Dietary Patterns among Pregnant Women in the West-North of Iran
This study was conducted to assess the food consumption
pattern and nutrient intakes of pregnant women residing in Maku-the west
north of Iran. In this cross-sectional study, 284 pregnant women (142
from urban area and 142 from rural areas) participated. Subjects were
interviewed privately, face-to-face. Dietary intake data was collected
using two 24 h recalls and a food frequency questionnaire for 3 months.
Mean consumption of grains and dairies was higher in rural women compared
to their counterparts in urban areas. Women in urban areas consumed 140
g fruits compared to 248 g consumed by rural women. There were no significant
differences regarding consumption of vegetables, pulses, fat and oils
between these two groups. All women consumed adequate amount of energy,
protein, thiamin and niacin (>75% RDA). Intake of vitamin B6, folate,
vitamins A and D, iron, phosphorus, calcium, magnesium and zinc was not
sufficient in these women. Inadequate intake of vitamin C and riboflavin
was also reported in urban women. Percentage of energy from carbohydrate,
fat and protein was 66, 23 and 11% for urban women, respectively and 68,
20 and 12% for rural women, respectively. Iron intake was lower in urban
women compared to rural women. The findings indicated that rural women
have better nutritional status than urban women. Future studies should
determine factors associated with food consumption pattern in these women.
Adequate nourishment is a human basic need and essentiality
of life. Nutrient requirement is influenced by genetic and environmental
factors, food pattern, age, sex and growth rate. Therefore, vulnerability
to nutrient deficiencies differs among individuals (Foroozani et al.,
1995). Pregnancy occupies a critical and unique place in the course of
life, which has both health and social importance for individuals, family
and the whole of society (Panwar and Punia, 1998). Thus, in
this course quantity and quality of nourishment is of particular importance.
The incidence of dietary inadequacies is higher during pregnancy than
at any other stage of life cycle. The expectant mothers appear to be more
vulnerable to malnutrition owing to considerable stress during pregnancy
because of physical, metabolic and hormonal changes (Panwar and Punia,
In developing countries such as Iran, women-particularly
of deprived districts-are nutritionally at risk. Gender biases influence
the food distribution within family with women as the last recipient of
food both in quality and quantity. Some studies suggest that the nutritive
status of women during gestation and even prior to pregnancy has a great
impact on the health of both mother and newborn and pregnancy outcome
(Panwar and Punia, 1998; Dava et al., 1980; Antal et al.,
1997). If energy intake is insufficient, there is an increased risk that
the newborn will have a low birth weight, whilst obesity is associated
with hypertension, preeclampsia and gestational diabetes (Osrin
and Costello, 2000). Thus it is important to identify the food consumption
pattern and nutritional status of this group so that corrective measures
can be implemented in time. Maku is a town in west Azerbaijan province
to the west north of Iran. No information exists on the dietary pattern
and nutrient intake of pregnant women residing in this town. The present
study, therefore, was carried out to obtain information on food consumption
pattern and nutrient intake of urban and rural pregnant women in Maku,
which included a comparison of the average dietary intakes of rural pregnant
women with their urban counterparts.
MATERIALS AND METHODS
Study participants: This cross-sectional study was performed in
2000-2001 in Maku, a city in the West-North of Iran near the border with
Turkey. To identify dietary pattern and nutrient intake of pregnant women
from different socioeconomic levels, two urban prenatal care centers and
six health houses were chosen. The inclusion criteria were freedom from
chronic diseases such as diabetes, being on no special diet, being between
18 to 35 years old. If the attending women were eligible, they were informed
orally about the purpose of the study and those who agreed to participate,
verbally consented. Two hundred and eighty four women (142 rural and 142
urban) from among 312 eligible ones agreed to participate. The proposal
of this study was approved by ethical committee of the research council
of School of Nutrition, Shaheed Beheshti University of Medical Sciences
and informed written consent was obtained from each subject.
Data collection: Subjects were interviewed privately and by face-to-face
method. Interviews were administered in the native language, Turkish and
Farsi and through an interpreter if necessary.
