Dietary Habits and Supplement Use in Relation to National Pregnancy Recommendations: Data from the...

Dietary Habits and Supplement Use in Relation to NationalPregnancy Recommendations: Data from the EuroPrevall BirthCohort

E. M. Oliver • K. E. C. Grimshaw • A. A. Schoemaker • T. Keil •

D. McBride • A. B. Sprikkelman • H. S. Ragnarsdottir • V. Trendelenburg •

E. Emmanouil • M. Reche • A. Fiocchi • A. Fiandor • A. Stanczyk-Przyluska •

J. Wilczynski • M. Busacca • S. T. Sigurdardottir • R. Dubakiene •

O. Rudzeviciene • G. D. Vlaxos • K. Beyer • G. Roberts

� Springer Science+Business Media New York 2014

Abstract Assessing maternal dietary habits across Eur-

ope during pregnancy in relation to their national preg-

nancy recommendations. A collaborative, multi-centre,

birth cohort study in nine European countries was con-

ducted as part of European Union funded EuroPrevall

project. Standardised baseline questionnaire data included

details of food intake, nutritional supplement use, exposure

to cigarette smoke during pregnancy and socio-demo-

graphic data. Pregnancy recommendations were collected

from all nine countries from the appropriate national or-

ganisations. The most commonly taken supplement in

pregnancy was folic acid (55.6 % Lithuania–97.8 % Spain)

and was favoured by older, well-educated mothers. Vita-

min D supplementation across the cohort was very poor

(0.3 % Spain–5.1 % Lithuania). There were significant

differences in foods consumed in different countries during

pregnancy e.g. only 2.7 % Dutch mothers avoided eating

peanut, while 44.4 % of British mothers avoided it. Some

countries have minimal pregnancy recommendations i.e.

Lithuania, Poland and Spain while others have similar,

very specific recommendations i.e. UK, the Netherlands,

Iceland, Greece. Allergy specific recommendations were

associated with food avoidance during pregnancy [relative

rate (RR) 1.18 95 % CI 0.02–1.37]. Nutritional supplement

recommendations were also associated with avoidance (RR

1.08, 1.00–1.16). Maternal dietary habits and the use of

dietary supplements during pregnancy vary significantlyE. M. Oliver and K. E. C. Grimshaw have contributed equally to this

work.

E. M. Oliver (&) � K. E. C. Grimshaw � G. Roberts

Clinical and Experimental Sciences Academic Unit, Level F,

South Academic Block, Faculty of Medicine, Southampton

General Hospital, University of Southampton, Tremona Road,

Southampton, SO16 6YD, UK

e-mail: [email protected]

A. A. Schoemaker � A. B. Sprikkelman

Department of Paediatric Respiratory Medicine and Allergy,

Emma Children’s Hospital Academic Medical Center,

Amsterdam, The Netherlands

T. Keil � D. McBride

Institute of Social Medicine, Epidemiology and Health

Economics, Charite - Universitatsmedizin Berlin, Berlin,

Germany

T. Keil

Institute of Clinical Epidemiology and Biometry, University of

Wurzburg, Wurzburg, Germany

H. S. Ragnarsdottir

Faculty of Nursing, University of Iceland, Reykjavık, Iceland

H. S. Ragnarsdottir

Department of Immunology, Landspitali - National University

Hospital, Reykjavık, Iceland

V. Trendelenburg � K. Beyer

Department of Paediatric Pneumology and Immunology,

Charite - Universitatsmedizin Berlin, Berlin, Germany

E. Emmanouil

Allergy Department, 2nd Pediatric Clinic, University of Athens,

Athens, Greece

M. Reche � A. Fiandor

Department of Allergy, Hospital la Paz, Madrid, Spain

A. Fiocchi � M. Busacca

Division of Allergy, Pediatric Department, Bambino Gesu

Pediatric Hospitaln, Piazza S. Onofrio 4, Rome, Holy See,

Vatican City, Italy

123

Matern Child Health J

DOI 10.1007/s10995-014-1480-5

across Europe and in some instances may be influenced by

national recommendations.

Keywords Pregnancy recommendations � Folic acid �Vitamin D � Iron

Introduction

The lifestyle choices a woman makes during pregnancy and

pre-pregnancy have important implications for her unborn

child. There is evidence that inappropriate nutrition and poor

perinatal growth are associated with increased risk of respi-

ratory disease, atopy, coronary heart disease, stroke, type 2

diabetes, adiposity, the metabolic syndrome and osteoporosis

in later life [1–5]. Promoting good health and nutrition during

pregnancy has beneficial effects for both mother and child and

is reflected by the World Health Organisations guidance on

improving pregnancy health outcomes [6–10]. This guidance

is in place to help countries make informed decisions on

appropriate nutrition actions. European countries have spe-

cific national recommendations which may or may not

incorporate this guidance and range from simply recom-

mending daily calorie requirements in pregnancy (e.g. in

Poland and Lithuania [11, 12]) to much more detailed rec-

ommendations concerning both general health and food safety

(e.g. in the UK and the Netherlands [13–15]). To date, a

comparison of recommendations across Europe and how

maternal habits may be influenced by them has not been made.

Such data would help assess the effectiveness of existing

pregnancy health policies and may help inform decisions

regarding the implementation of new recommendations or

how best to amend existing recommendations.

The aim of this paper is to describe maternal dietary

habits during pregnancy of women participating in the

EuroPrevall birth cohort [a multicentre research project

funded by the European Union (EU) investigating food

allergy] [16] and relate this to their national pregnancy

recommendations.

Methods

The methodology of the EuroPrevall birth cohort study has

been described in detail previously [16]. Only the aspects

relevant for this paper will be reiterated here. In summary,

the study was a collaborative multi-centre study of research

institutions from nine countries in Europe. They were

chosen to give a geographic spread across the European

continent. The regions were Nordic (Reykjavik, Iceland),

Maritime (Amsterdam, Netherlands and Southampton,

United Kingdom), Central European (Berlin, Germany;

Lodz, Poland and Vilnius, Lithuania) and the Mediterra-

nean region (Madrid, Spain; Milan, Italy and Athens,

Greece). Each centre obtained approval from their own

governing ethics committee or review board before com-

mencing recruitment. Infants were recruited from October

2005 to February 2010. Written informed consent was

obtained from all mothers (and fathers where required) at

time of recruitment after which a standardised baseline

questionnaire was administered by a trained interviewer.

All questionnaires were translated into the language of

each centre and validated by back translation.

The comprehensive baseline questionnaire included ques-

tions on socio-demographic characteristics and maternal diet

during pregnancy. Full details and a first comparison of data at

recruitment/birth are published elsewhere [16, 17]. Gesta-

tional age when the questionnaire was completed was not

collected, but according to the study protocol it had to be

completed after 28 weeks gestation, or if after delivery, to

limit recall bias the infant was to be younger than 4 weeks of

age. The maternal diet questions only asked the mother

whether they ate a particular food/food group rather than detail

of specific foods or food group eaten. They were then asked

the additional question as to whether they had eaten more, less,

or the same amount of that food during pregnancy compared to

when they were not pregnant. If the mothers reported that they

did not eat the food, they were asked whether they had ever

eaten it or whether they were just avoiding it during preg-

nancy. Mothers were coded as ‘stopped eating’ if she avoided

eating the food for the whole duration of her pregnancy. If she

only avoided for a limited period i.e. first trimester when

possibly feeling nauseous she would have been coded as

‘limiting intake’. If a mother avoided at least three or more

food/groups throughout the whole of pregnancy rather than a

limited period is suggests that factors other than taste prefer-

ence may be influencing behaviour. The foods/food groups

detailed in the questionnaire were: milk and other dairy pro-

ducts; soy and soy products; eggs and foods containing eggs;

peanuts and foods containing peanuts; tree nuts and food

A. Stanczyk-Przyluska

Department of Pediatrics, Clinical Immunology and Cardiology,

Medical University of Lodz, Lodz, Poland

J. Wilczynski

Department of Fetal-Maternal Medicine and Gynecology, Polish

Mothers Memorial Hospital Research Institute, Lodz, Poland

S. T. Sigurdardottir

Department of Immunology, Faculty of Medicine, Landspitali-

National University of Iceland, Reykjavık, Iceland

R. Dubakiene � O. Rudzeviciene

Faculty of Medicine, Vilnius University, Vilnius, Lithuania

G. D. Vlaxos

Department of Obstetrics and Gynecology, Alexandra Hospital,

University of Athens, Athens, Greece


123

containing tree-nuts; fish and fish products; shellfish and foods

containing shellfish; cereals and cereal products; vegetables;

fruit; and meat and meat products. Information about sup-

plements used was also gathered along with smoking status

(both before and during pregnancy). Mothers were asked if

they specifically took a folic acid supplement during preg-

nancy, a vitamin D supplement or a fish oil capsule. They were

also asked if they took a multivitamin or any other vitamins. If

they responded that they took a pre-natal multivitamin sup-

plement then mothers would have been coded as taking folic

acid, but not so if only a general multivitamin had been taken

due to the variations in formulations across Europe. This same

reasoning also applies for the coding of vitamin D and fish oil.

Mothers were only coded as taking it if they specifically stated

doing so. Any pregnancy recommendations were collated

from the appropriate national organisations of the study cen-

tres [11–15, 18–23] and common themes were drawn out into

‘general healthy eating’ recommendations, ‘food safety’

focused recommendations, ‘nutritional supplement’ recom-

mendations, ‘allergy specific’ recommendations and ‘any

other general recommendations’ for pregnancy.

Statistical Analysis

A descriptive analysis of the baseline characteristics of the

mothers involved in the study was carried out using SPSS

version 19 (SPSS Inc., Chicago, IL, USA). Continuous

variables were described in terms of means and standard

deviation. Categorical variables were described in terms of

numbers and percentages. Descriptive statistics, Chi square

and Poisson regression were used to determine differences

between countries considering a significance level of

p \ 0.05. A Poisson regression analysis was conducted for

the total cohort using parameters previous research has

demonstrated as affecting pregnancy related behaviours.

These were maternal ages, educational level achieved, body

mass index before pregnancy, smoking status, ethnicity and

whether national recommendations were in place.

Results

Sociodemographic Background

The study consisted of 12,049 participants. The whole cohort

was diverse with significant differences (p \ 0.001) between

centres. Maternal age ranged from 28.2 ± 5.2 years in Lith-

uania to 33.6 ± 4.7 years in Italy (mean 31.5 ± 5.0 years for

the whole cohort), for educational attainment those who

attended higher education ranged from 57.9 % in Greece to

88.3 % in the UK (Mean75.9 %), Body Mass Index (BMI)

ranged from 21.9 ± 3.8 kg/m2 Italy to 24.8 ± 4.6 kg/m2

Iceland (mean 23.3 ± 4.4 kg/m2), ethnicity ranged from Ta

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123

72.2 % Caucasian in the Netherlands to 99.9 % in Poland and

Lithuania (mean 93.3 %) and smoking during pregnancy

ranged from 16.3 % in UK to 34.7 % in Greece (mean

24.4 %)). A fuller description of the cohort has previously

been published [17].

