Associations of consumption of fruits and vegetables during pregnancy with infant birth weight or small for gestational age births: a systematic review of the literature

Figures & data

Figure 1 Flow diagram of study identification.

Table 1 Study populations and measures of fruits and vegetables consumption during pregnancy

Reference	Study design, location, sample size [n in analysis]	Time of diet assessment and period covered	Fruits and vegetables exposure method	Classification of vegetables	Classification of fruits
Cohorts in countries with a very high HDI
Mikkelsen et al 2006^Citation15	Prospective cohort Denmark (DNBC) 43,585	25 weeks’ gestation; covers previous month of dietary intake	Written FFQ returned by mail	Green leafy; categorized by frequency of intake as none, <1 time/week, >1 time/week, ≥ alternate days. Vegetables not specified; estimated in g/day, then categorized by quintile of intake of fruits and vegetables; also quintile of fruit, vegetable, and juice intake	Fruits not specified; estimated g/day, then categorized by quintile of intake of fruits; fruits and vegetables; also quintile of fruit, vegetable, and juice intake
McCowan et al 2010^Citation29	Prospective cohort New Zealand, Australia, UK, and Ireland (SCOPE cohort) 3,513	15±1 weeks’ gestation;* assessed current diet	Interview that included dietary information	Green leafy: high intake defined as ≥3 servings/day	Fruits not specified; high intake defined as ≥3 servings/day
Ramon et al 2009^Citation28	Prospective cohort Spain (INMA – Valencia cohort) 787	10–13 and 28–32 weeks’ gestation, with responses based on usual intake since last menstrual period and first FFQ, respectively	In-person semi-quantitative FFQ	Select types included green leafy, brassica, red/orange, starchy, other; vegetables categorized by quintile of intake	Select types included berries, grapes, citrus, pome, stone, tropical, melon, juice; fruits categorized by quintile of intake
Mitchell et al 2004^Citation16	Case–control New Zealand 844 cases, 870 controls [543 cases, 600 controls]	Following delivery; completed twice: once to reflect diet at the time of conception and once to reflect diet in the last month of pregnancy	Self-administered, semi-quantitative FFQ returned by mail	Select types included beans/peas, starchy, other; vegetables categorized as 0–0.75, >0.75–1.25, >1.25–2.0, >2.0–3.0, or >3.0 servings/day	Select types included berries, citrus, pome, stone, tropical, melon; fruits categorized as 0–0.75, >0.75–1.25, >1.25–2.0, >2.0–3.0, or >3.0 servings/day
Ricci et al 2010^Citation31	Case–control Italy 555 cases, 1,966 controls	Following delivery; reflects diet in the last month of pregnancy	Interviewer administered structured FFQ	Green vegetables not specified: categorized as ≤5, 6, or ≥7 times/week. Red/orange (carrots); categorized as ≤0.5, 0.5–1, or ≥2 times/week	Fruits not specified: categorized as ≤8, 9–13, or ≥14 times/week
Balazs et al 2014^Citation32	Retrospective cohort Hungary 5,632	Following delivery; period of exposure not specified	Questionnaire	Vegetables not specified: categorized as less often than every other day, or at least every other day	Fruits not specified: categorized as <every other day or more often
Petridou et al 1998^Citation30	Retrospective cohort Greece 368	Presumably at time of delivery; intake covered unspecified time during pregnancy, included adjustment for seasonally consumed items	Interviewer administered semi-quantitative FFQ	Select types included green leafy, brassica, red/orange, beans/peas, starchy, other; vegetables categorized in units of 1/day (presumably 1 serving/day)	Select types included berries, grapes, citrus, pome, stone, tropical, melon, dried, juice; fruits categorized in units of 1/day (presumably 1 serving/day)
Cohorts in countries with a medium or high HDI
Loy et al 2011^Citation35	Prospective cohort Malaysia 121	28–38 weeks’ gestation; intake in preceding 6 months	In-person semi-quantitative FFQ	Select types included green leafy, brassica, beans/peas, other, includes nuts and seeds; vegetables estimated as g/day	Fruits not specified; estimated as g/day
Rao et al 2001^Citation14	Prospective cohort India (rural) 633 [627, 609]	18 and 28 weeks’ gestation; intake in preceding 3 months	FFQ; no portion size information	Green leafy; categorized as never, <1 time/week, >1 time/week, or ≥ alternate days. Non-green leafy vegetables; categorization not specified	Fruits not specified; fruits categorized as <1 time/week, >1 time/week, or ≥1 time/day
Kanade et al 2008^Citation34	Prospective cohort India (urban) 236 [206, 179]	18 and 28 weeks’ gestation; intake in preceding month	FFQ; no portion size information	Green leafy; categorized as < alternate days, <1 time/day, or ≥1 time/day. Non-green leafy vegetables not specified; categorization not specified	Fruits not specified; categorized as <1 time/day, <2 times/day, ≥2 times/day
Hassan et al 2011^Citation33	Retrospective cohort Egypt 234	At time of delivery; responses for each trimester of pregnancy	Interviewer administered semi-quantitative FFQ	Vegetables not specified; categorized as 1 time/week, 2 times/week, or alternate days/every day. Green leafy; categorized as 1 time/week, 2 times/week, or alternate days/every day	Fruits not specified; categorized as 1 time/week, 2 times/week, or alternate days/every day

