Alimentazione Mediterranea

Presentazione sul tema: "Alimentazione Mediterranea"— Transcript della presentazione:

1 Alimentazione Mediterranea
Aggiornamento Marzo 2014 Prof Pierpaolo Mastroiacovo Professore di Pediatria Direttore ICBD – Alessandra Lisi International Centre on Birth Defects and Prematurity; Centro Collaborativo OMS, Roma

2 Raccomandazione Valutare le abitudini alimentari della donna, della coppia e incoraggiarli ad adottare un’alimentazione mediterranea. Anticipare alla donna l’opportunità di escludere o ridurre l’uso di alcuni specifici alimenti in vista della gravidanza a breve termine: Carni poco cotte, insaccati (non immune alla toxoplasmosi) Formaggi erborinati e patè (listeriosi) Fegato (vitamina A) Pesci di alto mare, es: tonno e pesce spada (metilmercurio)

3 Caratteristiche fondamentali dell’alimentazione mediterranea

4 Alcuni Consigli per Realizzare l’Alimentazione Mediterranea Prima parte
Assumi almeno 5 porzioni di frutta e verdura al giorno. A colazione puoi consumare, insieme al caffè e a un buon cereale una spremuta d’arancia. Utilizza come spuntino a metà mattinata un frutto a tua scelta invece che snack ricchi di grassi. Accompagna sempre i tuoi pasti con una porzione di verdura e una di frutta. Ricordali di lavarli sempre bene prima del consumo. Pranzo o cena: scegli spesso un minestrone, una bella zuppa di legumi (es.: pasta e ceci o pasta e fagioli). Non dimenticare mai i legumi dalla tua alimentazione: sono ottime fonti di proteine e di fibra. Mangia 2-3 volte a settimana il pesce. Circa la metà dei cereali che assumi giornalmente (es: pane, pasta, riso) dovrebbe essere costituita da cereali integrali: danno maggiore senso di sazietà e ci aiutano a prevenire l’aumento del peso corporeo.

5 Alcuni Consigli per Realizzare l’Alimentazione Mediterranea Seconda parte
Utilizza come condimento preferibilmente l’olio extravergine di oliva, evita le margarine. Assumi ogni giorno 1 o 2 bicchieri tra latte e yogurt. Quando consumi formaggi scegli quelli magri, se scegli quelli grassi riduci la loro porzione a g. Quando scegli la carne, privilegia quelle bianche (es: pollo, tacchino) a quelle rosse (es: manzo, maiale), rimuovi il grasso e la pelle prima di cucinare e preferisci cotture veloci come la cottura in padella, la cottura al vapore o arrostiscile senza mai bruciarle. Evita di aggiungere troppo sale alle pietanze, ed usa quello iodato. Non dimenticare durante la settimana di consumare qualche porzione di frutta secca (es.: mandorle, noci) e semi oleosi: sono ricchi di vitamine e di acidi grassi omega 3 Bevi molta acqua.

6 Alimentazione E’ ben dimostrato che l’alimentazione sana diminuisce l’incidenza di diabete, malattie cardio-vascolari (es.: infarto, ictus cerebrale) e tumorali Studi recenti indicano chiaramente che la sana alimentazione diminuisce anche l’incidenza di esiti avversi della riproduzione. Per sana alimentazione si intende l’alimentazione mediterranea o simili tipologie di alimentazione denominate in altri paesi come: “prudenti” contrapposte a tipologie di alimentazione non sane denominate “occidentali” più ricche di grassi e carne rossa. Pochi italiani adottano un’alimentazione veramente mediterranea.

7 Pattern Alimentare Valutare l’effetto sulla salute del “pattern alimentare” è più corretto che non valutare l’effetto dei singoli componenti dell’alimentazione, es.: oligoelementi, vitamine. Nella valutazione del pattern alimentare si valuta, tutto, compresa: L’ interazione tra i vari componenti, equilibrata dalla natura stessa. Sostanze che ancora non sono ben conosciute. La reale abitudine giornaliera.

8 Due domande e due risposte
Domanda 1: La sana alimentazione, in particolare quella mediterranea, magari ricca di verdure a foglia verde, sostituisce la necessità di assumere un integratore a base di acido folico? Risposta: No. Purtroppo l’alimentazione da sola non è sufficiente. Per raggiungere sicuramente una folatemia materna sufficiente a proteggere lo sviluppo embrionale è necessario assumere un integratore a base di acido folico, giornalemente, 0,4 mg (400 mcg). Domanda 2: Quali sono gli studi più significativi che indicano un benefico effetto dell’alimentazione mediterranea nella riduzione degli esiti avversi della riproduzione? Risposta: Vedi le prossime diapositive