Intake Differences Across Europe

There was significant variation in both the nature and fre-

quency of nutrient supplements taken in different countries

(p \ 0.001) (Table 1). The most commonly taken supple-

ment was folic acid with 79.8 % of all mothers reporting

taking it at some point during their pregnancy. The highest

uptake was in Spain and the UK (97.8, 88.1 % respec-

tively) and lowest in Lithuania (55.6 %). 57.7 % of

mothers supplemented their diet with a multivitamin [range

7.2 % (Greece)–87.7 % (Poland)]. Reported vitamin D

supplementation was low for the whole cohort at 2.2 %

[range 0.3 % (Spain)–5.1 % (Lithuania)]. Fish oil and fish

liver oil supplementation was below 21 % for all countries

except Iceland where 94.5 % of mothers took one of these

supplements.

Table 2 details maternal food avoidance during preg-

nancy for the whole cohort. There were statistically sig-

nificant differences (Chi square tests p \ 0.001) between

the countries. In total 90 % of mothers avoided at least one

nutrient rich food group during pregnancy, with 39 %

avoiding three or more. Appendix 1 details how women in

this cohort changed their diet during pregnancy. The most

common foods avoided were shell fish, peanuts and tree

nuts. The highest avoiders of shellfish during pregnancy

were British mothers at 41.7 %; the mean for all centres

was 12.1 %. Pregnant women in the UK were also the

highest avoiders of peanut (44.4 %), followed by Polish

mothers (13 %), the lowest peanut avoiders were Dutch

mothers (2.7 %). British and Polish mothers were also the

highest avoiders of tree nuts (16.8, and 13.7 % respec-

tively) with German and Italian mothers having the lowest

avoidance rate (1.2 %). Differences in soy intake were

significant, but only a third of mothers from Lithuania,

Spain and Italy actually provided an answer to this ques-

tion, therefore the validity of responses must be questioned.

Fruit intake was said to have increased in 49 % of the

cohort, with vegetable intake increasing in 30 % and the

intake of milk and milk products increasing in 35 %. The

mean increase in other foods consumed was 8.2 %.

National Recommendations

Table 3 summarises pregnancy recommendations for each

country at the time of recruitment (full details can be found

in Appendix 2). The UK, The Netherlands, Iceland, and

Greece have similar recommendations; they have general Ta

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123

nutrition recommendations about a healthy diet, with

guidelines on the intake of fruit, vegetable, dairy and car-

bohydrate plus very specific recommendations with a par-

ticular focus on food safety. Although Germany has similar

recommendations concerning food safety and supplemen-

tation there are no specific general nutrition guidelines. The

most common supplement recommendation across all

countries was to take 400 lg folic acid/day to prevent

neural tube defects (NTDs) [15, 18, 21–26], followed by

the recommendation to supplement dietary intake with

10 lg/day of vitamin D [13, 15, 21, 23]. Across the

countries, only the UK had a specific recommendation

regarding allergy and peanut intake at the time of data

collection [27, 28]. Germany recommended no restrictions

of allergenic foods during pregnancy [19]. Lithuania had

no recommendations specific to pregnant women and rec-

ommendations in Poland, Spain and Italy were sparse.

Spain suggested eating a varied, balanced diet and rec-

ommended a few nutrient supplements (but no dosage is

provided). Italy only recommended an increased calorie

intake with a few suggested nutrient supplements and

Poland had no specific dietary recommendations other

than calorie intake and a few nutrient supplement

recommendations.

Influence of National Recommendations

Poisson regression analysis showed that having an allergy

specific pregnancy recommendation was associated with a

much higher estimated relative rate (RR) of avoidance of

three or more foods (RR 1.18 95 % CI 0.02–1.37), so too

was having nutritional supplement recommendations (RR

1.08, 1.00–1.16) (Table 4). Having general healthy eating

recommendations was associated with a lower rate of

avoiding three or more foods (0.85, 0.77–0.93). Smoking

and Caucasian mothers were more likely to avoid 3 foods

or more also. Analyses showed that mothers were more

likely to take folic acid when recommendations to do so

were in place (RR 1.22 95 % CI 1.15–1.29). Folic acid was

more likely to be taken by older (RR 1.12, 1.05–1.18),

well-educated mothers (RR 1.09, 1.03–1.15); no factors

were associated with vitamin D recommendation compli-

ance (Appendix 3).

Discussion

This study has shown that intakes of various food groups

and dietary supplements during pregnancy vary signifi-

cantly across Europe. In some countries pregnancy rec-

ommendations are minimal and are no different to general

nutrition guidelines aimed at their whole population. Other

countries have specific recommendations for pregnancy

which appear to be associated with certain eating behav-

iours/supplement use. The WHO guidance for nutrition in

pregnancy covers iron, iodine, folate, vitamin D, vitamin A

and calcium [6–10] and has been applied in some coun-

tries, particularly for folate, vitamin D and iron. In some

parts of Europe iodine deficiency is a major public health

problem [7, 29] but only Germany and Poland recom-

mended women to supplement with iodine during preg-

nancy. However, specific detail of iodine supplementation

was not collected as part of this study so will not be con-

sidered further in this manuscript.

Folic Acid Intake

Folic acid is a vital nutrient throughout life but is particularly

important during periods of growth, especially pregnancy. It

is well documented that peri-conceptual folic acid intake

reduces the risk of pregnancies being affected by NTDs [30,

31]. The prevalence of NTDs varies across EU and is cur-

rently reported from 0.4 to 2.0/1,000 births, unfortunately

national representative data on prevalence is not available for

all countries [32]. All countries in the cohort apart from

Lithuania and Greece advised women of childbearing age

who might become pregnant to supplement their diet with

Table 3 Summary of national pregnancy recommendations

General recommendations

How to eat a healthy diet UK, Netherlands, Iceland, Greece,

Germanya, Spain

An increased calorie intake Italy

Safety recommendations

Shellfish, egg, cheeses and

meat

UK, Netherlands, Greece, Germanyb,

Iceland

Liver UK, Netherlands, Iceland,

Caffeine UK, Netherlands, Iceland, Greece,

Germany

Alcohol consumption UK, Netherlands, Iceland, Greece,

Germany, Spain

Micronutrient recommendations

Take 400 lg folic acid/day UK, Netherlands, Iceland, Italy,

Germany, Spainc, Poland

Take 10 lg vitamin D/day UK, Netherlands, Iceland, Italyd

Take iron Poland, Spainc, Italy

Allergy specific

recommendation about

peanut

UK

a No specific guidelines (implemented new specific guidelines in

2011)b No recommendations for egg and shellfishc This country does not specify dosaged Only for those not exposed to sunlight or not consuming dairy


123

400 lg folic acid daily, although the timing and duration of

supplementation recommended differed. Our findings

showed that women in countries with clear folic acid sup-

plement recommendations were more likely to take folic acid

during their pregnancy and supplementation use was asso-

ciated with older, well-educated mothers; this is in line with

findings of previous studies [3, 31, 33–36].

Even though the mean percentage of women taking folic

acid appeared quite high at 79.8 %, there was insufficient

detail in the question responses to determine if mothers

were taking adequate doses or that they were taking the

supplements during the recommended time period i.e. pre-

conception and first trimester so actual numbers of mothers

complying fully with their national recommendation may

not be as high as first appeared as many pregnancies may

have been unplanned.

Iron Intake

It is estimated that 41.8 % of pregnant women worldwide

are anaemic with half this burden being due to iron defi-

ciency. WHO recommends supplementing with iron as part

of antenatal care to reduce the risk of low birth weight,

maternal anaemia and iron deficiency [6]. Only Poland,

Spain and Italy specifically recommend iron supplemen-

tation during pregnancy. Other countries advocate eating a

healthy diet including iron rich foods. Information con-

cerning iron supplementation per se was not collected but

Table 4 Factors associated with the avoidance of three or more foods

Variables Parameter

estimate

SE Estimated

relative rate

95 % CIs for

relative rate

p value n = 5,677

Maternal age (years)

C34 -0.033 0.041 0.967 0.894–1.048 0.422 1,632

31–33.9 -0.060 0.044 0.942 0.863–1.027 0.174 1,160

27.1–30.9 -0.053 0.043 0.948 0.871–1.033 0.226 1,178

B27 Reference – 1,707

Maternal education

College/university -0.051 0.036 0.950 0.885–1.019 0.150 4,167

Basic education or less Reference – 1,510

Maternal BMI

Obese 0.087 0.058 1.090 0.974–1.221 0.133 406

Overweight 0.056 0.040 1.057 0.977–1.146 0.163 943

Underweight -0.004 0.058 0.996 0.887–1.116 0.939 409

Healthy weight Reference – 3,919

Maternal smoking

Smoked 0.149 0.047 1.015 1.058–1.271 0.002* 699

Ex-smoker -0.008 0.034 0.992 0.821 1,696

Never smoked Reference – 3,282

Ethnicity

Caucasian 0.148 0.067 1.159 1.017–1.320 0.027* 5,288

Non-Caucasian Reference – 389

Pregnancy recommendation

General healthy eating recommendation -0.164 0.049 0.849 0.771–0.934 0.001* 2,614

No health eating recommendation Reference – 3,063

Food safety recommendation -0.092 0.050 0.912 0.825–1.007 0.070 2,271

No food safety recommendation Reference – 3,406

Nutritional supplement recommendation 0.077 0.038 1.080 1.003–1.164 0.042* 4,302

No supplement recommendation Reference – 1,375

Allergy specific recommendation 0.166 0.075 1.180 0.019–1.368 0.027* 480

No allergen recommendation Reference – 5,197

Figures are estimated relative rates (95 % confidence interval) from a Poisson regression analyses for the avoidance of 3 or more foods

* p \ 0.05


123

there was a huge range in the use of multivitamins across

the cohort from 7.2 % in Greece to 87.7 % in Poland and it

is uncertain to what extent their use contributes to mini-

mising iron deficiency risk.

