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A total of 924 women were recruited, and 753 were followed up to the second dietary recalls (24-28 gestational weeks) before diagnosis of GDM. The median (interquartile range) of gestational week for the first time dietary recall was 12.7 (12.0, 13.3) weeks. Their three days of 24-h dietary recalls were recorded at 5-15 and 24-28 gestational weeks, respectively. The prevalence of GDM among study participants was 8.5% (64/753). Among 88 women who had been tested for HbA1c, the mean serum level was (5.36 ± 1.34)% and 63.6% (56/88) had elevated levels (> 5.1%) of serum HbA1c.
The gestational age of the dietary records ranged from 5-15 weeks in the first trimester and from 24-28 weeks in the secondtrimester. Four dietary patterns were identified in the first and second trimester, respectively (Table S3 and Table S4 available in www.besjournal.com). The dietary patterns during the period of 5-28 gestational weeks before the diagnosis of GDM are shown in Table 1. Four dietary patterns were identified by factor analysis, with eigenvalues of 1.41, 1.38, 1.31, and 1.22 for the Western, traditional, mixed and prudent patterns, respectively. The cumulative variance of the four dietary patterns was 22.2%. The Western pattern mainly included 'dairy, baked/fried food and white meat', accounting for 5.9% of the total variance. The traditional pattern was characterized by 'light-colored vegetables, fine grain, red meat and tubers' accounting for 5.7% of the total variance. The mixed pattern consisted of 'edible fungi, shrimp/shellfish and red meat', and the prudent pattern had 'dark-colored vegetables and deep-sea fish' accounting for 5.5% and 5.1% of the total variance, respectively.
Dietary Pattern Food Group Factor Loading Accumulative Variance (%) Western pattern Dairy products 0.718b 5.9 Baked/fried food 0.707 White meat 0.375 Algae 0.189 Nuts 0.179 Fruit products 0.171 Beverage -0.158 Fine grain -0.179 Traditional pattern Light-colored vegetables 0.673 11.6 Fine grain 0.592 Red meat 0.529 Tubers 0.351 Algae 0.239 Mixed pattern Edible fungi 0.586 17.1 Shrimp/shellfish 0.563 Red meat 0.413 Deep-sea fish 0.252 Light-colored vegetables 0.233 Coarse grain 0.222 White meat 0.170 Beverage 0.155 Fruit products -0.188 Fine grain -0.272 Tubers -0.334 Prudent pattern Dark-colored vegetables 0.722 22.2 Deep-sea fish 0.574 Tubers 0.281 Fine grain 0.277 Fresh fruit 0.164 Coarse grain 0.160 Light-colored vegetables -0.167 Algae -0.224 Note. aFactor loadings ≥ 0.150 or ≤ -0.150 were included in each factor. bThe positive factor loadings > 0.300 were included in each dietary pattern and are presented in bold. Table 1. Dietary Pattern during Pregnancy before Diagnosis of Gestational Diabetes Mellitus (GDM)a(n = 753)
The median age of pregnant women was 28 years, ranging from 19-38 years old. Over 80% of women had an education level above college. The mean pre-pregnancy BMI was 21.3 kg/m2, 14% (111/753) categorized as overweight, and 4% (30/753) obesity. More than 85% of the women were primipara. About half of the women's partners smoked. Approximately 25% of participants reported family history of diabetes. The proportion of women who suffered from moderate-severe nausea during early pregnancy was 44% (334/753). Maternal characteristics by quartiles of dietary pattern scores are presented in Table 2. Pregnant women with a higher score of the Western pattern (dairy, baked/fried food and white meat) appeared to have a higher education and were more likely to be nulliparous. A higher score of the mixed pattern (edible fungi, shrimp/shellfish and red meat) was associated with lower pre-pregnancy BMI. No significant difference was found among other characteristics by different dietary pattern scores.