9 Migliora la qualità dello sperma (Olanda-Vujkovic, 2009).
Ricerche che suggeriscono i vantaggi dell’alimentazione mediterranea o equivalente sulla salute riproduttiva Fertilità, complicanze ed esito della gravidanza Migliora la qualità dello sperma (Olanda-Vujkovic, 2009). Migliora la fertilità (Spagna-Toledo, 2011) e aumenta la probabilità di gravidanza in donne che si sottopongono a PMA (Olanda-Vujkovic, 2010). Livelli di pressione arteriosa più bassi in gravidanza (Olanda-Timmermans, 2011). Diminuisce il rischio di preclampsia del 28% (Norvegia- Brantsaeter 2009). Migliore il peso della placenta (+15g) e del neonato (+72g) (Olanda-Timmermans, 2012). Diminuisce rischio di SGA con un range variabile tra i vari: 14% (Nuova Zelanda-Thompson, 2010), 26% (Danimarca-Knudsen, 2007) e il 50% (Grecia/Spagna- Chatzi L, 2012). Diminuisce il rischio di prematurità del 12% (Norvegia-Englun-Ogge, 2014) Vujkovic M, de Vries JH, Dohle GR, Bonsel GJ, Lindemans J, Macklon NS, van der Spek PJ, Steegers EA, Steegers-Theunissen RP. Associations between dietary patterns and semen quality in men undergoing IVF/ICSI treatment. Hum Reprod. 2009 Jun;24(6): Epub 2009 Feb 19. PubMed PMID: 1: Vujkovic M, de Vries JH, Lindemans J, Macklon NS, van der Spek PJ, Steegers EA, Steegers-Theunissen RP. The preconception Mediterranean dietary pattern in couples undergoing in vitro fertilization/intracytoplasmic sperm injection treatment increases the chance of pregnancy. Fertil Steril. 2010 Nov;94(6): Epub 2010 Mar 1. PubMed PMID: 2. Fertil Steril Nov;96(5): Epub 2011 Sep 22. Dietary patterns and difficulty conceiving: a nested case-control study. Toledo E, Lopez-del Burgo C, Ruiz-Zambrana A, Donazar M, Navarro-Blasco I, Martínez-González MA, de Irala J. Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Navarra, Spain. OBJECTIVE: To investigate potential associations between dietary patterns (defined using factor analysis) and difficulty conceiving. DESIGN: Case-control study nested in a Spanish cohort of university graduates (Seguimiento Universidad de Navarra [SUN] Project). SETTING: Female university graduates all over Spain participating in the SUN Project. PATIENT(S): A total of 485 women, aged years, reporting having presented with difficulty getting pregnant, and 1,669 age-matched controls who had at least one child. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Reported difficulty getting pregnant. Data were collected from baseline and follow-up questionnaires of the SUN Project. RESULT(S): Two dietary patterns were identified. They were labeled as "Mediterranean-type" and "Western-type" patterns. A lower risk of difficulty getting pregnant was apparent in the highest quartile of adherence to the Mediterranean-type pattern compared with the lowest quartile (odds ratio 0.56, 95% confidence interval ). Greater adherence to the Western-type dietary pattern showed no association with this outcome. CONCLUSION(S): A greater adherence to the Mediterranean-type dietary pattern may enhance fertility. Further evidence about the relationship between this dietary pattern and fertility is needed to develop nutritional interventions for women desiring to get pregnant. Timmermans S, Steegers-Theunissen RP, Vujkovic M, Bakker R, den Breeijen H, Raat H, Russcher H, Lindemans J, Hofman A, Jaddoe VW, Steegers EA. Major dietary patterns and blood pressure patterns during pregnancy: the Generation R Study. Am J Obstet Gynecol Oct;205(4):337.e1-12. Epub 2011 May 14. PubMed PMID: Abstract OBJECTIVE: We sought to evaluate associations between dietary patterns and systolic blood pressure (SBP) and diastolic blood pressure during pregnancy. STUDY DESIGN: This was a prospective study of 3187 pregnant women. Participants completed a food-frequency questionnaire in early pregnancy. The Mediterranean dietary pattern, comprising high intake of vegetables, vegetable oils, pasta, fish, and legumes, and the Traditional dietary pattern, comprising high intake of meat and potatoes, were identified using factor analysis. RESULTS: A higher SBP was observed among mothers with high Traditional pattern adherence. Low adherence to the Mediterranean pattern was also associated with higher SBP but only in early and mid pregnancy. A higher diastolic blood pressure throughout pregnancy was observed in mothers with high adherence to the Traditional pattern and low adherence to the Mediterranean pattern. These effect estimates were most pronounced in mid pregnancy. CONCLUSION: Low adherence to a Mediterranean and high adherence to a Traditional dietary pattern is associated with a higher blood pressure in pregnancy. 14. J Nutr Jun;139(6): Epub 2009 Apr 15. A dietary pattern characterized by high intake of vegetables, fruits, and vegetable oils is associated with reduced risk of preeclampsia in nulliparous pregnant Norwegian women. Brantsaeter AL, Haugen M, Samuelsen SO, Torjusen H, Trogstad L, Alexander J, Magnus P, Meltzer HM. Division of Environmental Medicine, Norwegian Institute of Public Health, NO-0403 Oslo, Norway. Several dietary substances have been hypothesized to influence the risk of preeclampsia. Our aim in this study was to estimate the association between dietary patterns during pregnancy and the risk of preeclampsia in 23,423 nulliparous pregnant women taking part in the Norwegian Mother and Child Cohort Study (MoBa). Women participating in MoBa answered questionnaires at gestational wk 15 (a general health questionnaire) and (a FFQ). The pregnancy outcomes were obtained from the Medical Birth Registry of Norway. Exploratory factor analysis was used to assess the associations among food variables. Principal component factor analysis identified 4 primary dietary patterns that were labeled: vegetable, processed food, potato and fish, and cakes and sweets. Relative risks of preeclampsia were estimated as odds ratios (OR) and confounder control was performed with multiple logistic regression. Women with high scores on a pattern characterized by vegetables, plant foods, and vegetable oils were at decreased risk [relative risk (OR) for tertile 3 vs. tertile 1: 0.72; 95% CI: 0.62, 0.85]. Women with high scores on a pattern characterized by processed meat, salty snacks, and sweet drinks were at increased risk [OR for tertile 3 vs. tertile 1: 1.21; 95% CI: 1.03, 1.42]. These findings suggest that a dietary pattern characterized by high intake of vegetables, plant foods, and vegetable oils decreases the risk of preeclampsia, whereas a dietary pattern characterized by high consumption of processed meat, sweet drinks, and salty snacks increases the risk. PMCID: PMC PMID: [PubMed - indexed for MEDLINE] Timmermans S, Steegers-Theunissen RP, Vujkovic M, den Breeijen H, Russcher H, Lindemans J, Mackenbach J, Hofman A, Lesaffre EE, Jaddoe VV, Steegers EA. The Mediterranean diet and fetal size parameters: the Generation R Study. Br J Nutr Feb 21:1-11. [Epub ahead of print] PubMed PMID: Developmental adaptations due to early nutritional exposures may have permanent health consequences. Studies of diet and fetal size have mainly focused on individual nutrients despite evidence that the pattern of food consumption may be of significance. Hence, we evaluated the associations of dietary habits in early pregnancy (gestational age < 18 weeks) with fetal size, uteroplacental vascular resistance, placental weight and birth weight in a prospective observational study of 3207 Caucasian pregnant mothers in Rotterdam, the Netherlands. Participants completed a semiquantitative FFQ during early pregnancy. Logistic regression analysis was used to predict the occurrence of intra-uterine growth retardation at birth as a function of food intake. The derived solution was considered as the dietary pattern. As it was characterised by higher intakes of fruit, vegetables, vegetable oil, fish, pasta and rice, and lower intakes of meat, potatoes and fatty sauces, it was labelled the 'Mediterranean' diet. The degree of adherence to the diet was positively associated with plasma folate and serum vitamin B12 concentrations and showed an inverse relationship with homocysteine and high-sensitivity C-reactive protein plasma concentrations (P < 0·05). Important fetal size and placental parameters were associated with the degree of adherence to the diet, revealing a 72 g lower birth weight (95 % CI - 110·8, - 33·3) and a 15 g lower placental weight (95 % CI - 29·8, - 0·2) for women with low adherence to the diet. To conclude, low adherence to a Mediterranean diet in early pregnancy seems associated with decreased intra-uterine size with a lower placental and a lower birth weight. 