Diet and deprivation in pregnancy.
ABSTRACT Deprivation is associated with poor pregnancy outcome but the role of nutrition as a mediating factor is not well understood. We carried out a prospective cohort study of 1461 singleton pregnancies in Aberdeen, UK during 2000-6. We measured nutrient intake and supplement use, B vitamin and homocysteine status, birth weight, gestational age, neonatal treatment and socio-economic deprivation status. Women in the most deprived deciles were approximately 6 years younger and half as likely to take folic acid supplements periconceptually as the least deprived mothers. Deprivation was associated with low blood folate, high homocysteine and diets low in protein, fibre and many of the vitamins and minerals. The diets of the more deprived women were also characterised by low intakes of fruit, vegetables and oily fish and higher intakes of processed meat, fried potatoes, crisps and snacks. Deprivation was related to preterm birth (OR 1.14 (95 % CI 1.03, 1.25); P = 0.009) and whether the baby required neonatal treatment (OR 1.07 (95 % CI 1.01, 1.14); P = 0.028). Low birth weight was more common in women consuming diets low in vitamin C (OR 0.79 (95 % CI 0.64, 0.97); P = 0.028), riboflavin (OR 0.77 (95 % CI 0.63, 0.93); P = 0.008), pantothenic acid (OR 0.79 (95 % CI 0.65, 0.97); P = 0.023) and sugars (OR 0.78 (95 % CI 0.64, 0.96); P = 0.017) even after adjustment for deprivation index, smoking, marital status and parity. Deprivation in pregnancy is associated with diets poor in specific nutrients and poor diet appears to contribute to inequalities in pregnancy outcome. Improving the nutrient intake of disadvantaged women of childbearing age may potentially improve pregnancy outcome.
- SourceAvailable from: Ameyalli Rodríguez-Cano[Show abstract] [Hide abstract]
ABSTRACT: Background. Due to the higher prevalence of obesity and diabetes mellitus (DM), more pregnant women complicated with diabetes are in need of clinical care. Purpose. Compare the effect of including only low glycemic index (GI) carbohydrates (CHO) against all types of CHO on maternal glycemic control and on the maternal and newborn's nutritional status of women with type 2 DM and gestational diabetes mellitus (GDM). Methods. Women (n = 107, ≤29 weeks of gestation) were randomly assigned to one of two nutrition intervention groups: moderate energy and CHO restriction (Group 1: all types of CHO, Group 2: low GI foods). Results. No baseline differences in clinical data were observed. Capillary glucose concentrations throughout pregnancy were similar between groups. Fewer women in Group 2 exceeded weight gain recommendations. Higher risk of prematurity was observed in women in Group 2. No differences in glycemic control were observed between women with type 2 DM and those with GDM. Conclusions. Inclusion of low GI CHO as part of a comprehensive nutrition intervention is equally effective in improving glycemic control as compared to all types of CHO. This strategy had a positive effect in preventing excessive maternal weight gain but increased the risk of prematurity.International Journal of Endocrinology 01/2012; 2012:296017. · 1.52 Impact Factor
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ABSTRACT: To identify factors at 15 and 20 weeks' gestation associated with a subsequent uncomplicated pregnancy. Prospective international multicentre observational cohort study. Auckland, New Zealand and Adelaide, Australia (exploration and local replication dataset) and Manchester, Leeds, and London, United Kingdom, and Cork, Republic of Ireland (external confirmation dataset). 5628 healthy nulliparous women with a singleton pregnancy. Uncomplicated pregnancy, defined as a normotensive pregnancy delivered at >37 weeks' gestation, resulting in a liveborn baby not small for gestational age, and the absence of any other significant pregnancy complications. In a stepwise logistic regression the comparison group was women with a complicated pregnancy. Of the 5628 women, 3452 (61.3%) had an uncomplicated pregnancy. Factors that reduced the likelihood of an uncomplicated pregnancy included increased body mass index (relative risk 0.74, 95% confidence intervals 0.65 to 0.84), misuse of drugs in the first trimester (0.90, 0.84 to 0.97), mean diastolic blood pressure (for each 5 mm Hg increase 0.92, 0.91 to 0.94), and mean systolic blood pressure (for each 5 mm Hg increase 0.95, 0.94 to 0.96). Beneficial factors were prepregnancy fruit intake at least three times daily (1.09, 1.01 to 1.18) and being in paid employment (per eight hours' increase 1.02, 1.01 to 1.04). Detrimental factors not amenable to alteration were a history of hypertension while using oral