key: cord-0893759-vvjzyued authors: Naja, Farah; Ayoub, Jennifer; Baydoun, Samar; Nassour, Sahar; Zgheib, Pamela; Nasreddine, Lara title: Development of national dietary and lifestyle guidelines for pregnant women in Lebanon date: 2021-05-11 journal: Matern Child Nutr DOI: 10.1111/mcn.13199 sha: 12bc398cc20e6c4d11093021ad94a4bcecbe0738 doc_id: 893759 cord_uid: vvjzyued Although a number of international diet and lifestyle guidelines during pregnancy (DLGP) exist in the literature, contextualization to low‐ and middle‐income settings is less common. The aim of this study was to present the Lebanese DLGP and to describe the process followed for their development. A mixed‐method approach was used including a review and synthesis of existing international DLGP and a consensus building nominal group technique (NGT) with a multidisciplinary group of experts (n = 11). During the meeting, participants identified the themes of the guidelines, formulated the wording of each themes' guideline and translated the guidelines to the Arabic language. Consensus was defined as an agreement of 80%. Reviewing the literature, a list of 17 main topics were found to be common themes for the DLGP. For the Lebanese DLGP, participants in the NGT meeting selected seven themes from this list: gestational weight gain, diet diversity, hydration, food safety, harmful foods, physical activity and breastfeeding. In addition, the group formulated three themes based on merging/modifying existing themes: supplementation, alcohol and smoking and religious fasting. Two context‐specific new themes emerged: wellbeing and nutrition resilience. For each of the identified themes, the group agreed upon the wording of its guidelines and description. This study is the first from the Eastern Mediterranean Region to develop through consensus building, context and culture‐specific dietary and lifestyle guidelines for pregnant women. Putting maternal nutrition at the heart of tackling malnutrition and its detrimental health outcomes is a core investment for a better maternal and child health. used including a review and synthesis of existing international DLGP and a consensus building nominal group technique (NGT) with a multidisciplinary group of experts (n = 11). During the meeting, participants identified the themes of the guidelines, formulated the wording of each themes' guideline and translated the guidelines to the Arabic language. Consensus was defined as an agreement of 80%. Reviewing the literature, a list of 17 main topics were found to be common themes for the DLGP. For the Lebanese DLGP, participants in the NGT meeting selected seven themes from this list: gestational weight gain, diet diversity, hydration, food safety, harmful foods, physical activity and breastfeeding. In addition, the group formulated three themes based on merging/modifying existing themes: supplementation, alcohol and smoking and religious fasting. Two context-specific new themes emerged: wellbeing and nutrition resilience. For each of the identified themes, the group agreed upon the wording of its guidelines and description. This study is the first from the Eastern Mediterranean Region to develop through consensus building, context and culturespecific dietary and lifestyle guidelines for pregnant women. Putting maternal nutrition at the heart of tackling malnutrition and its detrimental health outcomes is a core investment for a better maternal and child health. consensus, lifestyle, nominal group technique, nutrition, pregnancy Samar Baydoun and Sahar Nassour contributed equally to this work. The first 1000 days of life (from conception through the child's second birthday) are recognized as a crucial period in the life cycle, representing a unique window of opportunity for 'developmental or metabolic programming' (Schwarzenberg & Georgieff, 2018) . These early-life stages start with women's pregnancy, where the maternal body goes through various physiological changes to provide a nurturing environment for fetal development and support the increased maternal metabolic demands (Beluska-Turkan et al., 2019) . Therefore, improving maternal nutrition and ensuring a healthy lifestyle are critical to cater for the maternal physiological changes, optimize fetal organogenesis and neural development and decrease the risk of non-communicable diseases (NCDs) later in life (Blake-Lamb et al., 2016) . During pregnancy, women were shown to be more determined to improve their dietary and lifestyle behaviours in order to foster their health status as well as that of their child (Pietrobelli & Agosti, 2017; World Health Organization, 2016a) . Pregnant women were reported as motivated and proactive subjects, feeling responsible for their own health care choices and decisions, and often encouraged by the increased communication with their healthcare providers (Paz-Pascual et al., 2019; World Health Organization, 2016a) . Hence, many countries developed national dietary and lifestyle guidelines as effective tools intended for use by healthcare providers, to counsel on prenatal care by linking scientific research to the needs and expectations of pregnant women (Australian Government National Health and Medical Research Council, 2013a; Brown et al., 2011; Health Canada, 2007; World Health Organization, 2016a) . National guidelines were also shown to be essential means for policymakers given their contribution to efficient policy development and implementation (World Health Organization, 2016a) . Although a number of international diet and lifestyle guidelines during pregnancy (DLGP) are published in the literature, contextualization to low-and middle-income settings is less common (Verschueren et al., 2019) . Women's pregnancies and behaviour can, in fact, be significantly affected by their social and cultural environment (Mukhopadhyay & Sarkar, 2009) , hence the need for country-specific dietary and lifestyle guidelines that tailor for the local context in terms of the population's beliefs, traditions and social norms (Mukhopadhyay & Sarkar, 2009 ). Lebanon, a small country of the Eastern Mediterranean Region (EMR), has witnessed, during the past two decades, a nutrition transition away from the traditional Mediterranean diet towards a more Westernized diet and lifestyle . This shift is associated with a double burden of malnutrition characterized by the coexistence of undernutrition, including stunting and micronutrient deficiencies, along with an escalating burden of overweight, obesity and associated NCDs (Nasreddine