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Dietary Fiber Intake in Early Pregnancy and Risk of
Subsequent Preeclampsia
Chunfang Qiu1, Kara B. Coughlin1, Ihunnaya O. Frederick1, Tanya K. Sorensen1 and Michelle A. Williams1,2
Background
Substantial epidemiological evidence documents diverse health
benefits, including reduced risks of hypertension, associated with
diets high in fiber. Few studies, however, have investigated the
extent to which dietary fiber intake in early pregnancy is associated
with reductions in preeclampsia risk. We assessed the relationship
between maternal dietary fiber intake in early pregnancy and risk
of preeclampsia. We also evaluated cross-sectional associations
of maternal early pregnancy plasma lipid and lipoprotein
concentrations with fiber intake.
Methods
The study population comprised 1,538 pregnant Washington
State residents. A 121-item food frequency questionnaire (FFQ)
was used to assess maternal dietary intake, 3 months before
and during early pregnancy; and generalized linear regression
procedures were used to derive relative risk (RR) and 95%
confidence intervals (CIs).
Preeclampsia, a vascular disorder of pregnancy is associated
with potentially lethal complications including abruptio pla-
centae, disseminated intravascular coagulation, cerebral hem-
orrhage, hepatic failure, and acute renal failure.1 Although
hypertension and renal dysfunction are clinically diagnostic
hallmarks, preeclampsia is well characterized by a multitude
of metabolic disturbances commonly observed in men and
nonpregnant women with cardiovascular disorders.1–2 These
metabolic disturbances include hypertriglyceridemia, hyper-
leptinemia, chronic systemic inflammation, insulin resis-
tance, oxidative stress, and diffuse endothelial dysfunction.3–7
Established preeclampsia risk factors include obesity, fam-
ily history of type 2 diabetes and/or essential hypertension,
depression and anxiety disorders, dietary intakes low in anti-
oxidants, fruits and vegetables, and physical inactivity.8–12
These risk factors are similar to those typically reported for
cardiovascular disorders.
1Center for Perinatal Studies, Swedish Medical Center, Seattle, Washington,
USA; 2Department of Epidemiology, University of Washington School of Public
Health and Community Medicine, Seattle, Washington, USA. Correspondence:
Chunfang Qiu (Chun-fang.Qiu@Swedish.org)
Received 4 January 2008; first decision 18 February 2008; accepted 5 May 2008;
advance online publication 17 July 2008. doi:10.1038/ajh.2008.209
© 2008 American Journal of Hypertension, Ltd.
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articles
Results
Dietary total fiber intake was associated with reduced preeclampsia
risk. After adjusting for confounders, the RR of preeclampsia for women
in the highest (≥21.2 g/day) vs. the lowest quartile (<11.9 g/day)
was 0.28 (95% CI = 0.11–0.75). We observed associations of similar
magnitude when the highest vs. the lowest quartiles of water-soluble
fiber (RR = 0.30; 95% CI = 0.11–0.86) and insoluble fiber (RR = 0.35; 95%
CI = 0.14–0.87) were evaluated. Mean triglyceride concentrations were
lower (−11.9 mg/dl, P = 0.02) and high-density lipoprotein cholesterol
concentrations were higher (+2.63 mg/dl, P = 0.09) for women in the
highest quartile vs. those in the lowest quartile.
Conclusions
These findings of reduced preeclampsia risk with higher total fiber
intake corroborate an earlier report; and expand the literature
by providing evidence, which suggests that dietary fiber may
attenuate pregnancy-associated dyslipidemia, an important clinical
characteristic of preeclampsia.
Am J Hypertens 2008; 21:903-909 © 2008 American Journal of Hypertension, Ltd.
Dietary fiber, a collective term for a variety of plant sub-
stances that are resistant to digestion by human gastrointestinal
enzymes,13 has been associated with reduced risks of cardio-
vascular disease, stroke, and diabetes.14–16 Other health bene-
fits of dietary fiber include favorable effects on plasma lipid and
lipoproteins,17 postprandial glucose metabolism,18 improved
insulin sensitivity,18,19 and reductions in blood pressure.20
Although a large and diverse literature suggests a potential
cardio-protective role of high-fiber diets,14–20 the literature is
quite sparse as it pertains to health benefits in pregnancy.21–23
In 1991, Skajaa et al.21 found that mean daily fiber intake dur-
ing the third trimester was similar for preeclamptic cases and
controls (27 g/day). Morris et al.,22 in their analysis of nullipa-
rous women who participated in a randomized clinical trial
of calcium supplementation, reported that fiber intake during
pregnancy, measured using a single 24-h dietary recall during
randomization (13–21 weeks gestation), was not associated
with the occurrence of preeclampsia. Inferences from the latter
study are limited, however, in part because dietary recall for a
single day is unlikely to be representative of habitual dietary
patterns.24 Frederick et al., in a case–control study of 172
preeclamptic women and 339 controls using food frequency
questionnaires (FFQs) to derive habitual dietary intake,
reported that preeclampsia risk was inversely related with fiber
 articles
intake.23 The authors observed that women with the highest
quartile (>24.3 g/day) compared with those with the lowest
quartile (<13.1 g/day) had a 51% reduced risk of preeclamp-
sia (adjusted OR = 0.49; 95% CI = 0.24–1.00). Inferences from
the study, however, are limited because participants completed
FFQs at the end of pregnancy. As a result, the authors were
unable to exclude the possibility that differential recall and
reporting of habitual dietary intake based on pregnancy out-
come. Results from the three published studies on this topic