Vitamin D Intake

In recent years prevalence estimates of rickets and other

features of vitamin D deficiency have been increasing. It

has been estimated that upwards of 50 % of both children

and adults in Europe, United States, Canada, Mexico, Asia,

Australia and New Zealand have vitamin D deficiency [37,

38]. The main risk factors for deficiency are those that

inhibit the body’s production of vitamin D in the skin,

which includes dark-pigmentation, too little exposure to

sunlight, clothes that limit exposure of skin, living in lati-

tudes above 40�, season of the year, use of sunscreen,

environmental pollution, ageing and dietary consumption

[9]. Pregnant women are identified as being a particularly

high-risk group. Even in Mediterranean countries where

there is abundant sunshine, studies have shown vitamin D

deficiency in pregnant women and their infants to be a

problem, particularly in winter months [39–43]. Despite

this, only four of the nine countries in the cohort specifi-

cally recommended pregnant women to take vitamin D,

possibly on the assumption that sunshine exposure is ade-

quate. Some countries such the USA and Canada have

mandatory fortification of milk and margarine since vita-

min D is only found in a few foods (e.g. oily fish and egg

yolk). In Europe the UK allows optional fortification of a

number of foods such as margarine and breakfast cereals

with other countries having limited or restricted use of

fortification [44] and therefore dietary sources may not be

sufficient [45, 46]. In the UK, the Scientific Advisory

Committee on Nutrition (SACN) state they are concerned

that vitamin D ‘recommendations are overlooked by health

professionals, as well as the general public’ [47, 48]. This

study provides data to support this concern for the UK, The

Netherlands, Iceland and Italy where a recommendation is

in place as mean supplementation was only 2.2 %. In these

countries the message is clearly not getting through to the

majority of women. There is currently much debate con-

cerning maternal vitamin D and its associations with var-

ious health outcomes [9, 50]. This contradictory evidence

may be why some countries don’t have a specific recom-

mendation. However for those that do, the recommendation

is clearly not being disseminated effectively.

Foods Consumed and Avoided

We have found that variation of food intake between coun-

tries in the EuroPrevall birth cohort does seem to be asso-

ciated with national recommendations. For example, the UK

and Greece recommend to ‘only eat thoroughly cooked egg’

and they had the highest proportion of mothers who limited

egg intake, which may be due to people’s preference for a

runny yolk or may be indicative of women receiving the

message that eggs are not safe and thinking that it is best to

avoid them altogether. The UK also recommends the

avoidance of raw shell fish and they have the highest num-

bers of avoiders of shell fish. The same recommendation is in

place in the Netherlands and Greece and even though

avoidance is lower compared to the UK, it is their most

commonly avoided food. Although no fish oil recommen-

dations are in place, perhaps due to insufficient evidence,

there were big differences in intake across Europe with

intake being particularly high in Iceland (94.5 %) compared

to the cohort mean (21.5 %). This study was unable to

determine whether mothers who did not consume fish oils

were achieving the recommended PUFA intakes during

pregnancy [49–51] but it is known that the Mediterranean

diet recommends moderate to high intake of fish [52].

The UK was the only country to have a specific allergy

recommendation about peanut. At the time of data collec-

tion, the Department of Health advice of 1998 was still in

place. This advice stated ‘‘pregnant women who are atopic,

or for whom the father or any sibling of the unborn child has

an atopic disease, may wish to avoid eating peanuts and

peanut products during pregnancy’’ [27]. This recommen-

dation seemed to influence behaviour as peanut was avoided

by 44 % of respondents. Analyses showed that having this

specific recommendation increased the likelihood of

mothers to avoid three or more foods. It is often perceived

that ‘good’ mothers should manage and avoid all risks to

protect their baby [53]. This particularly appears true in the

UK, where many mothers avoid certain foods such as shell

fish, peanuts and eggs. Many mothers may have avoided

three or more foods to try and avoid ‘risk’ to their baby even

if they had no need to (they or family were not atopic). This

allergy specific advice was amended in 2009 after the evi-

dence base was considered not strong enough to continue

recommending avoidance [28]. It would be interesting to

see if the UK avoidance rate is now more in line with

countries such as Germany which did not recommend any

avoidance of allergenic foods during pregnancy and have

avoidance rates of 3 foods or more of 26.7 %.

If a nation had nutritional supplement recommendations,

mothers were more likely to avoid foods perceived as

‘risky’ which supports the hypothesis that mothers are

trying to do the best for their baby and avoid risk whether

that involved food avoidance or food supplementation

which fits within the protection motivation theory [54].

This is also backed up by the fact that having general

healthy eating recommendations in place for pregnancy

reduced the risk of food avoidance as it encouraged women

to have a broad, balanced diet.


123

Even though some countries had very similar recom-

mendations, differences in food avoidance were consider-

able. In all countries women received some verbal and

written information on diet and dietary supplements at their

first pre-natal appointment. The UK, Germany, Spain, the

Netherlands and Iceland also had government websites

where women could access information. Some had periodic

nationwide health campaigns. The observed differences

seen in adherence to recommendations may have been due

to cultural differences in how health messages were per-

ceived or it may be that the method of delivery of the

national recommendations was more effective in some

countries than others, or it could be that certain recom-

mendations are being overlooked by health professionals.

Strengths and Weaknesses

Strengths of the EuroPrevall birth cohort project are its

provision of unique data, its large sample size and the

standardised data collection throughout the entire cohort

which covers all the climatic regions of Europe. The

questionnaire had been translated and back translated to

ensure uniformity so data between countries was compa-

rable. Potential limitations of this work were with ques-

tionnaire design. The questionnaire did not record amounts

of supplements taken per day, additionally they also did not

record the week and month supplements were used as has

been done in other studies or levels of consumption, so it

could not be determined if consumption was appropriate for

requirements during pregnancy. Additionally, reporting

bias may have occurred if women didn’t know what their

multivitamin contained. However, the mean percentage

taking a multivitamin was still only 58 %. Our findings may

have also been affected by social desirability bias when

reporting folic acid or prenatal multivitamin use. Another

limitation was that we did not know how national and local

health authorities, health professionals and media imple-

mented or emphasised national recommendations nor did

we ask if mothers were aware of any pregnancy recom-

mendations and why they took nutritional supplements or

avoided certain foods. Therefore we were not able to look at

any effect there may have been on how recommendations

were disseminated within a population. Consequently any

observed associations need to be interpreted with caution.

Finally some limitations regarding the representativeness of

the cohort could exist as study centres were mostly located

in large cities and therefore may not represent the general

population of these countries as a whole [18].

Public Health Implications

Findings of this study are useful for advising countries how

mothers are behaving during pregnancy in relation to

pregnancy recommendations that may or may not be in

place. It has highlighted differences between countries and

indicated where more detailed studies which look at con-

sumption of specific food groups or supplements during

pregnancy and their impact on the health and development

of their children need to be undertaken.

As already highlighted, a large number of women across

Europe are not supplementing their diet with folic acid. It may

be that some nations have diets that are traditionally high in

foods which are a good source of folate and so supplementation

is deemed unnecessary but this may not be the case. For those

countries who do not currently recommend folic acid supple-

mentation it may be prudent to assess routine folate intake

within the population and if this is found to be sub-optimal then

to advise folate-rich foods and/or supplementation for women

of child-bearing age and during early pregnancy. For those

countries who already recommend supplementation there is

variability in compliance. Further investigation into how

information is disseminated and perceived would be helpful to

inform public health strategies. However, it would be prudent

to not only target vulnerable groups such as the less educated

and young, but perhaps all women of child bearing age to

ensure adequate levels at conception. Many countries have had

campaigns to increase knowledge and the use of folic acid

supplements, but results are varied [31, 55–59]. Voluntary

fortification of foods with folic acid is common in Europe but

there is wide variation in levels added to foodstuffs and man-

datory fortification has not been implemented in any EU

country [32]. However, to improve women’s pre-conception

folate status the strategy of a legislative approach and man-

datory fortification of foods with folic acid may be something

these countries may wish to consider.

The level of vitamin D supplementation, particularly

where there is a recommendation to do so is of concern.

Clearly this recommendation is not being disseminated

efficiently and further investigation into how women access

information and how they determine which recommenda-

tions they will and will not adhere to needs to be conducted.

For countries where a recommendation is currently not in

place it may be prudent to investigate whether promoting

supplementation is a worthwhile public health strategy.

This study shows that having any advice that suggests the

avoidance of a food or food group for any reason increases the

risk of food avoidance. Consequently, to avoid unnecessary

food avoidance it is important that such advice is introduced

only after strong evidence of a population health value.

Conclusions

This study has demonstrated that maternal dietary habits i.e.

food avoidance and the use of dietary supplements during

pregnancy varies significantly across Europe and may be


123

influenced by national recommendations in some instances.

Further investigation into how recommendations are dissemi-

nated and how women determine what advice they will adhere

to would be useful for improving public health strategies which

promote healthy pregnancy and pregnancy outcomes.

Acknowledgments We thank all families who participated in the

EuroPrevall birth cohort study and the medical and nursing staff at the

obstetric departments of the participating hospitals, especially: GRE:

P. Saxoni-Papageorgiou, P. Xepapadaki, K. Zannikos, A. Vasilop-

oulou, C. Michopoulou, C. Skordali (P y A Kyriakou Hospital); S.

Gavrili, G. D. Vlachos (Alexandra Hospital); A. Malamitsi-Puchner,

D. Hasiakos, L. Kontara (Areteion Hospital); N. Paparisteidis (Elena

Venizelou Maternity Hospital, Athens, Greece); ICE: A.G. Gun-

narsdottir, H. Sigurdardottir, G.L. Gudjonsdottir (Landspitali - The

National University Hospital Reykjavik), prenatal care nurses at The

Primary Health Care of the Reykjavik Capital Area (Reykjavik,

Iceland); GER: S. Travis, S. Paschke-Goossens, S. Siegert, S. Dufour,

A. Kafert, K. Dobberstein, G. Schulz, A. Rohrbach, A. Scholz, A.

Reich, L. Grabenhenrich (Berlin, Germany); POL: L. Podciechowski

(Polish Mother’s Memorial Hospital, Lodz, Poland); SPA: M. Martın-

Esteban, S. Quirce, R. Gabriel, J. I. Larco, I. Bobolea, T. Cuevas

(Madrid, Spain); UK: K. Foote, L. Gudgeon, T. Kemp, K. Scally, E.

Gatrell, L. Bellis, A, Acqua, R. Kemp, T. Bryant (Southampton, UK);

NL: Midwives, Zorggroep Almere, Department of Gynaecology and

Obstetrics, Flevo Hospital Almere, N.v.d. Berg, De Kinderkliniek

Almere, W.M.C. van Aalderen, L Hulshof, NCM Petrus Department

of Pediatric Respiratory Medicine and Allergy, Emma Children’s

Hospital Academic Medical Center (Amsterdam, the Netherlands);

LIT: Audrone Arlauskiene, Jolita Zakareviciene, Laura Stoskute-

Malinauskiene (Lithuania); ITA: A. Martelli, P. Realini and F. Brandi

(both from Allegria, the Italian Research Foundation for Childhood

Allergy and Asthma), G.R. Bouygue, O. Mazzina, T. Sarratud, G.

