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Estimate of Dietary Total Antioxidant Capacity of Pregnant Women and Associated Factors Estimativa da capacidade antioxidante total da dieta de gestantes e fatores associados

Abstract

Objective

To investigate the dietary total antioxidant capacity (DTAC) of pregnant women, and associated factors.

Methods

Cross-sectional study conducted with 785 pregnant adult women attended in primary health care centers of Ribeirão Preto, state of São Paulo, Brazil. Two 24-hour dietary recalls were obtained, and the usual intake was estimated through the Multiple Source Method. The DTAC was estimated using the ferric reducing antioxidant power assay. The relationship between the higher DTAC estimate (≥ median of 4.3 mmol/day) and associated factorswas investigated usingadjusted logisticmodels with backward selection.

Results

In total, 25% of the pregnant women were classified as overweight, and 32% as obese. Themedian (P25, P75)DTAC was 4.3 (3.3-5.6)mmol/day. Through adjusted logistic regression models with backward selection, a higher chance of DTAC estimates above the median among pregnant womenaged ≥ 35 years old (2.01 [1.24-3.27])was verified when compared with younger pregnant women. Women with prepregnancy overweight (0.63 [0.45-0.89]) and obesity (0.59 [0.40-0.88]) presented a lower chance of DTAC estimates above the median when compared with eutrophic pregnant women. A higher DTAC estimate was positively associated with the use of dietary supplements (1.39 [1.03-1.88]), and negatively associated with total dietary energy (0.59 [0.42-0.85]).

Conclusion

The DTAC estimate over the median was associated with greater age, adequate body weight, use of dietary supplements, and lower energy intake.

Keywords:
total antioxidant capacity; pregnant women; diet; antioxidants

Resumo

Objetivo

Investigar a capacidade antioxidante total da dieta (CATd) de gestantes e os fatores associados.

Métodos

Estudo transversal conduzido entre 785 gestantes adultas em acompanhamento de pré-natal em Unidades Básicas de Saúde de Ribeirão Preto, São Paulo, Brasil. Para a estimativa da dieta usual, 2 inquéritos recordatórios de 24 horas foram obtidos e ajustados empregando-se o Multiple Source Method. A CATd foi estimada com base no ensaio de potência de redução de ferro. Para investigar a relação entre a maior estimativa de CATd (≥ mediana de 4,3 mmol/dia) e os fatores associados, foram empregados modelos de regressão logística ajustados em função backward.

Resultados

No total, 25% das gestantes foramclassificadas comsobrepeso e 32% com obesidade. A mediana (P25; P75) da CATd foi de 4,3 (3,3-5,6) mmol/dia. Em modelos de regressão logística ajustados em função backward, verificou-se maior chance da estimativa da CATd acima da mediana entre gestantes com idade ≥ 35 anos (2,01 [1,24-3,27]), quando comparadas às gestantes de menor idade. Mulheres com sobrepeso (0,63 [0,45-0,89]) e obesidade (0,59 [0,40; 0,88]) no período pré-gestacional apresentaram menor chance da estimativa da CATd acima da mediana, quando comparadas às eutróficas. A estimativa da CATd foi positivamente associada ao uso de suplementos dietéticos (1,39 [1,03-1,88]) e negativamente associada à energia total da dieta (0,59 [0,42-0,85]).

Conclusão

A estimativa da CATd acima da mediana foi positivamente associada à maior idade, eutrofia, ao uso de suplementos dietéticos e à menor ingestão energética.

Palavras-chave:
capacidade; antioxidante total; gestantes; dieta; antioxidantes

Introduction

Maternal nutrition during pregnancy has a great influence on birth outcomes and on the development of chronic diseases in adulthood.11 Chia AR, Chen LW, Lai JS,Wong CH, Neelakantan N, van Dam RM, et al. Maternal dietary patterns and birth outcomes: a systematic review and meta-analysis. Adv Nutr. 2019;10(04):685-695. Doi: 10.1093/advances/nmy123
https://doi.org/10.1093/advances/nmy123...
Evidence suggests that adherence to healthy eating patterns composed of foods that are sources of antioxidants, such as fruits, legumes, and vegetables (FLVs), have a protective effect during pregnancy in relation to prematurity and low birth weight (LBW), promoting adequate childhood growth and development.22 Kibret KT, Chojenta C, GreshamE, Tegegne TK, Loxton D. Maternal dietary patterns and risk of adverse pregnancy (hypertensive disorders of pregnancy and gestational diabetes mellitus) and birth (preterm birth and low birth weight) outcomes: a systematic review and meta-analysis. Public Health Nutr. 2018;22(03): 1-15. Doi: 10.1017/S1368980018002616
https://doi.org/10.1017/S136898001800261...