contraception, socioeconomic index, family history of any hypertensive complications in pregnancy, vaginal bleeding during pregnancy, and increasing uterine artery resistance index. Smoking in pregnancy was noted to be a detrimental factor in the initial two datasets but did not remain in the final model. This study identified factors associated with normal pregnancy through adoption of a novel hypothesis generating approach, which has shifted the emphasis away from adverse outcomes towards uncomplicated pregnancies. Although confirmation in other cohorts is necessary, this study implies that individually targeted lifestyle interventions (normalising maternal weight, increasing prepregnancy fruit intake, reducing blood pressure, stopping misuse of drugs) may increase the likelihood of normal pregnancy outcomes. Australian New Zealand Clinical Trials Registry ACTRN12607000551493.BMJ (online) 11/2013; 347:f6398. · 16.38 Impact Factor
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ABSTRACT: The aim of the CHANCE project is to develop novel and affordable nutritious foods to optimize the diet and reduce the risk of diet-related diseases among groups at risk of poverty (ROP). This paper describes the methodology used in the two initial steps to accomplish the project's objective as follows: 1. a literature review of existing data and 2. an identification of ROP groups with which to design and perform the CHANCE nutritional survey, which will supply new data that is useful for formulating the new CHANCE food. Based on the literature review, a low intake of fruit and vegetables, whole grain products, fish, energy, fiber, vitamins B1, B2, B3, B6, B12 and C, folate, calcium, magnesium, iron, potassium and zinc and a high intake of starchy foods, processed meat and sodium were apparent. However, the available data appeared fragmented because of the different methodologies used in the studies. A more global vision of the main nutritional problems that are present among low-income people in Europe is needed, and the first step to achieve this goal is the use of common criteria to define the risk of poverty. The scoring system described here represents novel criteria for defining at-risk-of-poverty groups not only in the CHANCE-participating countries but also all over Europe.Nutrients 04/2014; 6(4):1374-93. · 3.15 Impact Factor
Diet and deprivation in pregnancy
Paul Haggarty1,2*, Doris M. Campbell2, Susan Duthie1, Katherine Andrews1, Gwen Hoad1,
Chandrika Piyathilake3and Geraldine McNeill4
1Nutrition and Epigenetics Group, Rowett Institute of Nutrition and Health, University of Aberdeen, Greenburn Road, Bucksburn,
Aberdeen AB21 9SB, UK
2Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen AB9 2ZD, UK
3Division of Nutritional Biochemistry and Genomics, University of Alabama, Birmingham, AL 35294-3360, USA
4Population Health Section, University of Aberdeen, Aberdeen AB25 2ZD, UK
(Received 17 October 2008 – Revised 17 April 2009 – Accepted 22 April 2009 – First published online 17 August 2009)
Deprivation is associated with poor pregnancy outcome but the role of nutrition as a mediating factor is not well understood. We carried out a
prospective cohort study of 1461 singleton pregnancies in Aberdeen, UK during 2000–6. We measured nutrient intake and supplement use, B
vitamin and homocysteine status, birth weight, gestational age, neonatal treatment and socio-economic deprivation status. Women in the most
deprived deciles were approximately 6 years younger and half as likely to take folic acid supplements periconceptually as the least deprived
mothers. Deprivation was associated with low blood folate, high homocysteine and diets low in protein, fibre and many of the vitamins and
minerals. The diets of the more deprived women were also characterised by low intakes of fruit, vegetables and oily fish and higher intakes of
processed meat, fried potatoes, crisps and snacks. Deprivation was related to preterm birth (OR 1·14 (95% CI 1·03, 1·25); P¼0·009) and whether
the baby required neonatal treatment (OR 1·07 (95% CI 1·01, 1·14); P¼0·028). Low birth weight was more common in women consuming diets
low in vitamin C (OR 0·79 (95% CI 0·64, 0·97); P¼0·028), riboflavin (OR 0·77 (95% CI 0·63, 0·93); P¼0·008), pantothenic acid (OR 0·79 (95%
CI 0·65, 0·97); P¼0·023) and sugars (OR 0·78 (95% CI 0·64, 0·96); P¼0·017) even after adjustment for deprivation index, smoking, marital
status and parity. Deprivation in pregnancy is associated with diets poor in specific nutrients and poor diet appears to contribute to inequalities
in pregnancy outcome. Improving the nutrient intake of disadvantaged women of childbearing age may potentially improve pregnancy outcome.