Pezzoli (Milan, Italy). This birth cohort study was conducted within

the collaborative research initiative EuroPrevall, an integrated project

funded by the European Commission under the 6th Framework Pro-

gramme (FOOD-CT-2005-514000). The Icelandic birth cohort

received additional funds by Landspitali - The National University

Hospital of Iceland Science Fund and by GlaxoSmithKline, Iceland.

Four study sites were funded outside of EuroPrevall: the United

Kingdom birth cohort by the UK Food Standards Agency; the

Lithuanian birth cohort by unrestricted grants from Grida and MSD;

the Dutch birth cohort by unrestricted grants from Nutricia Advanced

Medical Nutrition Netherlands, AstraZeneca Netherlands, TEVA

Netherlands, and GlaxoSmithKline, Netherlands; and the Italian birth

cohort by own hospital funds and Allegria—the Italian Research

Foundation for Childhood Allergy and Asthma. None of the funding

bodies had any influence on the study design, data analysis or man-

uscript preparation.

Appendix 1

See Table 5.

Appendix 2

See Table 6.

Appendix 3

See Tables 7 and 8. Ta

ble

5C

han

ge

info

od

con

sum

pti

on

du

rin

gp

reg

nan

cy

Mar

itim

eN

ord

icC

entr

alE

uro

pea

nM

edit

erra

nea

nT

ota

lp

val

ue

Unit

edK

ingdom

Net

her

lands

Icel

and

Ger

man

yP

ola

nd

Lit

huan

iaS

pai

nIt

aly

Gre

ece

N1,1

40

976

1,3

41

1,5

70

1,5

13

1,5

56

1,3

87

1,4

86

1,0

80

12,0

49

Mil

kan

dm

ilk

pro

duct

sn

=888

n=

973

n=

1,3

35

n=

1,5

62

n=

1,5

04

n=

1,4

20

n=

1,3

72

n=

1,3

50

n=

1,0

78

n=

11,4

82

0.8

88

Ate

sam

eor

incr

ease

dam

ount

(%)

95.8

95.4

91.9

94.8

94.4

95.3

96.6

92.5

91.7

94.3

Lim

ited

inta

ke

(%)

3.9

4.4

7.7

4.9

5.3

4.1

3.1

7.3

8.0

5.4

Sto

pped

eati

ng

(%)

0.2

0.2

0.4

0.3

0.3

0.6

0.2

0.2

0.3

0.3

Egg

n=

889

n=

965

n=

1,3

33

n=

1,5

55

n=

1,4

94

n=

1,3

85

n=

1,3

70

n=

1,3

17

n=

1,0

77

n=

11,3

85

\0.0

01

Ate

sam

eor

incr

ease

dam

ount

(%)

77.8

91.2

95.0

89.9

94.4

89.7

94.4

87.4

84.0

89.9

Lim

ited

inta

ke

(%)

18.6

8.2

4.7

9.8

5.1

8.4

5.3

12.4

13.7

9.1

Sto

pped

eati

ng

(%)

3.6

0.6

0.3

0.3

0.5

1.9

0.3

0.2

2.3

1.0

Pea

nut

n=

886

n=

941

n=

1,3

22

n=

1,5

27

n=

1,1

77

n=

1,0

48

n=

799

n=

759

n=

1,0

78

n=

9,5

37

\0.0

01

Ate

sam

eor

incr

ease

dam

ount

(%)

35.3

93.4

86.6

90.0

66.8

84.4

85.1

73.9

87.3

79.3

Lim

ited

inta

ke

(%)

20.3

3.9

8.5

6.5

20.2

10.2

7.8

23.1

5.1

11.2

Sto

pped

eati

ng

(%)

44.4

2.7

4.9

3.5

13.0

5.4

7.1

3.0

7.6

9.5

Tre

enuts

n=

883

n=

941

n=

1,3

32

n=

1,5

37

n=

1,2

05

n=

1,1

18

n=

928

n=

941

n=

1,0

78

n=

9,9

63

\0.0

01

Ate

sam

eor

incr

ease

dam

ount

(%)

65.1

94.5

88.4

95.3

67.1

86.4

89.1

78.7

87.8

84.3

Lim

ited

inta

ke

(%)

18.1

3.8

7.3

3.5

19.2

8.9

5.5

20.1

7.3

10.0


123

Ta

ble

5co

nti

nu

ed

Mar

itim

eN

ord

icC

entr

alE

uro

pea

nM

edit

erra

nea

nT

ota

lp

val

ue

Unit

edK

ingdom

Net

her

lands

Icel

and

Ger

man

yP

ola

nd

Lit

huan

iaS

pai

nIt

aly

Gre

ece

Sto

pped

eati

ng

(%)

16.8

1.7

4.3

1.2

13.7

4.7

5.4

1.2

4.9

5.7

Soy

n=

886

n=

746

n=

1,3

34

n=

1,4

99

n=

804

n=

519

n=

492

n=

343

n=

1,0

79

n=

7,7

02

\0.0

01

Ate

sam

eor

incr

ease

dam

ount

(%)

96.4

94.4

98.0

94.6

83.2

79.2

76.2

84.6

97.8

92.0

Lim

ited

inta

ke

(%)

1.2

3.6

1.0

3.4

12.4

3.3

4.9

9.9

0.8

3.7

Sto

pped

eati

ng

(%)

2.4

2.0

1.0

2.0

4.4

17.5

18.9

5.5

1.4

4.3

Fis

hn

=890

n=

950

n=

1,3

33

n=

1,5

57

n=

1,4

57

n=

1,3

76

n=

1,3

63

n=

1,2

98

n=

1,0

77

n=

11,3

01

\0.0

01

Ate

sam

eor

incr

ease

dam

ount

(%)

89.4

90.4

92.8

90.5

91.2

93.8

94.6

91.6

90.8

91.8

Lim

ited

inta

ke

(%)

9.0

8.6

6.8

8.5

6.9

4.1

5.1

8.0

7.2

7.0

Sto

pped

eati

ng

(%)

1.6

1.0

0.4

1.0

1.9

2.1

0.3

0.4

2.0

1.1

Shel

lfish

n=

887

n=

802

n=

1,3

36

n=

1,5

30

n=

718

n=

670

n=

1,0

83

n=

509

n=

1,0

79

n=

8,6

14

\0.0

01

Ate

sam

eor

incr

ease

dam

ount

(%)

43.6

80.5

71.4

80.7

86.9

81.5

84.2

65.4

80.1

74.9

Lim

ited

inta

ke

(%)

14.7

11.0

17.4

9.1

9.1

5.8

11.7

28.9

9.3

13.0

Sto

pped

eati

ng

(%)

41.7

8.5

11.2

10.2

4.0

12.7

4.1

5.7

10.6

12.1

Cer

eal/

cere

alpro

duct

sn

=886

n=

974

n=

1,3

27

n=

1,5

61

n=

1,4

82

n=

1,3

83

n=

1,3

45

n=

1,2

09

n=

1,0

79

n=

11,2

46

\0.0

01

Ate

sam

eor

incr

ease

dam

ount

(%)

98.7

98.1

97.8

98.1

97.2

96.9

95.3

95.9

90.5

96.5

Lim

ited

inta

ke

(%)

1.1

1.8

2.0

1.9

2.3

2.0

4.6

3.7

9.4

3.2

Sto

pped

eati

ng

(%)

0.2

0.1

0.2

0.0

0.5

1.1

0.1

0.4

0.1

0.3

Veg

etab

les

n=

889

n=

973

n=

1,3

31

n=

1,5

61

n=

1,5

08

n=

1,4

45

n=

1,3

74

n=

1,3

37

n=

1,0

78

n=

11,4

96

\0.0

01

Ate

sam

eor

incr

ease

dam

ount

(%)

97.6

96.6

97.4

92.2

99.2

99.3

97.7

96.9

96.9

97.1

Lim

ited

inta

ke

(%)

2.4

3.4

2.5

7.2

0.8

0.7

2.2

3.1

2.9

2.8

Sto

pped

eati

ng

(%)

0.0

0.0

0.1

0.6

0.0

0.0

0.1

0.0

0.2

0.1

Fru

itn

=882

n=

974

n=

1,3

30

n=

1,5

66

n=

1,5

11

n=

1,4

47

n=

1,3

75

n=

1,3

50

n=

1,0

80

n=

11,5

15

0.9

83

Ate

sam

eor

incr

ease

dam

ount

(%)

97.8

97.1

97.7

96.2

98.9

98.5

97.5

97.7

94.7

97.3

Lim

ited

inta

ke

(%)

2.1

2.9

2.2

3.7

1.0

1.5

2.3

2.1

5.2

2.6

Sto

pped

eati

ng

(%)

0.1

0.0

0.1

0.1

0.1

0.1

0.2

0.2

0.1

0.1

Mea

tan

dm

eat

pro

duct

sn

=886

n=

957

n=

1,3

29

n=

1,5

61

n=

1,4

91

n=

1,4

38

n=

1,3

63

n=

1,3

44

n=

1,0

79

n=

11,4

48

\0.0

01

Ate

sam

eor

incr

ease

dam

ount

(%)

94.1

81.9

92.3

85.2

94.4

91.2

67.3

89.8

85.6

86.9

Lim

ited

inta

ke

(%)

5.2

17.6

7.5

14.5

5.6

7.7

31.0

10.1

14.0

12.6

Sto

pped

eati

ng

(%)

0.7

0.5

0.2

0.3

0.0

1.1

1.7

0.1

0.4

0.5

Tea

and

coff

een

=876

n=

968

n=

1,3

36

n=

1,5

59

n=

1,4

83

n=

1,4

02

n=

849

n=

1,1

67

n=

1,0

77

n=

10,7

17

\0.0

01

Ate

sam

eor

incr

ease

dam

ount

(%)

41.4

57.3

50.5

35.8

85.8

66.3

35.1

37.4

34.6

50.9

Lim

ited

inta

ke

(%)

43.4

38.6

40.4

53.0

12.8

30.7

49.1

60.9

40.6

40.2

Sto

pped

dri

nkin

g(%

)15.2

4.0

9.1

11.2

1.4

3.0

15.8

1.7

24.8

8.9

Alc

ohol

n=

882

n=

854

n=

1,3

37

n=

1,5

50

n=

880

n=

635

n=

206

n=

438

n=

1,0

75

n=

7,8

57

\0.0

01

Ate

sam

eor

incr

ease

dam

ount

(%)

43.3

23.1

10.5

20.8

7.0

32.7

4.4

17.1

43.3

20.2

Lim

ited

inta

ke

(%)

10.8

11.2

8.4

22.5

47.6

23.5

10.7

69.9

10.8

25.0

Sto

pped

dri

nkin

g(%

)45.9

65.7

81.1

56.7

45.3

43.8

84.9

13.0

45.9

54.8

Fig

ure

sar

eper

centa

ges

inea

chca

tegory

.p

val

ues

(p\

0.0

5)

repre

sent

resu

ltof

Chi

squar

edte

stof

food

eate

nag

ainst

food

full

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oid

ed.If

moth

ers

usu

ally

ate

afo

od

pre

-pre

gnan

cyan

dth

enav

oid

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ng

pre

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eyw

ere

coded

asst

opped

eati

ng.