et al., 2018 . In light of the high prevalence rates of malnutrition in the country, there have been attempts by the Lebanese government, as well as non-governmental organizations (NGOs) and academic institutions, to support infant and young child feeding practices and breastfeeding (Akik et al., 2015) . However, context-specific guidelines targeting the pregnancy period are lacking. In this context, the aim of this manuscript is to present the Lebanese DLGP and to describe the process that was followed for their development. A mixed-method approach was used including a review and synthesis of existing international DLGP and a consensus building nominal group technique (NGT) with a multidisciplinary group of experts. The project was part of a collaboration between the Ministry of Public Health (MOPH) in Lebanon and the Faculty of Agricultural and Food Science at the American University of Beirut. • This study is the first from the Eastern Mediterranean Region to develop diet and lifestyle guidelines during pregnancy (DLGP). • These guidelines are devised for women living in a nutrition transition context while building on available scientific evidence and taking long-term health consequences into account. • The DLGP can be used by healthcare providers during prenatal counselling while also serving as the seed for efficient policy development to foster maternal health during pregnancy. • Putting maternal nutrition at the heart of tackling malnutrition and its detrimental health outcomes is a core investment for better maternal and child health. To build consensus on the priority themes and guidelines to be included in the Lebanese guidelines, the NGT was used and included researchers and health professionals using a multidisciplinary approach. The NGT is a highly structured technique that encompasses interaction among a small group of participants, encourages ideas to be generated, shared and clarified, and thematic classifications to be discussed and refined (Cantrill et al., 1996; Siegfried et al., 2017) . Such technique is commonly used in medical and health service research and the development of guidelines, given its significance in strengthening the recommendations by harnessing the insights of experts in aspects for which published evidence is lacking or is not robust (Allen et al., 2004; Dicianno et al., 2020) . Although a significant body of literature suggests using the Delphi technique for the development of guidelines, in this study, the NGT was used for the following reasons: a. The interactive nature of the NGT offers the participants the opportunity for a discussion and group brainstorming (Manera et al., 2019) . Given the breadth of topics covered by the guidelines and the specialized backgrounds of the participants (paediatrician, nurse, pregnancy fitness trainer, specialist in infant and young child feeding, nutritionist, researchers, obstetrics and gynaecologist, pharmacist, midwife and public health officer), an interactive nature of the process was deemed essential for participants to be implicated in all the discussions. Using emails (as in the case of the Delphi), participants may feel that their input is restricted to their respective fields of specialties. b. Using the Delphi technique requires a high motivation level on behalf of the participants to respond to their emails (Health Knowledge, 2016) . In Lebanon, participation and response rate using emails are less common, and response rate could constitute a barrier (Atallah et al., 2018; Bizri et al., 2020) , a context that may raise concern of lack of contribution of participants. The latter cited as a main reason for using the NGT (Manera et al., 2019) . Researchers and health professionals from a range of disciplines were purposively sampled and invited to an experts' meeting to discuss and build consensus on the development of the first national dietary and lifestyle guidelines for Lebanese pregnant women. Every effort was made to include multi-sectorial participants from public, private, governmental and non-governmental sectors. The discussion was held in The NGT exercise was conducted for the following three purposes: (1) identification/selection of the themes to be included in the DLGP, (2) formulating the selected themes into guidelines and (3) translating the themes and their corresponding guidelines to the Arabic language. During these three phases, each participant was given the chance to speak, vote and propose ideas and discussions. In preparation for the NGT exercise and debate, experts were provided with the list of themes extracted from the literature review. Participants were given the choice to select, merge, delete or propose new themes from/to the list. Experts were asked to record their views or ideas privately on each of the themes. This was followed by a group discussion of each of the individual themes for clarification and evaluation of its relevance as well as its specificity to the Lebanese context. Selection of the themes was conducted by seeking consensus, defined as 80% agreement among the participants (Dobson et al., 2019; Murphy et al., 1998) . For each selected theme, further rounds of group discussion and voting on the formulation of the guidelines were held, followed by their translation to the Arabic language (see Appendix 1). For items that did not reach consensus, revision and repeat voting were performed. Results of the meeting were summarized by the moderator, and unanimous agreement was sought on the final draft. Figure 1 presents a summary of the NGT exercise used in our experts' meeting. Following the consensus group meeting, the final draft of the guidelines was shared via email with the participants who were asked to submit any additional feedback and comments. The final approved draft and the order of the themes were circulated after all reviews were provided. The protocol of the study was approved by Institutional Review Board at the American University of Beirut (Protocol ID: NUT. FN. 12). Oral consent was obtained from all participants. Based on the performed literature search, 14 internationally published guidelines were identified and reviewed. Based on this review, 17 different themes were extracted, including gestational weight gain (GWG), diet diversity/Mediterranean diet, folic acid, iron, omega-3 fatty acids, vitamin D, calcium, hydration, harmful foods, caffeine, smoking, alcohol, food safety, physical activity, breastfeeding, herbs and fasting (Table 1 ). The review showed that all of the