Pregnancy: Diet: Deprivation: Folic acid: Birth weight: Preterm birth: Social class
Pregnancy is acknowledged as a key life stage critical for both
the current and the next generation(1). Low birth weight is
associated with poor obstetric outcome and long-term disad-
vantage including reduced stature(2), poor cognitive func-
tion(3,4)and increased risk of CVD(5). Low birth weight is
more common in deprived areas of Britain(6)and low social
class is associated with increased risk of low birth weight
and perinatal mortality(7–10). Indeed, it has been estimated
that more than one-quarter of low birth weight is attributable
to social inequalities(11)and there is little evidence that the
situation is improving. Social inequalities in low birth
weight, preterm delivery and low birth weight for gestational
age decreased throughout the 1980s in Scotland but increased
again between 1991 and 2000 to levels similar to those found
20 years previously(7,8,12).
Smoking is known to account for some of the social
inequality in birth weight but nutrition is also thought to be
a causal factor and the Acheson report(1)highlighted the
importance of diet in policies aimed at improving health and
reducing health inequalities in women of childbearing age
and expectant mothers. Many UK health policies are aimed
at the elimination of food poverty and improvement of the
diet in poorer socio-economic groups(13). These range from
the Welfare Food Scheme, designed to protect children’s
health during rationing, to the recently introduced Healthy
Start programme through which pregnant women from low-
income families receive free fruit and vegetables and vitamin
supplements. Poor folate status in women of childbearing age,
particularly from the more deprived groups, also prompted the
recent recommendation that all flour in the UK be fortified
with folic acid in order to address the problem of neural
There is a need to understand the interaction between nutri-
tion and deprivation in pregnancy and their relationship to
pregnancy outcome. The aims of the present study were to
evaluate current nutrient intake and status in pregnancy in
relation to a high-resolution measure of multiple deprivation
in a Scottish population. Particular attention was given to
the B vitamins.
Materials and methods
The study was approved by the Grampian Research Ethics
Committee and all women in the study gave informed written
*Corresponding author: Dr P. Haggarty, fax þ44 1224 716622, email firstname.lastname@example.org
British Journal of Nutrition (2009), 102, 1487–1497
q The Authors 2009
British Journal of Nutrition
consent to take part. Women who were diabetic, carrying
multiple pregnancies, who conceived as a result of fertility
treatment, or in whom clinical data were not available, were
excluded. Of 1461 eligible women, 1277 were enrolled
sequentially (during 2000–6) at Aberdeen Maternity Hospital
when attending for ultrasound scan; a further 184 were
recruited later in pregnancy. Information on each pregnancy
was abstracted from the Aberdeen Maternity and Neonatal
Databank and the data anonymised before linking to the
dietary and laboratory data.
Low birth weight was defined as less than 2500g or the
lowest decile for the standardised birth weight score
(birth weight z-score adjusted for gestational age, sex and
parity)(15). The main advantage of this measure over an
absolute birth weight cut-off is that it allows the effect of
preterm delivery to be considered separately. Any delivery
that occurred before 37 weeks’ gestation was defined as
preterm. Pregnancies in which the newborn was admitted
to the neonatal unit for any reason were categorised as
requiring neonatal treatment. Deprivation was assessed
using the Scottish Index of Multiple Deprivation 2004(16).
This metric provides a comprehensive picture of multiple
deprivation by area (postcode) based on thirty-one indicators
which describe various aspects of deprivation within six
domains of current income, employment, housing, health,
education, skills and training and geographic access to
services and telecommunications. The deciles are based on
the whole population.