3. Br J Nutr May;107(10): Epub 2011 Sep 20. Maternal dietary patterns in pregnancy and fetal growth in Japan: the Osaka Maternal and Child Health Study. Okubo H, Miyake Y, Sasaki S, Tanaka K, Murakami K, Hirota Y; Osaka Maternal and Child Health Study Group, Kanzaki H, Kitada M, Horikoshi Y, Ishiko O, Nakai Y, Nishio J, Yamamasu S, Yasuda J, Kawai S, Yanagihara K, Wakuda K, Kawashima T, Narimoto K, Iwasa Y, Orino K, Tsunetoh I, Yoshida J, Iito J, Kaneko T, Kamiya T, Kuribayashi H, Taniguchi T, Takemura H, Morimoto Y, Matsunaga I, Oda H, Ohya Y. Department of Social and Preventive Epidemiology, Graduate School of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo , Japan. Maternal nutritional status during pregnancy is an important determinant of fetal growth. Although the effects of several nutrients and foods have been well examined, little is known about the relationship of overall maternal diet in pregnancy to fetal growth, particularly in non-Western populations. We prospectively examined the relationship of maternal dietary patterns in pregnancy to neonatal anthropometric measurements at birth and risk of small-for-gestational-age (SGA) birth among 803 Japanese women with live-born, singleton, term deliveries. Maternal diet in pregnancy was assessed using a validated, self-administered diet history questionnaire. Dietary patterns from thirty-three predefined food groups (g/4184 kJ) were extracted by cluster analysis. The following three dietary patterns were identified: the 'meat and eggs' (n 326), 'wheat products', with a relatively high intake of bread, confectioneries and soft drinks (n 303), and 'rice, fish and vegetables' (n 174) patterns. After adjustment for potential confounders, women in the 'wheat products' pattern had infants with the significantly lowest birth weight (P = 0·045) and head circumference (P = 0·036) among those in the three dietary patterns. Compared with women in the 'rice, fish and vegetables' pattern, women in the 'wheat products' pattern had higher odds of having a SGA infant for weight (multivariate OR 5·2, 95 % CI 1·1, 24·4), but this was not the case for birth length or head circumference. These results suggest that a diet high in bread, confectioneries, and soft drinks and low in fish and vegetables during pregnancy might be associated with a small birth weight and an increased risk of having a SGA infant. 4. Br J Nutr Jan;107(1): Epub 2011 Jun 29. Mediterranean diet adherence during pregnancy and fetal growth: INMA (Spain) and RHEA (Greece) mother-child cohort studies. Chatzi L, Mendez M, Garcia R, Roumeliotaki T, Ibarluzea J, Tardón A, Amiano P, Lertxundi A, Iñiguez C, Vioque J, Kogevinas M, Sunyer J; INMA and RHEA study groups. Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece. Dietary intake of specific nutrients or food groups during pregnancy could influence fetal growth, but scant evidence is available on effects of dietary patterns. The aim of this study was to evaluate the impact of Mediterranean diet (MD) adherence during pregnancy on fetal growth in two population-based mother-child cohorts in Spain and Greece. We studied 2461 mother-newborn pairs from the Spanish multi-centre 'INMA' study (Atlantic area: INMA-Atlantic; Mediterranean area: INMA-Mediterranean), and 889 pairs from the 'RHEA' study in Crete, Greece. Maternal diet during pregnancy was assessed by FFQ and MD adherence was evaluated through an a priori score. Fetal growth restriction was based on a customised model, and multivariate log-binomial and linear regression models were used to adjust for several confounders. MD scores differ significantly between the cohorts with women in INMA-Atlantic reporting higher intakes of fish and dairy products, while women in the Mediterranean area reported higher intakes of cereals, vegetables and fruits. Women with high MD adherence had a significantly lower risk of delivering a fetal growth-restricted infant for weight (risk ratios: 0·5; 95 % CI 0·3, 0·9) in the INMA-Mediterranean cohort. Stratified analysis by smoking revealed that higher MD adherence increased birth weight and birth length in smoking mothers, whereas this effect was not apparent in non-smoking mothers. The results of the present study show that several types of MD exist across European Mediterranean regions. High MD adherence may modify the detrimental effect of smoking on birth size, but overall effects of diet were not universal for the studies in this analysis. 12. Br J Nutr Jun;103(11): Epub 2010 Mar 9. Maternal dietary patterns in pregnancy and the association with small-for-gestational-age infants. Thompson JM, Wall C, Becroft DM, Robinson E, Wild CJ, Mitchell EA. Department of Paediatrics, University of Auckland, Private Bag Auckland, New Zealand. Maternal nutritional status before and during pregnancy is important for the growth and development of the fetus. The effects of pre-pregnancy nutrition (estimated by maternal size) are well documented. There is little information in today's Western society on the effect of maternal nutrition during pregnancy on the fetus. The aim of the study was to describe dietary patterns of a cohort of mothers during pregnancy (using principal components analysis with a varimax rotation) and assess the effect of these dietary patterns on the risk of delivering a small-for-gestational-age (SGA) baby. The study was a case-control study investigating factors related to SGA. The population was 1714 subjects in Auckland, New Zealand, born between October 1995 and November 1997, about half of whom were born SGA ( < or = 10th percentile for sex and gestation). Maternal dietary information was collected using FFQ after delivery for the first and last months of pregnancy. Three dietary patterns (traditional, junk and fusion) were defined. Factors associated with these dietary patterns when examined in multivariable analyses included marital status, maternal weight, maternal age and ethnicity. In multivariable analysis, mothers who had higher 'traditional' diet scores in early pregnancy were less likely to deliver a SGA infant (OR = 0.86; 95 % CI 0.75, 0.99). Maternal diet, particularly in early pregnancy, is important for the development of the fetus. Socio-demographic factors tend to be significantly related to dietary patterns, suggesting that extra resources may be necessary for disadvantaged mothers to ensure good nutrition in pregnancy. 24. Eur J Clin Nutr Apr;62(4): Epub 2007 Mar 28. Major dietary patterns in pregnancy and fetal growth. Knudsen VK, Orozova-Bekkevold IM, Mikkelsen TB, Wolff S, Olsen SF. Maternal Nutrition Group, Danish Epidemiology Science Centre, Statens Serum Institut, Copenhagen, Denmark. OBJECTIVES: To investigate possible associations between maternal diet during pregnancy and fetal growth. METHOD: Factor analysis was used to explore dietary patterns among pregnant women. The association between maternal dietary patterns and fetal growth (in terms of small for gestational age, SGA) was investigated by logistic regression. Prospective cohort study, including information on women in Denmark. RESULTS: Two major dietary patterns were defined: the first pattern was characterized by red and processed meat, high-fat dairy, and the second pattern was characterized by intake of vegetables, fruits, poultry and fish. Women were classified into three classes according to their diet: the first class had high intake of foods of the first dietary pattern, and was classified as 'the Western diet', the second class preferred foods of the second pattern and was classified as the 'Health Conscious'; and the third one had eaten foods of both patterns, and was classified as the 'Intermediate'. The odds ratio of having a small for gestational-age infant (with a birth weight below the 2.5th percentile for gestational age and gender) was 0.74 (95% CI ) for women in the Health Conscious class compared with women in the Western Diet class. The analyses were adjusted for parity, maternal smoking, age, height, pre-pregnancy weight and father's height. CONCLUSIONS: Our results indicated that a diet in pregnancy, based on red and processed meat and high-fat diary, was associated with increased risk for SGA. Further studies are warranted to identify specific macro-, or micronutrients that may be underlying these associations. PMID: [PubMed - indexed for MEDLINE]