are inconsistent.
We, therefore, used data from an ongoing prospective cohort
study to assess maternal dietary fiber intake in early pregnancy
with subsequent preeclampsia risk. We also evaluated the
influence of dietary fiber intake on maternal plasma lipid and
lipoprotein concentrations. This secondary objective was moti-
vated by reports documenting beneficial relationships between
dietary fiber intake and the plasma lipid profile in numerous
studies of men and nonpregnant women.17,18
Methods
Study design and setting. We analyzed data from the Omega
Study, an ongoing prospective cohort study primarily designed
to examine dietary risk factors of preeclampsia. Participants
were recruited from women attending prenatal care clinics
affiliated with Swedish Medical Center and Tacoma General
Hospital in Seattle and Tacoma, Washington. Recruitment
began in December 1996.25 The study protocol was approved
by the Institutional Review Boards of Swedish Medical Center
and Tacoma General Hospital. All participants provided
informed consent.
Eligible women were those who began prenatal care before
20 weeks gestation, spoke and read English, were ≥18 years
of age, and planned to carry the pregnancy to term and
deliver at either of the two hospitals. During early pregnancy,
­participants were asked to complete a structured interviewer-
administered questionnaire regarding socio-demographic
characteristics, lifestyle habits, and medical and reproduc-
tive histories. Participants also completed a 121-item semi-
quantitative FFQs,26 and provided nonfasting blood and urine
samples. Pregnancy outcome information was abstracted from
hospital and clinic medical records.
Analytical population. The analytical study population was
derived from participants enrolled in the Omega study
between 1996 and 2002. During this period, 2,420 eligible
women were approached and 1,986 (~82%) agreed to par-
ticipate. Women found to have chronic hypertension (n =
94), pregestational diabetes mellitus (n = 19), and both con-
ditions (n = 2) were excluded. Also excluded were those
women with missing dietary intake (i.e., fiber intake) informa-
tion (n = 293) and 40 women with either pregnancy lasting
<20 weeks gestation or moved elsewhere. A cohort of 1,538
women remained for analysis. Among them, we identified
64 women with preeclampsia. The diagnosis of preeclamp-
sia was made according to then-current American College of
Obstetricians and Gynecologists guidelines.27 These ­guidelines
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Dietary Fiber and Preeclampsia
defined ­preeclampsia as sustained gestational hypertension
with ­proteinuria. Hypertension was defined as sustained blood
pressure readings of ≥140/90 mm Hg taken ≥6 h apart or a sus-
tained 30 mm Hg systolic or 15 mm Hg diastolic rise above the
first trimester values. Proteinuria was defined as urine protein
concentrations of ≥30 mg/dl on ≥2 random specimens col-
lected at least 4 h apart. Post hoc analyses were conducted to
examine the relationship between maternal fiber intake and
preeclampsia risk using a newer preeclampsia diagnostic pro-
tocol, published after our study was implemented.1 Following
the new diagnostic protocol, we excluded proteinuric who
did not meet a minimal threshold of ≥140 mm Hg systolic or
≥90 mm Hg diastolic pressures. Forty-six patients were defined
as having preeclampsia for these post hoc analyses.
Data collection, interviews and periconceptional dietary assess-
ment. Interviewer-administered questionnaires were com-
pleted at a mean gestational age of 13.1 weeks. In our study, we
use the term “early pregnancy” referring to the first trimester.
Self-administered FFQs were completed at a mean gestational
age of 13.3 weeks. We used the FFQs from Women’s Health
Initiative Clinical Trial26 to assess maternal dietary intake dur-
ing the 3-month period (before conception and during the first
trimester of pregnancy). The Women’s Health Initiative FFQ
allows for assessment of intake, portion size, and food addi-
tives. Participants were provided clear instructions, including
photos of portion sizes. The Women’s Health Initiative FFQ has
documented reliability in accurately recording intake over an
extended period of observation.26 Total dietary fiber intake
was calculated by multiplying the frequency of consumption
of each unit of food by the soluble and insoluble fiber content
of the specified portion. Food composition values for other
nutrients including vitamin C, total fat, and carbohydrates were
obtained from the University of Minnesota Nutrition Coding
Center nutrient database (Nutrition Coordinating Center,
Minneapolis, MN).28
Determination of plasma lipids. Plasma lipid measurement
procedures used for this study have been described else-
where.29 Briefly, at 13.1 weeks gestation, on average, a 20-ml
nonfasting blood sample was collected. Blood was fraction-
ated using standard procedures and stored at −80 °C until
­analysis. Cholesterol and triglyceride concentrations were
measured enzymatically using assays standardized by the Lipid
Standardization Program of the Centers for Disease Control
and Prevention, Atlanta, GA. Analytical interassay coefficients
of variation for cholesterol, triglyceride, and HDL were 1.5, 2.5,
and 3.0%, respectively. All laboratory analyses were completed
without knowledge of maternal dietary fiber consumption and
pregnancy outcome.
Statistical analyses. We examined frequency distributions
of maternal socio-demographic, reproductive, and medical
characteristics according to quartiles of maternal total dietary
fiber intake. To examine the association between dietary fiber
intake and subsequent preeclampsia risk, we fitted ­generalized
 Dietary Fiber and Preeclampsia articles