Women provided a blood sample at Aberdeen Maternity
Hospital at approximately 19 weeks’ gestation. Total plasma
folate and plasma vitamin B12 were determined by RIA
using the Simultrac Radioassay Kit vitamin B12[57Co]/folic
acid [125I] (MP Biomedicals, Irvine, CA, USA). Plasma
total homocysteine (tHcy) was measured by reverse-phase
HPLC using a DS30 Hcy Homocysteine Assay Kit and
DS30 analyser system (Drew Scientific, Barrow-in-Furness,
Cumbria, UK). Total erythrocyte folate was measured using
the ninety-six-well plate adaptation of the Lactobacillus
casei microbiological assay(17).
Nutrient intake was determined at 19 weeks by a self-
administered FFQ developed for use in Scottish popu-
lations(18)designed to provide an estimate of habitual diet.
The validity of this questionnaire for ranking intake of nutri-
ents was assessed in forty non-pregnant women aged 19–50
years. Spearman correlation coefficients between intake from
the FFQ and from 4d weighed diet (subjects were asked to
record the description and weight of all the food and drink
they consumed over a period of 4d, including three weekdays
and one weekend day) were above 0·4 and mostly above 0·5
for all macronutrients and all minerals and vitamins apart
from Na, Cl, Se, iodine, vitamin B12, retinol and vitamin D
(all 0·25–0·39). For thiamine no correlation was found but
this is likely to reflect the fact that the 4d diet diary was
not long enough to capture variation in habitual intake of
mycoprotein meat substitutes that are extremely rich in thia-
mine. The questionnaire, which covers 170 different food
items and twenty different food groups, is semi-quantitative;
it asks subjects to estimate both the number of times per
week they consume each food and the number of measures
of food they consume on each of these occasions. Nutrient
intakes from natural foods are calculated using the UK
National Nutrient Databank (based on the fifth edition of
McCance & Widdowson’s The Composition of Foods and
related supplementary volumes). The energy-adjusted nutrient
intake provides an estimate of the nutrient density of the diet.
Additional questions relating to the use of food supplements
(type or brand, amount per d, timing and duration of consump-
tion in relation to stage of pregnancy), dietary restrictions and
habits are also included in the questionnaire. A database of the
composition of over 300 different supplement products was
developed ‘in house’ to estimate intake from these sources.
The supplement database was continually updated as and
when new products were recorded by mothers. The nutrient
content of the supplements was as recorded by the manufac-
turer on the product and therefore does not take into account
‘overage’ or other variations due to factors such as shelf
life. The FFQ was designed to provide data on nutrients
rather than food groups but it can be used to provide dimen-
sionless information on relative differences within a popu-
lation. The z-score for the intake of the main food groups
was calculated and related to deprivation index.
Statistical analysis was carried out using STATA/SE
(version 10.0; StataCorp LP, College Station, TX, USA).
Multiple linear regression was used for continuous dependent
variables (metabolite concentrations, nutrient intake) and
logistic regression for categorical outcomes (for example,
low birth weight, preterm birth), with adjustment for appro-
The study group characteristics are shown in Table 1. The
characteristics of the group were checked against information
on all singleton births in Aberdeen Maternity and Neonatal
Database over a similar period (data not shown). The group
Table 1. Study group characteristics and pregnancy outcomes (n 1461)
(Mean values and standard deviations, percentages or numbers)
Age at delivery (years)
SIMD quintile (%)
Baby sex (%)
Gestational age at delivery (weeks)
Preterm delivery (,37 weeks) (%)
Birth weight (g)
Admitted to neonatal unit (%)
Pregnancy loss, n
Neonatal death in first week
SIMD, Scottish Index of Multiple Deprivation.
P. Haggarty et al.1488
British Journal of Nutrition
was representative of singleton pregnancies in Aberdeen with
respect to the key indicators of maternal weight, height, preg-
nancy complications, birth weight and birth outcome. The fre-
quency of smoking was low (,10%) in the least deprived
groups with little change across the first four deciles (Fig. 1).
Higher levels of deprivation were related to smoking beha-
viour, with the highest rates of smoking observed in the
most deprived groups. Age at delivery and the presence of a
partner (married or cohabiting) were also related to level of
deprivation with the most deprived mothers being about 6
years younger and almost twice as likely to be without a part-
ner as the least deprived mothers.