Ifsh

eusu

ally

avoid

edan

dco

nti

nued

toav

oid

she

‘ate

the

sam

eas

usu

al’


123

Ta

ble

6N

atio

nal

pre

gn

ancy

reco

mm

end

atio

ns

acro

ssE

uro

pe

Countr

yan

dso

urc

eof

reco

mm

endat

ions

Gen

eral

nutr

itio

nre

com

men

dat

ions

Food

safe

tyre

com

men

dat

ions

Supple

men

t

reco

mm

endat

ions

Spec

ific

alle

rgy

reco

mm

endat

ions

Oth

erre

com

men

dat

ions

Unit

edK

ingdom

The

Nat

ional

Hea

lth

Ser

vic

e

(ww

w.n

hs.

uk

)

Food

Sta

ndar

ds

Agen

cy(w

ww

.

eatw

ell.

gov.u

k)

Dep

artm

ent

of

Hea

lth

(ww

w.

food.g

ov.u

k)

Fru

itand

veget

able

sea

tple

nty

of

fruit

and

veg

etab

les.

Eat

atle

ast

five

port

ions

aday

Sta

rchy

foods

(car

bohydra

te)

e.g.

bre

ad,

pota

toes

,bre

akfa

stce

real

s,ri

ce,

pas

ta

etc.

Thes

efo

ods

should

be

the

mai

n

par

tof

ever

ym

eal

Pro

tein

eat

som

epro

tein

ever

yday

.T

ry

toea

t2

port

ions

of

fish

aw

eek,

1

should

be

oil

y

Dair

yA

imfo

r2–3

port

ions

aday

Chee

sedon’t

eat

mould

-rip

ened

soft

chee

se(e

.g.

bri

e,ca

mem

ber

t),

blu

e-

vei

ned

var

ieti

es(e

.g.

stil

ton,

dan

ish

blu

e).

Ther

eis

risk

of

list

eria

infe

ctio

n

Mea

tco

ok

all

mea

tan

dpoult

ry

thoro

ughly

soth

ere

isno

trac

eof

pin

k

or

blo

od.

This

wil

lhel

pto

avoid

infe

ctio

nw

ith

toxopla

sma

Liv

erdon’t

eat

liver

or

liver

pro

duct

s

bec

ause

they

may

conta

ina

lot

of

vit

amin

A

Pate

avoid

all

types

of

pat

ein

cludin

g

veg

etab

lepat

ebec

ause

they

may

conta

inli

ster

ia

Eggs

only

eat

thoro

ughly

cooked

eggs

to

pre

ven

tri

skof

food

pois

onin

gby

salm

onel

labac

teri

a.D

on’t

eat

foods

conta

inin

gra

wor

under

cooked

eggs

(e.g

.hom

e-m

ade

may

onnai

se,

ice-

crea

m,

and

mouss

e)

Fis

hdon’t

eat

shar

k,

mar

lin,

sword

fish

and

lim

itam

ount

of

tuna

asth

ese

types

hav

ehig

hle

vel

sof

mer

cury

.L

imit

tuna

totw

ost

eaks

or

four

cans

(140

g

dra

ined

wei

ght)

aw

eek

Shel

lfish

only

eat

cooked

shel

lfish

asra

w

can

conta

inhar

mfu

lvir

use

san

d

bac

teri

ath

atca

use

food

pois

onin

g

Mil

konly

dri

nk

pas

teuri

zed

or

UH

T

mil

k.

Als

odon’t

dri

nk

unpas

teuri

zed

goat

sor

shee

p’s

mil

kor

foods

mad

e

from

them

(e.g

.goat

’sch

eese

)

Fru

it,

veget

able

sand

sala

ds

was

hfr

uit

,

veg

etab

les

and

sala

ds

tore

move

all

trac

esof

soil

whic

hm

ayco

nta

in

toxopla

sma

Caff

eine

caff

eine

does

n’t

nee

dto

be

cut

out

com

ple

tely

,but

don’t

hav

em

ore

than

200

mg/d

ay(o

ne

mug

inst

ant

coff

ee:

100

mg,

one

mug

tea:

75

mg)

400

lg

foli

cac

id

dai

lyunti

l

12

wee

ks

10

lg/d

ayof

vit

amin

D

Don’t

take

hig

h-d

ose

mult

ivit

amin

s,

hig

h-d

ose

fish

liver

oil

,or

any

supple

men

tsth

at

conta

invit

amin

A

1,9

98

reco

mm

endat

ion

‘‘pre

gnan

t

wom

enw

ho

are

atopic

,or

for

whom

the

fath

eror

any

sibli

ng

of

the

unborn

chil

dhas

anat

opic

dis

ease

,

may

wis

hto

avoid

eati

ng

pea

nuts

and

pea

nut

pro

duct

sduri

ng

pre

gnan

cy’’

[14]

2009

reco

mm

endat

ion

‘‘P

eanut

and

pea

nut

conta

inin

gfo

ods

(e.g

.pea

nut

butt

er,

confe

ctio

nar

y)

may

be

eate

nduri

ng

pre

gnan

cy,

unle

ssyou’r

eal

lerg

icto

them

or

your

hea

lth

pro

fess

ional

advis

esyou

not

to’’

[15]

Pro

tect

your

bab

yfr

om

tobac

cosm

oke.

Do

not

smoke

Bes

tto

avoid

alco

hol,

but

ifch

oose

to

dri

nk,

do

not

dri

nk

more

than

1–2

unit

s

once

or

twic

ea

wee

k,

and

don’t

get

dru

nk.

NIC

E(N

atio

nal

Inst

itute

for

Hea

lth

and

Cli

nic

alE

xce

llen

ce)

advis

espre

gnan

tw

om

ento

avoid

alco

hol

inth

efi

rst

3m

onth

sin

par

ticu

lar,

bec

ause

of

the

incr

ease

d

risk

of

mis

carr

iage

Alw

ays

chec

kw

ith

your

doct

or,

mid

wif

e

or

phar

mac

ist

bef

ore

takin

gan

y

med

icat

ion.

Tal

kto

your

doct

or

imm

edia

tely

ifyou

take

regula

r

med

icat

ions.

Use

asfe

wover

-the

–

counte

rm

edic

ines

asposs

ible

Not

all

‘nat

ura

l’re

med

ies

are

safe

in

pre

gnan

cy.

Tel

lth

epra

ctit

ioner

you

are

pre

gnan

tan

dte

llyour

phar

mac

ist,

mid

wif

eor

doct

or

whic

hher

bal

,

hom

eopat

hic

or

arom

ather

apy

rem

edie

syou

are

usi

ng

Don’t

han

dle

cat

litt

eran

dw

ear

glo

ves

when

gar

den

ing

toav

oid

infe

ctio

nw

ith

toxopla

sma


123

http://www.nhs.uk

http://www.eatwell.gov.uk

http://www.eatwell.gov.uk

http://www.food.gov.uk


Ta

ble

6co

nti

nu

ed

Countr

yan

dso

urc

eof

reco

mm

endat

ions

Gen

eral

nutr

itio

nre

com

men

dat

ions

Food

safe

tyre

com

men

dat

ions

Supple

men

t

reco

mm

endat

ions

Spec

ific

alle

rgy

reco

mm

endat

ions

Oth

erre

com

men

dat

ions

Net

her

lands

(ww

w.

voed

ingsc

entr

um

.nl)

Eat

avar

iety

of

foods

wit

hin

all

food

gro

ups

Mak

esu

reth

atyour

inta

ke

of

iron

is

suffi

cien

tby

eati

ng

whole

whea

tbre

ad

and

mea

t.E

atvit

amin

Cri

chfr

uit

and

veg

etab

les

wit

hev

ery

mea

lto

enhan

ce

iron

abso

rpti

on

Dair

yai

mfo

r3–5

port

ions

of

dai

ry

pro

duct

sa

day

.Id

eall

ych

oose

sem

i-

skim

med

or

non-f

atm

ilk

Ifveg

etar

ian,

mak

esu

reto

eat

enough

pro

duct

s,ri

chin

vit

amin

Ban

dir

on-

eat

enough

bre

ad,

whea

t-pro

duct

s,

legum

es,

dai

rypro

duct

s,eg

gs

or

mea

t-

anal

ogues

,li

ke

egg,to

fu,te

mpe

or

nuts

Do

not

eat/

dri

nk

for

two

Dri

nk

enough

(±2

l)

Do

not

try

tolo

sew

eight

Chee

sedo

not

eat

soft

chee

sem

ade

from

non

pas

teuri

zed

(raw

)m

ilk;

har

d

chee

sem

ade

from

non

pas

teuri

zed

mil

kca

nbe

eate

n

Mea

tdo

not

eat

raw

mea

tor

liver

(pro

duct

s)

Pate

do

not

eat

more

than

one

port

ion

of

liver

pro

duct

sper

day

toav

oid

too

much

inta

ke

of

vit

amin

A(p

refe

rably

max

1port

ion

ever

y3

day

s)

Eggs

only

eat

eggs

that

are

har

dboil

edor

wel

lfr

ied

Fis

hea

tfi

sh,

this

ishea

lthy,

but

do

not

eat

Vac

uum

seal

edre

ady

toea

tfi

shor

shel

l

fish

from

frid

ge(

e.g.

smoked

salm

on)

(if

hea

ted,

this

may

be

eate

n)

Raw

fish

or

shel

lfi

sh(e

.g.

oyst

ers)

Don’t

eat

shar

k,

mar

lin,

sword

fish

and

lim

itam

ount

of

tuna

asth

ese

types

hav

ehig

hle

vel

sof

mer

cury

No

eel

from

Dutc

hri

ver

s

No

more

than

two

port

ions/

wee

kof

fatt

y

fish

,bec

ause

of

dio

xin

s

Caff

eine

no

more

than

four

cups

of

coff

ee/d

ayor

eight

gla

sses

of

coke/

tea

Liq

uori

celi

mit

consu

mpti

on

toco

uple

of

swee

tsor

1–2

cups

of

liquori

cete

a/day

400

lg

foli

cac

id

dai

ly(a

tle

ast

firs

t

10

wee

ks)

10

lg/d

ayvit

amin

D

\3,0

00

lg/d

ay

vit

amin

A

Spec

ial

for

duri

ng

pre

gnan

cy,

do

not

take

more

than

advis

eddose

None

Do

not

dri

nk

alco

hol

Quit

smokin

g

Her

bal

supple

men

tsdo

not

take

efed

ra,

aloe,

sass

afra

s,dong

quai

,kav

akav

a,

absi

nt-

alse

m,

fennel

,an

ise,

cucu

mber

her

b,

colt

sfoot,

com

frey

and

fever

few

.

