International Journal of Food Sciences and Nutrition

ISSN: 0963-7486 (Print) 1465-3478 (Online) Journal homepage: http://www.tandfonline.com/loi/iijf20

Higher adherence to Mediterranean diet prior

to pregnancy is associated with decreased risk
for deviation from the maternal recommended
gestational weight gain

Antonios E. Koutelidakis, Olga Alexatou, Savvina Kousaiti, Elisavet Gkretsi,

George Vasios, Anastasia Sampani, Maria Tolia, Dimitrios N. Kiortsis &
Constantinos Giaginis

To cite this article: Antonios E. Koutelidakis, Olga Alexatou, Savvina Kousaiti, Elisavet Gkretsi,
George Vasios, Anastasia Sampani, Maria Tolia, Dimitrios N. Kiortsis & Constantinos Giaginis
(2017): Higher adherence to Mediterranean diet prior to pregnancy is associated with decreased
risk for deviation from the maternal recommended gestational weight gain, International Journal of
Food Sciences and Nutrition, DOI: 10.1080/09637486.2017.1330403

To link to this article: http://dx.doi.org/10.1080/09637486.2017.1330403

Published online: 14 Jun 2017.

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INTERNATIONAL JOURNAL OF FOOD SCIENCES AND NUTRITION, 2017
https://doi.org/10.1080/09637486.2017.1330403

RESEARCH ARTICLE

Higher adherence to Mediterranean diet prior to pregnancy is associated

with decreased risk for deviation from the maternal recommended
gestational weight gain
Antonios E. Koutelidakisa, Olga Alexatoua, Savvina Kousaitia, Elisavet Gkretsia, George Vasiosa,
Anastasia Sampanib, Maria Toliac, Dimitrios N. Kiortsisd and Constantinos Giaginisa
a
Department of Food Science and Nutrition, University of the Aegean, Myrina, Lemnos, Greece; bAthens General Hospital “Alexandra”,
Athens, Greece; cSchool of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece; dLaboratory of Physiology,
Medical School, University of Ioannina, Ioannina, Greece

ABSTRACT ARTICLE HISTORY

The present retrospective study was conducted on 1482 women in order to evaluate whether Received 3 October 2016
their pre-pregnancy adherence to the Mediterranean diet may affect maternal gestational weight Revised 7 May 2017
gain (GWG). For this purpose, the study population was classified according to the Institute of Accepted 10 May 2017
Medicine (IOM) recommendations concerning GWG. Pre-pregnancy adherence to the
Mediterranean diet was assessed with 11 food patterns groups based on their contribution in the KEYWORDS
Mediterranean diet pyramid. Women with high adherence to the Mediterranean diet were more Mediterranean diet;
frequently characterised by GWG inside the IOM recommendations. In multivariate analysis, pregnancy; gestational
women with low Mediterranean diet adherence were almost twice at risk in presenting deflection complications; total weight
from recommended GWG regardless of various confounding factors. These findings suggested gain during pregnancy;
that high pre-pregnancy adherence to the Mediterranean diet may be associated with reduced Institute of Medicine
risk for GWG outside the IOM recommendations. However, larger prospective studies are strongly recommendations
recommended in order for more precise conclusions to be drawn.