Analysis of non-nutritional factors in relation to pregnancy
outcome (Table 2) indicated that deprivation was related to
preterm birth (OR 1·14 (95% CI 1·03, 1·25); P¼0·009) and
whether the newborn required neonatal treatment (OR 1·07
(95% CI 1·01, 1·14); P¼0·028). The risk of low birth
weight (,2500g) was also related to deprivation (data not
shown) but this appeared to be largely due to an effect on
preterm birth as the gestation age-adjusted standardised birth
weight score was not significantly related to deprivation.
Smoking significantly increased the risk of low birth weight
even with adjustment for deprivation status (OR 2·87 (95%
CI 1·88, 4·40); P,0·001). Greater age at delivery also
increased the risk of neonatal treatment (OR 1·04 (95% CI
1·01, 1·07); P¼0·012). These analyses controlled for marital
status and parity, the latter of which was significantly related
to the probability of preterm birth (OR 0·43 (95% CI 0·26,
0·72); P¼0·001) and neonatal treatment (OR 0·38 (95% CI
0·28, 0·53); P,0·001), though again the link between parity
and low birth weight was primarily a function of preterm
birth as the effect was not present after adjustment for gesta-
tional age or when using the standardised birth weight score.
The significant relationships in Table 2 remained so after
adjustment for nutrient intake.
About 40–50% of the least deprived women reported
taking folic acid supplements periconceptually but the
women in the most deprived deciles were about half as
likely to take supplements at this time (Fig. 1). By week
12 of pregnancy the difference in reported intake by level of
Fig. 1. Trends (polynomial fit (—) with 95% CI (– – –)) by Scottish Index of Multiple Deprivation (SIMD) decile for proportions smoking, single, and taking folic
acid (FA) supplements periconceptually or within the first 12 weeks of pregnancy (week 12). Maternal age at delivery is also shown together with blood folate,
vitamin B12and homocysteine concentration (log transformed). Values are means, with 95% CI represented by vertical bars.
Diet and deprivation in pregnancy1489
British Journal of Nutrition
deprivation disappeared and about 80% of women reported
taking folic acid. However, blood folate status measured at
19 weeks showed strong stratification by level of deprivation,
with both plasma and erythrocyte folate following the same
pattern of a shallow fall in the first three to four deciles
followed by a steep decline with increasing level of depri-
vation. There was a complementary rise in homocysteine
concentration with increasing level of deprivation but no
change in plasma vitamin B12status.
Regression of energy-adjusted nutrient intake z-score on
deprivation decile allows comparison on the same graph of
a standardised unit change in intake per deprivation decile
across all the nutrients (Fig. 2). The diet of the more deprived
women was characterised by a low density of protein, fibre and
almost all of the vitamins and minerals. The main exceptions
were vitamin A and vitamin E, which showed no stratification
by deprivation category, and Na and Cl for which the intake
was higher in the most deprived women (though not statisti-
cally significant), largely reflecting a higher intake of salt-
rich foods. The diets of the more deprived women also
tended to be higher in sugars, starch and fats (with the excep-
tion of polyunsaturated fats) but these differences were not
statistically significant. Alcohol intake fell with increasing
level of deprivation. The generally poorer nutrient intakes
associated with deprivation were consistent with food choices:
the diet of the more deprived women was characterised by low
intakes of fruit and vegetables and higher intakes of fried pota-
toes, crisps and snacks. Deprived women also consumed more
processed meat but less unprocessed meat. Intakes of non-oily
fish varied little with level of deprivation but the intake of oily
fish was lower in deprived women (Fig. 3).
mary but for many nutrients the pattern of response to level of
deprivation was more complicated and this can be seen in
Table 2. Effect of non-nutritional factors on pregnancy outcome: risks of low birth weight, preterm delivery and whether the newborn
required neonatal care*
(Odds ratios and 95% confidence intervals)
Low birth weight (lowest SBS
decile)Preterm delivery (,37 weeks) Neonatal treatment
Parameter (OR units)OR95% CIPOR95% CIPOR95% CIP
Age at delivery (years)
SBS, standardised birth weight score; SIMD, Scottish Index of Multiple Deprivation.
*Results of logistic regression model with five variables: SIMD decile; smoking in pregnancy category – smoker (coded 1) v. non-smoker (coded 0); marital
status – married or cohabiting (coded 1) v. divorced or single (coded 0); parity – one or more previous pregnancy (coded 1) v. none (coded 0); age at
delivery (continuous variable).
