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                Open access                                                                                                                                 Original research
                                                  Associations between antenatal                                                                                                                     BMJ Open: first published as 10.1136/bmjopen-2020-046790 on 21 February 2022. Downloaded from 
                                                  maternal diet and other health aspects 
                                                  with infant temperament in a large 
                                                  multiethnic cohort study: a path 
                                                  analysis approach
                                                                                1,2                                            3                                     1                    3
                                                  Anja Schoeps     ,                 Teresa Gontijo de Castro,  Elizabeth R Peterson,  Clare Wall,  
                                                                                   4,5                            1                         6
                                                  Stephanie D'Souza,  Karen E Waldie,  Susan Morton
              To cite: Schoeps A, Gontijo         ABSTRACT                                                                  Strengths and limitations of this study
              de Castro T, Peterson ER,           Objectives  The aim of this study was to assess the 
              et al.  Associations between        association of antenatal maternal dietary patterns (DPs) 
              antenatal maternal diet and         and other health aspects with infant temperament in a                     ► This is the first study to look at the association be-
              other health aspects with           large multiethnic cohort, taking maternal personality and                     tween the whole of diet and infant temperament.
              infant temperament in a large       prenatal stress into account.                                             ► A major strength is the use of path analysis, which 
              multiethnic cohort study: a path    Design and methods  Using data from 3968 children born                        enables the exploration of the complex inter- 
              analysis approach. BMJ Open                                                                                       relations between antenatal maternal diet, antenatal 
              2022;12:e046790. doi:10.1136/       in 2009/2010 and their mothers from the Growing Up in                         stress and maternal personality.
              bmjopen-2020-046790                 New Zealand cohort, infant temperament was assessed at                    ► This analysis uses data from roughly 4000 chil-
              ► Prepublication history and        9 months using the Infant Behavior Questionnaire- Revised                     dren and their mothers from a large multiethnic 
              additional supplemental material    Very Short Form. Maternal antenatal diet and other health                     population- representative  cohort.
              for this paper are available        aspects were assessed antenatally. Maternal DPs (n=4) were                ► It is a limitation of this study that all information was 
              online. To view these files,        derived using principal components analysis based on food                     mother- reported and could be not validated by ob-
              please visit the journal online     intake reported on a 44- item food frequency questionnaire.                   served information.
              (http://dx.doi.org/10.1136/         Path analyses investigated factors associated with infant                 ► A further limitation, which comes as a result of the 
              bmjopen-2020-046790).               temperament, namely maternal personality, prenatal maternal                   large number of variables in the analysis, is that 
                                                  stress, DPs and other health aspects, including potential inter- 
              Received 09 November 2020           relations and mediating effects.                                              more than one- third of the initial study population                 http://bmjopen.bmj.com/
              Accepted 19 January 2022            Results  Women who scored higher in the fusion DP                             of about 6500 children could not be considered in 
                                                  (standardised beta (β)=0.05; 95% CI 0.02 to 0.09) and                         the analysis.
                                                  healthy DP (β=0.05; 95% CI 0.02 to 0.09), who exercised 
                                                  more (β=0.04; 95% CI 0.01 to 0.07), and who drank 
                                                  less alcohol (β=−0.05; 95% CI −0.08 to –0.02) were                      influenced over time by heredity, maturation, 
                                                  more likely to have infants with an overall less difficult              and experience’ (Rothbart and Derryberry, 
                                                  temperament. Sex- specific differences were found                                1
                                                  in the associations between maternal DP and infant                      p.37),  and is typically conceptualised in 
                                                  temperament. Maternal personality and prenatal stress                   the three broad dimensions: Negative Affec-                                 on January 9, 2023 by guest. Protected by copyright.
                                                  were significantly associated with all dimensions of infant             tivity—tearful, easily frustrated, difficult to 
                                                  temperament. The strongest predictors for a more difficult              soothe; Surgency—happy, active, sensation- 
                                                  temperament were prenatal stress (β=0.12; 95% CI 0.08                   seeking; and Effortful Control—attentive, 
                                                                                                                                                                     2
                                                  to 0.15) and the personality dimensions neuroticism                     concentrated, easy to please.  Temperament 
                                                  (β=0.10; 95% CI 0.07 to 0.14) and extraversion (β=−0.09;                in infancy is of public health interest, because 
              © Author(s) (or their               95% CI −0.12 to –0.06).                                                 it is the foundation on which behaviour and 
              employer(s)) 2022. Re- use          Conclusions  Associations of antenatal maternal diet and                personality develop, and thus has been shown 
              permitted under CC BY- NC. No       health aspects with infant temperament were statistically               to predict later problem behaviour, cognitive 
              commercial re- use. See rights      significant but small. While they should not be overinterpreted                                                                       3–8
              and permissions. Published by       as being deterministic, the findings of this study support the          outcomes and mental and physical health.