Introduction risk for potential complications for both the pregnant

Several substantial studies have supported the import-
ance of women’s nutritional patterns, not only during,
but also prior to pregnancy period (Ramakrishnan
et al. 2012). Nevertheless, it is currently not well estab-
lished whether nutritional status prior to pregnancy
may affect future pregnancy outcomes; thus improving
women’s nutrition and weight-related behaviours
should begin during their earlier reproductive years
(Dean et al. 2014). The American Dietetic Association
underlines the high importance of preconception
period, during which women should maintain good
nutritional status through a lifestyle that optimises
maternal health and reduces the risk of birth defects,
suboptimal foetal growth and development, and
chronic health problems in their children (Kaiser &
Allen 2008).
Body weight, physical activity, balanced diet and
general lifestyle before the beginning of pregnancy
constitute very important factors for the ideal weight
gain during pregnancy, as well as for the decrease of
woman and the foetus. Epidemiological evidence has
also suggested that maternal weight gain outside the
Institute of Medicine (IOM) recommendations
increases the risk for potential gestational complica-
tions in both the mother and the foetus (IOM 2009).
Excessive gestational weight gain has been associated
with maternal obesity postpartum and a number of
adverse pregnancy outcomes, such as gestational dia-
betes mellitus, pregnancy-induced hypertension, pree-
clampsia, venous thromboembolism, labour induction,
caesarean delivery and infant macrosomia (Guelinckx
et al. 2008; Chena et al. 2010; Mamun et al. 2010;
Streuling et al. 2010; Karamanos et al. 2014).
The basic guidelines for a health-promoting lifestyle
prior and during pregnancy include appropriate
weight gain, appropriate physical activity and con-
sumption of a variety of foods in accordance with the
dietary recommendations (Kaiser & Allen 2008). In
this aspect, it is currently well established that higher
adherence to the Mediterranean diet is associated with
reduced risk for cardiovascular diseases, certain types

CONTACT Giaginis Constantinos cgiaginis@aegean.gr Department of Food Science and Nutrition, University of the Aegean, Mitropoliti Ioakim 2,
Myrina, Lemnos 81440, Greece
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
2 A. E. KOUTELIDAKIS ET AL.
of cancer and several chronic inflammatory diseases.
However, the currently available epidemiological data
concerning the association between the pre-pregnancy
adherence to the Mediterranean diet and the maternal
weight gain during pregnancy remain scarce. In a
recent study, Schoenaker et al. (2015) concluded that
the adoption of the Mediterranean diet in the period
before pregnancy reduced pregnancy complications,
such as preeclampsia and hypertension. In another
study, high adherence to the Mediterranean diet prior
to pregnancy showed increased probability of appro-
priate weight gain, protecting against overweight and
obesity during pregnancy (Silva-del Valle et al. 2013).
Several scientific data support that the dietary pat-
terns of the Mediterranean diet and specifically high
consumption of fruits, vegetables, fish and legumes
may be associated with healthy pregnancy and normal
foetal growth. A diet with a lower glycaemic index
and adequate provision of iron, calcium, vitamins,
such as B12 and folic acid and antioxidants, may also
promote the health of both pregnant women and foe-
tus (Chatzi et al. 2012; Balcı et al. 2014; Gil & Gil
2015). The achievement of a normal weight gain dur-
ing pregnancy, in compliance with the relevant guide-
lines, is associated with a healthy pregnancy and is
strongly affected by women’s diet during pregnancy
(Streuling et al. 2010). Nevertheless, the evaluation of
the possible effect of maternal diet prior to pregnancy
on gestational weight gain, which is of high import-
ance, is not well studied up to date. In this aspect, the
aim of the current study was to evaluate whether the
adherence to the Mediterranean diet during the period
before pregnancy may affect maternal gestational
weight gain inside or outside IOM recommendations.
Materials and methods
Subjects
The present study conducted on 1432 white, Greek in
majority, women, with an average age of 33.1 ± 4.9
years old. The study was performed from February
2013 to June 2016 in the General Athens Hospital
“Alexandra”, the General Hospital “Elena Benizelou”
of Athens and the Gynecological Clinic “Ygeia” of
Larisa. The inclusion criteria were as follows: women
without high-risk pregnancy, without history of arter-
ial hypertension, heart disease, diabetes mellitus, high
cholesterol and viral infection. All participants were
informed about the purpose of the study and signed a
consent form. The enrolment was performed after
birth and the women were asked about their pre-
pregnancy eating habits. Dietary habits during preg-
nancy were not evaluated.
Study design
In this retrospective study, 1482 pregnant women were
randomly selected in three Greek hospitals to participate
from the 1st until the 3rd day after the delivery. From
the 1482 participants, 1432 finally completed the study,
while 50 women did not agree to participate in the
study. Sample size calculation was based on the use of a
calculator programme, while the randomisation was car-
ried with the use of a sequence of random binary num-
bers (i.e. 001110110 in which 0 represented enrolment
and 1 not enrolment to the study). The study was
approved by the hospital ethics committee and was in
compliance with the World Medical Organisation
(52nd WMA General Assembly, Edinburgh, Scotland,
2000). Anthropometric characteristics from the volun-
teers (height, weight) were self-recorded and repre-
sented the values at the beginning and at the end of
pregnancy, while the body mass index (BMI) was calcu-
lated. Demographic, social, economic and anthropomet-
ric parameters, physical activity, smoking status,
medical records and dietary habits before pregnancy
were assessed by a semiquantitative questionnaire.
The anthropometric characteristics of the neonates
(weight, height, head circumference) were also recorded.
Pre-pregnancy adherence to the Mediterranean diet was
assessed using a questionnaire based on 11 food pat-
terns based on their contribution in the Mediterranean
diet pyramid.
Evaluation of the adherence to the Mediterranean
diet
The assessment of Mediterranean diet adherence prior
to pregnancy was carried out with the use of a Food
Frequency Questionnaire (FFQ) with 11 selected food
groups based on MedDietScore index, according to
Panagiotakos et al. (2006). Each question accounted
six possible answers, marked from 0 to 5, depending
on the level of adherence for each food group. The
sum of the 11 questions led to a score from 0 to 55;
the higher score represents higher adherence to
Mediterranean diet (Panagiotakos et al. 2006, 2007;
Arvaniti & Panagiotakos 2008). For cereals, potatoes,
fruits, vegetables, dairies and olive oil, the scale of six
possible responses adjusted per day. For legumes, sea-
food, red meat and poultry, the scale of six possible
answers adjusted per week. The participants were also
asked about the duration they followed the specific
dietary patterns reported in the questionnaire with the
 INTERNATIONAL JOURNAL OF FOOD SCIENCES AND NUTRITION 3