linear models, using a log-link function, to derive relative
risks (RRs) and 95% confidence intervals (CIs).30 To assess
confounding, we entered covariates into each model one at a
time and compared the adjusted and unadjusted RRs.31 Final
models included covariates that altered unadjusted risk ratios by
at least 10%. The following covariates were considered as pos-
sible confounders: maternal age (<35 vs. ≥35 years), education
(≤12 vs. >12  years), race/ethnicity (non-Hispanic white vs.
others), parity (nulliparous vs. multiparous), smoking dur-
ing pregnancy (yes vs. no), and prepregnancy BMI (continu-
ous). Maternal educational attainment and smoking status was
found not to be a confounder, and therefore, was not included
in final models. We repeated a series of stratified analyses to
determine whether observed associations between dietary

Table 1 | Characteristics of subjects according to the quartiles of maternal total dietary fiber intake
Total fiber intake (g/day)
Entire cohort Quartile-1 Quartile-2 Quartile-3 Quartile-4
(N = 1538) (<11.9) (N = 383) (11.9–16.3) (N = 393) (16.4–21.1) (N = 378) (≥21.2) (N = 384)
Maternal age (years)a 32.2 ± 0.1 31.7 ± 0.2 32.4 ± 0.2 32.2 ± 0.2 32.6 ± 0.2
Maternal age (years)
  <35 71.1 74.4 68.7 73.5 68.0
  ≥35 28.9 25.6 31.3 26.5 32.0
Maternal race/ethnicitya
  Non-Hispanic white 86.0 78.6 84.5 90.5 90.4
  Other 14.0 21.4 14.9 9.5 9.6
Education ≤12 yearsa 4.2 6.5 4.1 2.7 3.4
Annual household income ($)
  <30,000 3.6 6.0 2.5 2.7 3.1
  30,000–69,999 24.1 25.9 24.4 24.3 21.6
  ≥70,000 69.9 66.3 69.7 70.9 72.7
Nulliparousa 68.1 64.0 65.7 70.4 72.4
Smoked during pregnancya 6.0 8.4 6.4 5.8 3.4
No exercise during pregnancy 16.7 17.8 19.1 15.6 14.3
Family history of hypertension 48.8 52.0 43.3 46.6 53.7
No prenatal vitamins 2.6 3.4 2.8 2.9 1.3
First trimester systolic blood pressure (mm Hg) 111.8 ± 0.3 112.2 ± 0.6 110.9 ± 0.6 112.2 ± 0.6 112.1 ± 0.6
First trimester diastolic blood pressure (mm Hg) 69.8 ± 0.2 70.2 ± 0.4 69.4 ± 0.4 70.1 ± 0.4 69.5 ± 0.4
Prepregnancy body mass index (kg/m2) 23.1 ± 0.1 23.4 ± 0.3 22.8 ± 0.2 23.1 ± 0.2 22.9 ± 0.2
  Non overweight (<25 kg/m2) 78.0 74.7 80.2 78.0 78.9
  Overweight (≥25 kg/m2) 21.1 24.5 18.8 21.2 20.1
Infant birth weight (g) 3418.8 ± 15.7 3422.6 ± 30.5 3417.3 ± 29.0 3437.7 ± 34.7 3397.9 ± 31.3
Gestational age at delivery (weeks) 38.8 ± 0.1 38.9 ± 0.1 38.9 ± 0.1 38.8 ± 0.1 38.7 ± 0.1
Gestational age at blood draw (weeks) 14.5 ± 0.1 14.3 ± 0.2 14.5 ± 0.2 14.5 ± 0.2 14.5 ± 0.2
Interval of meal to blood draw (hours) 2.7 ± 0.1 2.8 ± 0.1 2.6 ± 0.1 2.6 ± 0.1 2.6 ± 0.1
Carbohydrate (% energy)a 51.0 ± 0.2 48.4 ± 0.5 49.6 ± 0.3 52.3 ± 0.4 53.9 ± 0.3
Protein (% energy) 17.5 ± 0.1 17.7 ± 0.2 17.5 ± 0.1 17.5 ± 0.1 17.3 ± 0.1
Total fat (% energy)a 33.3 ± 0.2 35.0 ± 0.4 34.5 ± 0.3 32.3 ± 0.3 31.3 ± 0.3
Dietary vitamin C intake (mg/day)a 122.9 ± 1.7 72.8 ± 2.0 108.1 ± 2.4 132.4 ± 2.7 178.5 ± 3.6
Low vitamin C intake <85 mg/daya,b 31.3 68.9 34.6 16.7 5.0
Low fruit and vegetable <5 servings/daya 71.3 99.0 88.0 65.6 31.3
Total fiber intake (g/day)a 17.0 ± 0.2 8.8 ± 0.1 14.1 ± 0.1 18.6 ± 0.1 26.6 ± 0.3
  Water-soluble fiber intake (g/day)a 5.8 ± 0.1 3.1 ± 0.1 4.9 ± 0.1 6.2 ± 0.1 8.8 ± 0.1
  Insoluble fiber intake (g/day)a 11.2 ± 0.1 5.6 ± 0.1 9.1 ± 0.1 12.3 ± 0.1 17.6 ± 0.2
Data are presented as means ± s.e. or percent.
aP values from trend test are <0.05 for across quartiles of dietary total fiber intake. bLow vitamin C intake was defined using criteria from the Institute of Medicine, Food and Nutrition Board.