              BMJ.                                link between maternal modifiable health- related behaviours                Current research is making advances in 
              For numbered affiliations see       and infant temperament outcomes.                                        explaining differences in temperament, 
              end of article.                                                                                             behaviour and mental health not only by 
              Correspondence to                                                                                           examining genetic differences but also 
              Dr Anja Schoeps;                    INTRODUCTION                                                            through a multitude of early life exposures. 
               anja. schoeps@ uni- heidelberg.    Temperament is defined as ‘constitutional  Based on the Developmental Origins of 
              de                                  differences in reactivity and regulation…  Health and Disease approach, which puts 
                                                           Schoeps A, et al. BMJ Open 2022;12:e046790. doi:10.1136/bmjopen-2020-046790                                                     1
                 Open access 
                                                                                                                                                                                                                         BMJ Open: first published as 10.1136/bmjopen-2020-046790 on 21 February 2022. Downloaded from 
                the first 1000 days between conception and the second                                                  The aim of our study was to assess the association 
                birthday into focus, research has increasingly focused                                              between antenatal maternal dietary patterns and other 
                on common in utero exposures, such as stress, health                                                health aspects with infant temperament in a large multi-
                                                                                        9–11
                behaviour and variations in maternal diet.                                    There is              ethnic cohort using path analyses, which enable the 
                now growing evidence that the offspring’s psychological,                                            exploration of the complex inter-relations between ante                                     -
                behavioural and cognitive development is associated with                                            natal maternal diet and other health aspects, antenatal 
                such variations in the in utero environment, especially                                             stress and maternal personality.
                                                                   11–16
                with regards to maternal stress.                          Apart from its poten-
                tial direct effect on the fetus’s brain, stress experience 
                has also been shown to coincide with and to alter the 
                mother’s behaviour with regards to dietary intake, phys-                                            METHODS
                                                                                           17 18                    Study population
                ical activity or medication and drug intake,                                      which 
                may in turn have direct effects on the fetus’s develop-                                             This study was conducted within the contemporary New 
                         11 12 19 20                                                                                Zealand birth cohort study Growing Up in New Zealand 
                ment.
                   A number of studies have associated particular diets or                                          (GUiNZ), which enrolled 6822 pregnant women and their 
                                                                                                                    6853 children who survived to age 6 weeks.29
                specific nutrient intakes or deficiencies with changes in                                                                                                                          Written 
                                                                                  21–23                             informed consent was obtained from all mothers in this 
                temperament or behaviour in children,                                    however, to 
                date, no published study has looked at the associations                                             study. The cohort of children is broadly generalisable 
                between the whole of diet and temperament or behaviour                                              to New Zealand birth statistics with respect to ethnicity, 
                                 24                                                                                                                                                 29
                in infancy.  During the last few years, a small body of                                             maternal age and socioeconomic status.  This study used 
                studies has evolved which investigated potential effects                                            information from three data collection waves, completed 
                of certain aspects of maternal diet in conjunction with                                             antenatally and when the children were approximately 
                                        11 15                                                                       9 months and 2 years old. From the antenatal question-
                prenatal stress.               In their literature review, Monk et al 
                state, ‘These prenatal experiences exert their influence                                            naire, we used information on maternal stress, sociode-
                in the context of one another and yet, almost uniformly,                                            mographics and health aspects, including diet (assessed 
                are studied independently’. Since 2013, a small number                                              with a food frequency questionnaire (FFQ)). Infant 
                of studies have shown that a bidirectional effect between                                           temperament was assessed at the 9-month inter                                 view and 
                stress and diet exists, and that there are possible inter-                                          maternal personality was assessed at the 2-year inter                                view. 