10 Ricerche che suggeriscono vantaggi dell’alimentazione mediterranea o equivalente sulla salute riproduttiva Malformazioni congenite Alimentazione “occidentale” aumenta il rischio di labio e/o palatoschisi, dell’80%(Olanda-Vujkovic, 2007) Rischio ridotto di spina bifida (Olanda-Vujkovic, 2009; USA-Carmichael, 2012). Alimentazione ricca di donatori di metile (colina, B-Vitamine) (es.: ricca di pesce e crostacei) riduce il rischio di: cardiopatie congenite, del 70% ! (Olanda-Obermann-Borst, 2011) craniosinostosi (USA-Carmichael, 2010), (negativo per integratori con AF) difetti del tubo neurale (USA-Carmichael, 2010) Alimentazione non salutare aumenta rischio di ipospadia del 54% (UK-de Kort, 2011). Alimentazione occidentale (western type), o messicana aumentano il rischio di DTN nei confronti di un’alimentazione prudente rispettivamente del 45% e del 58% (Stati Uniti –Sotres Alvarez, 2013) 3: Vujkovic M, Ocke MC, van der Spek PJ, Yazdanpanah N, Steegers EA, Steegers-Theunissen RP. Maternal Western dietary patterns and the risk of developing a cleft lip with or without a cleft palate. Obstet Gynecol. 2007 Aug;110(2 Pt 1): PubMed PMID: Obermann-Borst SA, Vujkovic M, de Vries JH, Wildhagen MF, Looman CW, de Jonge R, Steegers EA, Steegers-Theunissen RP. A maternal dietary pattern characterised by fish and seafood in association with the risk of congenital heart defects in the offspring. BJOG Sep;118(10): doi: /j x. Epub 2011 May 18. PubMed PMID: Abstract OBJECTIVE: To identify maternal dietary patterns related to biomarkers of methylation and to investigate associations between these dietary patterns and the risk of congenital heart defects (CHDs) in the offspring. DESIGN: Case-control study. SETTING: Western part of the Netherlands, Population: One hundred and seventy-nine mothers of children with CHD and 231 mothers of children without a congenital malformation. METHODS: Food intake was obtained by food frequency questionnaires. The reduced rank regression method was used to identify dietary patterns related to the biomarker concentrations of methylation in blood. MAIN OUTCOME MEASURES: Dietary patterns, vitamin B and homocysteine concentrations, biomarkers of methylation (S-adenosylmethionine [SAM] and S-adenosylhomocysteine [SAH]) and the risk of CHD estimated by odds ratios and 95% confidence intervals. RESULTS: The one-carbon-poor dietary pattern, comprising a high intake of snacks, sugar-rich products and beverages, was associated with SAH (β = 0.92, P < 0.001). The one-carbon-rich dietary pattern with high fish and seafood intake was associated with SAM (β = 0.44, P < 0.001) and inversely with SAH (β =-0.08, P < 0.001). Strong adherence to this dietary pattern resulted in higher serum (P <0.05) and red blood cell (P < 0.01) folate and a reduced risk of CHD in offspring: odds ratio, 0.3 (95% confidence interval, ). CONCLUSIONS: The one-carbon-rich dietary pattern, characterised by the high intake of fish and seafood, is associated with a reduced risk of CHD. This finding warrants further investigation in a randomised intervention trial. 1. Birth Defects Res A Clin Mol Teratol Dec;88(12): doi: /bdra Epub 2010 Sep 14. Free full text Craniosynostosis and nutrient intake during pregnancy. Carmichael SL, Rasmussen SA, Lammer EJ, Ma C, Shaw GM; National Birth Defects Prevention Study. California Research Division, March of Dimes Foundation, Oakland, California, USA. OBJECTIVE: To examine the association of craniosynostosis with maternal intake of folic acid-containing supplements and dietary nutrients. METHODS: The study included deliveries from 1997 to 2005 from the National Birth Defects Prevention Study. Nonsyndromic infants with craniosynostosis (n = 815) were compared to nonmalformed, population-based liveborn control infants (n = 6789), by estimating adjusted odds ratios (AORs) and 95% confidence intervals (CIs) from logistic regression models that included mother's age, parity, race-ethnicity, education, body mass index, smoking, alcohol, fertility treatments, plurality, and study center. We compared quartiles of intake and specified nutrients as continuous. RESULTS: Intake of folic acid-containing supplements was not associated with craniosynostosis (AORs were close to 1). Analyses of dietary nutrients were restricted to mothers who took supplements during the first trimester (i.e., most women). Based on continuous specifications of nutrients, sagittal synostosis risk was significantly lower among women with higher intake of riboflavin and vitamins B₆, E, and C; metopic synostosis risk was significantly higher among women with higher intakes of choline and vitamin B₁₂; and coronal synostosis risk was significantly lower among women with higher intake of methionine and vitamin C. As examples, AORs for sagittal synostosis among women with intakes of vitamin B₆ and riboflavin in the highest versus lowest quartiles were 0.4 (95% CI, ) and 0.5 (95% CI, ), respectively. CONCLUSION: This analysis suggests that dietary intake of certain nutrients may be associated with craniosynostosis, and results may vary by suture type. 1. Birth Defects Res A Clin Mol Teratol Aug;88(8): Free full text Periconceptional nutrient intakes and risks of neural tube defects in California. Carmichael SL, Yang W, Shaw GM. California Research Division, March of Dimes Foundation, Oakland, California , USA. BACKGROUND: This study investigated the association of neural tube defects (NTDs) with maternal periconceptional intake of folic acid-containing supplements and dietary nutrients, including folate, among deliveries that occurred after folic acid