Numerous vitamins and minerals with antioxidant properties are used to explain the pathway that connects maternal healthy eating behavior with fetal growth. Increased maternal intake of vitamin D supplements reduces the risk of small for gestational age (SGA) infants.33 Roth DE, Leung M, Mesfin E, Qamar H, Watterworth J, Papp E. Vitamin D supplementation during pregnancy: state of the evidence from a systematic review of randomised trials. BMJ. 2017; 359:j5237. Doi: 10.1136/bmj.j5237
https://doi.org/10.1136/bmj.j5237...
Furthermore, the adequate intake of zinc, magnesium, calcium, and vitamin D supplements is associated with a reduction in oxidative stress in pregnant women with gestational diabetes mellitus (GDM).44 Jamilian M, Mirhosseini N, Eslahi M, Bahmani F, Shokrpour M, Chamani M, et al. The effects of magnesium-zinc-calcium-vitamin D co-supplementation on biomarkers of inflammation, oxidative stress and pregnancy outcomes in gestational diabetes. BMC Pregnancy Childbirth. 2019;19(01):107. Doi: 10.1186/s12884-019-2258-y
https://doi.org/10.1186/s12884-019-2258-...

Higher levels of reactive oxygen species are physiologically checked during pregnancy and may in fact be important for its organogenesis.55 Aouache R, Biquard L, Vaiman D, Miralles F. Oxidative stress in preeclampsia and placental diseases. Int J Mol Sci. 2018;19(05): 1496. Doi: 10.3390/ijms19051496
https://doi.org/10.3390/ijms19051496...
However, excessive production of free radicals associated with a low antioxidant defense can negatively impact the development of the placenta and, consequently, the health of the newborn.55 Aouache R, Biquard L, Vaiman D, Miralles F. Oxidative stress in preeclampsia and placental diseases. Int J Mol Sci. 2018;19(05): 1496. Doi: 10.3390/ijms19051496
https://doi.org/10.3390/ijms19051496...
To inhibit and/or reduce the damage caused by the action of free radicals, the human body has enzymatic and nonenzymatic antioxidant defense systems.66 Birben E, Sahiner UM, Sackesen C, ErzurumS, Kalayci O. Oxidative stress and antioxidant defense. World Allergy Organ J. 2012;5 (01):9-19. Doi: 10.1097/WOX.0b013e3182439613
https://doi.org/10.1097/WOX.0b013e318243...

The enzymatic defense system includes the enzymes superoxide dismutase, peroxidase, catalase, and glutathione-peroxidase. The activity of these enzymes depends on the participation of nonenzymatic cofactors, the diet being the main contributing factor for the regulation of the serum antioxidant status.77 Li Y, Guo H,WuM, Liu M. Serum and dietary antioxidant status is associated with lower prevalence of the metabolic syndrome in a study in Shanghai, China. Asia Pac J Clin Nutr. 2013;22(01):60-68. Doi: 10.6133/apjcn.2013.22.1.06
https://doi.org/10.6133/apjcn.2013.22.1....

Dietary antioxidants evaluated in isolation may not reflect the total antioxidant power of the diet, as this does not consider the additive or synergistic effects of the interaction between them. Therefore, the dietary total antioxidant capacity (DTAC) has been used to investigate the potential antioxidant effects of foods present in the diet, considering the synergy between them.88 Carlsen MH, Halvorsen BL, Holte K, Bøhn SK, Dragland S, et al. The total antioxidant content of more than 3100 foods, beverages, spices, herbs and supplements used worldwide. Nutr J. 2010;9:3. Doi: 10.1186/1475-2891-9-3
https://doi.org/10.1186/1475-2891-9-3...
The DTAC is recognized as a potential marker of the quality of the usual diet and is positively correlated with the consumption of FLVs, and negatively correlated with the ingestion of fats.99 Puchau B, ZuletMA, de Echávarri AG,HermsdorffHH,Martínez JA. Dietary total antioxidant capacity: a novel indicator of diet quality in healthy young adults. J Am Coll Nutr. 2009;28(06):648-656. Doi: 10.1080/07315724.2009.10719797
https://doi.org/10.1080/07315724.2009.10...