identified 14 guidelines have tackled diet diversity, folic acid, iron, alcohol and hydration. Other common themes were related to GWG, caffeine, food safety and physical activity (93% of the guidelines). The significance of calcium was tackled by 86% of the published guidelines and vitamin D and harmful foods by 79%, whereas smoking and breastfeeding were addressed by 64% of the guidelines. The significance of omega-3 fatty acids and the consumption of herbs was included in 57% of the reviewed guidelines, and the least common theme included fasting (14%). Of the 17 themes derived from the literature, seven themes were selected during the expert meeting ('gestational weight gain', 'diet diversity', 'hydration', 'food safety', 'harmful foods', 'physical activity' and 'breastfeeding'), eight themes were merged/modified ('folic acid', 'iron', 'omega three fatty acids', 'smoking', 'alcohol', 'caffeine' and 'fasting'), and two were eliminated ('herbs' and 'calcium'). In addition, two new themes emerged during the discussion ('wellbeing' and 'nutrition resilience'). As such, the Lebanese DLGP consisted of 12 themes. The themes and guidelines for which consensus was reached in the nominal group meeting are presented in Table 2 . Consensus was reached to include this theme at 90.9% from the first round of voting. For the formulation of the guideline, the group did not reach consensus from the first voting process (63.6% consensus), and many preferred the use of positive words. Accordingly, the following guideline was selected: 'Maintain a healthy weight gain during pregnancy: It's not about eating for two' (90.9% consensus). Given the lack of national or regional weight gain recommendations during pregnancy, that of the Institute of Medicine (IOM) will be adopted in this guideline (Institute of Medicine and National Research Council, 2009 ). In addition, the need to address adolescent pregnancy was raised by the attendees who suggested to include this topic under the 'special considerations' section within this theme. GWG is included in most of the available DLGP worldwide (Table 1) , given its potential impact on pregnancy and birth outcomes. Inadequate GWG was in fact reported to heighten the risk for low birthweight (LBW), preterm births and impaired fetal growth, whereas excess GWG was identified as a risk factor for gestational hypertension, gestational diabetes mellitus, preeclampsia, complicated deliveries, macrosomia (Siega-Riz et al., 2009 ) and adverse cardiometabolic profile in the offspring (Gaillard et al., 2015) . In addition, a convincing body of evidence shows that excessive GWG in all body mass index (BMI) categories is a strong predictor of postpartum weight retention, which itself is associated with increased risk of adverse health outcomes in subsequent pregnancies including hypertension, diabetes and stillbirth . In Lebanon, a previous cohort study conducted by our group showed that only 33.9% of pregnant women fell within the adequate GWG range based on the IOM guidelines, whereas 21.3% and 44.9% had inadequate or excessive GWG, respectively (Abdulmalik et al., 2019) . Excessive GWG was also shown to be an independent predictor of post-partum weight retention in Lebanese women . with lactose intolerance has also emerged under the 'special considerations' section, with the group recommending that calcium supplementation should be addressed in this section for these subgroups. The consumption of a balanced diet that ensures dietary diversity is a key strategy in optimizing nutrient intakes during pregnancy (Koletzko et al., 2019) . Maternal diet and its composition play a crucial role early in pregnancy on organ development and differentiation, whereas in late pregnancy, it can be a major modulator of fetal growth rate and brain development (Jansson, 2016) . In the proposed DLGP, the focus will be placed on the promotion of diet diversity in line with the traditional Lebanese diet, a variant of the Mediterranean dietary pattern (Naja, Hwalla, 2015) . The Lebanese diet, which is embedded in the local culture and tradition, was previously shown to be associated with healthier nutrient intakes as well as lower risk of obesity and cardiometabolic risk in the Lebanese population (Matta et al., 2016) . A total of 81.8% of attendees voted to group all supplements in one theme titled 'Supplementation: Know your supplements'. When formulating the guideline, the group agreed to include individual statements for each supplement (Table 2) . Compared with the modest rise in energy requirements, the requirements for several micronutrients increase to a much larger extent during pregnancy (Koletzko et al., 2019) . Particular attention should therefore be paid to micronutrient intakes during this crucial period, given the well-established link between maternal micronutrient deficiencies, increased prenatal complications and adverse outcomes on fetal growth and child development (Christian & Stewart, 2010 Pregnant women are among the most vulnerable population groups to iron deficiency, given the increased iron needs to supply the growing fetus and placenta as well as to increase the maternal red cell mass (Fisher et al., 2020) . It has been proposed that anaemia during pregnancy may increase the risk of LBW (Figueiredo et al., 2019) , preterm birth (Rahmati et al., 2020) and perinatal mortality (Smith et al., 2019 Under the 'special considerations' section for this theme, participants agreed to add the recommendation to increase awareness regarding the use of complementary and alternative medicine (CAM) during pregnancy. CAM, including herbal supplements, use is prevalent in the general Lebanese population (Naja, Alameddine, et al., 2015) . Acknowledging that CAM use, such as herbal products, may lead to serious side effects that may compromise fetal growth (Steel et al., 2015) , increasing awareness on the potential harmful impacts of CAM use during pregnancy was deemed important. After extensive discussion, the voting resulted in 81.8% consensus on the following guideline for this theme: 'Stay hydrated; drink plenty of safe water, around 8-12 cups of fluids per day'. During pregnancy, physiological changes lead to an increase in daily water requirements, and hence, adequate fluid intake is needed to cater for maternal needs as well as fetal growth requirements. Available studies conducted in various countries in the world have shown that pregnant women have insufficient fluid intake, hence increasing the risk of dehydration in this crucial