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Table 2 | Multivariable adjusted relative risk (ARR) and 95% confidence interval (CI) of preeclampsia according to dietary fiber
intake
Total fiber intake (g/day)
Quartile-1 Quartile-2 Quartile-3 Quartile-4 P for trend
Total fiber
  Quartile cut-points <11.9 11.9–16.3 16.4–21.1 ≥21.2
  Quartile median 9.1 14.2 18.5 25.0
  No. of cases/cohort 23/383 11/393 16/378 14/384
   ARR (95% CI)a 1.00 0.37 (0.18–0.79) 0.52 (0.26–1.05) 0.34 (0.14–0.82) 0.04
   ARR (95% CI)b 1.00 0.35 (0.16–0.77) 0.50 (0.25–1.02) 0.33 (0.14–0.79) 0.03
   ARR (95% CI)c 1.00 0.34 (0.15–0.75) 0.46 (0.22–0.97) 0.28 (0.11–0.75) 0.03
Water-soluble fiber
  Quartile cut-points <4.08 4.08–5.48 5.49–7.09 ≥7.10
  Quartile median 3.18 4.80 6.19 8.41
  No. of cases/cohort 23/387 13/382 13/384 15/385
   ARR (95% CI)a 1.00 0.47 (0.23–0.95) 0.42 (0.20–0.88) 0.38 (0.16–0.89) 0.02
   ARR (95% CI)b 1.00 0.51 (0.25–1.06) 0.44 (0.20–0.93) 0.39 (0.16–0.94) 0.03
   ARR (95% CI)c 1.00 0.49 (0.23–1.01) 0.38 (0.17–0.85) 0.30 (0.11–0.86) 0.03
Insoluble fiber
  Quartile cut-points <7.70 7.70–10.57 10.58–13.83 ≥13.83
  Quartile median 5.74 9.05 12.15 16.48
  No. of cases/cohort 22/384 11/385 17/384 14/385
   ARR (95% CI)a 1.00 0.42 (0.20–0.88) 0.60 (0.30–1.19) 0.40 (0.17–0.94) 0.07
   ARR (95% CI)b 1.00 0.40 (0.18–0.86) 0.57 (0.28–1.16) 0.37 (0.15–0.89) 0.06
   ARR (95% CI)c 1.00 0.38 (0.18–0.84) 0.55 (0.26–1.14) 0.35 (0.14–0.87) 0.06
aAdjusted for energy intake. bAdjusted for energy intake, maternal age, race/ethnicity, parity, and prepregnancy body mass index. cAdjusted for energy intake, maternal age, race/