At first, information on sociodemographics including age,
educational level, occupation, household size and spouse`s occupation
as well as their menstruation and medical history was collected by trained
interviewers using a pretested questionnaire. Then the data on dietary
intakes during pregnancy was collected by means of quantitative 24 h food
recall for two consecutive days and food frequency questionnaire for three
months. Although the women`s food consumption was recorded in the questionnaires
on the 3 monthly basis, subjects were asked to estimate their consumption
of different food items on daily (e.g., bread), weekly (e.g., rice, meat)
or monthly (e.g., fish) basis. The subjects were asked to recall all foods
and beverages consumed during preceding 24 h. To assist the women to recall
accurately, household utensils were used. Portion sizes of consumed foods
were converted to grams using household measures (Ghaffarpour
et al., 1999). Each food and beverage was then coded according
to prescribed protocol (William et al., 1998) and analyzed for
content of energy and the other nutrients using Nutritionist-III (N3)
Software program designed for Iranian foods. Almost all of foods eaten
by our subjects could be coded. When a particular ethnic food was not
in the database of N3, we coded it as a similar item. Although most of
the subjects studied were taking prenatal vitamin-mineral tablets at the
time of the diet history, these were not included in the analysis because
we wanted to study dietary nutrients only. Energy and nutrient intakes
were compared with the Recommended Dietary Allowances (RDA) (Food and
Nutrition Board, 1989). All dietary data we reported here were based on
the results from 24 h dietary recalls, because the FFQ we used in the
current study was a qualitative one.
Statistical methods: The data were analyzed by computer using Statistical Package
for Social Science (SPSS Inc.Chicago, IL, Version 10.0). Independent t-test
were used to determine the degree of significance of differences between
means. In those cases where the distribution of variables was not homogenous,
the Mann-Whitney U-test was applied. In all statistical tests performed,
p-values < 0.05 were considered significant.
1 shows mean daily consumption of food items by the subjects. Mean
daily intake of bread and cereals of urban and rural women were 523 and
616 g, respectively. Urban women`s intake was significantly lower than
those in rural areas (p< 0.05). Similarly, consumption of dairy products
in urban women was significantly lower than that of rural ones (p = 0.005).
Intake of meat and meat exchanges in urban women was higher than that
of rural ones but this difference was not significant. Surprisingly, fruits
consumption of urban women was significantly lower than that of rural
women (p = 0.02). Intake of vegetables, pulses, fat and oils was not different
between two groups. Sugar intake was higher in urban women (p = 0.02).
Comparisons of the two groups (Table
2) indicate that energy intake of urban women was lower than that
of rural pregnant women but this difference was not statistically significant
(p>0.05). Percent of energy derived from carbohydrate, fat and protein
in urban pregnant women were 66, 23 and 11%, respectively and for rural
women it was 68, 20 and 12%, respectively. Vitamin D, iron and calcium
intake of rural women was significantly higher than their urban counterparts
3, it is concluded that energy, protein, thiamin, niacin, pyridoxin
and magnesium intake of all subjects were adequate (>75% RDA). But intake
of folate, vitamin A and D, iron, calcium, phosphorus and zinc were inadequate
(< 75% RDA). In urban women, intake of vitamin C and riboflavin were also
(g day-1) of food groups intake among pregnant women
values are mean± standard deviation
nutrient intakes of pregnant women participated in the study1
values are mean±standard deviation. NS: Non-significant
nutrient intakes of pregnant women as percentage of RDA1
values are mean± standard deviation
The mean daily intake of major food items by the pregnant
subjects was estimated from their reported consumption. All subjects were
asked to report exactly the amount and frequency of food consumption.
In general, recalling the amounts of bread, rice, meat, egg and pulses
was easy for the subjects while most had difficulty in estimating the
amounts of vegetables and fruits consumed. None of the subjects consumed
food items such as fish.
Usually, women from lower household size could give a more
precise estimate of the amount of foods consumed. All subjects generally
followed the traditional Iranian food pattern although the effects of
food habits were evident. The main meal of the day was lunch or dinner.