period of the life cycle (Bardosono et al., 2016; McKenzie et al., 2017) . Insufficient fluid intake during pregnancy was suggested to be associated with spontaneous abortion, preterm births and LBW (Savitz et al., 1995) . It was also suggested that chronic hypovolaemia resulting from insufficient water intake may be among the main risk factors for the development of diabetes (Thornton, 2014) . With regard to the guideline formulation, discussions regarding the terms 'Avoiding' and 'Limiting' took place, and the latter was selected; a consensus of 81.8% was reached for the following guideline: 'Limit foods that are high in calories, sugar, artificial sweeteners, saturated fats, salt and caffeine'. The need to limit these types of food is backed up by the available scientific evidence. Like other countries of the EMR, Lebanon is undergoing the nutrition transition with its characteristic shifts in diet towards Western and obesogenic dietary patterns, which are high in energy, fat, saturated fat, added sugars and salt . Regular consumption of high-energy foods may result in excessive energy intake during gestation, which, through developmental programming, may lead to long-term health outcomes in the child including obesity, diabetes, hyperlipidaemia and the metabolic syndrome (Campisano et al., 2019; Eckert et al., 2015) . Another area of concern is the potential link between the consumption of foods that are high in fat, sugar or salt with adverse effects on both mother and child, including disturbing the hormonal and metabolite milieu and impacting insulin sensitivity, adiposity and glucose tolerance (Koletzko et al., 2019; Musial et al., 2017) . Dose-response relationships between caffeine intake and adverse pregnancy outcomes including LBW and miscarriage have been proposed by some systematic reviews (Greenwood et al., 2014; Rhee et al., 2015) . (Rhee et al., 2015) . This increases fetal exposure to this substance, given that caffeine can be easily transmitted across the placental barrier (Fortier et al., 1993) . The immature fetal liver produces low levels of enzymes needed for caffeine metabolism, thus increasing the risk of adverse outcomes including LBW (Bakker et al., 2010) . Despite the increasing consumption of artificial sweeteners, their long-term impact on health is poorly understood, and current intake recommendations are still unclear, especially for pregnant women (Azad et al., 2016) . A growing body of evidence suggests that chronic consumption of artificial sweeteners may in fact increase rather than decrease the risk of obesity and metabolic diseases (Swithers, 2013) . Cohort studies have reported associations between consumption of these sweeteners during pregnancy and preterm delivery (Halldorsson et al., 2010; Petherick, Goran, et al., 2014) , allergic diseases (Maslova et al., 2013) and increased BMI and overweight risk among the offspring (Azad et al., 2016) . Alcohol drinking is in general under-reported in research, due to the prevalent cultural and social norms in some countries, particularly in Muslim communities (Alhashimi et al., 2018) . A national crosssectional study conducted among Lebanese mothers of 0-to 2-year-old children estimated the prevalence of alcohol drinking during pregnancy at 3.3% (Zgheib, 2014) . However, a prospective study conducted among Lebanese pregnant women (n = 117) showed that more than 11% of participating women engaged in potentially high-risk drinking for the baby (Maalouf et al., 2011) . Therefore, as in many other countries in the world, alcohol use in pregnancy remains a public health priority in Lebanon. As women are often motivated to make lifestyle changes during their pregnancy, it is crucial to provide them with the needed knowledge and awareness and to ensure proper dissemination of the recommendations. Maternal smoking during pregnancy is another major public health concern (Knopik, 2009), given its association with LBW (Ricketts et al., 2005) , heightened risk of stillbirth (Salihu et al., 2008) , altered cardiorespiratory responses (Huang et al., 2006) and increased wheezing and asthma (Janson, 2004) as well as several neurodevelopmental disorders, including increased evidence of attentional deficits (Dong et al., 2018) , impaired learning and memory and cognitive dysfunction (Mortensen et al., 2005) . Despite the large literature suggesting adverse health outcomes in children exposed to maternal smoking during pregnancy, many pregnant women still engage in this practice (Dong et al., 2018) . In Lebanon, a national cross-sectional survey estimated the prevalence of maternal smoking during pregnancy at 15.3% (Zgheib, 2014) . Another study conducted on women from 23 healthcare centres in Lebanon showed that 23% of participants reported smoking during pregnancy (cigarette or arguileh) (Chaaya et al., 2004) . The importance of having 'Food Safety' as a theme on its own was agreed by all experts (100% consensus), and the guideline for the theme was voted for by 81.8%: 'Prepare and consume safe food using proper food handling and storage'. It is imperative to raise awareness on safe ways to prepare and consume foods to decrease the risk of food-borne illnesses such as listeriosis, salmonellosis and toxoplasmosis, which can induce spontaneous abortion, premature birth, severe fetal damage and stillbirth (Robert-Koch-Institut, 2011; Schöneberg, 2008) . Although, in many developed countries, improved surveillance and regulatory standards have reduced the availability of contaminated foods in retail outlets and restaurants, this may not be the case in Lebanon, a country that still suffers from a high burden of food-borne illnesses (Kharroubi et al., 2020) . Unpasteurized milk and its products, raw meat, smoked fish, soft cheeses and vegetables and salads may transfer listeriosis (Lamont et al., 2011; Oliveira et al., 2010) . Raw animal-based foods and soft-cooked eggs may also transmit salmonellosis, whereas toxoplasmosis may be transmitted through raw or not fully cooked meats from pork and lamb and potentially from beef (Bojar & Szymanska, 2010; Elsheikha, 2008) . Pregnant women are therefore advised to avoid the consumption of raw animal-based foods, including raw or not thoroughly cooked meat, salami, raw ham, raw fish, raw seafood, unpasteurized milk and raw eggs, as well as foods made of these products (Koletzko et al., 2019) . Recent studies in Lebanon have also documented prevalent food contamination with Escherichia coli and Staphylococcus aureus (Kharroubi