Fig. 2. Summary of regression analysis of change in nutrient intake by Scottish Index of Multiple Deprivation (SIMD). Data are presented as standard deviations
of intake per deprivation decile, with 95% CI represented by horizontal bars, to allow all nutrients to be compared in one graph. Results are shown for the major
macronutrient classes (X), fats (O), carbohydrates (B), fat-soluble vitamins (A), water-soluble vitamins (W), and for trace elements and minerals (K). The level of
statistical significance for each regression is indicated beside the relevant nutrient: * P,0·05, ** P,0·01, *** P,0·001.
P. Haggarty et al.1490
British Journal of Nutrition
graphs of intake with deprivation decile (Figs. 4–6). For those
nutrients patterned by deprivation there were a few, such as Fe,
protein and possibly vitamin C, where the response was
approximately linear across all deprivation deciles. However,
for most nutrients there was a graded change by decile in the
most deprived groups with little difference in intake across
the four or five least deprived deciles. This pattern was
observed for folate and most of the other B vitamins, vitamin
C, b-carotene, dietary fibre and many of the minerals including
Zn, Mg and K. Interestingly, the pattern for Na and Cl intake
with deprivation was almost the mirror image, i.e. increasing
intake with increasing deprivation, particularly in the most
deprived groups. Habitual intake of folate and vitamin B12
from foods (Fig. 6) followed essentially the same pattern by
deprivation decile as the blood status measures (Fig. 1). The
pattern for dietary fat was complicated, with total fat, saturated,
monounsaturated and polyunsaturated fat following a biphasic
relationship with deprivation decile. The generally poorer
intake of essential nutrients, minerals and fibre in the more
deprived women is consistent with the lower intake of fruit
and vegetables, for example (Fig. 7). The graphs of food
intake with deprivation decile also illustrate that, as for many
of the individual nutrients, there was a differential effect with
level of deprivation, with little difference in intake across the
least deprived deciles but greater sensitivity to the level of
deprivation in the most disadvantaged women. A number of
nutrients were related to pregnancy outcome before and after
controlling for deprivation index, smoking, marital status
and parity (OR units are energy-adjusted dietary intake stan-
dard deviations as in Fig. 2). Births of babies in the lowest
decile for standardised birth weight were most common in
women consuming diets low in vitamin C (OR 0·79 (95% CI
0·64, 0·97); P¼0·028), riboflavin (OR 0·77 (95% CI 0·63,
0·93); P¼0·008), pantothenic acid (OR 0·79 (95% CI 0·65,
0·97); P¼0·023) and sugars (OR 0·78 (95% CI 0·64, 0·96);
P¼0·017). These nutrient relationships with birth weight
were also significant without adjustment for deprivation
index, smoking, marital status and parity. Preterm delivery
was associated with diets rich in protein (OR 1·43 (95% CI
1·03, 1·98); P¼0·031) and fat (OR 1·51 (95% CI 1·10, 2·01);
P¼0·012) though this relationship was only significant after
adjustment for deprivation index, smoking, marital status and
parity. The requirement for neonatal care was associated with
higher intakes of Na (OR 1·18 (95% CI 1·01, 1·38);
P¼0·034), Cl (OR 1·20 (95% CI 1·03, 1·40); P¼0·018),
folate (OR 1·17 (95% CI 1·00, 1·36); P¼0·045), niacin (OR
1·32 (95% CI 1·14, 1·54); P,0·001) and vitamin C (OR 1·18
(95% CI 1·04, 1·37); P¼0·032). With the exception of Na
these nutrient relationships were also significant before adjust-
ment for the deprivation index, smoking, marital status and
parity. It has been suggested that Caesarean delivery is associ-
ated with a higher requirement for neonatal care, a link which
was also observed in the present study, but even after adjust-
ment for delivery type the relationship between intake of
these nutrients and requirement for neonatal care remained sig-
nificant; the only exception was Na (P¼0·057).