ethnicity, parity, prepregnancy body mass index, and daily vitamin C intake.

fiber and preeclampsia risk were evident and/or modified by
other established preeclampsia risk factors (e.g., advanced
maternal age, prepregnancy overweight status, parity, exercise
during pregnancy, family history of hypertension, low daily
vitamin C intake).
We then examined distributions of plasma triglyceride, total
cholesterol, and LDL-cholesterol as well as HDL-cholesterol
concentrations and found them to be approximately normal.
We, therefore, reported mean lipid concentrations across
quartiles of maternal fiber intake. We examined linear rela-
tionships between mean lipid concentrations and ordered
categorical covariates using tests of linear trend. Multivariable
linear regression analyses with robust variances (i.e., Huber–
White sandwich estimator of variance32) were performed to
evaluate associations between total fiber intake and plasma
lipid concentrations. All analyses were performed using Stata
9.0 statistical software (Stata, College Station, TX). We present
continuous variables as mean ± s.e. All reported P values are
two-sided and considered significant at α = 0.05.
Results
Population characteristics
Selected socio-demographic and lifestyle characteristics of the
study cohort were summarized in Table 1. Average ­consumption
of total fiber was 17.0 ± 0.2 g/day (mean ± s.e.) for this cohort,
similar to report from other US populations.14,16 Mean total
fiber intake varied substantially in this cohort, with median
intake for each successive quartile from lowest to highest as fol-
lows: 9.1, 14.2, 18.5, and 25.0 g/day. A similar 2.5- to 3-fold dif-
ference in median values for extreme quartiles was observed for
water-soluble and insoluble fiber. Women who reported diets
high in fiber were less likely to smoke during pregnancy. In
addition, total fiber intake was positively associated with daily
fruit and vegetable consumption, and dietary vitamin C intake;
and was inversely related with percentage of calories from fat
intake (tests for trend were <0.05).
Preeclampsia risk in relation to fiber intake
Table 2 presents energy-adjusted and multivariable adjusted
risk ratios for preeclampsia risk according to quartiles of
maternal intake of total fiber, water-soluble fiber, and insoluble
fiber. Total fiber consumption was associated with reductions
in preeclampsia risk. The association remained after adjust-
ing for total energy intake, maternal age, race/ethnicity, parity,
and prepregnancy body mass index. The corresponding RRs
were 1.00, 0.35, 0.50, and 0.33 with each successive quartile
of maternal daily total fiber intake. Women who habitually
consumed diets high in total fiber (≥21.2 g/day, the ­highest