et al., 2020) , which highlights the urgency to tackle food safety and safe preparation of food among pregnant women in the country. Physical activity was considered by most participants to be an important theme (81.8% consensus). Two participants suggested adding 'Sleep' to this theme, but only 18% agreed to this grouping. Although this suggestion did not reach consensus, it shed the light on the importance of mental and physical wellbeing during pregnancy, which led to the emersion of a new theme entitled 'Wellbeing'. As for the formulation of the guideline, 81.8% of participants selected 'Enjoy an active lifestyle: aim for at least 20-30 minutes of moderate intensity, safe exercise on most days of the week'. Based on traditional and cultural norms, pregnant women are often advised to avoid or reduce their levels of physical activity because of the belief that physical activity may increase the risk of miscarriages, preterm deliveries and intrauterine growth retardation (Schramm et al., 1996) . However, the scientific evidence that has accumulated during the last two decades have provided solid counterarguments to these misconceptions, showing that physical activity during pregnancy has numerous beneficial effects for both mother and offspring (American The importance of breastfeeding was acknowledged in the first round of voting (100% consensus). Regarding the guideline's formulation, 91.9% of the attendees voted for the following: 'Prepare for breastfeeding; it is your baby's optimal food'. Breastfeeding should be encouraged, supported and protected. Breastfeeding is associated with several benefits for the mother and her child and is universally recommended as the optimal method of infant feeding (Prell & Koletzko, 2016) . In addition to its positive impact on growth and development, recent studies suggest that breastfeeding and early nutrition constitute an important determinant of NCD risk later in life (Khanna et al., 2007; Singhal, 2016) . Several studies have suggested that compared with infant formula, breastfeeding was associated with healthier weight gain during the first year of life and beyond (Li et al., 2012; Lindholm et al., 2020) . Breastfeeding was also linked with a modest risk reduction for overweight and obesity later in childhood and adulthood by approximately 10% (Horta et al., 2015; Moss & Yeaton, 2014; Poorolajal et al., 2020; Umer et al., 2015; Yan et al., 2014) . Based on available evidence, the WHO has recommended exclusive breastfeeding for the first 6 months of life (World Health Organization, 2002) . Available data in Lebanon show that despite a relatively high initiation rate of breastfeeding (41.5%), the prevalence rate of exclusive breastfeeding at 6 months is low, estimated at 12.3% (Chehab et al., 2020) . In a national survey, inadequate breastfeeding knowledge was identified as a determinant of short breastfeeding duration among Lebanese women (Zgheib, 2014) . Breastfeeding decisions are embedded and continuously being made, within a woman's cultural and social context, and these decisions appear to be made prenatally (Dykes, 2006) . Based on the theory of planned behaviour, breastfeeding intention is an immediate precursor to breastfeeding behaviour, and in turn, intention is influenced by maternal knowledge and awareness related to breastfeeding (Kavanagh et al., 2012; Sheeham & Schmied, 2011) . Hence, the inclusion of breastfeeding in the DLGP and tackling its benefits, ways to prepare for it and potential barriers and challenges that may be encountered by the lactating mother may help in encouraging Lebanese women to breastfeed their infant. Consensus was reached at 81.8% to present 'Religious Fasting' as an independent theme. As for the guideline formulation, consensus was reached (81.8% during the second round of voting) on the following: 'Always consult with your physician in case you decide to fast (Ramadan or Lent)'. Lebanon includes large Muslim and Christian communities, within which religious fasting is commonly practised (Henley, 2016) . Despite being exempt, many pregnant Muslim women practise fasting during the month of Ramadan, abstaining from eating and drinking from sunrise until sunset (Glazier et al., 2018) . It has been suggested that exposure to a restricted or suboptimal diet during gestation may affect fetal development and can carry lifelong health impacts on the offspring (Glazier et al., 2018) . Although the effects of Ramadan fasting during pregnancy on the health status of the child have been investigated (Awwad et al., 2012; Petherick, Tuffnell, et al., 2014) , conflicting results were reported, and sample sizes were often too small to allow for generalization of findings (Glazier et al., 2018) . A recent systematic review and meta-analysis of observational studies and randomized controlled trials, including 18,920 pregnant women, concluded that Ramadan fasting does not adversely influence birthweight, although there is insufficient evidence related to the potential effects of fasting on other perinatal outcomes (Glazier et al., 2018) . Less data are available on the potential impact of Lent fasting on pregnancy outcomes. This type of fasting, which is based on abstaining from animal source foods, was previously shown to negatively affect maternal nutritional status and dietary patterns, including significant decreases in the average number of meals and diet diversity scores (Desalegn et al., 2018) . Given the lack of clear guidance on fasting during pregnancy, women are advised to seek advice from their physician and health practitioners regarding the safety of Ramadan or Lent fasting (Glazier et al., 2018) . This was a new theme that emerged within the meeting. A total of 82% of attendees agreed on the following guideline: 'Take care of yourself: Eat well, sleep well, feel well'. Psychological wellbeing during pregnancy is increasingly recognized as a crucial factor that may impact pregnancy and birth outcomes (Urech et al., 2010) . Pregnancy, which was once portrayed as a time of greater emotional wellbeing for women, is now acknowledged to be associated with anxiety and other mood disorders, with some women being more vulnerable than others (Cohen et al., 2010; Staneva, 2013) . Low psychological wellbeing and prenatal maternal stress are associated with numerous adverse outcomes, such as fetal growth restriction, LBW and increased risk for preterm delivery (Alder et al., 2007; Lopez Bernal, 2007) . Some studies have also shown that maternal stress and anxiety