fortification in selected California counties. METHODS: The population-based case-control study included fetuses and live born infants with spina bifida (189) or anencephaly (141) and 625 nonmalformed, live born controls delivered from 1999 to Mothers reported supplement use during telephone interviews, which included a 107-item food frequency questionnaire. For dietary nutrients, intakes <25th, 25th to <75th (reference), and > or =75th percentile were compared, based on control distributions. RESULTS: After adjustment for potential confounders, any versus no supplement intake resulted in ORs of 0.8 (95% CI, ) for anencephaly and 0.8 (95% CI, ) for spina bifida. After stratification by maternal intake of vitamin supplements, most factors in the glycemic pathway were not associated with either NTD, with the exception of low levels of fructose and glucose that were significantly associated with anencephaly. Some nutrients that contribute to one-carbon metabolism showed lowered risks (folate, riboflavin, vitamins B(6) and B(12)); others did not (choline, methionine, zinc). Antioxidant nutrients tended to be associated with lowered risks (vitamins C, E, A, beta-carotene, lutein). CONCLUSIONS: Mothers' intake of vitamin supplements was modestly if at all associated with a lowered risk of NTDs. Dietary intake of several nutrients contributing to one-carbon metabolism and oxidative stress were associated with reduced NTD risk. 7. Paediatr Perinat Epidemiol May;25(3): doi: /j x. Epub 2011 Mar 21. Relationship between maternal dietary patterns and hypospadias. de Kort CA, Nieuwenhuijsen MJ, Mendez MA. Little is known about the role of maternal nutrition in the development of hypospadias, which is the most common urogenital congenital anomaly. This study investigated the relationship between maternal nutrition and the risk of hypospadias, particularly focusing on maternal food patterns. We compared 471 hypospadias cases with 490 controls in the United Kingdom. A questionnaire including information on life style, occupation, usual maternal diet and dietary supplements was administered using telephone interviews. Cases and controls were compared for individual food item intake and food patterns derived by cluster analysis. Multivariable logistic regression analysis adjusted for income, maternal age, low birthweight, smoking and folic acid supplement use was used to assess the relationship between maternal nutrition and hypospadias. Three food patterns were created with the labels 'health conscious', 'mixed' and 'non-health conscious'. 'Non-health conscious' subjects (low frequency of consumption of yoghurt, cheese, eggs, fruit and vegetables, fish, beans and pulses, olive oil and organic food) had a higher risk of hypospadias (odds ratio 1.54; 95% confidence interval 1.06, 2.26) compared with 'health conscious' subjects (high frequency of consumption of fresh fruit and vegetables, dried fruit, fresh or frozen fish, beans, pulses, soya products, olive oil and organic food), after adjustment for potential confounders. Intakes of individual foods were not strongly associated with hypospadias. We could not exclude the possibility of residual confounding, and this needs to be further investigated. We found an association between food pattern and hypospadias, with those with less health conscious food patterns having a higher risk. Further study is needed to confirm this association. 1. Obstet Gynecol Aug;110(2 Pt 1): Maternal Western dietary patterns and the risk of developing a cleft lip with or without a cleft palate. Vujkovic M, Ocke MC, van der Spek PJ, Yazdanpanah N, Steegers EA, Steegers-Theunissen RP. Departments of Obstetrics and Gynecology/Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center, 3000 CA Rotterdam, the Netherlands. OBJECTIVE: To identify maternal dietary patterns in association with a cleft lip or cleft palate or both in the offspring. METHODS: In a case-control study of 203 mothers of a child with a cleft lip or cleft palate and 178 mothers with non-malformed offspring, maternal nutritional intakes were assessed 14 months after the birth of the index child to estimate the preconception intake. We measured serum and red blood cell folate, serum vitamin B12, whole blood vitamin B6, and total plasma homocysteine as biomarkers. Dietary patterns were analyzed by factor analysis. Univariate and multivariate analyses were performed and odds ratios with 95% confidence intervals calculated. RESULTS: Two major dietary patterns were identified. The Western dietary pattern, eg, high in meat, pizza, legumes, and potatoes, and low in fruits, was associated with a higher risk of a cleft lip or cleft palate (odds ratio 1.9; 95% confidence interval ). This risk remained significant after adjustment for potential confounders of maternal education and smoking at the time of the study, and periconception use of folic acid or multivitamins. This dietary pattern was associated with lower red blood cell folate (P=.02), vitamin B6 (P=.001), vitamin B12 (P=.02), and higher homocysteine (P=.05) concentrations. The use of the Prudent pattern, eg, high intakes of fish, garlic, nuts, vegetables, increased vitamin B12 (P<.001) and serum folate (P=.05) levels, was not associated with cleft lip or cleft palate risk compared with the Western diet. CONCLUSION: The use of the maternal Western diet increases the risk of offspring with a cleft lip or cleft palate approximately two fold. Therefore, dietary and lifestyle profiles should be included in preconception screening programs. LEVEL OF EVIDENCE: II. PMID: [PubMed - indexed for MEDLINE]