possible answers being: in the last one year, in the last
5–6 years, for about 10 years, for about 20 years and
for about 30 years.
Statistical analysis
Statistical analysis was performed by Student’s t-test
and chi-square for continuous and categorical varia-
bles, respectively. The categorical demographic varia-
bles were subjected to statistical analysis after
categorisation into two groups in such a manner that
each group included, as much as possible, an equal
number of cases. Food groups’ intake variables were
subjected to statistical analysis after categorisation into
two groups: one including the upper quartile and
another including the rest quartiles. Logistic regression
analysis was performed to assess the influence of pre-
pregnancy adherence to the Mediterranean diet in the
maternal weight gain during pregnancy after adjust-
ment for potential confounders. In fact, logistic model
was constructed taking into account all the confound-
ing factors, e.g. age, educational level, economic status,
smoking history. Differences were considered signifi-
cant at p < .05, 95% confidence interval. The statistical
analysis of the survey data was performed with the
SPSS 17.0 programme (Statistical Package for Social
Sciences, Chicago, IL).
Women with higher education levels, better eco-
nomic status, increased physical activity and no smok-
ers had lower prevalence of gestational weight gain
outside IOM recommendations (Table 2, p ¼ .002,
p ¼ .001, p < .001 and p < .001, respectively).
Moreover, women with pre-pregnancy BMI above
25 kg/m2 (overweight and obese) showed significant
increased probability to deviate from the recom-
mended gestational weight gain according to IOM cri-
teria (Table 2, p < .001).
In order to investigate the effect of the degree of
Mediterranean diet adherence before pregnancy on
the gestational weight gain, the statistical analysis was
carried out after consideration of a validated
Mediterranean diet score. Overall, women presenting
gestational weight gain inside the IOM recommenda-
tions were characterised by a higher MedDietScore
compared to those with gestational weight gain out-
side the IOM recommendations (Table 2, p < .001).
More specifically, by dividing MedDietScore into two
groups according to median value, women with higher
adherence to Mediterranean diet (MedDietScore >28)
were more frequently characterised by gestational
weight gain inside the IOM recommendations com-
pared to women with lower adherence to
Mediterranean diet (MedDietScore 28). However,
adherence to the Mediterranean diet was not

