BACKGROUND Gestational weight gain is positively associated with fetal growth, and observational studies of food supplementation in pregnancy have reported increases in gestational weight gain and fetal growth. OBJECTIVES To assess the effects of advice to increase or reduce energy or protein intake, or of actual energy or protein supplementation or restriction, during pregnancy on energy and protein intakes, gestational weight gain, and the outcome of pregnancy. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group trials register (October 2002) and contacted researchers in the field. SELECTION CRITERIA Acceptably controlled trials of dietary advice to increase or reduce energy or protein intake, or of actual energy or protein supplementation or restriction, during pregnancy. DATA COLLECTION AND ANALYSIS Data were extracted by the authors from published reports, and supplemented by additional information from trialists contacted by the authors. MAIN RESULTS In five trials involving 1134 women, nutritional advice to increase energy and protein intakes was successful in achieving those goals, but no consistent benefit was observed on pregnancy outcomes. In 13 trials involving 4665 women, balanced energy/protein supplementation was associated with modest increases in maternal weight gain and in mean birth weight, and a substantial reduction in risk of small-for-gestational-age (SGA) birth. These effects did not appear greater in undernourished women. No significant effects were detected on preterm birth, but significantly reduced risks were observed for stillbirth and neonatal death. In two trials involving 1076 women, high-protein supplementation was associated with a small, nonsignificant increase in maternal weight gain but a nonsignificant reduction in mean birthweight, a significantly increased risk of SGA birth, and a nonsignificantly increased risk of neonatal death. In 3 trials involving 966 women, isocaloric protein supplementation was also associated with an increased risk of SGA birth. In three trials involving 384 women, energy/protein restriction of pregnant women who were overweight or exhibited high weight gain significantly reduced weekly maternal weight gain and mean birth weight but had no effect on pregnancy-induced hypertension or pre-eclampsia. REVIEWER'S CONCLUSIONS Dietary advice appears effective in increasing pregnant women's energy and protein intakes but is unlikely to confer major benefits on infant or maternal health. Balanced energy/protein supplementation improves fetal growth and may reduce the risk of fetal and neonatal death. High-protein or balanced protein supplementation alone is not beneficial and may be harmful to the infant.Protein/energy restriction of pregnant women who are overweight or exhibit high weight gain is unlikely to be beneficial and may be harmful to the infant.

Energy and protein intake in pregnancy.

Background
Gestational weight gain is positively associated with fetal growth, and observational studies of food supplementation in pregnancy have reported increases in gestational weight gain and fetal growth.

Objectives
To assess the effects of education during pregnancy to increase energy and protein intake, or of actual energy and protein supplementation, on energy and protein intake, and the effect on maternal and infant health outcomes.

Search methods
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015), reference lists of retrieved studies and contacted researchers in the field.

Selection criteria
Randomised controlled trials of dietary education to increase energy and protein intake, or of actual energy and protein supplementation, during pregnancy.

Data collection and analysis
Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors independently extracted data and checked for accuracy. Extracted data were supplemented by additional information from the trialists we contacted.

Main results
We examined 149 reports corresponding to 65 trials. Of these trials, 17 were included, 46 were excluded, and two are ongoing. Overall, 17 trials involving 9030 women were included. For this update, we assessed methodological quality of the included trials using the standard Cochrane criteria (risk of bias) and the GRADE approach. The overall risk of bias was unclear.

Nutritional education (five trials, 1090 women)

Women given nutritional education had a lower relative risk of having a preterm birth (two trials, 449 women) (risk ratio (RR) 0.46, 95% CI 0.21 to 0.98, low-quality evidence), and low birthweight (one trial, 300 women) (RR 0.04, 95% CI 0.01 to 0.14). Head circumference at birth was increased in one trial (389 women) (mean difference (MD) 0.99 cm, 95% CI 0.43 to 1.55), while birthweight was significantly increased among undernourished women in two trials (320 women) (MD 489.76 g, 95% CI 427.93 to 551.59, low-quality evidence), but did not significantly increase for adequately nourished women (MD 15.00, 95% CI -76.30 to 106.30, one trial, 406 women). Protein intake increased significantly (three trials, 632 women) (protein intake: MD +6.99 g/day, 95% CI 3.02 to 10.97). No significant differences were observed on any other outcomes such as neonatal death (RR 1.28, 95% CI 0.35 to 4.72, one trial, 448 women, low-quality evidence), stillbirth (RR 0.37, 95% CI 0.07 to 1.90, one trial, 431 women, low-quality evidence), small-for-gestational age (RR 0.97, 95% CI 0.45 to 2.11, one trial, 404 women, low-quality evidence) and total gestational weight gain (MD -0.41, 95% CI -4.41 to 3.59, two trials, 233 women). There were no data on perinatal death.

Balanced energy and protein supplementation (12 trials, 6705 women)

Risk of stillbirth was significantly reduced for women given balanced energy and protein supplementation (RR 0.60, 95% CI 0.39 to 0.94, five trials, 3408 women, moderate-quality evidence), and the mean birthweight was significantly increased (random-effects MD +40.96 g, 95% CI 4.66 to 77.26, Tau² = 1744, I² = 44%, 11 trials, 5385 women, moderate-quality evidence). There was also a significant reduction in the risk of small-for-gestational age (RR 0.79, 95% CI 0.69 to 0.90, I² = 16%, seven trials, 4408 women, moderate-quality evidence). No significant effect was detected for preterm birth (RR 0.96, 95% CI 0.80 to 1.16, five trials, 3384 women, moderate-quality evidence) or neonatal death (RR 0.68, 95% CI 0.43 to 1.07, five trials, 3381 women, low-quality evidence). Weekly gestational weight gain was not significantly increased (MD 18.63, 95% CI -1.81 to 39.07, nine trials, 2391 women, very low quality evidence). There were no data reported on perinatal death and low birthweight.