11 Depressione post-partum
Ricerche che suggeriscono vantaggi dell’alimentazione mediterranea o equivalente sulla salute riproduttiva Depressione postpartum, wheezing, tumori Depressione post-partum L’alimentazione salutare diminuisce il rischio di depressione post-partum del 50% (Grecia-Chatzi, 2011). L’alimentazione salutare non protegge dalla depressione post-partum (Giappone-Kanzaki, 2011). Wheezing – asma L’alimentazione mediterranea riduce il rischio di asma, OR: e di wheezing OR: 0.64 (Messico-de Battle, 2008); wheezing OR: 0.22 (Spagna-Chatzi, 2008) e (Irlanda-Fitzsimon, 2007). L’alimentazione “occidentale” riduce il rischio di wheezing, OR: 0.59 (Giappone-Miyake, 2011). Nessuna associazione tra wheezing e tre pattern alimentari analizzati (USA-Lange, 2010; UK-Shaheen, 2009) Alimentazione ricca di frutta e verdura diminuisce il rischio di tumori infantili nei maschi, OR: (USA-Musselman, 2011). 6. Public Health Nutr Sep;14(9): Epub 2011 Apr 11. Dietary patterns during pregnancy and the risk of postpartum depression: the mother-child 'Rhea' cohort in Crete, Greece. Chatzi L, Melaki V, Sarri K, Apostolaki I, Roumeliotaki T, Georgiou V, Vassilaki M, Koutis A, Bitsios P, Kogevinas M. OBJECTIVE: To identify and describe dietary patterns in a cohort of pregnant women, and investigate whether dietary patterns during pregnancy are related to postpartum depression (PPD). DESIGN: The study uses data from the prospective mother-child cohort 'Rhea' study. Pregnant women completed an FFQ in mid-pregnancy and the Edinburg Postpartum Depression Scale (EPDS) at 8-10 weeks postpartum. Dietary patterns during pregnancy ('health conscious', 'Western') were identified using principal component analysis. Associations between dietary patterns categorized in tertiles and PPD symptoms were investigated by multivariable regression models after adjusting for confounders. SETTING: Heraklion, Crete, Greece, SUBJECTS: A total of 529 women, participating in the 'Rhea' cohort. RESULTS: High adherence to a 'health conscious' diet, characterized by vegetables, fruit, pulses, nuts, dairy products, fish and olive oil, was associated with lower EPDS scores (highest v. lowest tertile: β-coefficient = -1·75, P = 0·02). Women in the second (relative risk (RR) = 0·52, 95 % CI 0·30, 0·92) or third tertile (RR = 0·51, 95 % CI 0·25, 1·05) of the 'health conscious' dietary pattern were about 50 % less likely to have high levels of PPD symptoms (EPDS ≥ 13) compared with those in the lowest tertile. CONCLUSIONS: This is the first prospective study showing that a healthy diet during pregnancy is associated with reduced risk for PPD. Additional longitudinal studies and trials are needed to confirm these findings. 8. Br J Nutr Apr;105(8): Epub 2010 Dec 13. Dietary patterns during pregnancy and the risk of postpartum depression in Japan: the Osaka Maternal and Child Health Study. Okubo H, Miyake Y, Sasaki S, Tanaka K, Murakami K, Hirota Y; Osaka Maternal and Child Health Study Group. Collaborators: Kanzaki H, Kitada M, Horikoshi Y, Ishiko O, Nakai Y, Nishio J, Yamamasu S, Yasuda J, Kawai S, Yanagihara K, Wakuda K, Kawashima T, Narimoto K, Iwasa Y, Orino K, Tsunetoh I, Yoshida J, Iito J, Kaneko T, Kamiya T, Kuribayashi H, Taniguchi T, Takemura H, Morimoto Y, Matsunaga I, Oda H, Ohya Y. Department of Social and Preventive Epidemiology, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo , Japan. Although several nutrients and foods are suggested to be preventive against postpartum depression, all previous studies have primarily focused on single nutrients or foods. In contrast, studies on dietary patterns, namely the measurement of overall diet by considering the cumulative effects of nutrient, may provide new insights into the influence of diet on postpartum depression. We prospectively examined the association between dietary patterns during pregnancy and the risk of postpartum depression among 865 Japanese women. Diet was assessed with a validated, self-administered diet history questionnaire. Dietary patterns from thirty-three predefined food groups (energy-adjusted food (g/d)) were extracted by factor analysis. Postpartum depression was defined as present when the subjects had an Edinburgh Postnatal Depression Scale score of ≥ 9 at 2-9 months postpartum. A total of 121 women (14·0 %) were classified as having postpartum depression. Three dietary patterns were identified: 'Healthy', 'Western' and 'Japanese' patterns. After adjustment for potential confounders, neither the 'Healthy' nor the 'Japanese' pattern was related to the risk of postpartum depression. Compared with the first quartile of the 'Western' pattern, only the second quartile was independently related to a decreased risk of postpartum depression (multivariate OR 0·52, 95 % CI 0·30, 0·93), although no evident exposure-response associations were observed (P for trend = 0·36). The present study failed to substantiate clear associations between dietary patterns and the risk of postpartum depression. Further studies with more accurate measurements are warranted to confirm the relationship between dietary patterns and the risk of postpartum depression. 5. Pediatr Allergy Immunol Nov;22(7): doi: /j x. Epub 2011 May 4. Maternal dietary patterns during pregnancy and risk of wheeze and eczema in Japanese infants aged months: the Osaka Maternal and Child Health Study. Miyake Y, Okubo H, Sasaki S, Tanaka K, Hirota Y. BACKGROUND: Maternal diet during pregnancy might influence the development of childhood allergic disorders. Aims:  This prospective study examined the relationship between maternal dietary patterns during pregnancy and the risk of wheeze and eczema in the offspring aged months. MATERIALS & METHODS: Subjects were 763 mother-child pairs. Data on maternal intake during pregnancy were assessed with a diet history questionnaire. Dietary patterns were derived from factor analysis of 33 predefined food groups. Symptoms of wheeze and eczema were based on criteria of the International Study of Asthma and Allergies in Childhood. Adjustment was made for maternal age, gestation, residential municipality, family income, maternal and paternal education, maternal and paternal history of allergic disorders, changes in maternal diet in pregnancy, season at baseline, maternal smoking during pregnancy, baby's older siblings, sex, birth weight, age at the third survey, household smoking, and breastfeeding duration. RESULTS: Three dietary patterns were identified: 'healthy', characterized by high intake of green and yellow vegetables, seaweed, mushrooms, white vegetables, pulses, potatoes, fish, sea products, fruit, and shellfish; 'Western', characterized by high intake of vegetable oil, salt-containing seasonings, beef and pork, processed meat, eggs, chicken, and white vegetables; and 'Japanese', characterized by high intake of rice, miso soup, sea products, and fish. There was a tendency for an inverse exposure-response relationship between the maternal Western pattern during pregnancy and the risk of childhood wheeze by crude analysis. After adjustment for the confounding factors under study, the inverse relationship was strengthened: the adjusted OR between extreme quartiles was 0.59 (95% CI: , p for trend = 0.02). No such inverse association was observed for childhood eczema. Neither the maternal healthy pattern nor the Japanese pattern during pregnancy was related to childhood wheeze or eczema. CONCLUSION: The maternal Western pattern during pregnancy may be preventive against wheeze in the offspring. 