Note:

* Investigators also examined associations between intakes of fruits and vegetables in the month before conception and infant birth weight, though only intakes during pregnancy were considered in the current review. HDI as defined by the United Nations Development Program.³⁶

Abbreviations: DNBC, Danish National Birth Cohort; FFQ, food frequency questionnaire; HDI, Human Development Index; INMA, Infancia y Medio Ambiente (Childhood and Environment); SCOPE, Screening for Pregnancy Endpoints.

Table 2 Adjustment factors in identified observational studies of fruits and vegetables consumption during pregnancy and birth weight

Study (location)	Very high HDI							Medium/high HDI
	Mikkelsen et al 2006^Citation15 (Denmark)	McCowan et al 2010^Citation29 (New Zealand, Australia, UK, and Ireland)	Ramon et al 2009^Citation28 (Spain)	Mitchell et al 2004^Citation16 (New Zealand)	Ricci et al 2010^Citation31 (Italy)	Balazs et al 2014^Citation32 (Hungary)	Petridou et al 1998^Citation30 (Greece)	Loy et al 2011^Citation35 (Malaysia)	Rao et al 2001^Citation14 (India)	Kanade et al 2008^Citation34 (India)	Hassan et al 2011^Citation33 (Egypt)
Factor
Maternal age	X	X	X		X	X	X
Race/ethnicity		X	X	X		X		X
Pre-pregnancy BMI/weight	X	X	X	X	X	X		X	X	X
Maternal height	X		X	X			X	X	X
SES/income/education/occupation		X		X	X	X	X	X	X	X
Pregnancy weight gain			X		X		X		Xa
Infant sex	Xb		X				X	X	X	X	X
Gestational age	Xb		X					X	X	X
First born/parity	X	X	X		X		X	X	X	X	X
Maternal hypertension		X		X	X
Physical activity in pregnancy		X							X	X
Smoking	X	X	X	X	X	X	X	X
Alcohol			Xc		X		X
Caffeine			X				X
Total energy intake	X		X				X		X	X
Intake of food groups			Xd			Xe	Xf
Dietary supplements/folate	X	X					X
Other		Xg	Xh		Xi	Xj	Xk

Notes:

a Weight gain at 28 weeks’ gestation

b adjusted only in analyses of birth weight z score

c adjustment in dichotomous analysis only

d vegetables and fruit in same model, adjusted in dichotomous analysis only

e fruits, vegetables, dairy, and meat

f food groups assessed individually and simultaneously

g family history of preeclampsia, high-density lipoprotein cholesterol, Rhesus-negative blood group, drug use

h paternal height, residence, working in first trimester

i history of small for gestational age births

j marital status

k history of spontaneous abortion, seasonality of intake. HDI as defined by the United Nations Development Program.³⁶

Abbreviations: BMI, body mass index; HDI, Human Development Index; SES, socioeconomic status.

Table 3 Associations of maternal fruits and vegetables consumption during pregnancy and infant birth weight or risk of small for gestational age births in women from countries with a very high Human Development Index