Lim

itco

nsu

mpti

on

of

fenugre

ek,

nig

ella

,fe

ather

few

,se

nna,

and

may

flow

er

Her

bs

Lim

itco

nsu

mpti

on

of

fennel

,

sage,

tarr

agon,

anis

e,bas

il,

pes

to,

rubar

ban

dci

nnam

on

Sw

eete

ner

sli

ke

aspar

tam

ein

light

sodas

are

not

har

mfu

l

Was

hyour

fruit

san

dveg

etab

les

Eat

your

raw

veg

etab

les/

fruit

sfr

esh

quic

kly

,do

not

kee

pth

emto

olo

ng

in

the

frid

ge

(as

wel

las

left

over

s)

Pim

ba

do

not

use

pim

ba

or

cala

bas

h

chal

kag

ainst

nau

sea

Do

not

take

any

med

icat

ion

wit

hout

consu

ltin

ga

doct

or,

mid

wif

eor

a

phar

mac

ist,

regar

dle

ssif

the

med

icat

ion

isover

—th

e—co

unte

ror

pre

scri

pti

on.

Wom

ensh

ould

ther

efore

alw

ays

mak

esu

reto

info

rmab

out

thei

r

pre

gnan

cy.

Her

bal

pro

duct

san

d

hom

eopat

hic

rem

edie

ssh

ould

not

be

use

dduri

ng

pre

gnan

cyunle

ss

consu

ltin

ga

doct

or

Do

not

clea

nca

tli

tter

box

Gar

den

wea

ring

glo

ves


123

http://www.voedingscentrum.nl


Ta

ble

6co

nti

nu

ed

Countr

yan

dso

urc

eof

reco

mm

endat

ions

Gen

eral

nutr

itio

nre

com

men

dat

ions

Food

safe

tyre

com

men

dat

ions

Supple

men

t

reco

mm

endat

ions

Spec

ific

alle

rgy

reco

mm

endat

ions

Oth

erre

com

men

dat

ions

Icel

and

Dir

ecto

rate

of

Hea

lth,

Rey

kja

vik

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d.

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p:/

/

ww

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utg

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em11446/

Dep

artm

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Ante

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ecto

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The

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Eat

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wit

hin

all

food

gro

ups

Aim

atfi

ve

port

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of

fruit

san

d/o

r

veg

etab

les/

day

Eat

ing

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rich

inir

on

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lybas

is

should

be

enough

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the

incr

ease

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nee

d

Low

fat

dai

rypro

duct

sar

ere

com

men

ded

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nk

2–3

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pas

teuri

zed

mil

k/

day

(or

equiv

alen

tam

ount

of

oth

er

dai

rypro

duct

s).

Idea

lly

choose

sem

i-

skim

med

or

non-f

atm

ilk.

For

those

wom

enw

ho

don’t

eat

dai

rypro

duct

s

they

are

reco

mm

ended

toco

nsu

me

pro

duct

sen

rich

edw

ith

calc

ium

.

1,0

00

mg

calc

ium

isth

ere

com

men

ded

dai

lyin

take

for

pre

gnan

tw

om

en

Mea

tdo

not

eat

raw

mea

t

Eggs

avoid

raw

eggs.

Fulm

aran

dfu

lmar

eggs

are

tobe

avoid

edbec

ause

of

conta

min

ants

.G

uil

lem

ot

eggs

should

not

be

eate

nm

ore

than

once

aw

eek

Liv

erav

oid

liver

,pat

ean

dsh

eep

liver

sausa

ge

due

tohig

hle

vel

sof

vit

amin

A

Fis

his

reco

mm

ended

atle

ast

2ti

mes

a

wee

kbut

avoid

:R

awfi

sh,

cod

liver

,

shar

k,

sword

fish

and

larg

ehal

ibut

([1.8

mor

60

kg).

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fish

stea

kan

d

ora

nge

roughy

should

not

be

eate

n

more

than

once

aw

eek

bec

ause

of

conta

min

ants

Fis

hoil

avoid

poll

ock

fish

oil

due

tohig

h

level

sof

vit

amin

A

Caff

eine

dri

nk

no

more

than

1–2

cups

of

coff

eea

day

or

3–4

cups

of

tea.

Itis

pre

fera

ble

toco

nsu

me

cola

san

d

ener

gy

dri

nks

inm

oder

atio

n

Foli

caci

d400

lg

dai

ly,

4w

eeks

bef

ore

pre

gnan

cy

and

unti

lth

e12th

wee

k.

Itis

also

advis

edto

eat

foods

rich

info

late

s

10

lg/d

ayvit

amin

D

800

lg

dai

ly

reco

mm

ended

inta

ke

of

vit

amin

A

Cod

liver

oil

is

reco

mm

ended

asa

good

sourc

efo

rA

and

Dvit

amin

,

5m

l/day

Ifw

om

enar

eta

kin

g

cod

liver

oil

and

takin

gm

ult

ivit

amin

choose

mult

ivit

amin

that

do

not

conta

in

vit

amin

A

Iron

supple

men

tsar

e

not

reco

mm

ended

unle

ssit

’snee

ded

None

Itis

reco

mm

ended

toav

oid

alco

hol

alto

get

her

duri

ng

pre

gnan

cy

Wom

enar

ead

vis

edto

stop

smokin

gan

d

are

info

rmed

about

the

ben

efits

of

non-

smokin

gpre

gnan

cy

Wom

enar

ere

com

men

ded

not

tota

ke

any

med

icat

ion

wit

hout

consu

ltin

ga

doct

or,

mid

wif

eor

aphar

mac

ist,

regar

dle

ssif

the

med

icat

ion

is‘o

ver

the

counte

r’or

pre

scri

pti

on.

Wom

en

should

ther

efore

alw

ays

mak

esu

reto

info

rmab

out

thei

rpre

gnan

cy

Her

bal

pro

duct

san

dhom

eopat

hic

rem

edie

ssh

ould

not

be

use

dduri

ng

pre

gnan

cyunle

ssco

nsu

ltin

ga

doct

or

Expec

ting

moth

ers

are

reco

mm

ended

at

leas

t30

min

of

physi

cal

acti

vit

y/d

ay

Good

den

tal

hygie

ne

isem

pth

asis

ed

duri

ng

pre

gnan

cy

Incr

ease

dhygie

ne

around

food

is

reco

mm

ended

duri

ng

pre

gnan

cyas

har

mfu

lbac

teri

aan

dpar

asit

esca

n

affe

ctth

ehea

lth

of

both

moth

eran

d

chil

d


123

http://www.landlaeknir.is/utgefid-efni/skjal/item11446/






Ta

ble

6co

nti

nu

ed

Countr

yan

dso

urc

eof

reco

mm

endat

ions

Gen

eral

nutr

itio

nre

com

men

dat

ions

Food

safe

tyre

com

men

dat

ions

Supple

men

t

reco

mm

endat

ions

Spec

ific

alle

rgy

reco

mm

endat

ions

Oth

erre

com

men

dat

ions

Ital

y

Ital

ian

Min

istr

y

ww

w.s

alute

.gov.i

t

Incr

ease

dca

lori

cin

take

(by

300–500

kca

l/day

)

None

400

lg/d

ayfo

lic

acid

10–15

mg/d

ayIr

on

Vit

amin

C—

no

dose

pro

vid

ed

Vit

amin

D—

for

those

not

expose

dto

sun

or

not

consu

min

g

dai

ryfo

ods

Vit

amin

B12

for

veg

etar

ians

and

veg

ans

DH

Afo

rveg

etar

ians

and

veg

ans;

obli

gat

ory

if

pre

gnan

tan

d

smoke

Mult

ivit

amin

sin

veg

etar

ians,

veg

ans,

alco

holi

cs

and

twin

pre

gnan

cies

Zin

cand

copper

no

dose

pro

vid

ed

Calc

ium

no

dose

pro

vid

ed

None

None

Gre

ece

No

nat

ional

guid

elin

esfo

r

pre

gnan

cynutr

itio

nhav

ebee

n

imple

men

ted

inG

reec

e.

How

ever

som

e

reco

mm

endat

ions

are

giv

en

by

the

maj

ori

tyof

the

obst

etri

cian

san

dth

e

mid

wiv

es

Fru

itand

veget

able

s2–3

serv

ings

of

fruit

s/day

,an

d2–4

veg

etab

les/

day

Carb

ohyd

rate

s6–11

bre

ad/s

tarc

h

serv

ing/d

ay

Dair

y3–5

serv

ing

of

dai

rypro

duct

s/day

Wate

r6–8

gla

sses

/day

Mea

tA

void

under

cooked

mea

tsan

d

poult

ry

Chee

se:

Avoid

unpas

teuri

zed

chee

ses

Eggs

Avoid

raw

egg

Shel

lfish

Avoid

raw

shel

lfish

Caff

eine

Avoid

dri

nkin

gco

ffee

and

sodas

Avoid

canned

foods

None

None

Avoid

dri

nkin

gal

cohol

Was

hal

lgre

ensa

lads

Ger

man

y

The

Ger

man

Nutr

itio

nS

oci

ety

ww

w.d

ge.

de

The

Fed

eral

Inst

itute

for

Ris

k

Ass

essm

ent

ww

w.b

fr.d

e

[Much

e-B

oro

wsk

iet

al.:

All

ergy

pre

ven

tion.

JD

tsch

Der

mat

ol

Ges

.2010

Sep

;8(9

):718–24]

Eat

avar

ied

and

bal

ance

ddie

tduri

ng

pre

gnan

cy

Do

not

eat

for

two

(ener

gy

nee

ds

are

incr

ease

dab

out

200–300

kca

l/day

)

Eat

fish

1–2

tim

es/w

eek

Fis

his

reco

mm

ended

duri

ng

pre

gnan

cy

(sin

ce2009)

Mea

tA

void

raw

mea

tan

dm

eat

pro

duct

s.