may be associated with increased arterial blood pressure and pre-eclampsia as well as decreased uterine blood flow (Field et al., 2006; Hern andez-Valencia et al., 2007) . In addition, women with high anxiety, stress or depressive symptoms during pregnancy are more likely to experience mood disorders in the post-partum period, which carries negative consequences on infant development (Schetter & Tanner, 2012) . For instance, post-partum depression and anxiety syndromes were found to be associated with early breastfeeding cessation, lower rates of exclusive breastfeeding and reduced breastfeeding initiation, duration and intensity (Wouk et al., 2017) . It is therefore crucial to raise awareness among pregnant women of the importance to address mental wellbeing during pregnancy by seeking professional help when needed and by instilling lifestyle practices. Such lifestyle practices include, in addition to adequate sleep and optimal diet, maintaining an active lifestyle. Another theme that emerged during the meeting was 'Nutrition Resilience'. Given that the country has been facing frequent emergency conditions (a refugee crisis, an economic meltdown and the global pandemic), the group agreed on the need to address resilience using the following guideline: 'Consider your guidelines when coping with exceptional circumstances'. The concept of 'resilience' and its practical application in nutrition and food security are gaining increasing attention, particularly in regions that witness natural disasters or human-induced political crises (Food and Agriculture Organization of the United Nations, 2014). Lebanon is unfortunately a country that experiences a high frequency of political unrest, financial instability and conflict. The recent financial meltdown experienced by the country is one of the multifaceted challenges that the population is subjected to, with its serious ramifications on food and nutrition security (UNHCR, 2020) . This difficult financial situation is further complicated by the COVID-19 pandemic, with its far-reaching ramifications on the economic welfare and financial self-sufficiency of many families in the country. Amidst this chaotic turmoil, it is crucial that the developed DLGP be adaptable to difficult and emergent situations: It can involve making adjustments in choices related to food utilization; the types of foods to be consumed can be adjusted to favour affordable ones, without jeopardizing the nutrition quality of the diet as a whole (Naja & Hamadeh, 2020) . The developed DLGP will enhance awareness among pregnant women on the importance of showing resilience in face of a crisis and maintaining a healthy lifestyle including eating diets that are high in fruits and vegetables, getting some physical activity when possible, trying to maintain a healthy weight and getting an adequate amount of sleep (Naja & Hamadeh, 2020) . To our knowledge, this study is the first from the EMR to develop through a consensus building exercise, dietary and lifestyle guidelines for pregnant women. The study, however, has few limitations. The selection of participants for the nominal group workshop was not based on objective criteria or randomization. It was rather based on professional opinions with respect to the length of experience of these participants in relevant areas and their involvement in teaching, research or advocacy in maternal nutrition, and they all brought a significant level of expertise to the discussion and consensus building exercise. In addition, the priority themes and guidelines presented in this paper for inclusion in the DLGP are based on a thorough review of currently available literature, but in a number of instances, there is still a scarcity of data. Progress in scientific evidence over time may lead to future updates and revisions of these guidelines. Another limitation is the fact that the literature review undertaken in this study was restricted to the English language. This study has identified the priority themes to be included in the dietary and lifestyle guidelines for pregnant women in Lebanon. These guidelines are devised for women living in a low-middle income country, undergoing the nutrition transition, while building on available scientific evidence and taking long-term health consequences into account. The study responds to the need for improving maternal nutrition as a strategy for enhancing, not only their health but also the health and development of the next generation. Putting maternal nutrition at the heart of tackling malnutrition and its detrimental health outcomes is a core investment for successfully achieving the sustainable development goals of the United Nations (Godfrey, 2017) . Given that the results of consensus methods are, in many instances, considered as first step towards the formulation of the final guidelines (Manera et al., 2019) , the developed guidelines in this study will be put at the disposition of the Lebanese MOPH, as preliminary guidelines for which approval of a larger body of experts is recommended in the future. The authors would like to acknowledge the following graduate students at the Public Health and Nutrition Program at the American University of Beirut for their assistance in the preparations for the The authors declare that they have no competing interests. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Farah Naja https://orcid.org/0000-0002-8861-3498 Jennifer Ayoub https://orcid.org/0000-0003-4866-5856 Lara Nasreddine https://orcid.org/0000-0003-3707-8218 Pre-pregnancy BMI, gestational weight gain and birth outcomes in Lebanon and Qatar: Results of the MINA cohort K2P briefing note: Protecting breastfeeding in Lebanon. Knowledge to Policy (K2P) Center Folate deficiency is associated with nutritional anaemia in Lebanese women of childbearing age Depression and anxiety during pregnancy: A risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature Attitudes and beliefs related to reporting alcohol consumption in research studies: A case from Building consensus in health care: A guide to using the nominal group technique Exercise during pregnancy and the postpartum period. Committee opinion 267 American College of Obstetricians and Gynecologists (ACOG). (2020). Physical activity and exercise during pregnancy and the postpartum period Prevalence of anemia and associated factors in women of childbearing age in rural Lebanon Clinical research ethics review process in Lebanon: Efficiency and functions of research ethics committees-results from a