Characteristics All Participants Western Patterna Traditional Patterna Mixed Patterna Prudent Patterna Quartile 1 Quartile 4 Quartile 1 Quartile 4 Quartile 1 Quartile 4 Quartile 1 Quartile 4 Age (years) x±s 28.0 ± 3.2 28.0 ± 2.8 28.0 ± 3.0 28.0 ± 3.1 28.0 ± 2.9 28.0 ± 3.5 28.0 ± 2.5 28.0 ± 2.4 28.0 ± 3.4 Pb 0.34 0.22 0.64 0.91 19-28 537 (71.3) 132 (73.3) 131 (70.8) 129 (71.7) 125 (67.2) 133 (73.5) 124 (67.4) 123 (66.8) 130 (69.9) 29-38 216 (28.7) 48 (26.7) 54 (29.2) 51 (28.3) 61 (32.8) 48 (26.5) 60 (32.6) 61 (33.2) 56 (30.1) Pb 0.59 0.35 0.20 0.53 Education vBelow college 132 (17.5) 47 (26.1) 25 (13.5) 34 (18.9) 29 (15.6) 29 (16.0) 21 (11.4) 33 (17.9) 27 (14.5) College and above 621 (82.5) 133 (73.9) 160 (86.5) 146 (81.1) 157 (84.4) 152 (84.0) 163 (88.6) 151 (82.1) 159 (85.5) Pb 0.002 0.40 0.20 0.37 Pre-pregnancy BMI (kg/m2) x±s 21.3 ± 3.4 21.6 ± 3.5 21.1 ± 3.4 21.5 ± 3.7 21.2 ± 3.1 21.6 ± 3.9 20.8 ± 3.3 21.4 ± 3.2 21.2 ± 3.2 Pb 0.14 0.35 0.04 0.53 Underweightc 156 (20.7) 32 (17.8) 46 (24.9) 37 (20.6) 37 (19.9) 38 (21.0) 44 (23.9) 39 (21.2) 32 (17.2) Normal weightc 456 (60.6) 112 (62.2) 109 (58.9) 106 (58.9) 111 (59.7) 103 (56.9) 113 (61.4) 104 (56.5) 128 (68.8) Overweightc 111 (14.7) 27 (15.0) 24 (13.0) 26 (14.4) 32 (17.2) 31 (17.1) 20 (10.9) 34 (18.5) 19 (10.2) Obesityc 30 (4.0) 9 (5.0) 6 (3.2) 11 (6.1) 6 (3.2) 9 (5.0) 7 (3.8) 7 (3.8) 7 (3.8) Pb 0.35 0.55 0.13 0.06 Parity 0 648 (86.1) 144 (80.0) 162 (87.6) 150 (83.3) 154 (82.8) 148 (81.8) 163 (88.6) 157 (85.3) 154 (82.8) ≥ 1 105 (13.9) 36 (20.0) 23 (12.4) 30 (16.7) 32 (17.2) 33 (18.2) 21 (11.4) 27 (14.7) 32 (17.2) Pb 0.05 0.89 0.07 0.51 Partner smokers No 405 (53.8) 101 (56.1) 93 (50.3) 98 (54.4) 107 (57.5) 93 (51.4) 90 (48.9) 105 (57.1) 99 (53.2) Yes 348 (46.2) 79 (43.9) 92 (49.7) 82 (45.6) 79 (42.5) 88 (48.6) 94 (51.1) 79 (42.9) 87 (46.8) Pb 0.26 0.55 0.64 0.46 Family history of diabetes No 564 (74.9) 134 (74.4) 130 (70.3) 137 (76.1) 135 (72.6) 126 (69.6) 132 (71.7) 142 (77.2) 137 (73.7) Yes 189 (25.1) 46 (25.6) 55 (29.7) 43 (23.9) 51 (27.4) 55 (30.4) 52 (28.3) 42 (22.8) 49 (26.3) Pb 0.37 0.44 0.66 0.43 Note. Data are shown as mena ± SD n(%). aWestern pattern: dairy, baked/fried food and white meat; traditional pattern: light-colored vegetables, fine grain, red meat and tubers; mixed pattern: edible fungi, shrimp/shellfish and red meat; prudent pattern: dark-colored vegetables and deep-sea fish. bANOVA and Chi-square tests were used to test the associations between maternal characteristics and dietary patterns. cUnderweight: BMI < 18.5 kg/m2; normal weight: 18.5 kg/m2 ≤ BMI < 24.0 kg/m2; Overweight: 24.0 kg/m2 ≤ BMI < 28.0 kg/m2; obesity: BMI ≥ 28.0 kg/m2. Table 2. Distributions of Maternal Characteristics by Quartiles of Dietary Pattern Scores (n = 753)
Multiple logistic regression analysis showed that neither in the first trimester nor in the second trimester, there was significant association between dietary patterns and GDM (Table S5 and Table S6 available in www.besjournal.com). After combining the data of two times, during the period of 5-28 gestational weeks, compared with the women in the lowest quartile (Q1) of the Western pattern scores, pregnant women in the second quartile (Q2) did not have a statistically significant difference in the risk of GDM (OR = 1.78, 95% CI: 0.72-4.43); the women in the thirdquartile (Q3) had a significantly higher risk of GDM (OR = 3.29, 95% CI: 1.39-7.82); while the fourth quartile (Q4) did not show a statistically significant difference (OR = 1.68, 95% CI: 0.66-4.29). The P-value for the trend of the risk of GDM across increasing quartiles of the Western pattern scores was not significant (P trend = 0.15). Compared to pregnant women in the Q1 of the traditional pattern scores, no significant association was found for Q2 for the risk of GDM (OR = 1.29, 95% CI: 0.50-3.33), while Q3 and Q4 had a significantly higher risk of GDM (OR = 2.86, 95% CI: 1.19-6.83; OR = 2.92, 95% CI: 1.19-7.17). The trend between the risk of GDM and increasing quartiles of the traditional pattern scores was statistically significant (P trend = 0.005). Compared with the lowest consumption (Q1), there was no significant difference of other individual qualities including Q2, Q3, and Q4 on the risk of GDM, neither for the mixed pattern, nor for the prudent pattern (Table 3).