Results
The mean weight gain at the end of pregnancy for the
1432 women who participated in the study was
13.4 ± 5.2 Kg. Table 1 presents the mean gestational
weight gain of the study population and the recom-
mended values according to IOM recommendations.
In fact, 44.4% of women had a total gestational weight
gain within the IOM recommendations, 35.2% had
greater overall weight gain, while 20.4% had less over-
all weight gain than the IOM recommendations
(Figure 1). Overall, gestational weight gain outside the
IOM recommendations was recorded for 55.9% of the
total sample.
Figure 1. Proportions of women under study with gestational
weight gain inside and outside IOM recommendations.

Table 1. Categorization of women according to their body mass index (BMI) before pregnancy, their mean gestational weight
gain at the end of the pregnancya and the recommended weight gain according to the IOM criteria.
Women percent before Mean weight gain at the Recommended weight gain at
Body mass index (BMI) pregnancy (N¼1432) end of pregnancy (kg) the end of pregnancy (kg)
<18.5 kg/m2 (underweight) 76 (5.3%) 13.1 ± 6.6 12.7–18.1
18.5–24.9 kg/m2 (normal weight) 1003 (70.0%) 13.9 ± 4.7 11.3–15.9
25.0–29.9 kg/m2 (overweight) 225 (15.7%) 13.8 ± 5.6 6.8–11.3
30 kg/m2 (obese) 128 (8.9%) 9.7 ± 6.1 5.0–9.1
a
Total weight gain from before pregnancy to the end of the pregnancy.
4 A. E. KOUTELIDAKIS ET AL.

Table 2. Demographics characteristics of participants before pregnancy in association with gestational

weight gain outside and inside IOM recommendations.
Gestational weight gain outside and
inside IOM recommendations
Demographics characteristicsa N ¼ 1432 Inside IOM Outside IOM p-Value
Age 32.9 ± 5.0 33.1 ± 5.0 .582
Education level .002
<12 years 645 271 (42.0%) 374 (58.0%)
12 years 787 395 (50.2%) 392 (49.8%)
Economic status .001
Very low to moderate 862 370 (42.9%) 492 (57.1%)
Good to excellent 570 296 (52.0%) 274 (48%%)
Physical activity <.001
<1–2 times per week 887 375 (42.3%) 512 (57.7%)
1–2 times per week 545 291 (53.4%) 254 (46.6%)
Smoking status <.001
No smokers 915 461 (50.4%) 454 (49.6%)
Smokers 517 205 (39.7%) 312 (60.3%)
Body mass index (BMI) <.001
<25 kg/m2 1076 577 (53.6%) 499 (46.4%)
25 kg/m2 356 89 (25.0%) 267 (75.0%)
Mediterranean diet score <.001
28 810 326 (40.2%) 484 (59.8%)
>28 622 340 (54.7%) 282 (45.3%)
a
The categorical variables were subjected to statistical analysis after categorisation into two groups in such a manner that
each group included, as possible, an equal number of cases.