Evidence suggests that the DTAC is directly associated with a lower risk of all-cause mortality, cancer, and cardiovascular disease.1010 Parohan M, Anjom-Shoae J, Nasiri M, Khodadost M, Khatibi SR, Sadeghi O. Dietary total antioxidant capacity and mortality from all causes, cardiovascular disease and cancer: a systematic review and dose-response meta-analysis of prospective cohort studies. Eur J Nutr. 2019;58(06):2175-2189. Doi: 10.1007/s00394-019-01922-9
https://doi.org/10.1007/s00394-019-01922...
In a study conducted among pregnant women, it was found that women classified in the third tertile of the DTAC estimation had a 46% lower chance of premature births, regardless of confounding factors. In addition, at an intermediate level, the DTAC was associated with a 75% lower chance of LBW infants.1111 Sartorelli DS, Carvalho MR, da Silva Santos I, Crivellenti LC, Souza JP, Franco LJ. Dietary total antioxidant capacity during pregnancy and birth outcomes. Eur J Nutr. 2021;60(01):357-367. Doi: 10.1007/s00394-020-02251-y
https://doi.org/10.1007/s00394-020-02251...

Sociodemographic and lifestyle characteristics and the presence of morbidities influence food choices. Studies suggest that older pregnant women, who live with a partner, who perform paid work and have a higher level of education tend to adopt more diverse and healthier diets.1212 Gomes CDB, Vasconcelos LG, Cintra RMGDC, Dias LCGD, Carvalhares MADBL. Hábitos alimentares das gestantes brasileiras:revisão integrativa da literatura. Ciênc Saúde Coletiva. 2019;24 (06):2293-2306. Doi: 10.1590/1413-81232018246.14702017
https://doi.org/10.1590/1413-81232018246...
Conversely, it has been observed that younger pregnant women present greater adherence to the patterns of snacks (breads, cheese, sweets, and chocolate, among others).1313 Zuccolotto DCC, Crivellenti LC, Franco LJ, Sartorelli DS. Dietary patterns of pregnantwomen, maternal excessive bodyweight and gestational diabetes. Rev Saude Publica. 2019;53:52. Doi: 10.11606/s1518-8787.2019053000909
https://doi.org/10.11606/s1518-8787.2019...
However, we are unaware of the existence of studies that have investigated the factors associated with higher DTAC estimates in pregnant women.

The aim of the present study was to investigate the factors associated with higher DTAC estimates in pregnant women and to identify the main dietary sources of the DTAC.

Methods

This is a secondary analysis of a cross-sectional study conducted with 785 adult pregnant women attended at Primary Health Units of the Brazilian National Health System (SUS, in the Portuguese acronym) in the city of Ribeirão Preto, state of São Paulo, Brazil. Conducted between 2011 and 2012, the study aimed to investigate the association between the usual diet during pregnancy and GDM, as described in detail in the publication by Barbieiri et al.1414 Barbieiri P, Nunes JC, Torres AG, Nishimura RY, Zuccolotto DCC, Crivellenti LC, et al. Indices of dietary fat quality during midpregnancy is associated with gestational diabetes. Nutrition. 2016;32 (06):656-661. Doi: 10.1016/j.nut.2015.12.002
https://doi.org/10.1016/j.nut.2015.12.00...

The pregnant women were invited to participate in the study when the oral glucose tolerance test (OGTT) was performed. A shift plan was established in five laboratories with the health department of the municipality. All interviews were conducted by previously trained nutritionists. The women that fulfilled the inclusion criteria and agreed to participate in the study were interviewed after signing the consent form.

Fasting blood samples, 1 and 2 hours after ingestion of a 75 g glucose overload, were obtained from all study participants. The glucose oxidase method was used to determine plasma glucose. The diagnosis of GDM was based on the 2014 World Health Organization (WHO) criteria.1515 Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy: a World Health Organization Guideline. Diabetes Res Clin Pract. 2014;103(03):341-363. Doi: 10.1016/j.diabres.2013.10.012
https://doi.org/10.1016/j.diabres.2013.1...

The sample size calculation was based on the primary outcome of the study, GDM. Considering a prevalence of 20% of GDM among adult women attended in the SUS, with an acceptable margin of error of 5%, a sample of 512 pregnant women was necessary.1616 Trujillo J, Vigo A, Duncan BB, Falavigna M,Wendland EM, Campos MA, et al. Impact of the International Association of Diabetes and Pregnancy Study Groups criteria for gestational diabetes. Diabetes Res Clin Pract. 2015;108(02):288-295. Doi: 10.1016/j.diabres.2015.02.007
https://doi.org/10.1016/j.diabres.2015.0...
Considering that, in logistic regression models, 10 cases are required for each exploratory variable, the sample was considered sufficient for the analysis of the present study.1717 Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49(12):1373-1379. Doi: 10.1016/s0895-4356(96)00236-3
https://doi.org/10.1016/s0895-4356(96)00...