                action effects of prenatal stress and diet/nutrition on                                             Baby’s sex and gestational age were collected perinatally 
                infant and child temperament and behaviour develop-                                                 and linked to GUiNZ data set from perinatal and mater-
                         11 17 25–27                                                                                nity records.30
                ment.                   However, only two of the above studies 
                looked at infant temperament, one at the association with                                              Infants were included in the analysis: if information 
                                                           26                                                       on infant temperament was available from the 9- month 
                antenatal chocolate intake  and the other at the associa-
                tion with antenatal omega 3 to omega 6 fatty acid intake                                            interview; if mothers had provided information on stress,                                            http://bmjopen.bmj.com/
                        27                                                                                          sociodemographics, diet and other health aspects ante-
                ratio,  and none has investigated the influence of the 
                whole of maternal diet during pregnancy on the offspring                                            natally; if mothers had provided information on maternal 
                temperament.                                                                                        personality at the 2-year inter                 view; and if perinatal infor-
                   In summary, while there is a body of studies on the asso-                                        mation could be linked from the official records (n=6129 
                ciations between certain domains of prenatal stress, diet                                           of the 6476 children who took part in the 9- month inter-
                and other health aspects with infant and child tempera-                                             view) (online supplemental figure 1). Children were 
                ment, the literature in this field is very patchy, excessively                                      excluded from analysis if factors were present, which 
                heterogeneous and conspicuously devoid of null results.                                             would likely affect the validity of the infant temperament                                            on January 9, 2023 by guest. Protected by copyright.
                Moreover, most of the studies have three major shortcom-                                            scale: inadequate English language skills of the mother 
                ings in common: (1) failure to draw a complete picture                                              (n=161); infant’s behaviour during the preceding week 
                of antenatal maternal diet and other health aspects: a                                              less than somewhat typical (scores 1–2) (n=703); born 
                large proportion of publications studied single micro-                                              preterm (n=393); or older than 52 weeks old at the inter-
                nutrients or macronutrients in isolation, thus neglecting                                           view (n=107), as this is outside the target range of the 
                                                                                                                                                                     31
                the context of the whole of diet or other health aspects,                                           infant temperament measure.  Children whose mothers 
                such as exercise or smoking and alcohol consumption;                                                had not been able to respond to the antenatal question-
                (2) poor confounder adjustment: while the majority of                                               naire prior to giving birth were excluded to minimise 
                studies adjusted for sociodemographic variables, such as                                            recall bias for the FFQ (n=712). Finally, n=179 children 
                maternal age and education, maternal personality was                                                had to be excluded from analysis because of missing 
                not considered as potential confounder, even though                                                 values in at least one of the explanatory or adjustment 
                a substantial part of temperament is thought to be                                                  variables other than body mass index (BMI) and gesta-
                             28                                                                                     tional weight gain. Thus, the final number of children 
                genetic;  and (3) limited statistical analyses techniques 
                to explore inter- related factors such as maternal person-                                          assessed was 3968, corresponding to 61.3% of the chil-
                ality, maternal stress, maternal diet, other health aspects                                         dren who took part in the 9-month inter                                view (online 
                and their effect on temperament.                                                                    supplemental figure 1).
                2                                                                                                  Schoeps A, et al. BMJ Open 2022;12:e046790. doi:10.1136/bmjopen-2020-046790
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Open access
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                                                                                                                                 Study variables                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             In alignment with these recommendations, we calculated 
                                                                                                                                 Antenatal maternal diet                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     a weighted exercise score, towards which vigorous physical 
                                                                                                                                 Antenatal maternal diet was assessed by a semiquantita-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     activity counted with a factor of 1, and moderate physical 
                                                                                                                                 tive 44- item FFQ during pregnancy, for which mothers                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       activity with a factor of 0.4.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Pre-
                                                                                                                                 recalled their food intake over the 4 weeks preceding the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       pregnancy  BMI was calculated based on self- 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             reported pre-pregnancy weight and height and it was clas
                                                                                                                                 antenatal interview. The food list of the FFQ was devel-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             -
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   37
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          offs.                                                                           Monthly gestational 
                                                                                                                                 oped based on the New Zealand Ministry of Health guide-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     sified according to the WHO cut-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  32                                                                                                                                                                                                                                                                                                                                                                         weight gain (kg) was calculated as the difference between 
                                                                                                                                 lines for healthy pregnant women,  which recommends 
                                                                                                                                 the adequate intake of four core food groups: fruits and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    the current weight at the time of the antenatal interview 
                                                                                                                                 vegetables, breads and cereals, milk and milk products                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      and the reported pre- pregnancy weight. To take account 
                                                                                                                                 and lean meat, meat alternatives and eggs. The frequency                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    of different gestational ages at the time of the interview, 
                                                                                                                                 of the intake of individual foods was described by catego-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  this difference was divided by the elapsed months of preg-
                                                                                                                                 ries increasing from not at all or less than once a month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   nancy up to the time of the interview.