19. Thorax Jun;63(6): Epub 2008 Jan 15. Mediterranean diet in pregnancy is protective for wheeze and atopy in childhood. Chatzi L, Torrent M, Romieu I, Garcia-Esteban R, Ferrer C, Vioque J, Kogevinas M, Sunyer J. Department of Social Medicine, Faculty of Medicine, University of Crete, PO Box 2208, Heraklion, 71003, Crete, Greece. Comment in Thorax Jun;63(6):483-5. INTRODUCTION: Dietary intake of specific nutrients or food groups during pregnancy could play a role in the risk of asthma and atopy in offspring, but specific dietary patterns have not been implicated. The authors evaluated the impact of maternal (during pregnancy) and child adherence to a Mediterranean diet on asthma and atopy in childhood. METHODS: Women presenting for antenatal care at all general practices in Menorca, a Mediterranean island in Spain, over a 12 month period starting in mid-1997 were recruited. 460 children were included in the analysis after 6.5 years of follow-up. Maternal dietary intake during pregnancy and children's dietary intake at age 6.5 years were assessed by food frequency questionnaires, and adherence to a Mediterranean diet was evaluated by a priori defined scores. During follow-up, parents completed questionnaires on the child's respiratory and allergic symptoms. Children underwent skin prick tests with six common aeroallergens. RESULTS: The prevalence rates of persistent wheeze, atopic wheeze and atopy at age 6.5 years were 13.2%, 5.8% and 17.0%, respectively. One-third (36.1%) of mothers had a low quality Mediterranean diet during pregnancy according to the Mediterranean Diet Score, while the rest had a high score. A high Mediterranean Diet Score during pregnancy (at two levels, using "low" score as the reference) was found to be protective for persistent wheeze (OR 0.22; 95% CI 0.08 to 0.58), atopic wheeze (OR 0.30; 95% CI 0.10 to 0.90) and atopy (OR 0.55; 95% CI 0.31 to 0.97) at age 6.5 years after adjusting for potential confounders. Childhood adherence to a Mediterranean diet was negatively associated with persistent wheeze and atopy although the associations did not reach statistical significance. CONCLUSION: These results support a protective effect of a high level of adherence to a Mediterranean diet during pregnancy against asthma-like symptoms and atopy in childhood. PMID: [PubMed - indexed for MEDLINE] 22. Ir Med J Sep;100(8):suppl Mothers' dietary patterns during pregnancy and risk of asthma symptoms in children at 3 years. Fitzsimon N, Fallon U, O'Mahony D, Loftus BG, Bury G, Murphy AW, Kelleher CC; Lifeways Cross Generation Cohort Study Steering Group. UCD School of Public Health and Population Science. There is increasing evidence that dietary factors in early life play a role in the aetiology of childhood asthma. Our objective in this analysis was to assess whether maternal dietary patterns during pregnancy, as measured by a validated food frequency questionnaire, influenced general practitioner diagnosis of asthma by the age of 3 years in the Life-ways cohort of children. General Practice follow-up records were available for 631 of 1001 singleton children, twins having been excluded (63% follow-up rate). Overall 10.4% of children had diagnosed asthma, a prevalence rate comparable with other studies. In logistic regression models, based on quartiles of intake, which adjusted for maternal lifestyle and socio-economic circumstances, relatively higher maternal fruit and vegetable intake and oily fish consumption were associated with lower risk of children developing asthma, whilst those with relatively higher spreadable fat intake had a higher risk of asthma. These findings warrant further investigation as they imply an important role for maternal diet in childhood asthma, though the confounding effect of other social and lifestyle factors should be assessed as the children get older. PMID: [PubMed - indexed for MEDLINE] 11. J Allergy Clin Immunol Aug;126(2):250-5, 255.e1-4. Epub 2010 Jun 26. Maternal dietary pattern during pregnancy is not associated with recurrent wheeze in children. Lange NE, Rifas-Shiman SL, Camargo CA Jr, Gold DR, Gillman MW, Litonjua AA. Channing Laboratory, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA. BACKGROUND: The rise in asthma prevalence over the last few decades may be a result of changes in prenatal or early-life environment, including maternal diet during pregnancy. Previous studies have found associations between individual foods or nutrients consumed during pregnancy and asthma or wheeze in children, but these may be confounded by overall dietary pattern. OBJECTIVE: To determine whether overall maternal dietary pattern during pregnancy is associated with recurrent wheeze in children. METHODS: A total of 1376 mother-infant pairs from Project Viva, a longitudinal prebirth cohort, who had responses for food frequency questionnaires in the first and second trimester and outcome data at 3 years of age were included. Multivariable logistic regression was used to look at associations between dietary pattern and the primary outcome of recurrent wheeze at 3 years. Overall dietary pattern was examined by using Mediterranean diet score, Alternate Healthy Eating Index modified for pregnancy (AHEI-P), and principal components analysis to look at Western and Prudent diets. RESULTS: None of these dietary patterns was associated with the primary outcome of recurrent wheeze in children in either the crude or the multivariable model (multivariable model, odds ratio per 1-point increase in Mediterranean diet, 0.98 [95% CI, ]; AHEI-P, 1.07 [ ]; Prudent, 1.02 [ ]; Western, 0.98 [ ]). CONCLUSION: Overall dietary pattern during pregnancy is not associated with recurrent wheeze in this cohort. Maternal intake