Women aged ≥ 20 years, with pregestational BMI ≥ 20kg/m2 and screened for GDM from the 24th gestational week were included. Pregnant women diagnosed with previous type 1 or type 2 diabetes mellitus (DM), twin pregnancies, who reported use of drugs that altered blood glucose (such as glucocorticoids) and reported diseases that interfered with their habitual food consumption (chronic renal failure, acquired immunodeficiency syndrome or cancer) were excluded. In total, 1,446 women were invited to participate in the study, with 785 eventually included, as described in Fig. 1.

Fig. 1
Flowchart of the study.

The estimation of the diet of the pregnant women was performed by means of 2 24-hour dietary recalls (24hR), following the “multiple-pass” methodology in 3 stages, between the 24th and 39th gestational weeks. The first 24hR was collected from all pregnant women on the day of the face-to-face interview.1818 Johnson RK, Soultanakis RP, Matthews DE. Literacy and body fatness are associated with underreporting of energy intake in US low-income women using the multiple-pass 24-hour recall: a doubly labeled water study. J Am Diet Assoc. 1998;98(10): 1136-1140. Doi: 10.1016/S0002-8223(98)00263-6
https://doi.org/10.1016/S0002-8223(98)00...
The second 24hR was obtained from a subsample of 73% of the pregnant women through telephone contact, on nonconsecutive days, with at least 1 week between replications, regardless of the day of the week or season.

For the estimation of dietary nutrients, the Brazilian Table of Chemical Composition of Food (TACO) was used with the NutWin® Program (Programa de Apoio à Nutrição. Version 1.5. São Paulo: Escola Paulista de Medicina; 2002).1919 Universidade Estadual de Campinas. Núcleo de Estudos e Pesquisas em Alimentação. Tabela brasileira de composição de alimentos: TACO 2. ed. Campinas: NEPA-UNICAMP; 2006 The underreporting of energy intake was estimated using the method by Goldberg et al.2020 Goldberg GR, Black AE, Jebb SA, Cole JT,Murgatroyd PR, CowardWA, et al. Critical evaluation of energy intake data using fundamental principles of energy physiology: 1. Derivation of cut-off limits to identify under-recording. Eur J Clin Nutr. 1991;45(12):569-581, adopting a cutoff point of 1.35 for the ratio between the energy estimate and the basal metabolic rate.

The DTAC (in mmol/100 g), represented by the sum of the TAC of the food and the TAC determined in the supplements, was estimated using data from previous studies that established the total amount of antioxidant present in food and drink through the Ferric Reducing Antioxidant Power assay (FRAP).88 Carlsen MH, Halvorsen BL, Holte K, Bøhn SK, Dragland S, et al. The total antioxidant content of more than 3100 foods, beverages, spices, herbs and supplements used worldwide. Nutr J. 2010;9:3. Doi: 10.1186/1475-2891-9-3
https://doi.org/10.1186/1475-2891-9-3...
2121 Rufino MS, Alves RE, Brito ES, Pérez-Jiménez J, Saura-Calixto F, Mancini-Filho J. Bioactive compounds and antioxidant capacities of 18 non-traditional tropical fruits fromBrazil. Food Chem. 2010; 121(04):996-1002. Doi: 10.1016/j.foodchem.2010.01.037
https://doi.org/10.1016/j.foodchem.2010....
For foods without TAC determination, the value of a similar food item or of the same botanical group was used: for chicory, endive and arugula, the spinach estimate was used. For red fruits, nectarines and cream, the TAC values of strawberry, peach and butter were used, respectively. For cooked foods that did not have certain TAC values, the value of the fresh food was used. To obtain the TAC value of homemade preparations, previously broken down into ingredients, the calculation of the TAC of each item of the recipe was performed. It was not possible to consider the TAC values of coconut water, salted cod, cane juice, flaxseed, maxixe, sardines, sova, and sushi, as the TAC has not been established for these foods.

The TAC of dietary supplements was estimated by multiplying the amount of antioxidant compound (mg or IU) present in the capsule by its TAC value (mmol/100 g). Of the antioxidant compounds present in the dietary supplements, it was not possible to estimate the TAC values of thiamine (B1), riboflavin (B2), nicotinamide (B3), pantothenic acid (B5), and biotin (B7), as the TAC has not been determined for these.