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Table 3 | Multivariable adjusted relative risk (ARRa) and 95% confidence interval (CI) of preeclampsia according to total fiber intake,
after stratification by selected maternal characteristics
Total fiber intake (g/day)
P value from
Stratifying Characteristics No. Cases /No. Cohort Quartile 1 Quartile 2 Quartile 3 Quartile 4 trend test
ARRa ARRa (95% CI) ARRa (95% CI) ARRa (95% CI)
Advanced maternal age
  <35 years 42/1,094 1.00 0.27 (0.09–0.77) 0.50 (0.21–1.19) 0.34 (0.11–1.07) 0.12
  ≥35 years 22/444 1.00 0.41 (0.12–1.41) 0.42 (0.11–1.56) 0.17 (0.03–1.09) 0.09
Prepregnancy overweight status
  <25 kg/m2 40/1,199 1.00 0.30 (0.11–0.84) 0.49 (0.19–1.28) 0.30 (0.08–1.10) 0.14
  ≥25 kg/m2 23/325 1.00 0.37 (0.10–1.28) 0.40 (0.12–1.31) 0.24 (0.05–1.14) 0.08
Parity
  Multiparous 11/491 1.00 b b b —
  Primiparous 53/1,047 1.00 0.32 (0.13–0.77) 0.48 (0.21–1.07) 0.26 (0.09–0.77) 0.04
Exercise during pregnancy
  Yes 60/1,281 1.00 0.28 (0.12–0.66) 0.44 (0.20–0.96) 0.27 (0.10–0.77) 0.04
  No 4/257 1.00 b b b —

Family history of hypertension

  No 34/787 1.00 0.58 (0.22–1.58) 0.60 (0.21–1.75) 0.52 (0.13–2.11) 0.38
  Yes 30/751 1.00 0.11 (0.02–0.52) 0.28 (0.09–0.84) 0.10 (0.02–0.45) 0.01
Daily vitamin C intake
  ≥85 mg/day 44/1,012 1.00 0.25 (0.09–0.72) 0.38 (0.15–0.91) 0.26 (0.09–0.72) 0.06
  <85 mg/day 20/462 1.00 b b b —

Daily intake of fruits and vegetables

  ≥5 servings/day 17/442 1.00 b b b —

  <5 servings/day 47/1,096 1.00 0.38 (0.17–0.88) 0.45 (0.17–1.16) 0.23 (0.05–1.05) 0.05
aAdjusted for energy intake, maternal age, race/ethnicity, parity, prepregnancy body mass index, and daily vitamin C intake. bThere were too few subjects in this stratum to estimate

adjusted risk ratios.

Table 4 | Relationships between quartiles of maternal daily total fiber intake (g/day) and plasma lipid concentrations (mg/dl):
estimated linear regression coefficients and standard error
Maternal total fiber intake (g/day)
Quartile 1 (<11.9) Quartile 2 (11.9–16.3) Quartile 3 (16.4–21.1) Quartile 4 (≥21.2)
Maternal plasma lipids (N = 381) (N = 389) (N = 375) (N = 383) P value for trend
Adjusted β ± s.e.a Adjusted β ± s.e.a Adjusted β ± s.e.a Adjusted β ± s.e.a
Cohort
 Triglyceride (mg/dl) Referent −8.4 ± 4.3b −12.5 ± 4.4b −11.9 ± 5.3b 0.01
  HDL-cholesterol (mg/dl) Referent 0.63 ± 1.21 1.75 ± 1.28 2.63 ± 1.54 0.06
  LDL cholesterol (mg/dl) Referent −2.67 ± 2.30 0.72 ± 2.43 −1.53 ± 2.95 0.96
 Total cholesterol (mg/dl) Referent −2.33 ± 2.65 1.35 ± 2.84 −0.50 ± 3.52 0.72
Ten subjects without plasma lipid measures were excluded from this analysis.
aAdjusted for total energy, maternal race/ethnicity, gestational age at blood draw and prepregnancy body mass index. bP value < 0.05 from pair-wise independent Student t test

comparison of each quartile vs. lowest quartile (i.e., the referent group).