                                                                                                                                 to a number of times per month, week or day. Show cards                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Nausea experience was reported during the first 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         33 34                                                                                                                                                                                                               trimester and after the first trimester on a 4-point scale,  
                                                                                                                                 were used to illustrate a standard portion size.
                                                                                                                                                             A previous study identified four distinct dietary patterns                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      ranging from 0 – no nausea, over 1 – mild nausea and 
                                                                                                                                 (DPs) during pregnancy using principal components                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           2 – moderate nausea, to 3 – severe nausea, respectively. 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            34                                                                               In this study, nausea was defined as the maximum severity 
                                                                                                                                 analysis and performing a varimax orthogonal rotation.  
                                                                                                                                 High loadings for the food items were defined as being                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      of nausea experienced at any time during pregnancy. 
                                                                                                                                 larger than 0.30 or smaller than −0.30. The DP junk was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Finally, we also captured self- reported alcohol consump-
                                                                                                                                 characterised by high positive loadings for confectionary,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  tion and smoking during pregnancy. We created three 
                                                                                                                                 snacks, takeaways, hot chips, soft/energy drinks, cakes/                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    categories: women who did not drink any alcohol before 
                                                                                                                                 biscuits, processed meats, battered fried fish/seafood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      pregnancy; women who stopped drinking alcohol at the 
                                                                                                                                 and ice cream. The healthy DP had high positive loadings                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    beginning of pregnancy; and women who drank alcohol 
                                                                                                                                 for vegetables, brown whole meal bread, cheese, non-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        during pregnancy. Self-reported                                                                                                                                                                                                                                                                                                                                                                                                                                                      smoking behaviour was 
                                                                                                                                 citrus fruits, yoghurt, dried fruits, high fibre cereal and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 categorised likewise.
                                                                                                                                 Vegemite/Marmite. The traditional DP had high positive 
                                                                                                                                 loadings for whole/standard milk, white bread, marga-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Prenatal stress
                                                                                                                                 rine, jam/honey/marmalade, peanut butter/Nutella and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Prenatal perceived stress was assessed during the ante-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        38
                                                                                                                                 a high negative loading for skim/trim milk. The fusion                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      natal interview by the 10- item Perceived Stress Scale,  for 
                                                                                                                                 DP had high positive loadings for noodles/rice/pasta,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       which women have to report the frequency of different 
                                                                                                                                 seafood, chicken, green leafy vegetables, eggs, red meat,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   stress- related experiences and feelings during the 
                                                                                                                                 processed fish and citrus fruits (online supplemental                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       preceding 4 weeks on a 5- point scale (1=Never, 2=Almost 
                                                                                                                                                                                                                                                       34                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    never, 3=Sometimes, 4=Fairly often, 5=Very often). The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     http://bmjopen.bmj.com/
                                                                                                                                 table 1).  Together, these four DPs explained 23.4% of 
                                                                                                                                 the total dietary variance in this population and individu-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 perceived stress score was retrieved by summing up over 
                                                                                                                                 ally the junk, healthy, traditional and fusion DPs explained                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                the 10 items.
                                                                                                                                 7.7%, 5.6%, 5.4% and 4.8% of the dietary variance, 
                                                                                                                                 respectively. For all following analyses, the women were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Maternal personality
                                                                                                                                 ranked in quintiles of the score in each of the four respec-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Maternal personality was assessed by the big five inven-
                                                                                                                                                                                                                                                       34                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   39 40
                                                                                                                                 tive DPs.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   tory (BFI) at the 2- year interview.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                The 44 items for 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             the assessment of personality are a popular measure of 
                                                                                                                                 Other relevant health aspects                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               personality due to the established factor structure, high                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   on January 9, 2023 by guest. Protected by copyright.
