Integrative development of a concise screening questionnaire for early detection of pregnant women at risk for dystrophy | BMC Pregnancy and Childbirth

This study introduces a concise prenatal nutrition screening scale, the pregnancy nutrition checklist, comprising 15 food and beverage behaviors and 3 lifestyle behaviors (Table 1). Through various statistical comparisons, the pregnancy nutrition checklist has proven to be effective in reflecting the dietary status of pregnant women and identifying differences in various biochemical indicators, making it highly feasible for clinical application.

In this study, the average time for pregnant women to complete the FFQ questionnaire was 15.9 ± 5.5 min, and the time required to complete the pregnancy nutrition checklist was 4.2 ± 2.1 min. The FFQ questionnaire needs to be calculated based on the frequency and portion size of various foods after completion, leading to a longer duration from completion to obtaining results [27,28,29]. This scale summarizes the dietary categories of pregnant women that have been the focus of many studies. With reference to the Dietary Guidelines for Pregnant Women in China, the pictures and contents of the Dietary Guidelines have been reduced to 15 yes or no questions, each of which contains a method of measuring dietary portion size so that pregnant women can answer as accurately as possible and at the same time, help clinicians to immediately understand whether or not a specific type of diet complies with the standards for pregnant women. The 15 questions not only included the staples, vegetables, fruits, proteins, nuts, and cooking oils highlighted in the dietary pagoda but also highlighted the proportion of whole and mixed grains and dark-green vegetables. We have also included four unrecommended food groups, including the guidance on fatty meats, sugary drinks, highly palatable snacks, and fried foods, which are not mentioned in the Dietary Guidelines. Dietary feedback is automatically generated once all questions are completed and submitted. The feedback includes the health benefits and harms of each food group, the harms caused by insufficient or excessive intake, and how to make your diet satisfy the requirements in your daily life in a simple way. Non-nutritionist clinical obstetricians can use questionnaires as a guide and conduct brief inquiries to quickly and conveniently understand the main unhealthy diets and behaviors of pregnant women and then re-emphasize to pregnant women in an authoritative capacity based on the feedback given by us to increase the likelihood of pregnant women changing their dietary behaviors. Additionally, using food categories as the question stem not only reduces the number of questions and response time but also enhances the inclusiveness of the question stem, covering a wider range of foods and facilitating response accuracy [27].

Pregnant women and related medical personnel generally have a low level of understanding of basic nutrition-related knowledge [30]. A survey in China revealed that the average awareness rate of basic nutritional knowledge among normal pregnant women is significantly higher than that of gestational diabetes mellitus (GDM), but does not exceed 50% [31]. Among medical personnel, the average awareness rate of pregnancy nutrition among doctors is 68.04%, and that of nurses is 64.41% [31]. Higher health literacy among women can help reduce the risk of obesity, improve diet, and increase the weight and height of offspring [32]. Due to limited access to nutritionists, popularizing prenatal dietary assessment and guidance is a challenge [33]. In China, pre-pregnancy and prenatal care are an important measure for reducing the incidence and mortality rates of complications in pregnant women and fetuses, as well as for reducing the incidence of birth defects [34]. Community hospitals and obstetricians are responsible for the main prenatal care work. Pregnant women lack nutrition knowledge, and learning a large amount of nutrition knowledge and improving nutrition in a short period of time is a challenge. Therefore, the development of a simple nutritional assessment and guidance questionnaire for clinical doctors is needed. Through simple inquiries, the main unhealthy dietary behaviors of pregnant women can be identified. This approach allows highly feasible and specific nutritional behavior guidance. For example, if a pregnant woman is currently experiencing iron deficiency and consumes less than one palm-sized portion of red meat per day without other iron supplements, a direct recommendation can be made to increase her daily intake of red meat, such as beef or lamb. This will help improve the efficiency and effectiveness of maternal nutrition and healthcare. When pregnant women can fully adhere to the pregnancy nutrition checklist, they will likely achieve a balanced diet. If time and energy permit, screening can be conducted through FFQ dietary surveys, and more nutritional knowledge can be learned.