To estimate the usual DTAC, the Multiple Source Method (MSM) was used. This program was developed by the European Prospective Investigation in Cancer and Nutrition (EPIC) (https://msm.dife.de/). 2222 HarttigU,Haubrock J,Knüppel S,BoeingH.TheMSMprogram:webbased statistics package for estimating usual dietary intake using the Multiple Source Method. Eur J Clin Nutr. 2011;65(Suppl 1) S87-S91. Doi: 10.1038/ejcn.2011.92
https://doi.org/10.1038/ejcn.2011.92...
The MSM estimates the usual intake of food and nutrients through the product of the probability of intake and the usual intake, corrected for variability. Correction for variability in intake eliminates the need for a large number of 24hR replications. The DTAC estimate was adjusted for the total dietary calories using the residual method.2323 Willett WC. Nutritional epidemiology. 2nd ed. New York: Oxford University Press; 1998

Information on age, self-reported skin color, education of the pregnant woman and of the head of the family, possession of items, occupation, marital status, parity, physical activity, smoking, consumption of alcoholic beverages, and use of dietary supplements was obtained by through a structured questionnaire. For the classification of the economic stratum, the Brazil Economic Classification Criterion was used, which defines the strata from A (highest level) to E (lowest level), based on the possession of items and on the educational level of the head of the family.2424 Ministério da Saúde. Secretaria de Vigilância em Saúde. Vigitel Brasil 2011: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2011 [Internet]. Brasília (DF): Ministério da Saúde 2012 [cited 2021 Feb 15]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/ vigitel_brasil_2011_fatores_risco_doencas_cronicas.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...

Weight (kg) and height (m) measurements were obtained using a digital scale (TANITA model HS302 Arlington Heights, Illinois, 60005, USA) and a portable stadiometer (SANNY model ES2040 São Bernardo do Campo, São Paulo, 09628-060, Brazil), respectively. Gestational age was estimated from the date of the last menstrual period recorded on the card of the pregnant woman and was subsequently corrected through ultrasound. Pregestational weight was self-reported and corrected from recording on the card of the pregnant woman. The Institute of Medicine criteria were used to assess the adequacy of pregestational BMI (kg/m2).2525 Suitor CW. Perspectives on nutrition during pregnancy: Part I, Weight gain; Part II, Nutrient supplements. J AmDiet Assoc. 1991; 91(01):96-98. Doi: 10.1016/S0002-8223(21)01073-7
https://doi.org/10.1016/S0002-8223(21)01...

Descriptive data were presented as mean ± standard deviation (SD) or median (P25, P75) for continuous variables, and n (%) for categorical variables. To investigate differences in maternal characteristics according to the DTAC tertiles, the chi-squared test (X 2) was used for the categorical variables and analysis of variance (ANOVA) or the Kruskal-Wallis tests for the continuous variables. The Spearman coefficient was used to investigate the correlation between the DTAC and the food and nutrient groups of the maternal diet.

The factors associated with the higher DTAC estimate (≥ 4.3 mmol/day) were investigated in age-adjusted backward logistic regression models (20–25/25–30/30–35/≥ 35 years old), self-reported skin color (white/not white), socioeconomic strata (A + B/C/D + E), living with a partner (yes/no), paid work (yes/no), pregestational BMI (kg/m2), current smoker (no/yes), physical activity (< 150 minutes/≥ 150 minutes of walking and/or physical exercises per week), education (< 4/4–8/≥ 9 years of study), parity (< 1/≥ 2 children), consumption of alcoholic beverages (yes/no), use of food supplement (yes/no), underreport of energy intake (yes/no), total dietary energy (kcal/day tertiles), and gestational trimester at the time of the interview (2nd/3rd). The associated factors investigated were determined through theoretical assumptions; however, the final models were established based on backward selection.

P values <.05 were considered significant. Statistical analyses were performed using the SPSS Statistics for Windows, version 17.0 (SPSS Inc., Chicago, IL, USA).

The present article complies with the ethical principles contained in the Declaration of Helsinki. The study was approved by the Research Ethics Committee of the School Health Center of the Faculdade de Medicina de Ribeirão Preto (Auth. No. 014/2018-CEP/CSE - FMRP - USP).

Results

In total, 785 pregnant women were investigated. The mean (SD) age of the pregnant women was 28 (5) years old, and the education level varied between zero and 15 years of study. Among them, 25% were overweight and 32% were obese. The mean (SD) of the DTAC exclusively from the diet was 4.7 (2.4) mmol/day, with the mean considering the use of dietary supplements being 4.8 (2.5) mmol/day. The median (P25, P75) of the DTAC was 4.3 (3.3–5.6) mmol/day. Among the women classified in the third tertile of the DTAC, a greater proportion of self-reported white skin color presented a lower mean pregestational BMI when compared with the pregnant women with lower DTAC estimates (Table 1).