descriptive questionnairebased study Eat for health. Australian dietary guidelines. Providing the scientific evidence for healthier Australian diets Healthy eating pregnancy during your pregnancy Australian Government National Health and Medical Research Council The effect of maternal fasting during Ramadan on preterm delivery: A prospective cohort study Association between artificially sweetened beverage consumption during pregnancy and infant body mass index Maternal caffeine intake from coffee and tea, fetal growth, and the risks of adverse birth outcomes: The generation R study Fluid intake of pregnant and breastfeeding women in Indonesia: A cross-sectional survey with a seven-day fluid specific record Nutritional gaps and supplementation in the first 1000 days Vitamin D-Role in pregnancy and early childhood Prevalence of eating disorders among medical students in a Lebanese medical school: A cross-sectional study Interventions for childhood obesity in the first 1,000 days a systematic review Environmental exposure of pregnant women to infection with Toxoplasma gondii-state of the art Healthy living: Nutrition for pregnancy A review of consumer awareness, understanding and use of food-based dietary guidelines Interplay between early-life malnutrition, epigenetic modulation of the immune function and liver diseases Maternal caffeine intake during pregnancy and risk of fetal growth restriction: A large prospective observational study Knowledge, attitudes, and practices of argileh (water pipe or hubble-bubble) and cigarette smoking among pregnant women in Lebanon Exclusive breastfeeding during the 40-day rest period and at six months in Lebanon: A cross-sectional study Maternal micronutrient deficiency, fetal development, and the risk of chronic disease Treatment of mood disorders during pregnancy and postpartum Prevention of vitamin D deficiency in mothers and infants worldwide-A paradigm shift. Paediatrics and International Child Health Alcohol use in pregnancy Effects and safety of periconceptional oral folate supplementation for preventing birth defects CD007950.pub3 Ethiopian orthodox fasting and lactating mothers: Longitudinal study on dietary pattern and nutritional status in rural Tigray Scientific methodology of the development of the guidelines for the care of people with spina bifida: An initiative of the spina bifida association UK consensus on pregnancy in multiple sclerosis: 'Association of British Neurologists' guidelines Prenatal exposure to maternal smoking during pregnancy and attention-deficit/hyperactivity disorder in offspring: A meta-analysis Breastfeeding in hospital: Mothers, midwives and the production line The complex myeloid network of the liver with diverse functional capacity at steady state and in inflammation Scientific opinion on the safety of caffeine Congenital toxoplasmosis: Priorities for further health promotion action Prenatal depression effects on the fetus and newborn: A review. Infant Behavior and Development Maternal anemia and birth weight: A prospective cohort study Fetal and amniotic fluid iron homeostasis in healthy and complicated murine, macaque, and human pregnancy Strengthening the links between resilience and nutrition in food and agriculture Relation of caffeine intake during pregnancy to intrauterine growth retardation and preterm birth Maternal weight gain in different periods of pregnancy and childhood cardio-metabolic outcomes. The generation R study Dietary calcium and vitamin D intake in an adult Middle Eastern population: Food sources and relation to lifestyle and PTH Prevalence and predictors of vitamin D inadequacy amongst Lebanese osteoporotic women Maternal serum 25-hydroxyvitamin D and measures of newborn and placental weight in a US multicenter cohort study The effect of Ramadan fasting during pregnancy on perinatal outcomes: A systematic review and metaanalysis 1758-Sensible%20Guide%20to%20Healthy%20Pregnancy-EN-Webfinal-v3.pdf Government of Canada Folic acid supplementation and pregnancy: More than just neural tube defect prevention Caffeine intake during pregnancy and adverse birth outcomes: A systematic review and dose-response meta-analysis Intake of artificially sweetened soft drinks and risk of preterm delivery: A prospective cohort study in 59,334 Danish pregnant women The International Federation of Gynecology and Obstetrics (FIGO) recommendations on adolescent, preconception, and maternal nutrition Vitamin D supplementation in pregnancy: A systematic review Eating well with Canada's food guide Religious authority and sectarianism in Lebanon Catecholamines level variation during pregnancy in women with diabetes and preeclampsia Long-term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure and type 2 diabetes: A systematic review and metaanalysis Differential control of central cardiorespiratory interactions by hypercapnia and the effect of prenatal nicotine Dietary reference intakes for vitamin a, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc Weight gain during pregnancy: Reexamining the guidelines nutrition-for-pregnancy.pdf International Food Information Council Foundation and American Academy of Physician Assistants (AAPA) The effect of passive smoking on respiratory health in children and adults Placenta plays a critical role in maternal-fetal resource allocation Breastfeeding knowledge, attitudes, prior exposure, and intent among undergraduate students Vitamin D deficiency among the healthy population in Lebanon Fetal origin of adult disease First nation-wide analysis of food safety and acceptability data in Lebanon. Food Maternal smoking during pregnancy and child outcomes: Real or spurious effect? Nutrition during pregnancy, lactation and early childhood and its implications for maternal and long-term child health: The early nutrition project recommendations Listeriosis in human pregnancy: A systematic review Risk of bottle-feeding for rapid weight gain during the first year of life Nutrition-and feeding practice-related risk factors for rapid weight gain during the first year of life: A population-based birth cohort study Overview. Preterm labour: Mechanisms and management Awareness and knowledge about risks of drinking during pregnancy in pregnant Lebanese women Hypocalcaemia and vitamin D deficiency: An important, but preventable, cause of lifethreatening infant heart failure Consensus methods: Nominal group technique Consumption of artificially-sweetened soft drinks in pregnancy and risk of child asthma and allergic rhinitis Metabolically