The 15 dietary behavior questions in this questionnaire focus on six nutrients: dietary fiber, fat, sugar, calcium, iron, and protein, among which fat includes plant fat, animal fat, and unsaturated fatty acids. Dietary behaviors include dietary behaviors and cooking behaviors. Three lifestyle behaviors are alcohol consumption and smoking, which are known to be highly correlated with fetal malformations and are therefore added as screening indicators at the end of the questionnaire [35]. Whole grains, tubers, fruits, and vegetables are important sources of dietary fiber. Studies have shown that dietary fiber intake is associated with appropriate weight gain during pregnancy, reduced GDM, and prevention of constipation [36, 37]. Although the correlation coefficients between fat-related questions and the questions in the dietary FFQ questionnaire were not statistically significant, they addressed important dietary aspects such as cooking oils, nuts, seafood, and cooking methods that jointly determine dietary fat content. Moreover, studies have shown that excessive animal fat, including cholesterol and monounsaturated fatty acid intake, increases the risk of GDM [38]. The results of our analysis similarly showed that excessive fatty meat intake increased cholesterol in pregnant women. Therefore, fat-related questions are retained in the questionnaire as a reminder item in the guidance. Red meat is an important source of divalent iron, which helps prevent iron deficiency and the resulting anemia in pregnant women. This study showed that pregnant women who consumed more red meat had a significant increase in Hb. Milk is the main source of calcium, and the Chinese Dietary Guidelines for Pregnant Women recommend the daily consumption of no less than 300 ml of milk during pregnancy to supplement calcium and protein, which can help alleviate lower back and leg pain caused by calcium deficiency [39]. Highly palatable foods and beverages present characteristics such as high sugar, high salt, and high-fat content. Coffee and milk tea, in particular, contain caffeine, which can affect the mother’s metabolism and fetal health [35, 40]. Soybeans are an important source of plant protein, and the Chinese Dietary Guidelines recommend that pregnant women consume 20 g of protein per day. Studies have shown that plant protein intake is a protective factor for against GDM [41]. Therefore, this scale covers common issues of dietary fiber, calcium, iron, protein, polyunsaturated fatty acid deficiency, and excessive sugar and fat levels during pregnancy and childbirth. This approach can help pregnant women with limited nutritional knowledge quickly identify dietary problems, prevent calcium and iron deficiencies, mitigate constipation, and even prevent GDM and other adverse pregnancy outcomes.

The repeated measures showed a significant increase in the intake of foods such as coarse grains, vegetables, milk, and nuts, which we encouraged pregnant women to increase their intake of, while there was no significant improvement in the intake of foods such as fatty meats, highly palatable snacks, and sugar-sweetened beverages, which we encouraged to decrease their intake of. This may be due to increased craving for highly palatable foods during pregnancy leading to difficulty in overcoming the temptation of such foods [42]. The fact that pre-packaged high palatable snacks and drinks can be more convenient and quicker to help pregnant women to obtain energy is also one of the important reasons. This also suggests that future interventions should focus on helping pregnant women to overcome the barriers to reducing the intake of high-energy, low-nutrient foods, such as by providing healthier and more convenient alternatives to pregnant women’s snacks.

The 2016 dietary survey of pregnant women in Shaanxi Province sorted and analyzed the proportions of energy sources and extracted five important food groups. The main sources of energy for pregnant women are snacks (19%), poultry and livestock meat (16%), and edible oil (11%), whereas the main sources of fat are edible oil (25%), meat (24%), and nuts (16%) [40]. Table 4 shows that excessive intake of edible oil and highly palatable snacks significantly increases fetal birth weight, whereas consuming more vegetables helps to reduce fetal birth weight. The current dietary issues among pregnant women and the dietary behaviors highly correlated with fetal birth weight that we screened are consistent, further indicating that replacing highly palatable snacks with vegetables and fruits and controlling oil intake will help improve pregnancy outcomes.

Burgraff et al. summarize the preferred features of a priori indices for the questionnaire validation process, including theoretical framework, index structure, indicator selection, normalization methods, valuation function, weighting and aggregation [43]. Against the above summary, first, our checklist covered all key aspects of diet, including adequacy (enough or not), moderation (not exceeding the limit level), and balance (right proportion). Second, our checklist was arranged in a clear and nested structure, with eating behaviors at the beginning and cooking and lifestyle questions at the end. Third, we used food-group indicators so the checklist is more understandable for individuals receiving health advice. We carefully select components for accuracy and ease of use. Fourth, we set meaning standards and use normative cutoff values (set standards by referring to the Chinese dietary guidelines). Fifth, we added all the scores and used scoring that reflects complex health relationships.

The main limitation of this study stems from its focus on pregnant women from Beijing, the capital city of China, with 76% possessing a bachelor’s degree or higher, thus potentially limiting the generalizability of the questionnaire. Second, the description of the question stem has broad coverage and is more influenced by the individual cognition of pregnant women. Third, although this questionnaire yields research results similar to those of the FFQ and can reflect biochemical indicators, it is not suitable for calculating the specific intake of various foods by pregnant women. Instead, it falls under the category of a relatively rough screening method. Last but not least, due to the survey site and time issues, we used the FFQ rather than the WFR as a criterion for assessing dietary intake to compare with the assessment scales, and the results were somewhat biased.