associated, at a statistically significant level, with wom-
en’s age, educational level, economic status, physical
activity, smoking status and BMI (p > .05). Although
the above associations did not reach a statistically sig-
nificant level, it should be noted that older age
(p ¼ .060), higher educational level (p ¼ .276), higher
economic status (p ¼ .144) and non-smoking history
(p ¼ .132) were more frequently observed in women
with high adherence to the Mediterranean diet
(MedDietScore >28). On the other hand, pre-preg-
nancy physical activity (p ¼ .937) and BMI (p ¼ .770)
did not show any trend of correlation with
Mediterranean diet adherence prior to pregnancy. In
multivariate logistic regression analysis, women with
low Mediterranean diet adherence (MedDietScore
28) were almost twice at risk for presenting devi-
ation from recommended gestational weight gain com-
pared to women with high Mediterranean diet
adherence (MedDietScore >28), regardless of various
confounding factors (Table 3). Pre-pregnancy reduced
physical activity, smoking history and BMI >25 kg/m2
were also independently associated with increased risk
for deviation from the recommended gestational
weight gain in conjunction with Mediterranean diet
adherence (Table 3).
Table 4 presents the food frequency consumption
of the population under study before pregnancy in
association with the deviation from the recommended
weight gain at the end of pregnancy. In fact, the high
consumption of fruits (p ¼ .008), legumes (p ¼ .004)
and seafood (p < .001) and the low consumption of
red meat (p < .001) and dairy products (p ¼ .004)
before pregnancy were significantly associated with
increased possibility of presenting gestational weight
gain inside the IOM recommendations. The pre-preg-
nancy consumption of one or two glasses of alcoholic
drinks per day was also significantly associated with
increased possibility of presenting gestational weight
gain inside the IOM recommendations. The majority
(70.5%) of the subjects answered that they had fol-
lowed the diet mentioned in the questionnaire for at
least five years, 6.8% in the last year and 23.7% for a
period of 2–3 years.
Discussion
Numerous epidemiological studies have concluded
that pregnant women with gestational weight gain
within the IOM recommendations exhibit less risk for
pregnancy complications compared to pregnant
women with weight gain outside the recommended
limits (Guelinckx et al. 2008; Chena et al. 2010;
Mamun et al. 2010; Streuling et al. 2010; Karamanos
et al. 2014). Specifically, gestational weight gain greater
than recommended has been associated with increased
risk for gestational diabetes, hypertension, preeclamp-
sia, foetus macrosomia, foetus nervous tube disorders
and premature birth. Moreover, gestational weight
gain less than recommended has been associated with
increased risk for foetus microsomia, foetus anaemia
and premature births (Catalano 2007; Crane et al.
2009; Yu et al. 2013). Body weight, physical activity
and dietary patterns for women before the beginning
of pregnancy have also been considered as very
 INTERNATIONAL JOURNAL OF FOOD SCIENCES AND NUTRITION 5

Table 3. Multivariate logistic regression analysis assessing the effect of the degree of pre-pregnancy adherence to the
Mediterranean diet on the gestational weight gain outside IOM recommendations in 1432 women by adjustment with potential
confounding factors.
Parameters studied (N ¼ 1432) Odds ratios 95% Confidence interval p-Value Wald
Age (<33.1 vs. 33.1 years) 1.01 0.99–1.03 .278 1.17
Education level (<12 vs. 12 years) 1.15 0.92–1.45 .208 1.58
Economic status (very low to moderate vs. good to excellent) 1.18 0.94–1.44 .142 2.15
Physical activity (<1–2 times vs. 1–2 per week) 1.36 1.09–1.71 .006 7.43
Smoking status (no smokers vs. smokers) 0.69 0.55–0.87 .002 9.62
Body mass index (BMI) (<25 vs. 25m /Kg)
2
1.08 1.05–1.11 <.001 32.33
Mediterranean diet adherence (very low–low 28 vs. moderate–high adherence >28) 1.90 1.52–2.37 <.001 32.99
All the variables studied were categorical and were subjected to statistical analysis after categorisation into two groups in such a manner that each
group included, as possible, an equal number of cases.