Table 1
Sociodemographic and lifestyle characteristics according to tertiles of the estimated dietary total antioxidant capacity of the pregnant women (n = 785)

A positive correlation was observed between the DTAC and the estimates of carbohydrates, fiber, vitamin A, vitamin E, folic acid, and the consumption of sugar, coffee and tea, beans, fruits, vegetables, dairy products, breads, and natural fruit juice. Conversely, there was a negative correlation between the DTAC and the consumption of snacks and sandwiches, soft drinks, and artificial juices (Table 2).

Table 2
Characteristics of the diet according to the tertiles of the estimated dietary total antioxidant capacity of pregnant women (n = 785)

The main food groups that contributed to the DTAC estimate were coffee and tea (24.12%), dairy products (21.34%), fruits, and natural fruit juices (20.37%) (Fig. 2).

Fig. 2
Main dietary contributors to the DTAC intake of the pregnant women (n = 785).

In the backward logistic regression models, it was found that pregnant women ≥ 35 years old were twice as likely to have an antioxidant intake above the median when compared with the younger pregnant women. The women that were overweight or obese in the pregestational period had a 37 and 41% lower likelihood of the DTAC estimate being above the median, respectively, when compared with the eutrophic pregnant women. Those that reported using dietary supplements during pregnancy had a 39% higher chance of ingesting DTAC above the median when compared with those who did not ingest them. There was also an inverse relationship between total dietary energy intake and the higher DTAC estimate. There was no significant association between the DTAC and the other factors investigated (Table 3).

Table 3
Factors associated with the determination of the DTAC above the median (≥ 4.3 mmol/day) (n = 785)

Discussion

Among the pregnant women investigated, women ≥ 35 years old, with pregestational BMI < 25kg/m2, and who reported using dietary supplements during pregnancy had a greater chance of ingesting antioxidants above the median DTAC (≥ 4.3mmol/day). However, it was observed that pregnant women with higher energy intakes had less chance of ingesting antioxidants above the median DTAC (≥ 4.3mmol/day).

The median DTAC observed among the pregnant women using the FRAP method was 4.3mmol/day, which is much lower than that reported in studies with adults in Spain (17mmoL/day) and France (13mmoL/day).2626 Henríquez-Sánchez P, Sánchez-Villegas A, Ruano-Rodríguez C, Gea A, Lamuela-Raventós RM, Estruch R, et al. Dietary total antioxidant capacity and mortality in the PREDIMED study. Eur J Nutr. 2016;55(01):227-236. Doi: 10.1007/s00394-015-0840-2
https://doi.org/10.1007/s00394-015-0840-...
2727 Bastide N, Dartois L, Dyevre V, Dossus L, Fagherazzi G, Serafini M, et al. Dietary antioxidant capacity and all-cause and causespecific mortality in the E3N/EPIC cohort study. Eur J Nutr. 2017;56(03):1233-1243. Doi: 10.1007/s00394-016-1172-6
https://doi.org/10.1007/s00394-016-1172-...
The findings of the present study agree with previous evidence that suggests a high prevalence of inadequate intake of nutrients with antioxidant properties by pregnant women in Brazil.2828 Malta MB, Carvalhaes MA, Parada CM, Corrente JE. Utilização das recomendações de nutrientes para estimar prevalência de consumo insuficiente das vitaminas C e E em gestantes. Rev Bras Epidemiol. 2008;11(04):573-583. Doi: 10.1590/S1415-790X2008000400006
https://doi.org/10.1590/S1415-790X200800...
The discrepancy in DTAC values observed in the present study, when compared with data from other countries, can be partially explained by the low consumption of fruits and vegetables by the pregnant women in the sample. The mean daily consumption of fruits and vegetables observed was 87.30 g and 43.37 g, respectively, values well below those recommended by the WHO.2929 Amine EK, Baba NH, Belhadj M, et al. Diet, nutrition and the prevention of chronic diseases. Geneva: WHO; 2003. (World Health Organization Technical Report Series; no. 916).