Dietary Pattern Non-GDM GDM OR (95% CI)b Pb P-trendc Western pattern
(Dairy, baked/fried food and white meat)Q1 179 8 1.00 Q2 172 16 1.78 (0.72, 4.43) 0.21 Q3 165 25 3.29 (1.39, 7.82) 0.007 Q4 173 15 1.68 (0.66, 4.29) 0.28 0.15 Traditional pattern
(Light-colored vegetables, fine grain, red meat and tubers)Q1 179 9 1.00 Q2 179 11 1.29 (0.50, 3.33) 0.60 Q3 164 20 2.86 (1.19, 6.83) 0.02 Q4 167 24 2.92 (1.19, 7.17) 0.02 0.005 Mixed pattern
(Edible fungi, shrimp/shellfish and red meat)Q1 171 17 1.00 Q2 175 14 0.88 (0.41, 1.93) 0.76 Q3 169 20 1.15 (0.56, 2.38) 0.70 Q4 174 13 0.70 (0.32, 1.55) 0.39 0.56 Q1 170 18 1.00 Prudent pattern
(Dark-colored vegetables and deep-sea fish)Q2 171 15 0.92 (0.43, 1.96) 0.82 Q3 167 22 1.42 (0.69, 2.92) 0.34 Q4 181 9 0.49 (0.20, 1.22) 0.12 0.35 Note. aControlled for maternal age, pre-pregnancy BMI, education, partner smoking, family history of diabetes, parity, daily food energy intake and physical activity. bOdds ratios (and 95% CI) and P-value according to the reference of Q1. cP-trend value for the trend test. Table 3. Multiple Logistic Regression for the Risk of GDM According to the Quartiles of Dietary Pattern Scores during Pregnancy before Diagnosis of GDMa(n = 753)
Furthermore, we examined the association of dietary patterns during 5-28 gestational weeks with the risk of GDM. There were 192, 190, 195, and 176 women assigned to each dietary pattern, respectively. Compared with the prudent pattern, both the Western pattern and the traditional pattern were significantly associated with GDM (OR = 4.40, 95% CI: 1.58-12.22; OR = 4.88, 95% CI: 1.79-13.32), but the mixed pattern was not associated with GDM (OR = 1.61, 95% CI: 0.52-4.97) (Table 4). In addition, compared with the prudent pattern, both the Western pattern and the traditional pattern were also significantly associated with a high level of HbA1c (OR = 12.37, 95% CI: 1.47-103.91; OR = 26.23, 95% CI: 2.54-270.74), but the mixed pattern showed no significant difference (OR = 7.06, 95% CI: 0.90-55.45) (Table 5).
Dietary Pattern Non-GDM
(n = 689)GDM
(n = 64)OR (95% CI) P Western pattern (dairy, baked/fried food and white meat) 170 (88.5%) 22 (11.5%) 4.40 (1.58, 12.22) 0.004 Traditional pattern (light-colored vegetables, fine grain, red meat and tubers) 163 (85.8%) 27 (14.1%) 4.88 (1.79, 13.32) 0.002 Mixed pattern (edible fungi, shrimp/shellfish and red meat) 185 (94.9%) 10 (5.1%) 1.61 (0.52, 4.97) 0.41 Prudent pattern (dark-colored vegetables and deep-sea fish) 171 (97.2%) 5 (2.8%) 1.00 - Note. aControlled for maternal age, pre-pregnancy BMI, education, partner smoking, family history of diabetes, parity, daily food energy intake, and physical activity; the prudent pattern as the reference group. Table 4. Multiple Logistic Regression for Risk of GDM According to the Type of Dietary Patterns during Pregnancy before Diagnosis of GDMa(n = 753)
Dietary Pattern HbA1c < 5.1%
(n = 32)HbA1c ≥ 5.1%
(n = 56)OR (95% CI) P Western pattern (dairy, baked/fried food and white meat) 12 (40.0%) 18 (60.0%) 12.37 (1.47, 103.91) 0.013 Traditional pattern (light-colored vegetables, fine grain, red meat and tubers) 4 (18.2%) 18 (81.8%) 26.23 (2.54, 270.74) 0.004 Mixed pattern (edible fungi, shrimp/shellfish and red meat) 8 (34.8%) 15 (65.2%) 7.06 (0.90, 55.45) 0.06 Prudent pattern (dark-colored vegetables and deep-sea fish) 8 (61.5%) 5 (38.5%) 1.00 - Note. aControlled for maternal age, pre-pregnancy BMI, education, partner smoking, family history of diabetes, parity, daily food energy intake and physical activity; the prudent pattern as the reference group. Table 5. Multiple Logistic Regression for the Level of HbA1c According to the Type of Dietary Patterns during Pregnancy before Diagnosis of GDMa(n = 88)