                                                                                                                                 Folic acid supplementation during pregnancy was  reliability, good convergent validity with other longer 
                                                                                                                                 described in three categories: folic acid supplementation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Big Five measures of personality and acceptable self- 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       39–41
                                                                                                                                 that started before pregnancy; folic acid supplementation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   peer agreement.                                                                                                                                                                                                                                                                                  While few studies have looked at 
                                                                                                                                 that started in first trimester; and folic acid supplementa-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                the stability of the BFI 44 across adulthood, high stability 
                                                                                                                                 tion that started after the first trimester or never.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       has been reported with the BFI 44 over a 3-year period  
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     42
                                                                                                                                                             Women reported on their moderate and vigorous                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   across middle adulthood.  In addition, research using 
                                                                                                                                 weekly physical activity before and during pregnancy by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     the Big Five personality traits more generally, has repeat-
                                                                                                                                 providing the number of days with exercise and the dura-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    edly shown that the rank order stability of the Big Five 
                                                                                                                                 tion of an average exercise episode over the last 7 days.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   personality increases with age peaking at around the age 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            42 43
                                                                                                                                 Using an abbreviated version of the International Phys-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     of 60 and does not vary much by assessment method.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     35
                                                                                                                                 ical Activity Questionnaire,  we decided to focus on pre-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   The BFI 44 used in this study uses a 5-point Likert scale  
                                                                                                                                 pregnancy exercise because pre-pregnancy exercise levels                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    which asks how strongly a person agrees or disagrees with 
                                                                                                                                 are not affected by pregnancy health problems. The Amer-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    statements about themselves. Each item is associated with 
                                                                                                                                 ican College of Sports Medicine and the American Heart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      one of the five personality factors: extraversion—sociable, 
                                                                                                                                 Association recommend 150 min of moderate or 60 min                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         outgoing, energetic; agreeableness—forgiving, compliant, 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            36
                                                                                                                                 of vigorous physical activity for adults aged 18–65 years.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  sympathetic;                                                                                                                                                                                                                    conscientiousness—organised, efficient, 
                                                                                                                                 Schoeps A, et al. BMJ Open 2022;12:e046790. doi:10.1136/bmjopen-2020-046790                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   3
                      Open access 
                                                                                                                                                                                                                                                                                         BMJ Open: first published as 10.1136/bmjopen-2020-046790 on 21 February 2022. Downloaded from 
                    thorough;  neuroticism—irritable, shy, moody; and open-                                                                           one at the household level. Area deprivation was based 
                    ness—imaginative, curious, excitable.39 Scores for the five                                                                       on results from the 2006 National Census around nine 
                    personality factors are derived by averaging over all items                                                                       socioeconomic indicators, which enabled assignment of 
                    that load on the respective factors.                                                                                              a 10-point             deprivation index to each geographical area, 
                                                                                                                                                      where 1 was assigned to the least deprived areas and 10 
                    Infant temperament                                                                                                                                                                         46
                                                                                                                                                      to the most deprived areas.  Household deprivation was 
                    The 37- item Infant Behavior Questionnaire-Revised V                                                              ery             based on six questions from the 9- month interview, asking 
                    Short Form (IBQ- R VSF) was used to assess infant temper-                                                                         mothers if their financial situation during the preceding 
                    ament at the 9- month interview.31 In a previous analysis it                                                                      12 months had affected their access to adequate food, 
                    was shown that a five-factor                                 structure was a better statis-                                       clothing and/or heating. A mean score was calculated 
                    tical fit for the Growing Up in New Zealand Cohort than                                                                           over the six variables, with higher values indicating more 
                                                                                               44
                    the original three- factor structure.  The fit of the five-                                                                       severe household deprivation.
                                                                                                                                         44
                    factor model was found to be acceptable in this cohort  
                    and the factors were found to be similarly precise across                                                                         Statistical analysis
                    four ethnic groups (European, Maori, Pacific Peoples and                                                                          We fitted path analysis models to assess the associations 
                                     45
                    Asians).  In addition, within this cohort, the five factors                                                                       between the dimensions of maternal personality, stress, 
                    have also been related to mother- and partner- reported                                                                           maternal diet/other health aspects and infant tempera-
                    infant closeness, parenting confidence and parenting                                                                              ment. To determine the important paths, we first assessed 
                                                                                                       44
                    satisfaction in the expected direction.  The five- factor                                                                         pairwise associations between these dimensions. We used 
                    model consists of Negative Affectivity (NEG), Positive Affect                                                                     directed acyclic graphs (DAGs) to describe hypothesised 
                    and Surgency (PAS) and a slightly altered factor Orienting                                                                        associations between our exposures, outcome, and poten-
                                                                                                                                                                                                              47
                    Capacity (OC), along with two new factors Affiliation/                                                                            tial confounding variables.  A graphical presentation of 
                    Regulation (AR) and Fear, which separated out from the                                                                            our proposed DAGs can be found in online supplemental 
                    broader factors of Orienting and Regulatory Capacity and                                                                          figure 2. We made decisions about which confounders we 
                    NEG, respectively (see online supplemental table 2) for a                                                                         needed to adjust for in the respective analyses based on 
                    brief description of these factors).                                                                                              the respective DAGs. All regression models and path anal-
                         In completing the IBQ-R VSF                                      , mothers or caregivers                                     yses were adjusted for the six sociodemographic variables.