In the present study, the coffee and tea groups (24.12%), dairy products (21.34%), and fruits and natural fruit juices (20.37%) were the ones that most contributed to the DTAC estimate of the usual diet of the pregnant women. Coffee stood out as the main DTAC source both due to its high antioxidant capacity and its high consumption, corroborating findings of other studies.1313 Zuccolotto DCC, Crivellenti LC, Franco LJ, Sartorelli DS. Dietary patterns of pregnantwomen, maternal excessive bodyweight and gestational diabetes. Rev Saude Publica. 2019;53:52. Doi: 10.11606/s1518-8787.2019053000909
https://doi.org/10.11606/s1518-8787.2019...
3030 Kobayashi S, Asakura K, SugaH, Sasaki SThree-generation Study of Women on Diets and Health Study Groups. Inverse association between dietary habits with high total antioxidant capacity and prevalence of frailty among elderly Japanese women: amulticenter cross-sectional study. J Nutr Health Aging. 2014;18(09):827-839. Doi: 10.1007/s12603-014-0478-4
https://doi.org/10.1007/s12603-014-0478-...
However, coffee consumption during pregnancy should be moderate because caffeine is absorbed rapidly upon ingestion and passes the placental barrier leading to higher exposure for the fetus.3030 Kobayashi S, Asakura K, SugaH, Sasaki SThree-generation Study of Women on Diets and Health Study Groups. Inverse association between dietary habits with high total antioxidant capacity and prevalence of frailty among elderly Japanese women: amulticenter cross-sectional study. J Nutr Health Aging. 2014;18(09):827-839. Doi: 10.1007/s12603-014-0478-4
https://doi.org/10.1007/s12603-014-0478-...
Observational studies suggest that excess intake of caffeine may be associated with negative birth results. In a meta-analysis of observational studies, there was a 3% increase in the risk of babies with low birth weight (LBW) for each additional 100 mg of caffeine consumed per day during pregnancy.3131 Rhee J, Kim R, Kim Y, TamM, Lau Y, KeumN, et al.Maternal caffeine consumption during pregnancy and risk of low birth weight: a dose-response meta-analysis of observational studies. PLoS One. 2015;10(07):e0132334. Doi: 10.1371/journal.pone.0132334
https://doi.org/10.1371/journal.pone.013...

The milk and dairy products group was the second group that most contributed to the determination of the DTAC of pregnant women. Despite the fact that milk is not a relevant source of TAC, a high consumption was verified in the study population. The group of fruits and natural fruit juices was the third that most contributed to the determination of DTAC. However, the mean consumption of fruit by the pregnant women was below that recommended by the WHO, contributing to a low mean intake of antioxidants.2929 Amine EK, Baba NH, Belhadj M, et al. Diet, nutrition and the prevention of chronic diseases. Geneva: WHO; 2003. (World Health Organization Technical Report Series; no. 916).

There was a positive correlation between sugar consumption and the DTAC. A possible explanation for this unexpected result is that sugar is commonly added to some of the DTAC source foods by the study population, such as coffee, tea, milk, and natural fruit juices.

The DTAC, in addition to measuring antioxidant intake, can be considered a potential marker of diet quality, allowing a comparison between our results and studies that assessed diet quality using dietary indices.1010 Parohan M, Anjom-Shoae J, Nasiri M, Khodadost M, Khatibi SR, Sadeghi O. Dietary total antioxidant capacity and mortality from all causes, cardiovascular disease and cancer: a systematic review and dose-response meta-analysis of prospective cohort studies. Eur J Nutr. 2019;58(06):2175-2189. Doi: 10.1007/s00394-019-01922-9
https://doi.org/10.1007/s00394-019-01922...
The data from the present study suggest a higher chance of estimating the DTAC above the median among eutrophic women, in agreement with previous evidence. In a study conducted by Laraia et al.,3232 Laraia BA, Bodnar LM, Siega-Riz AM. Pregravid body mass index is negatively associated with diet quality during pregnancy. Public Health Nutr. 2007;10(09):920-926. Doi: 10.1017/S1368980007657991
https://doi.org/10.1017/S136898000765799...
the pregestational BMI was inversely associated with the quality of the diet of pregnant women, evaluated using the Diet Quality Index for Pregnancy (DQI-P).

A direct relationship between the age of the pregnant women and the DTAC was observed in the present study, corroborating studies that also found better quality diets in older pregnant women.1313 Zuccolotto DCC, Crivellenti LC, Franco LJ, Sartorelli DS. Dietary patterns of pregnantwomen, maternal excessive bodyweight and gestational diabetes. Rev Saude Publica. 2019;53:52. Doi: 10.11606/s1518-8787.2019053000909
https://doi.org/10.11606/s1518-8787.2019...
3333 Shin D, Lee KW, Song WO. Dietary patterns during pregnancy are associated with gestational weight gain. Matern Child Health J. 2016;20(12):2527-2538. Doi: 10.1007/s10995-016-2078-x
https://doi.org/10.1007/s10995-016-2078-...
One of these studies, conducted with Brazilian pregnant women, found that older women presented greater adherence to a “healthy” dietary pattern, composed of vegetables and legumes, fruits, and natural fruit juices.1414 Barbieiri P, Nunes JC, Torres AG, Nishimura RY, Zuccolotto DCC, Crivellenti LC, et al. Indices of dietary fat quality during midpregnancy is associated with gestational diabetes. Nutrition. 2016;32 (06):656-661. Doi: 10.1016/j.nut.2015.12.002
https://doi.org/10.1016/j.nut.2015.12.00...