High-protein supplementation (one trial, 1051 women)

High-protein supplementation (one trial, 505 women), was associated with a significantly increased risk of small-for-gestational age babies (RR 1.58, 95% CI 1.03 to 2.41, moderate-quality evidence). There was no significant effect for stillbirth (RR 0.81, 95% CI 0.31 to 2.15, one trial, 529 women), neonatal death (RR 2.78, 95% CI 0.75 to 10.36, one trial, 529 women), preterm birth (RR 1.14, 95% CI 0.83 to 1.56, one trial, 505 women), birthweight (MD -73.00, 95% CI -171.26 to 25.26, one trial, 504 women) and weekly gestational weight gain (MD 4.50, 95% CI -33.55 to 42.55, one trial, 486 women, low-quality evidence). No data were reported on perinatal death.

Isocaloric protein supplementation (two trials, 184 women)

Isocaloric protein supplementation (two trials, 184 women) had no significant effect on birthweight (MD 108.25, 95% CI -220.89 to 437.40) and weekly gestational weight gain (MD 110.45, 95% CI -82.87 to 303.76, very low-quality evidence). No data reported on perinatal mortality, stillbirth, neonatal death, small-for-gestational age, and preterm birth.

Authors' conclusions
This review provides encouraging evidence that antenatal nutritional education with the aim of increasing energy and protein intake in the general obstetric population appears to be effective in reducing the risk of preterm birth, low birthweight, increasing head circumference at birth, increasing birthweight among undernourished women, and increasing protein intake. There was no evidence of benefit or adverse effect for any other outcome reported.

Balanced energy and protein supplementation seems to improve fetal growth, and may reduce the risk of stillbirth and infants born small-for-gestational age. High-protein supplementation does not seem to be beneficial and may be harmful to the fetus. Balanced-protein supplementation alone had no significant effects on perinatal outcomes.

The results of this review should be interpreted with caution. The risk of bias was either unclear or high for at least one category examined in several of the included trials, and the quality of the evidence was low for several important outcomes. Also, as the anthropometric characteristics of the general obstetric population is changing, those developing interventions aimed at altering energy and protein intake should ensure that only those women likely to benefit are included. Large, well-designed randomised trials are needed to assess the effects of increasing energy and protein intake during pregnancy in women whose intake is below recommended levels.

Antenatal dietary education and supplementation to increase energy and protein intake.

The nutritional status of a woman before and during pregnancy is important for a healthy pregnancy outcome. Maternal malnutrition is a key contributor to poor fetal growth, low birthweight (LBW) and short- and long-term infant morbidity and mortality. This review summarised the evidence on association of maternal nutrition with birth outcomes along with review of effects of balanced protein-energy supplementation during pregnancy. A literature search was conducted on PubMed, WHOLIS, PAHO and Cochrane library. Only intervention studies were considered for inclusion and data were combined by meta-analyses if available from more than one study. Sixteen intervention studies were included in the review. Pooled analysis showed a positive impact of balanced protein-energy supplementation on birthweight compared with control [mean difference 73 (g) [95% confidence interval (CI) 30, 117]]. This effect was more pronounced in undernourished women compared with adequately nourished women. Combined data from five studies showed a reduction of 32% in the risk of LBW in the intervention group compared with control [relative risk (RR) 0.68 [95% CI 0.51, 0.92]]. There was a reduction of 34% in the risk of small-for-gestational-age babies in the intervention compared with the control group [RR 0.66 [95% CI 0.49, 0.89]]. The risk of stillbirth was also reduced by 38% in the intervention group compared with control [RR 0.62 [95% CI 0.40, 0.98]]. In conclusion, balanced protein-energy supplementation is an effective intervention to reduce the prevalence of LBW and small-for-gestational-age births, especially in undernourished women.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-3016.2012.01308.x

Maternal nutrition and birth outcomes: effect of balanced protein-energy supplementation.

OBJECTIVES: This National Cancer Institute-funded study sought to increase fruit and vegetable consumption among women served by the WIC program in Maryland. METHODS: Over a 2-year period, a multifaceted intervention program using a randomized crossover design sought to increase fruit and vegetable consumption at 16 WIC program sites in Baltimore City and 6 Maryland counties. Participants were surveyed at baseline, 2 months postintervention, and 1 year later. RESULTS: Two months postintervention, mean daily consumption had increased by 0.56 +/- 0.11 servings in intervention participants and 0.13 +/- 0.07 servings in control participants (P = .002). Intervention participants also showed greater changes in stages of change, knowledge, attitudes, and self-efficacy. Changes in consumption were closely related to number of nutrition sessions attended, baseline stage of change, race, and education. One year later, mean consumption had increased by an additional 0.27 servings in both intervention and control par...

https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.88.8.1161

Final results of the Maryland WIC 5-A-Day Promotion Program.

https://paa2013.princeton.edu/papers/130349

WIC in Your Neighborhood: New Evidence on the Impacts of Geographic Access to Clinics

Effect of food supplementation (WIC) during pregnancy on birth weight.

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Effect of food supplementation (WIC) during pregnancy on birth weight.