                    were asked to indicate how frequently their child engaged 
                    in specific behaviours during the past week on a scale                                                                            Preparatory analysis
                    from 1 to 7 (1=Never, 2=Very rarely, 3=Less than half the time,                                                                   To determine the important paths for the path analysis, 
                    4=About half the time, 5=More than half the time, 6=Almost                                                                        in the preparatory analyses we first assessed pairwise 
                    always, 7=Always). The mothers could choose the option                                                                            associations via multivariable linear regressions between 
                    ‘not applicable’ if they had not seen the child in the situ-                                                                      the following dimensions: (A) maternal personality and 
                    ation. Temperament scores were calculated by averaging                                                                            prenatal perceived stress; (B) maternal personality/stress                                                                         http://bmjopen.bmj.com/
                    over all items that were found to load on the respective                                                                          and DPs/other health aspects; (C) maternal person-
                    temperament factors. Because infant behaviour is very                                                                             ality/stress and infant temperament; and (D) DPs/other 
                    changeable over any given week (eg, due to illness or                                                                             health aspects and infant temperament. Associations 
                    teething), and the reference period for the questionnaire                                                                         between maternal personality and prenatal perceived 
                    was the behaviour over the last week, an additional ques-                                                                         stress were examined by regressing stress on the five 
                    tion was asked: ‘In terms of your baby’s behaviour, how                                                                           factors of maternal personality (online supplemental 
                    typical has the last week been for your baby?’, in which                                                                          figure 2, Panel A). Associations between maternal person-
                    mothers were asked to respond on a scale from 1 (not at                                                                           ality/stress and DPs/other health aspects were assessed                                                                             on January 9, 2023 by guest. Protected by copyright.
                    all typical) to 5 (very typical).44                                                                                               by regressing each of the eleven maternal health aspects 
                                                                                                                                                      (DPs and other health aspects) on the five factors of 
                    Sociodemographic variables/adjustment set                                                                                         maternal personality and the one stress factor: a total of 
                    We used six antenatal sociodemographic variables in our                                                                           11 distinct linear regression models, adjusting for the 
                    analyses: parity; maternal education; maternal age; self-                                                                         six major confounders from the adjustment set (online 
                    prioritised ethnicity; deprivation at area level; and depri-                                                                      supplemental figure 2, Panel B). Continuous outcomes 
                    vation at household level. Parity is binary in these analyses                                                                     are a requirement for linear regression. To be able to 
                    and discriminates between first-born                                          and subsequent chil-                                use diet and other health aspect variables as outcomes, 
                    dren. Mothers’ education was assessed in five categories,                                                                         these variables were transformed from categorical to 
                    namely: no secondary school qualification; secondary                                                                              ordinal scale, which implies a clear order of values: 
                    school qualification; diploma or trade certificate; bach-                                                                         DPs (in quintiles); folic acid supplementation; nausea; 
                    elor’s degree; and higher degree. The maternal self-                                                                              alcohol consumption; and smoking. To give an example, 
                    prioritised ethnic group was categorised into: European;                                                                          alcohol was used as a continuous variable, taking on the 
                    Māori; Pacific Peoples; Asian; and Middle Eastern, Latin                                                                          values 0–1–2 for women who: did not drink any alcohol 
                    American, African and Other. We used two distinct vari-                                                                           before pregnancy (0); who stopped drinking alcohol at 
                    ables to account for deprivation, one at the area level and                                                                       the beginning of pregnancy (1); and who drank alcohol 
                    4                                                                                                                                 Schoeps A, et al. BMJ Open 2022;12:e046790. doi:10.1136/bmjopen-2020-046790
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...Open access original research associations between antenatal bmj first published as bmjopen on february downloaded from maternal diet and other health aspects with infant temperament in a large multiethnic cohort study path analysis approach anja schoeps teresa gontijo de castro elizabeth r peterson clare wall stephanie d souza karen e waldie susan morton to cite abstract strengths limitations of this t er objectives the aim was assess et al association dietary patterns dps is look at be taking personality tween whole prenatal stress into account major strength use which design methods using data children born enables exploration complex inter relations doi their mothers growing up new zealand assessed uses roughly chil prepublication history months behavior questionnaire revised dren additional supplemental material very short form population representative for paper are available were antenatally n it limitation that all information online view these files derived principal component...

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