healthy overweight and obesity is associated with higher adherence to a traditional dietary pattern: A cross-sectional study among adults in Lebanon Relationships between hydration biomarkers and total fluid intake in pregnant and lactating women Proper maternal nutrition during pregnancy planning and pregnancy: A healthy start in life recommendations for health care professionals -The experience from Latvia. Ministry of Health A dose-response relationship between maternal smoking during late pregnancy and adult intelligence in male offspring Early childhood healthy and obese weight status: Potentially protective benefits of breastfeeding and delaying solid foods. Maternal and Child Health Journal Physical activity and maternal obesity: cardiovascular adaptations, exercise recommendations, and pregnancy outcomes Pregnancy-related food habits among women of rural Sikkim Consensus development methods, and their use in clinical guideline development A Western-style obesogenic diet alters maternal metabolic physiology with consequences for fetal nutrient acquisition in mice The use of complementary and alternative medicine among lebanese adults: Results from a national survey Nutrition amid the COVID-19 pandemic: A multi-level framework for action A novel Mediterranean diet index from Lebanon: Comparison with Europe Postpartum weight retention and its determinants in Lebanon and Qatar: Results of the mother and infant nutrition assessment (MINA) cohort Review of the nutrition situation in the eastern Mediterranean region Differences in dietary intakes among Lebanese adults over a decade: Results from two national surveys Food consumption patterns in an adult urban population in Beirut Omega-3 fatty acids. Fact sheet for health professionals New Zealand Government Ministry of Health documents/Healthy-Eating-During-Pregnancy.pdf Office on Women's Health/US Department of Health & Human Services Effects of packaging type and storage temperature on the growth of foodborne pathogens on shredded 'Romaine' lettuce Consensus on priorities in maternal education: Results of Delphi and nominal group technique approaches Relationship between artificially sweetened and sugar-sweetened cola beverage consumption during pregnancy and preterm delivery in a multi-ethnic cohort: Analysis of the Born in Bradford cohort study Experiences and outcomes of maternal Ramadan fasting during pregnancy: Results from a sub-cohort of the Born in Bradford birth cohort study Nutrition in the first 1000 days: Ten practices to minimize obesity emerging from published science Behavioral factors influencing childhood obesity: A systematic review and meta-analysis Breastfeeding and complementary feeding: Recommendations on infant nutrition Position of the Academy of Nutrition and Dietetics: Nutrition and lifestyle for a healthy pregnancy outcome The relationship between maternal anemia during pregnancy with preterm birth: A systematic review and meta-analysis Maternal caffeine consumption during pregnancy and risk of low birth weight: A dose-response meta-analysis of observational studies Reducing low birthweight by resolving risks: Results from Colorado's prenatal plus program Infektionsepidemiologisches Jahrbuch meldepflichtiger Krankheiten für 2010 Prenatal tobacco use and risk of stillbirth: A case-control and bidirectional casecrossover study Drinking water and pregnancy outcome in central North Carolina: Source, amount, and trihalomethane levels Anxiety, depression and stress in pregnancy: Implications for mothers, children, research, and practice. Current Opinion in Rare infectious diseases in Germany. Obligatory notification results Exercise, employment, other daily activities, and adverse pregnancy outcomes Advocacy for improving nutrition in the first 1000 days to support childhood development and adult health The need for strategies that support women who are breastfeeding A systematic review of outcomes of maternal weight gain according to the Institute of Medicine recommendations: Birthweight, fetal growth, and postpartum weight retention Identifying and prioritizing information needs and research priorities of public health emergency preparedness and response practitioners Conference on 'Nutrition at key life stages: new findings, new approaches'; Symposium 2: Nutrition in early life. The role of infant nutrition in the global epidemic of non-communicable disease Maternal and perinatal morbidity and mortality associated with anemia in pregnancy The important connection: Psychological wellbeing during pregnancy and birth outcomes The outcomes of complementary and alternative medicine use among pregnant and birthing women: Current trends and future directions Physical activity and gestational weight gain: A meta-analysis of intervention trials Eating habits and dietary guidelines Artificial sweeteners produce the counterintuitive effect of inducing metabolic derangements Prevalence of anemia among women of reproductive age (% of women ages 15-49) -Lebanon Diabetes and hypertension, as well as obesity and Alzheimer's disease, are linked to hypohydration-induced lower brain volume Association between breastfeeding and childhood obesity: Analysis of a linked longitudinal study of rural Appalachian fifth-grade children Food security and agriculture 2020 mid year sector report Nutrition during pregnancy and breastfeeding -Brochure. https:// www.unicef.org/nutrition/files/Brochure_maternal_nutrition.pdf University of Arkansas/Division of Agriculture Effects of relaxation on psychobiological wellbeing during pregnancy: a randomized controlled trial Bottom-up development of national obstetric guidelines in middle-income country Suriname The global prevalence of anaemia in 2011 World Health Organisation guideline: Optimal serum and red blood cell folate concentrations in women of reproductive age for prevention of neural tube defects. World Health Organisation The optimal duration of exclusive breastfeeding: Report of an expert consultation Good maternal nutrition: The best start in life WHO recommendations on antenatal care for a positive pregnancy experience Postpartum mental health and breastfeeding practices: An analysis using the 2010-2011 pregnancy risk assessment monitoring system The association between breastfeeding and childhood obesity: a meta-analysis Infant and young child feeding practices in Lebanon: A national cross-sectional study (master of science) The 12 identified themes for the Lebanese DLGP and their respective guidelines, in Arabic language :