The consequences of adverse pregnancy outcome can be life-
long. Social inequalities in adverse pregnancy outcomes per-
sist in the UK and actually increased between 1991 and
2000 to reach levels found 20 years previously(7,8,12). In
order to develop effective strategies to reverse this trend
there is a need to identify the causal factors linking depri-
vation to poor pregnancy outcome. Deprivation is a complex
Fig. 3. Summary of regression analysis of change in intake of food types by Scottish Index of Multiple Deprivation (SIMD). Data are presented as standard
deviations of intake per deprivation decile, with 95% CI represented by horizontal bars, to allow all foods to be compared in one graph. Results are shown for the
main foods (X), dairy produce (W), staples (K), fruit and vegetables (A), and for sweets and drinks (B). The level of statistical significance for each regression is
indicated beside the relevant nutrient: * P,0·05, ** P,0·01, *** P,0·001.
Diet and deprivation in pregnancy1491
British Journal of Nutrition
metric – defined by factors such as income, employment, hous-
ing, health, education, skills and training and access to services
– which is also linked to behaviours, such as smoking, which
are important determinants of health. Poor diet has been pro-
posed as a key area for interventions designed to improve the
health of the most deprived sector of the population.
In this population of pregnant women dietary choices
were patterned by deprivation, with the most deprived
women consuming diets poor in protein, fibre and a range of
essential minerals such as Fe and vitamins such as folate,
vitamin B6, niacin, vitamin C and b-carotene. However, the
link was not observed for all nutrients and there was no
evidence that intakes of vitamins A and E, for example,
were lower in the more deprived women. Diets in the deprived
group were richer in Na and Cl – the main source of which is
salt – and fat, particularly saturated and monounsaturated fat.
This overall dietary pattern is generally accepted as being det-
rimental to health and the food choices underpinning this
nutritional deprivation are consistent with much of the current
advice on healthy eating being most relevant to the deprived in
society. More deprived women had lower intakes of fruit, veg-
etables and oily fish and higher intakes of processed meat,
milk and cream, crisps and snacks and soft drinks. Interest-
ingly, the relationship between nutrient intake and deprivation
Fig. 4. Trends (polynomial fit (—) with 95% CI (– – –)) by Scottish Index of Multiple Deprivation (SIMD) decile for dietary intake of the macronutrients, fibre,
alcohol and cholesterol. Values are means, with 95% CI represented by vertical bars.
P. Haggarty et al.1492
British Journal of Nutrition
was not a simple linear one. In general, there was a modest
reduction in the quality of the diet with level of deprivation
for the first four or five deciles but much greater dependency
on the level of deprivation in the most disadvantaged in
society. This deprivation-related gradient extended to sup-
plement use. In the case of periconceptual supplementary
folic acid use, the uptake by level of deprivation mirrored
almost exactly the intake of folates from food. An effect of
deprivation on folic acid supplement use has been reported
elsewhere(19)though that quintile-based analysis, using a
less detailed index of deprivation, showed similar levels of
periconceptual supplement use in quintiles 4 and 5. The stron-
gest evidence for a beneficial effect of folic acid on neural
tube defect is found in the periconceptual period, though the
recommendation for supplement use extends to 12 weeks’
gestation(20). Reported folic acid use after conception but
before 12 weeks of pregnancy was high (80%) and not differ-
ent between the most and least deprived women. These data
for reported folic acid use are similar to those described else-
where(19,21,22). However, the strong relationship between
blood folate status at 19 weeks’ gestation and level of depri-
vation suggests that deprived women may over-report folic
acid use in the period up to 12 weeks’ gestation. Taken over-
all, these results suggest that folic acid use in the critical
period is lowest in precisely those women who would benefit
most because of a poor general diet.
Fig. 5. Trends (polynomial fit (—) with 95% CI (– – –)) by Scottish Index of Multiple Deprivation (SIMD) decile for dietary intake of minerals. Values are means,
with 95% CI represented by vertical bars.
Diet and deprivation in pregnancy1493
British Journal of Nutrition
In 1937 Boyd-Orr reported that the nutritional quality of
the Scottish diet was proportional to income(23). The data
presented here for pregnant mothers suggest that this
picture remains broadly true today, although the nature of
deprivation has changed since 1937. It is now defined by a
range of factors including, but not limited to, income. Further-
more, increasing sophistication of food processing and
the ability to manipulate the nutrient composition of highly
processed foods, differential pricing of fresh and processed
food, and differential access to food of high nutritional
value has complicated the nature of nutritional associations
with deprivation. Poor diets in the UK in the 21st century
have adequate energy but are characterised by a low density
of many, but not all, of the essential nutrients. Such diets
appear to contribute to inequalities in pregnancy outcomes
even after adjustment for the level of deprivation.