Mea

tsh

ould

only

be

consu

med

when

cooked

thoro

ughly

Chee

seA

void

soft

chee

sem

ade

from

raw

mil

k

Fis

hA

void

raw

fish

.L

imit

consu

mpti

on

of

sea

fish

(tuna,

mar

lin,

shar

k,

sword

fish

,et

c.)

asth

ese

spec

ies

may

conta

inhig

hle

vel

sof

mer

cury

Mil

kav

oid

raw

mil

kan

dra

wm

ilk-

pro

duct

s

Caff

eine

Dri

nk

coff

eein

moder

ate

amounts

(\300

mg

caff

eine/

day

,=

3

cups

of

coff

ee)

400

lg

foli

cac

id/d

ay

100–150

lg

iodin

e/

day

No

gen

eral

rest

rict

ive

die

t(a

void

ance

of

pote

nt

food

alle

rgen

s)duri

ng

pre

gnan

cyfo

ral

lerg

ypre

ven

tion

Dri

nk

atle

ast

1.5

ldai

ly

Avoid

alco

hol

duri

ng

pre

gnan

cy

Avoid

acti

ve

and

pas

sive

tobac

cosm

oke

exposu

re(e

spec

iall

yduri

ng

pre

gnan

cy)


123

http://www.salute.gov.it

http://www.dge.de

http://www.bfr.de

Ta

ble

6co

nti

nu

ed

Countr

yan

dso

urc

eof

reco

mm

endat

ions

Gen

eral

nutr

itio

nre

com

men

dat

ions

Food

safe

tyre

com

men

dat

ions

Supple

men

t

reco

mm

endat

ions

Spec

ific

alle

rgy

reco

mm

endat

ions

Oth

erre

com

men

dat

ions

Pola

nd

[The

gen

eral

reco

mm

endat

ions

of

the

Poli

shS

oci

ety

of

Obst

etri

cs

and

Gynec

olo

gy

(2005)]

No

spec

ific

die

tary

reco

mm

endat

ions

oth

erth

ansu

gges

ted

num

ber

of

calo

ries

(2,2

00–2,5

00

kca

l/day

)

None

Foli

cac

id0.4

mg/d

ay

(4m

g/d

ay—

CN

S

def

ect

inpas

t

pre

gnan

cyhis

tory

)

Mult

ivit

amin

san

d

min

eral

s—2nd

and

3rd

trim

este

r

Poss

ibly

iodin

e

150–200

lg/d

ay

Iron

25

mg/d

ayfr

om

13

wee

ks

None

Rec

om

men

dat

ions

for

spec

ial

gro

ups

(pre

gnan

tw

om

en:

ver

yyoung,

veg

etar

ians,

wit

hso

cial

pro

ble

ms,

chro

nic

gas

troin

test

inal

dis

ease

s,

mal

nouri

shed

)

Wat

er2

l/day

Lit

huan

ia

The

Lit

huan

ian

Min

istr

yof

Hea

lth

(ord

erN

o.

510

of

Min

iste

r1999

Novem

ber

25)

and

publi

shed

inO

ffici

alP

ress

or

Min

istr

yin

1999,

No.

102-2

936

No

nat

ional

reco

mm

endat

ions

mad

eto

moth

ers

regar

din

ghow

they

should

be

eati

ng

duri

ng

pre

gnan

cy

Ther

ear

eonly

nat

ional

nutr

itio

nst

andar

ds

for

ener

gy,

pro

tein

,

fats

,ca

rbohydra

tes,

min

eral

s(C

a,P

,

Mg,

Fe,

Zn,

Na,

K,

J)an

dV

itam

ins

(C,

A,

E,

D,

B1,

B2,

B6,

B12,

PP

,fo

lic

acid

)

Bas

edon

the

appro

ved

stan

dar

ds,

sever

al

loca

l(u

niv

ersi

ty,

hosp

ital

,

reco

mm

endat

ions

wer

eis

sued

.

V(O

zera

itie

ne,

Vio

leta

Nes

ciuju

mit

ybos

pri

eziu

ra:

mokom

oji

knyga/

-

(Nutr

itio

nof

pre

gnan

tw

om

en,

texbook)

Vil

niu

s:V

aist

uzi

nio

s(D

rugs

new

s)[2

008].

—127

p.:

iliu

str.

—

Bib

liogr.

:pp.

124–127—

ISB

N

978-9

955-5

11-9

8-4

None

None

None

None

Spai

n

Nat

ional

Soci

ety

of

Ped

iatr

ics

ww

w.a

eped

.es/

com

ite-

lact

anci

a-

mat

erna/

reco

men

dac

iones

Eat

avar

ied

and

bal

ance

ddie

tN

one

Foli

cac

id(n

odosa

ge

pro

vid

ed)

Iron

Vit

amin

B

None

Avoid

alco

hol

duri

ng

pre

gnan

cy


123

http://www.aeped.es/comite-lactancia-materna/recomendaciones


Table 7 Factors associated with folic acid supplement use

Variables Parameter

estimate

SE Estimated

relative rate

95 % CIs for

relative rate

p value n = 10,998


Nutritional supplement recommendation 0.198 0.0278 1.220 (1.154–1.287) \0.001** 8,554

No nutritional supplement recommendation Reference 2,444


C34 0.110 0.0296 1.116 (1.053–1.183) \0.001** 3,304

31–33.9 0.090 0.0322 1.094 (1.027–1.165) 0.005 2,302

27.1–30.9 0.095 0.0317 1.010 (1.034–1.167) 0.003 2,360

B27 Reference – – – – 3,032

Maternal education

College/University 0.084 0.0269 1.088 (1.033–1.147) 0.002 8,306

Basic education or less reference . . 2,692

Maternal BMI

Obese –0.066 0.0429 0.936 (0.861–1.019) 0.127 790

Overweight –0.031 0.0291 0.969 (0.916–1.026) 0.292 1,867

Underweight –0.006 0.0442 0.994 (0.911–1.083) 0.889 713

Healthy weight Reference – – – – 7,628

Maternal smoking

Smoked 0.052 0.0348 1.053 (0.984–1.127) 0.134 1,313

Ex-smoker 0.011 0.0241 1.011 (0.965–1.060) 0.651 3,263

Never smoked Reference – – – – 6,422

Figures are estimated relative rates (95 % CI) from a multivariate Poisson regression analyses for the use of folic acid supplements

* p \ 0.05; ** p \ 0.001

Table 8 Factors associated with Vitamin D supplement use

Variables Parameter

estimate

SE Estimated relative

rate

95 % CIs for relative

rate

p value n = 10,998


Nutritional supplement recommendation 0.019 0.017 1.019 (0.985–1.054) 0.23 8,827

No nutritional supplement

recommendation

Reference 2,258


C34 -0.001 0.019 0.999 (0.963–1.037) 0.10 3,158

31–33.9 -0.005 0.021 0.995 (0.961–1.041) 1.00 2,229

27.1–30.9 -0.001 0.020 0.999 (0.960–1.039) 0.95 2,270

B27 Reference – – – – 2,929

Maternal education

College/university -0.003 0.017 0.997 (0.965–1.030) 0.86 7,957

Basic education or less Reference – – – – 2,628

Maternal BMI

Obese 0.002 0.027 1.002 (0.950–1.055) 0.95 770

Overweight 0.001 0.019 1.001 (0.965–1.038) 0.96 1,823

Underweight 0.001 0.029 1.001 (0.946–1.060) 0.96 666

Healthy weight Reference – – – – 7,326


123

References

1. Pike, K., Rose-Zerilli, M., Osvald, E., Inskip, H., Godfrey, K.,

Crozier, S., et al. (2011). The relationship between infant lung

function and the risk of wheeze in the pre-school years. Pediatric

Pulmonology, 46, 75–82.

2. Pike, K., Crozier, S., Lucas, J., Inskip, H., Roberts, G., & God-

frey, K. (2010). Patterns of and infant growth are related to atopy

and wheezing disorders at age 3 years. Thorax, 65, 1099–1106.

3. Inskip, H., Crozier, S., Godfrey, K., Borland, S., Cooper, C., &

Robinson, S. (2009). Women’s compliance with nutrition and

lifestyle recommendations before pregnancy: General population

cohort study. British Medical Journal, 338, b481.

4. Gluckman, P., Hanson, M., Cooper, C., & Thornburg, K. (2008).

Effect of in utero and early-life conditions on adult health and

disease. New England Journal of Medicine, 35(1), 61–73.

5. Godfrey, K., & Barker, D. (1995). Maternal nutrition in relation

to fetal and placental growth. European Journal of Obstetrics,

Gynecology, and Reproductive Biology, 61, 15–22.

6. WHO. (2012). Guideline. Daily iron and folic acid supplemen-

tation in pregnant women. Geneva: World Health Organization

(cited February 12, 2014). http://www.who.int/elena/titles/daily_

iron_pregnancy/en/index.html.

7. WHO. (2007). Iodine deficiency in Europe: A continuing public

health problem. WHO and UNICEF (cited February 12, 2014).

http://www.who.int/nutrition/publications/micronutrients/iodine_

deficiency/en/.

8. WHO. (2011). Guideline: Vitamin A supplementation in pregnant

women. Geneva: World Health Organization (cited February 12,

2014). http://www.who.int/nutrition/publications/micronutrients/

guidelines/vas_pregnant/en/.

9. WHO. (2012). Guideline: Vitamin D supplementation in preg-

nant women. Geneva: World Health Organization (cited February

12, 2014). http://www.who.int/elena/titles/vitamind_supp_preg

nancy/en/.

10. WHO. (2013). Guideline: Calcium supplementation in pregnant

women. Geneva: World Health Organization (cited February 12,

2014). http://www.who.int/elena/titles/calcium_pregnancy/en/.

11. The Lithuanian Ministry of Health Order No. 510. (1999). http://

www.sam.lt.

12. Spaczynski, M. (2005). Recommendations of the Polish Society

of Obstetrics and Gynaecology for prenatal care in normal

pregnancy. Ginekologia Polska, 76(7), 517–527.

13. The Food Standards Agency. (2012). Eat well, be well (cited

February 12, 2014). http://www.eatwell.gov.uk/ageandstages/

pregnancy/.

14. The National Health Service. (2012) (cited February 12, 2014).

http://www.nhs.uk/conditions/pregnancy-and-baby/.

15. The Netherlands Pregnancy Recommendations. (2012) (cited

February 12, 2014). http://www.voedingscentrum.nl.

16. Keil, T., McBride, D., Grimshaw, K., Niggemann, B., Xepapa-

daki, P., & Zannikos, K. (2010). The multinational birth cohort of

Europrevall: Background, aims and methods. Allergy, 20(65),

482–490.

17. McBride, D., Keil, T., Grabenhenrich, L., Dubakiene, R., Dras-

utiene, G., & Fiocchi, A. (2012). The Europrevall birth cohort

study on food allergy: Baseline characteristics of 12,000 new-

borns and their families from nine European countries. Pediatric

Allergy and Immunology, 23(3), 230–239.

18. SpanishNationalSocietyofPediatrics. (2012) (citedFebruary12,2014).

http://www.aeped.es/comite-lactancia-materna/recomendaciones.

19. The German Nutrition Society. 2012 (cited February 12, 2014).

http://www.dge.de.

20. Italian Ministry Pregnancy Guidelines. (2010). http://www.

archeo.salute.gov.it/indexEnglish.jsp.

21. Italian Ministry Pregnancy Guidelines. (2007). http://www.salute.

gov.it.

22. Department of Antenatal Care, Directorate of Health and The Ice-

landic food and veterinary Authority. (2012) (cited February 12,

2014). http://www.landlaeknir.is/utgefid-efni/skjal/item18504/.