Although most subjects ate breakfast, its contribution to daily energy
intake was not much. Breakfast consisted of tea with bread, yogurt and
cheese and in some cases, milk. Consumption of butter, jam and honey for
breakfast was rare. Bread and potato were the staple foods. Rice was consumed
two to three times per week. In general, if one meal included rice, the
other did not. Snacks were usually bread, cheese and tea and occasionally
fruits. Most of these findings were consistent with those of Rahmanifar
and Bond (1990) in Shiraz.
Mean daily consumption in this study was lower than those
reported in other countries (Panwar and Punia, 1998). Because
of high calcium content of dairy products, women are encouraged to increase
their intake during pregnancy (Rahmanifar and Bond, 1990).
The reported intake of milk products and calcium seen in these subjects
could impair the health of mother and the newborn. The higher consumption
of dairy products in rural women than urban ones may be due to keeping
their own milch animals in the house. Higher intake of dairy products
by rural adults has been reported earlier by Panwar and Punia
(1998). The finding of higher fruit intake in rural as compared to urban
areas was surprising. The expectation is higher intake of fruits in urban
areas because those residing in urban areas have higher educational levels
and previous studies have shown healthier diet among those with higher
educational levels. In the current study, higher fruit intakes in rural
areas might be attributed to seasonal variation and more availability
of fruits in rural areas.
Energy and nutrient intake in this study, in comparison
with that of RDA, showed intake of folate, vitamin A, D, iron, calcium,
phosphorus and zinc to be inadequate (< 75% RDA). In urban subjects, also,
inadequate intake of vitamin C and riboflavin should be added to the mentioned
Ortega et al. (1998) reported inadequate intake of
vitamin B6, folate, iron, calcium, zinc and magnesium in their study but
vitamin A, D and phosphorus intake of their subjects were adequate. The
high mean vitamin C intake of their subjects was attributed to isoascorbic
acid, which has no vitamin C activity, being added as antioxidant to processed
The lower intake of folate in the present study is probably
due to lower intake of vegetables. Since the recommended intake for folate
is increased during pregnancy, increased consumption of dark-green vegetables
by pregnant women should be encouraged. Currently, at least three servings
of vegetables and two servings of fruits per day are recommended for the
general population. Pregnant women should consume an additional serving
of vegetables and fruits to help meet their increased energy and nutrient
Mean energy intake in this study was higher than those reported
for pregnant women in previous studies Tunikabon and Ramsar (Pouretedal,
1998), Bandar Abbas (Habibi, 1997), Kerman (Doostan,
1996), Karaj-Shemiranat (Houshiar-Red et al., 1998).
Protein intake was higher than all above-mentioned studies
except for Karaj-Shemiranat which was similar to our study. Calcium intake
was lower than that reported in west-Azarbayejan (Allafmoghaddam,
1998) and Karaj-Shemiranat women (Houshiar-Red, 1998). In theory,
insufficient calcium supply during pregnancy could result in maternal
bone loss or impaired fetal bone development (Prentice, 1998).
Further interpretation of the food energy and nutrient intakes determined
in the current study is limited by the lack of published data on dietary
intakes of Iranian pregnant women, which could serve as a basis of comparison.
Lower calcium intakes of urban pregnant women than their
rural counterparts may be due to lower consumption of dairy products.
Although consumption of meat and alternatives were high in urban women,
their meat consumption, alone, was lower than that of rural ones. This
can probably explain higher intake of rural women. Recent studies differentiated
animal and vegetable proteins in terms of their effect on human health.
Unfortunately, we couldn`t analyze the data separately by animal and vegetable
protein intake in this group of pregnant women due to limitations of Iranian
food composition table. Therefore, identifying the quality of protein
intake among pregnant women is warranted. Another important issue that
should be kept in mind is the importance of other nutrients in pregnancy.
On of these conditionally essential nutrients during pregnancy is choline
which plays an important role in fetal brain development. We couldn`t
determine its` intake in this study, because Iranian food composition
table is very incomplete and the choline content of Iranian foods have
not been assessed. Future studies might consider this important nutrient.
The results reported here suggest less than acceptable nutritional
status in pregnant women of Maku. Education regarding increased needs
during this period is called for. In order to identify factors affecting
dietary pattern and nutrient intake of pregnant women residing in this
district, further investigation is needed.
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