The mean (SD) of the TAC exclusively from the diet was 4.7 (2.4) mmol/day, with the mean considering the use of dietary supplements being 4.8 (2.5) mmol/day. There was a small variation in the DTAC when considering the use of a dietary supplement; however, this showed a direct relationship with the higher median of the DTAC. The combination of dietary sources rich in antioxidants and the use of supplements contributes to favorable health outcomes for the baby. However, further studies in other populations are needed. Pregnant women with lower energy intake were more likely to present DTAC estimates above the median. Evidence show that healthier diets are rich in foods with a high nutrient density and low energy density, as they are based on foods of plant origin. Consequently, they are rich in vitamins and minerals with antioxidant properties, as well as rich in fiber.3434 Ledikwe JH, Blanck HM, Kettel Khan L, Serdula MK, Seymour JD, Tohill BC, et al. Dietary energy density is associated with energy intake and weight status in US adults. Am J Clin Nutr. 2006;83 (06):1362-1368. Doi: 10.1093/ajcn/83.6.1362
https://doi.org/10.1093/ajcn/83.6.1362...

The present study has some limitations, the main one being its cross-sectional design. The DTAC determination of the diet of the pregnant women was based mainly on an international database, in which the values may vary in relation to the food produced in Brazil, considering the differences in soil and climate. The underreporting of energy intake was estimated using the formula by Goldberg et al.2020 Goldberg GR, Black AE, Jebb SA, Cole JT,Murgatroyd PR, CowardWA, et al. Critical evaluation of energy intake data using fundamental principles of energy physiology: 1. Derivation of cut-off limits to identify under-recording. Eur J Clin Nutr. 1991;45(12):569-581, adopting a cutoff point ≤ 1.35.2020 Goldberg GR, Black AE, Jebb SA, Cole JT,Murgatroyd PR, CowardWA, et al. Critical evaluation of energy intake data using fundamental principles of energy physiology: 1. Derivation of cut-off limits to identify under-recording. Eur J Clin Nutr. 1991;45(12):569-581 The high proportion of underreporting of the diet among the participants in our study (47%) corroborates an investigation conducted among pregnant women in Ireland, in which the underreporting of energy intake was 42%, even adopting a cutoff ≤ 1.2.3535 McGowan CA,McAuliffe FM. Maternal nutrient intakes and levels of energy underreporting during early pregnancy. Eur J Clin Nutr. 2012;66(08):906-913. Doi: 10.1038/ejcn.2012.15
https://doi.org/10.1038/ejcn.2012.15...
It is important to note that the method by Goldberg et al.2020 Goldberg GR, Black AE, Jebb SA, Cole JT,Murgatroyd PR, CowardWA, et al. Critical evaluation of energy intake data using fundamental principles of energy physiology: 1. Derivation of cut-off limits to identify under-recording. Eur J Clin Nutr. 1991;45(12):569-581 may not be the best approach to estimate the underreporting of the energy intake during pregnancy, as it does not consider the practice of physical activity of the individual and presupposes the maintenance of body weight. In addition, the cutoff point of the BMI adopted as an inclusion criterion in the study was ≥ 20kg/m2, not allowing the extrapolation of data for pregnant women with lower BMI values.

Among the strengths of the present study, its originality stands out. Furthermore, the data collection was performed by trained nutritionists, and the DTAC estimate was performed using 24hR adjusted through the MSM. Future studies are necessary to confirm the findings of the present study.

Conclusion

In conclusion, pregnant women ≥ 35 years old, eutrophic, using dietary supplements, and with lower energy intake had a greater likelihood of presenting DTAC estimates above the median. It should be highlighted that the DTAC of the evaluated pregnant women was the lowest value ever described in the literature, showing the importance of developing public policies that encourage adherence to the recommendations for the consumption of FLVs during the different life cycles.

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Publication Dates

  • Publication in this collection
    08 Apr 2022
  • Date of issue
    Feb 2022

History

  • Received
    22 Feb 2021
  • Accepted
    05 Oct 2021
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