23. Directorate of Health, Reykjavik, Iceland. (2012) (cited February

12, 2014). http://www.landlaeknir.is/utgefid-efni/skjal/item11446.

24. Scientific Advisory Committee on Nutrition. (2006). Folate and

disease prevention. London: Stationery Office. (cited February

12, 2014). http://www.sacn.gov.uk/pdfs/folate_and_disease_pre

vention_report.pdf.

25. Bundesinstitut fur Risikobewertung (BfR) und Arbeitskreis Jo-

dmangel (AKJ): Jod, Folsaure und Schwangerschaft - Ratschlage

fur Arzte. (2006).

26. Drews, K., Spaczynski, M., Br1zert, J., Breborowicz, G., Cele-

wicz, Z., Czajkowski, K., et al. (2006). Rekomendacje Zarz1du

G3ownego PTG w zakresie opieki przedporodowej w ci1>y o

prawid3owym przebiegu. Ginekol Dypl; T.8 Wyd. Specjalne,

59–66.

27. COT report on Peanut Allergy. Department of Health. (1998)

(cited February 12, 2014). http://www.food.gov.uk.

28. Department of Health. (2009). UK Government advice on peanut

consumption during early life and allergy risk (cited February 12,

2014). http://www.food.gov.uk/safereating/allergyintol/

peanutspregnancy.

29. Bath, S., Walter, A., Taylor, A., Wright, J., & Rayman, M.

(2014). Iodine deficiency in pregnant women living in the South

East of the UK: The influence of diet and nutritional supplements

on iodine status. British Journal of Nutrition, 111(9), 1622–1631.

30. MRC Vitamin Study Research Group. (1991). Prevention of

neural tube defects: Results of the MRC vitamin study. Lancet,

338(131), 137.

31. Knudsen, V., Orozova-Bekkevold, I., Rasmussen, L., Mikkelsen,

T., Michaelsen, K., & Olsen, S. (2004). Low compliance with

recommendations on folic acid use in relation to pregnancy: Is

Table 8 continued

Variables Parameter

estimate

SE Estimated relative

rate

95 % CIs for relative

rate

p value n = 10,998

Maternal smoking

Smoked -0.001 0.022 0.999 (0.956–1.044) 0.98 1,273

Ex-smoker -0.001 0.016 0.999 (0.967–1.027) 0.83 3,095

Never smoked Reference – – – – 6,217

Figures are estimated relative rates (95 % CI) from a multivariate Poisson regression analyses for the use of vitamin D supplements

* p \ 0.05


123

http://www.who.int/elena/titles/daily_iron_pregnancy/en/index.html

http://www.who.int/elena/titles/daily_iron_pregnancy/en/index.html

http://www.who.int/nutrition/publications/micronutrients/iodine_deficiency/en/

http://www.who.int/nutrition/publications/micronutrients/iodine_deficiency/en/

http://www.who.int/nutrition/publications/micronutrients/guidelines/vas_pregnant/en/

http://www.who.int/nutrition/publications/micronutrients/guidelines/vas_pregnant/en/

http://www.who.int/elena/titles/vitamind_supp_pregnancy/en/

http://www.who.int/elena/titles/vitamind_supp_pregnancy/en/

http://www.who.int/elena/titles/calcium_pregnancy/en/

http://www.sam.lt

http://www.sam.lt

http://www.eatwell.gov.uk/ageandstages/pregnancy/

http://www.eatwell.gov.uk/ageandstages/pregnancy/

http://www.nhs.uk/conditions/pregnancy-and-baby/



http://www.dge.de

http://www.archeo.salute.gov.it/indexEnglish.jsp

http://www.archeo.salute.gov.it/indexEnglish.jsp




http://www.landlaeknir.is/utgefid-efni/skjal/item11446

http://www.sacn.gov.uk/pdfs/folate_and_disease_prevention_report.pdf

http://www.sacn.gov.uk/pdfs/folate_and_disease_prevention_report.pdf


http://www.food.gov.uk/safereating/allergyintol/peanutspregnancy

http://www.food.gov.uk/safereating/allergyintol/peanutspregnancy

there a need for fortification? Public Health Nutrition, 7(7),

843–850.

32. EFSA. (2009). ESCO report prepared by the EFSA Scientific

Cooperation Working Group on Analysis of risks and benefits of

fortification of food with folic acid. EFSA (European Food Safety

Authority). http://www.efsa.europa.eu/en/supporting/pub/3e.htm.

33. Crozier, S., Robinson, S., Borland, S., Godfrey, K., Cooper, C., &

Inskip, H. (2009). Do women change their health behaviours in

pregnancy? Findings from the Southampton Women’s survey.

Paediatric and Perinatal Epidemiology, 23(5), 446–453.

34. Matthews, F., Yudkin, P., Smith, R., & Neil, A. (2000). Nutrient

intake during pregnancy: The influence of smoking and age.

Journal of Epidemiology and Community Health, 54, 17–23.

35. Erkkola, M. (1998). Folate, vitamin D and iron intakes are low

among pregnant Finnish women. European Journal of Clinical

Nutrition, 52, 742–748.

36. Arkkola, T., Uusitalo, U., Pietikainen, M., Metsala, J., Kronberg-

Kippila, C., Erkkola, M., et al. (2006). Dietary intake and use of

dietary supplements in relation to demographic variables among

pregnant Finnish women. British Journal of Nutrition, 96(5),

913–920.

37. Holick, M. (2007). Vitamin D deficiency. New England Journal

of Medicine, 357, 266–281.

38. Dini, C., & Bianchi, A. (2012). The potential role of vitamin D

for prevention and treatment of tuberculosis and infectious dis-

eases. Annali dell Istituto Superiore di Sanita, 48(3), 319–327.

39. Adami, S., Romagnoli, E., Carnevale, V., Scillitani, A., Giusti,

A., Rossini, M., et al. (2011). Guidelines on prevention and

treatment of vitamin D deficiency. Reumatismo, 63(3), 129–147.

40. Nicolaidou, P., Hatzistamatiou, Z., Papadopoulou, A., Kaleyias,

J., Floropoulou, E., Lagona, E., et al. (2006). Low vitamin D

status in mother–newborn pairs in Greece. Calcified Tissue

International, 78, 337–342.

41. Challa, A., Ntourntoufi, A., Cholevas, V., Bitsori, M., Galanakis,

E., & Andronikou, S. (2005). Breastfeeding and vitamin D status

in Greece during the first 6 months of life. European Journal of

Pediatrics, 164, 724–729.

42. Carnevale, V., Modoni, S., Pileri, M., Di Giorgio, A., Chiodini, I.,

Minisola, S., et al. (2001). Longitudinal evaluation of vitamin D

status in healthy subjects from southern Italy: Seasonal and gender

differences. Osteoporosis International, 12(12), 1026–1030.

43. Yeste, D., & Carrascosa, A. (2003). Nutritional rickets in child-

hood: Analysis of 62 cases. Medical Clinica (Barcelona), 121(1),

23–27.

44. Calvo, M., Whiting, S., & Barton, C. (2005). Symposium: Vita-

min D insufficiency: A significant risk factor in chronic diseases

and potential disease-specific biomarkers of vitamin D suffi-

ciency. The Journal of Nutrition, 135, 310–316.

45. de Lourdes Samaniego-Vasesken, M., Alonso-Aperte, E., &

Varela-Moreiras, G. (2012). Vitamin food fortification today.

Food & Nutrition Research, 56, 5459–5468.

46. Czech-Kowalska, J., Dobrzanska, A., Gruszfeld, D., Zochowska,

A., Malinowska, E., Golkowska, M., et al. (2008). High

prevalence of neonatal vitamin D deficiency—Rationale for

reevaluation of vitamin D supplementation during pregnancy.

Archives of Perinatal Medicine, 14(4), 18–22.

47. Scientific Advisory Committee on Nutrition, Update on Vitamin

D. (2007). Norwich: The Stationery Office (cited February 12,

2014). http://www.sacn.gov.uk/reports_postion_statements/.

48. Hypponen, E., & Boucher, B. (2010). Avoidance of vitamin D

deficiency in pregnancy in United Kingdom: The case for a

unified approach in National policy. British Journal of Nutrition,

104, 309–314.

49. Scientific Advisory Committee on Nutrition & Committee on

Toxicity. (2004). Advice on fish consumption: Benefits and risks.

London, UK: The Stationary Office.

50. EFSA Panel on Dietetic Products, Nutrition and Allergies.

(2010). Scientific opinion on dietary reference values for fats,

including saturated fatty acids, polyunsaturated fatty acids and

cholesterol. EFSA Journal, 8, 1461.

51. Joint FAO/WHO Expert consultation on fats and fatty acids in

human nutrition. (2010). Fats and fatty acids in human nutrition:

Report on expert consultation. Rome, Italy: Food and Agriculture

Organization.

52. Arvaniti, F., Priftis, K., Papadimitriou, A., Papadopoulos, M.,

Roma, E., Kapsokefalou, M., et al. (2011). Adherence to the

Mediterranean type of diet is associated with lower prevalence of

asthma symptoms, among 10–12 years old children: The PAN-

ACEA study. Pediatric Allergy and Immunology, 22, 283–289.

53. McDonald, K., Amir, L., & Davey, M. (2011). Maternal bodies

and medicines: A commentary on risk and decision-making of

pregnant and breastfeeding women and health professionals.

BMC Public Health, 25(11 Suppl 5), 1–8.

54. McMath, B. F., & Prentice-Dunn, S. (2005). Protection motiva-

tion theory and skin cancer risk. The role of individual differ-

ences in responses to persuasive appeals. Journal of Applied

Social Psychology, 35, 621–635.

55. Department of Health. (2000). Folic acid and the prevention of

disease. Report on health and social subjects no. 50. London: The

Stationary Office.

56. McDonald, R., Johnson, Z., Doyle, A., & Sayers, G. (1999).

Determinants of folic acid knowledge and use amongst antenatal

women. Journal of Public Health Medicine, 21, 145–149.

57. McGovern, E., Moss, H., Grewal, G., Taylor, A., Bjornsson, S., &

Pell, J. (1997). Factors affecting the use of folic acid supplements

in pregnant women in Glasgow. British Journal of General

Practice, 47, 635–637.

58. Van der Pal-de Bruin, K., de Walle, H., Jeeninga, W., de Rover,

C., Cornel, M., & de Jong-van den Berg, L. (2000). The Dutch

‘Folic acid campaign’—Have the goals been achieved? Paedi-

atric and Perinatal Epidemiology, 14, 111–117.

59. Chan, A., Pickering, J., Haan, E., Netting, M., Burford, A., &

Johnson, A. (2001). ‘Folate before pregnancy’: The impact on

women and earth professionals of a population-based health

promotion campaign in South Australia. Medical Journal of

Australia, 174, 631–636.


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