Table 4. Proportions of women with gestational weight gain inside and outside IOM recommendations according to food groups
belonging to the pre-pregnancy Mediterranean diet intake.
Proportions of women with gestational weight
gain inside and outside IOM recommendations
Food groups belonging to the Mediterranean
diet pre-pregnancy intakea N ¼ 1432 Inside IOM Outside IOM p-Value
Unprocessed cereals .581
<1–2 portions/day 1174 542 (46.2%) 632 (53.8%)
1–2 portions/day 258 124 (48.1%) 134 (51.9%)
Potatoes .173
<1=2–1 portions/day 1088 517 (47.5%) 571 (52.5%)
1=2–1 portions/day 344 149 (43.3%) 195 (56.7%)
Fruits .008
<2–3 portions/day 1002 443 (44.2%) 559 (55.8%)
2–3 portions/day 430 223 (51.9%) 207 (48.1%)
Vegetables .189
<1–2 portions/day 1225 561 (45.8%) 664 (54.2%)
1–2 portions/day 207 105 (50.7%) 102 (49.3%)
Legumes .004
<1–2 portions/week 1298 588 (45.3%) 710 (54.7%)
1–2 portions/week 134 78 (58.2%) 56 (41.8%)
Sea Food <.001
<1=2 portions/week 752 310 (41.2%) 442 (58.8%)
1=2 portions/week 680 356 (52.4%) 324 (47.6%)
Red meat <.001
<4–5 portions/week 1114 561 (50.4%) 553 (49.6%)
4–5 portions/week 318 105 (33.0%) 213 (67.0%)
Chicken .990
3 portions/week 1071 498 (46.5%) 573 (53.5%)
>3 portions/week 361 168 (46.5%) 193 (53.5%)
Dairies .004
2–3 portions/day 892 441 (49.4%) 451 (50.6%)
>2–3 portions/day 540 225 (41.7%) 315 (58.3%)
Olive oil .239
4–5 portions/week 1277 587 (46.0%) 690 (54.0%)
Daily 155 79 (51.0%) 76 (49%)
Alcoholic drinks .034
0 glasses/day or 3 glasses/day 1288 587 (45.6%) 701 (54.4%)
1–2 glasses/day 144 79 (54.9%) 65 (45.1%)
a
Food groups’ intake variables were subjected to statistical analysis after categorisation into two groups: one including the upper quartile and another
including the rest three quartiles.