Reference	Analysis	Outcome	Vegetables		Fruits
			Daily intake	Results	Daily intake	Results
Mikkelsen et al 2006^Citation15	Multiple linear regression analyses	Birth weight	5% never consumed, 29% consumed <1 time/week, 42% consumed >1 time/week, 24% consumed ≥1 time on alternate days	No significant association between energy-adjusted green leafy vegetable intake and birth weight (5.5 g; 95% CI −0.23–11.3; P.0.05)	156.9±108.7 g/day (mean)	Significantly higher birth weight with energy-adjusted fruit intake (10.4 g; 95% CI 6.9–13.9; P<0.0001)
		Birth weight z score		No significant association between energy-adjusted green leafy vegetable intake and birth weight z score (0.001; 95% CI −0.01–0.014; P>0.05)		No significant association between energy-adjusted fruit intake and birth weight z score (0.0023; 95% CI −0.005–0.10; P>0.05)
		Birth weight		Significantly higher birth weight with energy-adjusted vegetable and fruit intake (8.4 g; 95% CI 4.8–12.0; P<0.0001) Significantly higher birth weight with energy-adjusted vegetable, fruit, and juice intake (7.7 g; 95% CI 4.0–11.3; P<0.0001)
		Birth weight z score		No significant association between energy-adjusted vegetable and fruit intake and birth weight z score (0.002; 95% CI −0.006–0.010; P>0.05) Significantly higher birth weight z score with energy-adjusted vegetable, fruit, and juice intake (0.013 g; 95% CI 0.0049–0.020; P>0.05)
Balazs et al 2014^Citation32	Multiple linear regression model	Birth weight	Less than every other day versus more often: 1,347 versus 4,248 (24%)	No significant difference in birth weight with vegetable intake less than every other day versus more often, difference of −2.60±18.51 g (95% CI −38.90–33.69; P=0.888)	Less than every other day versus more often: 1,112 versus 4,485 (20%)	Significantly lower birth weight with fruit intake less than every other day versus more often; difference of 51.55±20.16 g (95% CI 12.02–91.82; P=0.011)
Petridou et al 1998^Citation30	Multiple regression analysis	Birth weight	11.7% consumed <2 times/day; 62.5% consumed 2–4 times/day, 25.8% consumed ≥5 times/day	No significant association; −8±27 g birth weight with each additional serving per day (P=0.76)	15.5% consumed ≤2 times/day; 73.4% consumed 3–5 times/day, 11.1% consumed ≥6 times/day	No significant association; −11±23 g birth weight with each additional serving per day (P=0.62)
Ramon et al 2009^Citation28	Multiple regression analysis; logistic regression analysis	Birth weight	213.3±121.0 g/day (mean)	Women in the first (lowest) and second quintile of vegetable intake in first trimester of pregnancy had infants with significantly lower birth weight than women in the fourth quintile of vegetable intake in model using fruit and vegetable variables adjusted for energy intake, differences were 148.2±46.6 g and 132.5±45.1 g, respectively (P<0.01). In the third trimester, there was no significant difference in birth weight of infants born to women in the lowest versus fourth quintile of vegetable intake; infants weighed 122.2±47.1 g less (P=0.10)	293.0±216.1 g/day (mean)	No significant association between fruit intake and birth weight; in first trimester, birth weight in first quintile 57.2 g (95% CI −150.3–35.9) lower than in fifth quintile (P for trend =0.08). In third trimester, birth weight in first quintile was 3.2 g (95% CI −101.3–95.0) lower than in fifth quintile (P for trend =0.90)
		SGA		Women in the lowest quintile of energy-adjusted vegetable intake during the first trimester of pregnancy had an increased risk of having an SGA infant versus women in highest quintile (aOR =3.1; 95% CI 1.4–6.9; P=0.01); P for trend <0.001		No significant association between quintile of fruit intake in first or third trimester and risk for SGA birth: in first trimester, OR =1.0 (95% CI 0.5–2.2) for first quintile versus fifth quintile (P=0.08); in third trimester, OR =0.5 (95% CI 0.2–1.1) for first quintile versus fifth quintile (P=0.44)
Mitchell et al 2004^Citation16	Logistic regression models	SGA	At conception: 1.4, 1.6 servings/day (SGA, non-SGA mothers; P=0.11). Last month of pregnancy: 1.6, 1.6 servings/day (SGA, non-SGA mothers; P=0.30)	In unadjusted analysis, mothers of SGA infants reported no different vegetable intake at the time of conception (P=0.11) or in the last month of pregnancy (P=0.30). No significant association with SGA risk by servings/day at time of conception, 0–0.75 versus >3 servings/day: aOR =1.25 (95% CI 0.79–1.97; P=0.32); or in last month of pregnancy, 0–0.75 versus >3 servings/day: aOR =1.20 (95% CI 0.76–1.92; P=0.12)	At conception: 1.4, 1.5 servings/day (SGA, non-SGA mothers; P=0.03). Last month of pregnancy: 1.9, 2.1 servings/day (SGA, non-SGA mothers; P=0.007)	In unadjusted analysis, mothers of SGA infants reported lower fruit intake at the time of conception (P=0.03) and in the last month of pregnancy (P=0.007). No significant association with SGA risk by servings/day at time of conception, 0–0.75 versus >3 servings/day: aOR =1.49 (95% CI 1.00–2.24; P for trend 0.12); or in last month of pregnancy, 0–0.75 versus >3 servings/day: aOR =1.53 (95% CI 0.99–2.35; P=0.19)
McCowan et al 2010^Citation29	Multivariate analysis using stepwise logistic regression	SGA	Not reported	No significant association with high leafy green vegetable intake in multivariate analysis using forward stepwise logistic regression (unadjusted univariate OR =0.485; 95% CI 0.275–0.803; P=0.0039)	Not reported	No significant association with low fruit intake in multivariate analysis using forward stepwise logistic regression (unadjusted univariate OR =1.495; 95% CI 0.903–2.379; P=0.0823)
Ricci et al 2010^Citation31	Conditional multiple logistic regression with maximum likelihood fitting	SGA	Green vegetables – high intake: 60% cases, 58% controls; medium intake: 10% cases, 13% controls; low intake: 30% cases, 30% controls Carrots – high intake: 37% cases, 33% controls; medium intake: 44% cases, 51% controls; low intake: 19% cases, 16% controls	No significant association with high green vegetable consumption (aOR =1.1; 95% CI 0.8–1.3; P=0.59); no significant association with high carrot consumption (aOR =1.0; 95% CI 0.8–1.4; P=0.61)	Fruit – high intake: 51% cases, 57% controls; medium intake: 11% cases, 11% controls; low intake: 38% cases, 31% controls	No significant association with high fruit consumption (aOR =0.9; 95% CI 0.7–1.1; P=0.45)

Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; SGA, small for gestational age; OR, odds ratio.

Table 4 Associations of maternal fruits and vegetables consumption during pregnancy and infant birth weight or risk of small for gestational age births in women from countries with a medium or high Human Development Index

Reference	Analysis	Outcome	Vegetables		Fruits
			Daily intake	Results	Daily intake	Results
Loy et al 2011^Citation35	Multiple linear regression analyses	Birth weight	48.2 g/day (sum of median intakes by type of vegetable)	No significant association with total vegetable intake or intake of any subgroup of vegetables; change of −1.2–1.2 g of birth weight per additional 10 g vegetable by type/day (P>0.05)	147 g/day (median)	Increase of 1.9 g of birth weight per additional 10 g fruit/day during pregnancy (P=0.04)
Kanade et al 2008^Citation34	Multiple regression analysis	Birth weight	At 18 weeks’ gestation: 36% consumed <1 time on alternate days, 35% consumed <1 time/day, 29% consumed ≥1 time/day	No significant association at 18 or 28 weeks’ gestation (data not shown)	At 18 weeks’ gestation: 24% consumed <1 time/week, 70% consumed <1 time/week, 6% consumed ≥1 time/day	No significant association at 18 weeks (P=0.34); no significant association at 28 weeks (data not shown)
Rao et al 2001^Citation14	Multiple regression analysis	Birth weight	At 28 weeks’ gestation: 10% never consumed, 29% consumed <1 time/week, 37% consumed >1 time/week, 24% consumed ≥ alternate days	Increase of 19.4 g (95% CI 8–30; P<0.001) per additional weekly serving at 28 weeks’ gestation; no significant association at 18 weeks	At 28 weeks’ gestation: 7% consumed <1 time/week, 60% consumed >1 time/week, 33% consumed ≥1 time/day	No significant association: increase of 4 g of birth weight (95% CI −1–10; P=0.12) per additional weekly serving at 28 weeks’ gestation; no significant association at 18 weeks
Hassan et al 2011^Citation33	Analysis of variance	Birth weight	Second trimester, mothers of boys: 2% 1 time/week, 28% 2 times/week, 70% alternate/every day Second trimester, mothers of girls: 3% 1 time/week, 29% 2 times/week, 68% alternate/every day	Increased frequency of intake in second trimester associated with higher birth weight for boys (3.33±0.11 kg, 3.02±0.43 kg, 3.40±0.47 kg; P<0.001) and girls (2.74±0.91 kg, 3.08±0.39 kg, 3.24±0.43 kg; P=0.029) Increased frequency of intake in third trimester associated with higher birth weight for boys (3.05±0.39 kg, 3.24±0.48 kg, 3.44±0.48 kg; P<0.001); no association for girls (3.13±0.52 kg, 3.19±0.38 kg, 3.21±0.49 kg; P=0.409)	Second trimester, mothers of boys: 12% 1 time/week, 29% 2 times/week, 59% alternate/every day Second trimester, mothers of girls: 21% 1 time/week, 32% 2 times/week, 47% alternate/every day	Increased frequency of intake in second trimester associated with higher birth weight for boys (2.83±0.34 kg, 3.17±0.49 kg, 3.45±0.43 kg; P<0.001) and girls (2.82±0.39 kg, 3.18±0.45 kg, 3.33±0.37 kg; P,0.001) Increased frequency of intake in third trimester associated with higher birth weight for boys (3.12±0.34 kg, 3.29±0.52 kg, 3.46±0.50 kg; P=0.026) and girls (3.02±0.26 kg, 3.15±0.53 kg, 3.64±0.42 kg; P<0.001)

Abbreviations: CI, confidence interval.

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