Deprivation is related to a number of other factors that
could confound the apparent link between maternal nutrition
and adverse pregnancy outcome. In this population, depri-
vation was associated with a lower level of partner support,
with the most deprived mothers being almost twice as likely
to be single (not married or cohabiting) as the least deprived
Fig. 6. Trends (polynomial fit (—) with 95% CI (– – –)) by Scottish Index of Multiple Deprivation (SIMD) decile for dietary intake of vitamins. Values are means,
with 95% CI represented by vertical bars.
P. Haggarty et al.1494
British Journal of Nutrition
mothers. Behaviours with a potential impact on health and
pregnancy, such as smoking and supplement use, were also
patterned by level of deprivation. A link between smoking
and low birth weight has been reported elsewhere. The
effect reported here persisted here even after adjustment for
deprivation and a number of other potential confounders.
The intake of a number of nutrients was related to birth out-
come with and without adjustment for deprivation. In the
case of low birth weight, the risk was highest in women
with poor intakes of vitamin C, pantothenic acid, riboflavin
and sugars. Similar observations have been reported elsewhere
on data that have not been adjusted for deprivation(24–27).
For preterm birth and the need for neonatal treatment
the risk was highest in women with diets high in particular
nutrients – for example, protein and fat in the case of preterm
birth – although this relationship was only apparent after
adjustment for deprivation.
The strong relationship observed between homocysteine
concentration and deprivation is consistent with data from
non-pregnant populations in the USA(28)and Europe(29).
Plasma homocysteine reflects folate intake but cannot be com-
pletely explained by nutritional factors such as folate status
alone(28). This marker of cardiovascular health may be respon-
sive to other non-nutritional factors linked to deprivation.
Fig. 7. Trends (polynomial fit (—) with 95% CI (– – –)) by Scottish Index of Multiple Deprivation (SIMD) decile for intake of foods (z-scores). Values are means,
with 95% CI represented by vertical bars.
Diet and deprivation in pregnancy 1495
British Journal of Nutrition
Even after accounting for diet and other factors, such as
smoking, presence of a partner, parity and age at delivery,
there remained a significant relationship between deprivation
and risk of preterm birth, and the need for neonatal treatment.
This direct link with deprivation may be practical, possibly
resulting from a higher incidence of infection or poorer
uptake of obstetric services in more deprived women. Poten-
tial organic explanations include psychosocial stress and the
physiological responses to stress which are thought to be pat-
terned by social class(28,30). Low birth weight is associated
with levels of maternal stress(31,32)and plausible biological
mechanisms, involving the programming of hypothalamic–
pituitary–adrenal function, have been proposed to explain
Social disadvantage in the UK persists throughout life and
across generations and is proving increasingly difficult to
overcome. Poor birth outcome is itself associated with lower
educational attainment and disadvantage throughout life.
Improving the nutrient intake of disadvantaged women of
childbearing age may help to break the vicious cycle of
deprivation by improving pregnancy outcome. Other factors
linked to deprivation also appear to influence pregnancy out-
come and it is important to also identify these if we are to
break the transmission of disadvantage across the generations.
I. Fraser and A. Skene helped with recruitment, measurement of
nutrient intake and laboratory analysis. The authors would like
The present study was funded by the UK Food Standards
Agency (grant no. N05040). P. H., S. D., G. H. and G. M.
received support from the Scottish Government Rural and
Environment Research and Analysis Directorate.
P. H. was responsible for study design, data collection
and statistical analysis, and preparation of the manuscript.
D. M. C. was responsible for study design, the clinical data-
base and recruitment, and manuscript revision. S. D. was
responsible for plasma folate and homocysteine analysis, and
manuscript revision; K. A. and G. H. were responsible for
sample processing and the supplement database. C. P. was
responsible for erythrocyte folate analysis and manuscript
revision. G. M. was responsible for study design, the dietary
questionnaire and manuscript revision.
The authors report no conflict of interest in relation to the
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