quartile), as compared with those whose total fiber intake
ranked in the lowest quartile (<11.9 g/day), experienced
a 67% reduced risk of preeclampsia (RR = 0.33; 95% CI =
0.14–0.79). As can be seen in Table 2, further adjustment for
dietary ­vitamin C intake did not materially alter the observed
a­ ssociation. The multivariate RR for preeclampsia for women
in the top quartile of total fiber intake vs. the lowest quartile
was 0.28 (95% CI = 0.11–0.75).
Given that preeclampsia risk appeared to be graded across
quartiles of total fiber intake, we also evaluated preeclampsia

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 articles
risk in relation to a 5 g/day increment in total fiber intake. An
increment of this magnitude is approximately equivalent to
the amount of fiber intake one would consume by adding two
slices of whole grain bread each day. We noted that a 5 g/day
increase in total fiber intake was associated with a 14%
reduction in preeclampsia risk (adjusted RR = 0.86; 95%
CI = 0.66–1.11), though the association did not reach statisti-
cal significance.
Associations of similar directions and magnitudes were
observed when maternal dietary intakes of water-soluble fiber
and insoluble fiber were examined separately. The risk of preec-
lampsia decreased with each successive quartile of maternal
daily water-soluble fiber intake (adjusted RRs were 1.00, 0.49,
0.38, and 0.30, P for trend = 0.03) (Table 2). Women report-
ing to have consumed ≥13.8 g/day of insoluble fiber experi-
enced a 65% reduced risk of preeclampsia (adjusted RR = 0.35;
95% CI  = 0.14–0.87) as compared with women whose daily
­insoluble fiber intake was <7.7 g/day.
Inferences regarding the relationship between maternal
fiber intake and preeclampsia risk were generally similar in
direction and magnitude when analyses were restricted to
those patients meeting the newer criteria for preeclampsia.1
However, 95% CI were wider and tended to be statistically
insignificant, possibly because of a considerable reduction
in the sample preeclampsia cases. For example, adjusted RR
for preeclampsia across each successive quartile of total fiber
intake were 1.00 (referent), 0.33, 0.54, and 0.37 (P for trend =
0.17). Women reporting to have consumed ≥21.2 g/day of total
fiber experienced a 63% reduced risk of preeclampsia (95%
CI = 0.12–1.12) as compared with women whose intake was
<11.9 g/day (data not shown).
Because associations of preeclampsia with total fiber intake
may be modified by other covariates, we re-examined quartile-
specific RRs after stratifying participants according to some
established preeclampsia risk factors. Observed associations
between preeclampsia risk and total fiber intake did not dif-
fer much according to maternal age, prepregnancy over-
weight status, or parity (Table 3). Total fiber intake, however,
did appear to be more strongly related with preeclampsia
risk among women with a positive family history of essential
hypertension (adjusted RR for extreme quartiles: 0.10) than for
women with no such family history (adjusted RR for extreme
quartiles: 0.52) although the interaction P value of 0.25 was
not statistically significant. There were too few women with
low vitamin C intake and low intakes of fruits and vegetables.
Nevertheless, analyses restricted to women with high intakes
of both yielded associations similar to those reported for the
entire study population.
Plasma lipids in relation to fiber intake
We next examined the relationship between total fiber intake
and plasma lipid concentrations in early pregnancy. Mean
plasma triglyceride decreased as total fiber intake increased
(P for trend = 0.01) (Table 4). The adjusted mean triglyceride was
11.9 mg/dl lower among women with highest total fiber intake
(≥21.2 g/day) vs. those with the lowest intake (<11.9 g/day).
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Dietary Fiber and Preeclampsia
Mean HDL-cholesterol concentrations increased across suc-
cessive quartiles of total fiber intake, though the trend did not
reach statistical significance (P for trend = 0.06). Mean HDL-
cholesterol concentrations were +2.63 mg/dl higher, on aver-
age, among women in the highest quartile of total fiber intake
vs. those in the lowest quartile. There was no clear evidence of
associations between total fiber intake and LDL-cholesterol as
well as total cholesterol (Table 4).
Discussion
This prospective study provides additional evidence of reduced
preeclampsia risk associated with higher maternal dietary fiber
intake in early pregnancy. We are aware of only three other
published studies that have directly evaluated preeclampsia risk
in relation to maternal fiber intake, however with inconsistent
results. Of note, findings from the Frederick et al.23 study and
our present study are consistent with previously published stud-
ies of cardiovascular disorder in men and nonpregnant women.
