group SGA (Figure 2). The calcium intake of the women in Groups AGA and SGA met the criterion for AI, while the levels recorded for Group PTB did not. Lactose was the only carbohydrate in the mothers’ diet that differed statistically between the groups (Figure 3). Daily intake of this carbohydrate was 25.8, 17.0, and 21.28 g, respectively, in Groups AGA, PTB, and SGA. Group PTB had significantly lower levels of lactose intake compared with Group AGA (p < .05). Intake of FAs was the most diverse aspect of the mothers’ diets. These data are shown in their entirety in Table 2.

1200.00

AI=1000mg

1000.00 800.00 600.00 400.00 200.00 0.00 AGA

PTB

SGA

Figure 2. Daily calcium intake of mothers who gave birth to healthy, full-term infants (appropriate for gestational age [AGA]), mothers who gave birth prematurely (preterm birth [PTB]) to infants of normal weight, and mothers who gave birth to full-term infants who were small for gestational age (SGA). Groups AGA and SGA met the criterion for an adequate intake (AI) of calcium. *p < .05.

Most of the significant differences were observed in the intake levels between Groups AGA and PTB in the shortand medium-chain acids butyric acid (C4:0), caproic acid (C6:0), caprylic acid (C8:0), capric acid (C10:0), and miristic acid (C14:0). In each case, women in Group PTB had a lower daily intake than those in Group AGA. Among longchain acids, only stearic acid (C18:0) intake differed between the groups, with the women in Group AGA having a significantly higher daily intake than those in Group PTB. Saturated fatty acid intake also differed between Groups AGA and PTB (p < .05), with women in Group AGA again having a higher intake (Figure 4).

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Table 2. Quantity of Fatty Acids Consumed by Participating Women in the Final Month of Pregnancy, by Study Group.

*

40.00

Lactose [g/day]

35.00 30.00 25.00 20.00 15.00 10.00 5.00 0.00

AGA

PTB

SGA

Figure 3. Daily lactose intake of mothers who gave birth to healthy, full-term infants (appropriate for gestational age [AGA]), mothers who gave birth prematurely (preterm birth [PTB]) to infants of normal weight, and mothers who gave birth to full-term infants who were small for gestational age (SGA). *p < .05.

Discussion Analysis of nutrients such as microelements, vitamins, macronutrients, carbohydrates, and others revealed that maternal dietary intake was relatively stable across the three groups. Calcium was the only trace element for which we detected a significant difference, with the calcium intake of mothers in Group PTB being only 95.5% of the recommended level. Our findings also revealed an unfavorable ratio of calcium to phosphorus of more than 1:2 across all three groups. A few studies have identified a relationship between prematurity and dietary calcium content (Smolarczyk et al., 1997); however, the mechanism of this relationship is still unknown. We also identified lower levels of dietary disaccharide lactose in the women in Group PTB, which raises the possibility that reduced gestation length may be associated with both calcium and lactose deficiencies. The components mutually affect intestinal absorption, which can increase the deficit of both calcium and lactose in a pregnant woman and affect fetal development. Lactose plays a role in many metabolic processes (Khan et al., 2013; Mitoulas et al., 2002), particularly in the metabolism of sugars and other related processes including energy processes. Lactose contained in food is hydrolyzed in the intestine into glucose and galactose. Intestinal glucose absorption is facilitated by the presence of Naþ, which is the energy source for the transport of glucose into the cell. The transport system operates via symporters, whereby the loads on the outside and inside of the cell and the corresponding chemical gradient are maintained by the flow of calcium ions to the outside. A calcium deficiency in the maternal diet may affect this delicate mechanism, limiting the absorption of glucose. A reduced supply of lactose in the diet over time may adversely affect the systemic metabolism of pregnant women. These deficiencies may also limit the biosynthesis of FAs in maternal tissues, especially the formation of shortchain FAs (SCFAs) and MCFAs, the acids for which

FA

AGA

PTB

SGA

C4:0 C6:0 C8:0 C10:0 C12:0 C14:0 C15:0 C16:0 C17:0 C18:0 C20:0 SFAs C14:1 C15:1 C16:1 C17:1 C18:1 C20:1 C22:1 MUFAs C18:2 C18:3 C18:4 C20:3 C20:4 C20:5 C22:5 C 22:6 PUFAs

1.25 0.77 0.48 1.09 1.45 4.86 0.50 20.87 0.45 10.56 0.31 42.57 0.57 0.26 2.05 0.44 40.59 0.35 0.36 44.62 13.96 2.95 0.02 0.00 0.13 0.08 0.02 0.16 17.32

0.95 0.59 0.37 0.86 1.16 3.94 0.43 18.10 0.38 8.73 0.27 35.76 0.47 0.21 1.99 0.36 35.32 0.38 0.35 39.06 11.26 2.38 0.02 0.00 0.12 0.06 0.01 0.13 13.99

1.16 0.72 0.46 1.04 1.35 4.58 0.47 17.75 0.43 7.82 0.29 36.04 0.55 0.25 1.94 0.41 34.38 0.33 0.36 38.19 11.31 2.71 0.01 0.00 0.10 0.04 0.01 0.13 14.32

p Value for Significant Results (AGA: (AGA: (AGA: (AGA: (AGA: (AGA:

PTB) PTB) PTB) PTB) PTB) PTB) ns ns ns (AGA: PTB) ns (AGA: PTB) ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns

.012 .013 .022 .021 .026 .003

.030 .041

Note. AGA ¼ mothers who gave birth to full-term neonates whose weights were appropriate for gestational age; FA ¼ fatty acid; ns ¼ no statistical difference; MUFAs ¼ monounsaturated fatty acids; PTB ¼ mothers who gave birth slightly prematurely (35–37 weeks’ gestation) to neonates whose weights fell in the AGA range; PUFAs ¼ polyunsaturated fatty acids; SFAs ¼ saturated fatty acids SGA ¼ mothers who gave birth to full-term neonates who were small for gestational age (weight < 10th percentile). Results are expressed in gram per day (g/day).

carbohydrates are substrates (Bobin´ski, Mikulska, Mojska, & Simon, 2013b; Innis, 2007; Nasser, Stephen, Goh, & Clandinin, 2010; Thompson & Smith, 1985). Our findings on the fatty acid intake of the pregnant women in our study were quite surprising. We had expected greater differences in the LCPUFA intake between groups, specifically in n-3 and n-6 levels, due to the significant role these FAs play in numerous metabolic and structural processes. Instead, we found significant differences in intake only in SCFAs and MCFAs, the FAs used mainly for energy purposes (Bobin´ski et al., 2013b; Bobin´ski, Mikulska, Mojska, & Simon, 2013a). As with the calcium and lactose levels, we found lower levels of these acids in the diets of women who delivered prematurely compared with those in the Group AGA. Our research revealed the same findings for all the SCFAs and MCFAs we studied. The total dietary level of saturated FAs was also significantly lower in Group PTB compared with Group AGA. From an energy point of view, SCFAs and MCFAs seem to be

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70.00

*

Saturated fay acids [g/day]

60.00 50.00 40.00 30.00 20.00 10.00 0.00

AGA

PTB

SGA

Figure 4. Daily saturated fatty acid intake of mothers who gave birth to healthy full-term infants (appropriate for gestational age [AGA]), mothers who gave birth prematurely (preterm birth [PTB]) to infants of normal weight, and mothers who gave birth to full-term infants who were small for gestational age (SGA). *p < .05.

particularly important for infants born prematurely. They serve as a much better substrate for the mitochondrial energy production process than LCFAs due to the fact that they do not consume ATP during transport into the mitochondria like LCFAs do (Bobin´ski et al., 2013a, 2013b). Net energy gain is therefore greater, which may be important for infants who are born prematurely and, consequently, have reduced metabolic endurance compared to AGA infants. Obviously, the reduction in fatty acid intake in the diet of mothers in Group PTB in this study is not sufficient evidence of a link to shortening of gestational length or a reduction in birth weight. To support such a link, we should also find that the levels of these FAs are reduced in the maternal and/or cord blood in cases of PTB or SGA. However, in a previous study, we found that the percentage of C12:0 in the cord blood was doubled in Group PTB compared to Group AGA (Bobin´ski et al., 2013a). Taking these two findings together, we find that there is an inverse ratio of C12:0 in the cord blood in relation to the maternal diet, with a lower dietary intake of SCFAs and MCFAs, resulting in a higher percentage of at least one MCFA in the cord blood. This inverse relationship likely results from compensational biosynthesis of this FA by the mother’s body and/or the release of MCFAs from tissue deposits. The placenta plays a primary role in this compensatory process by using specialized FA transport systems and biosynthesis to regulate the supply of the relevant FAs. Specialized proteins bind and transport FAs as part of these processes, the most important of which are fatty acid binding proteins in the membrane of the microvilli and basal membrane of syncytiotrophoblast cells and fatty acid transfer proteins (FATPs), which convey nonesterified FAs to the fetal circulation (Haggarty, 2002). It is likely that the placental regulatory system is sensitive to changes in the composition of important substances in the mother’s diet and can, within certain limits, regulate the levels of FAs in the fetal circulation by placental transfer of FAs and/or placental hormonal stimulation of both maternal and fetal tissues to biosynthesize and/or release required FAs.

Overall, we found that dietary intake was relatively stable and did not vary much among the three groups of pregnant women in this study. However, it is possible that the relatively small number of women accepted into the study because the strict inclusion criteria limited our ability to identify additional differences. Our findings suggest that even a small degree of prematurity may be related to the mother’s diet, as we observed lower levels of calcium, lactose, and FAs in mothers of PTB infants compared to those of AGA infants. We did not, however, observe significant differences in the dietary levels of any of these components between the SGA and the AGA groups. To get a more complete picture of the relationships between the diet of pregnant women and the length of gestation and gestational weight, further research with a larger population of mothers of SGA neonates is necessary. However, the results of this study may be useful in the practice of nursing and in the education of pregnant women concerning the selection and development of appropriate dietary habits. Such measures may help to reduce the number of premature births and reduce the number of possible future health complications associated with PTB. Author Contributions RB contributed to conception and design, acquisition, analysis, and interpretation, drafted the manuscript, critically revised the manuscript, gave final approval, and agreed to be accountable for all aspects of work ensuring integrity and accuracy. MM contributed to conception and design, analysis, and interpretation, drafted the manuscript, critically revised the manuscript, gave final approval, and agreed to be accountable for all aspects of work ensuring integrity and accuracy. MM contributed to design, acquisition, and interpretation, drafted the manuscript, critically revised the manuscript, gave final approval, and agreed to be accountable for all aspects of work ensuring integrity and accuracy. IU-W contributed to design and interpretation, drafted the manuscript, critically revised the manuscript, gave final approval, and agreed to be accountable for all aspects of work ensuring integrity and accuracy

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by Nutricia Foundation grant number RG3/2006.

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The Dietary Composition of Women Who Delivered Healthy Full-Term Infants, Preterm Infants, and Full-Term Infants Who Were Small for Gestational Age.

The impact of diet on the health of pregnant women remains an unresolved clinical issue. The aim of this study was to determine and compare the dietar...
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