important factors for the achievement of suitable
weight at the end of pregnancy; thus these factors may
strongly affect the possibility for avoidance of poten-
tial complications for both the pregnant woman and
the foetus.
It is currently well known that the adherence to the
Mediterranean diet, which recommends increased con-
sumption of fruits, vegetables, unprocessed cereals,
olive, nuts and sea food, is associated with reduced
risk for cardiovascular diseases, cancer and other
chronic inflammatory diseases (Trichopoulou et al.
2005). Although there are several studies supporting
that the adherence to Mediterranean diet during preg-
nancy may decrease the deviation from the recom-
mended weight gain (Hillesund et al. 2014; Shin et al.
2014) and minimise the risk for premature childbirth
(Khoury et al. 2005; Haugen et al. 2008), there are no
enough data about the pre-pregnancy period. More
specifically, according to the existing literature, the
degree of adherence to the Mediterranean diet prior to
6 A. E. KOUTELIDAKIS ET AL.
pregnancy has not sufficiently been studied as a pos-
sible factor that may affect the gestational weight gain
and thus the possibility of avoidance of potential com-
plications during pregnancy.
In this aspect, the first important finding of the
present retrospective study was that enhanced adher-
ence to Mediterranean diet prior to pregnancy was
associated with lower risk for deviation from the rec-
ommended gestational weight gain according to IOM
criteria. More specifically, the percent of women with
gestational weight gain outside the IOM recommenda-
tions was significantly lower when they exhibited high
adherence to Mediterranean diet (45.3%) compared to
those with low adherence to Mediterranean diet
(59.8%). Therefore, women who systematically fol-
lowed the Mediterranean diet prior to their pregnancy
seem to have lower risk of deviation from IOM rec-
ommended gestational weight gain. These results were
obtained after multivariate logistic regression analysis
performance, regardless of various confounding fac-
tors, and by using the MedDietScore index. To this
point, it should be noted that the MedDietScore index
is a useful, validated methodological tool for assessing
the adherence to the Mediterranean diet. In several
substantial clinical studies, this index has systematic-
ally be used as a tool that well predicts the possible
effect of Mediterranean food groups on the prevalence
of hypertension, hypercholesterolaemia, diabetes and
obesity, among healthy adults (Panagiotakos et al.
2006, 2007; Arvaniti & Panagiotakos 2008).
The importance of the present results lays in the
fact that there is a lack of sufficient evidence support-
ing the potential effect of the Mediterranean diet prior
to pregnancy on gestational weight gain. In a similar
study in Canary Islands with a sample of 170 pregnant
women, Silva-del Valle et al. (2013) reported that
pregnant women with high adherence to the
Mediterranean diet before pregnancy exhibited less
gestational overweight gain compared to women with
low adherence to the Mediterranean diet. These results
are in accordance with the present study. In another
study, Schoenaker et al. (2015) observed in Australian
women that the adoption of the Mediterranean diet in
the period before pregnancy minimised possible
obstetric complications, such as preeclampsia and ges-
tational hypertension.
The second important finding reported herein was
that high consumption of fruits, legumes and seafood
and low red meat and dairy intake were associated
with decreased risk of deviation from the recom-
mended gestational weight gain. Nevertheless, it
should be noted that these food items were individu-
ally associated with decreased risk of deviation,
although these analyses were not adjusted for other
dietary factors or potential confounding factors, since
such an analysis required a larger sample size in order
for more precise conclusions to be drawn. In this
aspect, there are epidemiological data which support
that the possible beneficial effects of Mediterranean
diet are not the result of its individual components,
but its beneficial effects are attributed to potential syn-
ergistic actions of the multiple ingredients of this type
of diet (Trichopoulou et al. 2009). However, the provi-
sion of high biological value protein, dietary fibre,
anti-inflammatory agents and antioxidants, such as
polyphenols, minerals, such as calcium, iron and zinc
and vitamins, such as folic acid and B12 during preg-
nancy period, could also affect positively, both syner-
gistically and individually, the pregnancy outcome and
the infants’ health; these components are fully
provided from the Mediterranean diet adherence
(Balcı et al. 2003; Lv et al. 2014; Koutelidakis &
Kapsokefalou 2015).
Increased consumption of seafood before pregnancy
is of high importance due to the numerous bioactive
compounds of this food group. It is proven that the
consumption of sea food within the guidelines before
and during pregnancy is essential for both the preg-
nant woman and the foetus. The bioactive compounds
of sea food may support foetal development, decreas-
ing the possibility for neural tube defects and improv-
ing the visual activity and the cognitive functions of
the infant (Olsen et al. 2008; Gil & Gil 2015).
Moreover, although we did not find any significant
effects of olive oil consumption, there are data that
olive oil consumption during pregnancy may decrease
possible complications, eliminating the risk for infant’s
asthma (Olsen et al. 2008). The beneficial effect of
olive oil in human health and especially in pregnancy
could be ascribed to the various bioactive compounds
that it contains such as oleic acid, tocopherols, squa-
lene, oleuropein and hydroxytyrosol (Koutelidakis &
Dimou 2016). Numerous substantial studies also sup-
port the importance of mono- and poly-unsaturated
fatty acid consumption during pregnancy. However,
there are no data indicating the effect of its pre-preg-
nancy intake, via sea food and olive oil consumption,
on gestational weight gain.
Regarding legumes and fruits consumption, there is
no scientific evidence strongly supporting that the
consumption of fruits and legumes prior to pregnancy
may affect the gestational weight gain. It is currently
well known that both legumes and fruits constitute
rich sources of dietary fibres, antioxidants, minerals
and vitamins (Koutelidakis & Dimou 2016). In the
Nurses’ Health Study (NHSII), a low intake of dietary