In the Nurses’ Health Study, women in the highest quintile of
fiber intake (median: 22.9 g/day) had a 47% lower age-adjusted
RR for major coronary events than women who were in the low-
est quintile (median: 11.5 g/day).15 Furthermore, Mozaffarian et
al.,14 in their study of participants in the Cardiovascular Health
Study, reported that cereal fiber consumption was inversely
associated with cardiovascular disease.
To our knowledge, we are the first to examine the relation-
ship between maternal plasma lipid concentrations and habit-
ual fiber intake during pregnancy. Maternal plasma ­lipids
are known to be significantly elevated during pregnancy and
women who develop preeclampsia experience even more dra-
matic lipid changes.2–3 Several prospective studies indicate
that dyslipidemia, particularly hypertriglyceridemia, precede
the clinical manifestation of preeclampsia; and thus may be of
etiologic and pathophysiological importance.3,6 The trend of a
more favorable lipid profile with higher total fiber intake noted
in our study is largely similar to those observed in numerous
studies of men and nonpregnant women.17,18
Our study has several strengths. The prospective design and
exclusion of women with pregestational hypertension and dia-
betes reduced the potential for bias from recall differences or
dietary changes secondary to these disorders. Collection of
dietary intake information in early pregnancy, before preec-
lampsia was diagnosed, enhances causal inference given our
increased ability to infer the temporal relationship between
dietary fiber intake and subsequent preeclampsia risk. The
high follow-up rate of enrolled participants (>95%) minimized
possible selection bias.
Several limitations should be considered when interpreting
our study results. First, dietary fiber intake was assessed only
once in early pregnancy and there may have been changes in
fiber consumption between the first and second trimesters.
Longitudinal studies of pregnant women are needed to dem-
onstrate these potential causal relationships more conclusively.
Second, measurement error from the use of self-reported
dietary fiber consumption is likely to have occurred. However,
this error is unlikely to have systematically biased our ­findings,
 Dietary Fiber and Preeclampsia
because the reporting error is not associated with either the
laboratory determination of maternal plasma lipid concen-
trations or preeclamptic status. Third, use of nonfasting lipids
concentration may have influenced our findings. Because sub-
jects were recruited and enrolled while they attended obstetric
clinics to receive standard prenatal care, and because prolonged
fasting is contraindicated during pregnancy, we were restricted
to measuring lipids in nonfasting blood samples. We queried
participants about elapsed time since eating during blood
draw. Pair-wise correlations between elapsed time since eat-
ing and each of the plasma lipids in this population was small,
ranging from −0.01 to 0.04 (0.29 < P values < 0.75). We also
controlled for elapsed time since eating and blood draw in
multivariable regression analyses and found it was not con-
founder. Furthermore, available data indicate high correla-
tions between fasting and postprandial plasma lipids, ranging
from 0.90 to 0.99 (P < 0.001),33 and suggest that nonfasting
triglyceride concentrations may be useful in clinical practice.34
Fourth, inferences from some of our analyses were hindered
by the small number of preeclamptic participants, especially in
the stratified analysis. Finally, although we adjusted for known
and suspected confounders, we cannot exclude the possibility
of residual confounding from unmeasured covariates.
In summary, results from our study suggest that maternal
total fiber intake in early pregnancy, assessed using Women’s
Health Initiative FFQ, is associated with reduced ­preeclampsia
risk. Fiber intake was also inversely related with maternal trig-
lyceride and positively related with HDL-cholesterol concen-
trations (though to a lesser degree) during early pregnancy.
Taken together with previously published literature,23,35 these
results suggest important health benefits of increased fiber
consumption before and during early pregnancy. If confirmed
by other studies, our findings may motivate increased efforts
aimed at exploring lifestyle approaches, particularly dietary
approaches, to lower the risk of preeclampsia.
Acknowledgments: This research was supported by an award from the
National Institutes of Health (HD 32562). We are indebted to the participants
of the Omega Study for their cooperation. They are also grateful for the
technical expertise contributed by the staff of the Center for Perinatal
Studies, Swedish Medical Center.
Disclosure: The authors declared no conflict of interest.
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