of individual nutrients may be more important determinants of offspring wheeze-associated illness than is dietary pattern. Copyright 2010 American Academy of Allergy, Asthma & Immunology. Published by Mosby, Inc. All rights reserved. PMCID: PMC PMID: [PubMed - indexed for MEDLINE] 16. Thorax May;64(5): Epub 2009 Feb 12. Dietary patterns in pregnancy and respiratory and atopic outcomes in childhood. Shaheen SO, Northstone K, Newson RB, Emmett PM, Sherriff A, Henderson AJ. National Heart and Lung Institute, Imperial College London, UK. BACKGROUND: Studies of the relation between maternal diet in pregnancy and respiratory and atopic outcomes in the offspring have focused on the effects of individual nutrients and foods rather than dietary patterns. A study was undertaken to determine whether dietary patterns in pregnancy are related to childhood asthma and related outcomes. METHODS: In a population-based birth cohort, the Avon Longitudinal Study of Parents and Children (ALSPAC), dietary patterns in pregnancy previously identified using principal components analysis ("health conscious", "traditional", "processed", "vegetarian" and "confectionery") were related to early wheezing phenotypes and eczema; wheezing, hay fever, eczema, doctor-diagnosed asthma, atopy and total IgE at 7 years; lung function and bronchial responsiveness at 8-9 years. In regression models, confounders were controlled for using propensity scores. RESULTS: Univariately, the "health conscious" pattern was positively associated with eczema, total IgE, forced expiratory volume in 1 s and forced expiratory flow and negatively associated with early wheezing and asthma (unadjusted odds ratios per standard deviation increase in pattern score for early persistent wheeze and asthma: 0.78 (95% CI 0.70 to 0.87), p = 7.3x10(-6), N = 8886 and 0.90 (95% CI 0.84 to 0.97), p = 0.007, N = 7625, respectively). The "processed" pattern was positively associated with early wheezing and negatively associated with atopy and forced vital capacity. On controlling for confounders, the effects were substantially attenuated and became non-significant (adjusted odds ratios for the associations of the "health conscious" pattern with early persistent wheeze and asthma: 1.00 (0.86 to 1.16), p = 0.99 and 0.95 (0.86 to 1.04), p = 0.27, respectively). CONCLUSIONS: In this cohort, dietary patterns in pregnancy did not predict asthma and related outcomes in the offspring after controlling for confounders. PMID: [PubMed - indexed for MEDLINE] 17. Allergy Oct;63(10): Mediterranean diet is associated with reduced asthma and rhinitis in Mexican children. de Batlle J, Garcia-Aymerich J, Barraza-Villarreal A, Antó JM, Romieu I. Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain. BACKGROUND: Diet during pregnancy and childhood has been suggested to play an important role in children's asthma risk. We assessed whether the adherence to a Mediterranean dietary pattern, for children in the last 12 months and their mothers during pregnancy, was associated with both childhood asthma and allergic rhinitis. METHODS: A cross-sectional study was conducted in 2004 using a random sample of 1476 children (6- to 7-year old) from the Mexicali region, Mexico. Dietary data of children's intake in the last 12 months and their mothers' intake during pregnancy was collected, through a parental food frequency questionnaire. A Mediterranean diet score was computed [Trichopoulou et al., N Engl J Med 348 (2003), 2599]. Data on seven asthma and rhinitis-related outcomes were obtained from the International Study of Asthma and Allergies in Childhood questionnaire. RESULTS: Adherence to a Mediterranean dietary pattern was inversely associated with asthma ever (OR = 0.60, 95% CI = ), wheezing ever (0.64, ), rhinitis ever (0.41, ), sneezing ever (0.79, ), current sneezing (0.71, ) and current itchy-watery eyes (0.63, ). No associations were found using the mothers' pregnancy diet score, except for current sneezing (0.71, ). CONCLUSIONS: Our findings suggest a protective effect of following a healthy dietary pattern on asthma and allergic rhinitis in Mexican children. PMID: [PubMed - indexed for MEDLINE] 9. Am J Epidemiol Feb 1;173(3): Epub 2010 Nov 23. Maternal dietary patterns during early pregnancy and the odds of childhood germ cell tumors: A Children's Oncology Group study. Musselman JR, Jurek AM, Johnson KJ, Linabery AM, Robison LL, Shu XO, Ross JA University of Minnesota, Minneapolis, USA., Maternal diet during pregnancy may be associated with cancer in offspring. Intake of individual foods, as well as dietary patterns, can be used when examining these relations. Here, the authors examined associations between maternal dietary intake patterns and pediatric germ cell tumors (GCTs) using principal components analysis and logistic regression. Mothers of 222 GCT cases aged less than 15 years who were diagnosed at a Children's Oncology Group institution between 1993 and 2001 and those of 336 frequency-matched controls completed a self-administered food frequency questionnaire of diet during early pregnancy. Four dietary patterns were identified: "Western," "fruits and vegetables," "protein," and "healthful." With adjustment for birth weight, parity, and vitamin use, the fruits and vegetables pattern was significantly associated with a lower odds for GCTs (odds ratio (OR) = 0.83, 95% confidence interval (CI): 0.69, 0.99; 2 sided). Upon stratification, the fruits and vegetables pattern was significantly associated with a lower odds in males (OR = 0.66, 95% CI: 0.47, 0.92) but not females (OR = 0.91, 95% CI: 0.72, 1.14). A quantitative assessment of assumed nondifferential reporting error indicated no notable deviations from unadjusted odds ratio estimates. Results of this exploratory analysis suggest that maternal prenatal dietary patterns could be considered in future studies of GCTs in offspring ICBD – Agrigento – Sciacca -- Novembre 21-22, | 11

12 Conclusione La lista dei vantaggi dell’alimentazione mediterranea, anche per la procreazione è molto ampia. L’alimentazione mediterranea ha innumerevoli vantaggi, che non sono legati ad una specifica vitamina o oligoelemento, ma al loro equilibrio complessivo. L’importante è dapprima convincere se stessi e adottare per primi le sane abitudini alimentari e poi trasmetterle agli altri. ICBD – Agrigento – Sciacca -- Novembre 21-22, | 12

13 Domande Pierpaolo Mastroiacovo icbd@icbd.org Professore di Pediatria
Direttore ICBD – Alessandra Lisi International Centre on Birth Defects and Prematurity; Centro Collaborativo OMS, Roma

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