fibres from fruits and cereals before pregnancy was
associated with increased risk of gestational diabetes
(Zhang et al. 2006). In the same study, no correlation
was observed between fruit consumption before preg-
nancy and the risk of gestational diabetes, with the
exception of apples consumption, while a possible
association was detected for several types of fresh fruit
juices (Zhang et al. 2006).
An interesting finding of our study was that the
pre-pregnancy consumption of one or two glasses of
alcoholic drinks, per day, especially red or white wine,
was also significantly associated with increased possi-
bility of presenting gestational weight gain inside the
IOM recommendations. However, these preliminary
results should be confirmed by larger sample size
studies in order for an accurate adjustment for poten-
tial confounding factors to be performed. It is possible
that other food habits or a different life style in gen-
eral explains the observed association between alcohol
in moderation and weight gain. In view of the above
preliminary findings, it is currently well established
that moderate alcohol, and especially red wine, con-
sumption may reduce the risk of cardiovascular dis-
eases, promoting the vasodilation due to the alcohol
effect and the polyphenol content. Although it is pro-
ven that high intakes of alcohol during pregnancy
increase the risk for complications and affect the foe-
tus development, the moderate pre-pregnancy intake
may have beneficial effects for the women health
(Payne et al. 2005; Inskip et al. 2009). However, there
are not existing data about the possible effect of pre-
pregnancy alcohol consumption on maternal gesta-
tional weight gain.
Surprisingly enough, adherence to Mediterranean
diet prior to pregnancy was not associated, at least at
a statistically significant level, with women’s age, edu-
cational level and economic status, as well as with pre-
pregnancy physical activity, smoking habits and BMI.
However, these preliminary results should be con-
firmed by larger sample size studies in order for more
precise conclusions to be drawn. Furthermore, it
should be noted that older and higher educated
women, reporting higher economic status, as well as
non-smokers were characterised by higher adherence
to the Mediterranean diet. In this aspect, Silva-del
Valle et al. (2013) observed that older and higher edu-
cated women adopted highly the Mediterranean diet
standard. Moreover, in another prospective study of
1175 women, low adherence to the Mediterranean diet
before pregnancy was more frequently observed in
younger women, of lower social status, less educated,
smokers and decreased physical activity (Olmedo-
Requena et al. 2014).
INTERNATIONAL JOURNAL OF FOOD SCIENCES AND NUTRITION 7
Although the present study presents data which
support the importance of the Mediterranean diet for
the period before the pregnancy, we have to underline
several limitations of our study. Specifically, this is a
retrospective study and thus the results should be fur-
ther confirmed by large prospective studies. The study
sample is limited and includes women who were hos-
pitalised in the urban areas of Attica and Larissa.
Larger epidemiological studies with sample from other
areas of the country, urban, rural and island regions
are essential in order for more reliable conclusions
regarding the Greek population to be drawn. The
recall bias is also a limitation of the study. The recall
bias may be prevented due to the reliability of the
questionnaire and the guidance provided to women
during the completion of the questionnaire by quali-
fied dietitians.
Conclusion
This is a retrospective study conducted for the first
time on a Greek population which supported evidence
that high pre-pregnancy adherence to the
Mediterranean diet may be associated with reduced
risk for gestational weight gain outside the IOM rec-
ommendations. Moreover, increased consumption of
fruits, legumes and seafood, moderate consumption of
alcohol, and low red meat and dairy intake were asso-
ciated with reduced risk of deviation from the recom-
mended gestational weight gain. Large prospective
studies are strongly recommended in order to confirm
the potential protective role of the Mediterranean diet
against the risk of deviation from the recommended
gestational weight gain, as well as the individual effect
of each food component of the Mediterranean diet.
Disclosure statement
No potential conflict of interest was reported by the
authors.
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