The Double-Future Dilemma: Dietary Diversity, Pregnancy Outcomes, and Planetary Health

Background: Dietary quality has been linked to adequate nutrient intake and women’s health. However, the relationships among dietary diversity, pregnancy outcomes and environmental sustainability remain uncertain. Methods: This study evaluated the associations between adherence to the Minimum Dietary Diversity for Women (MDD-W), pregnancy outcomes, and the environmental footprints of maternal diets. This was a multicentre prospective cohort that included 1,318 low-risk nulliparous women in Brazil and used 24-hour dietary recall (24hR). Maternal diets were classified according to adherence to the Minimum Dietary Diversity for Women (MDD-W) guidelines. Associations between MDD-W adherence and pregnancy outcomes were assessed via logistic regression. The environmentalimpacts of maternal diets were estimated via the Footprints of Foods and Culinary Preparations Consumed in the Brazil database. Results: In the total sample, 904 women achieved MDD-W adequacy (≥5 food groups), whereas 414 were classified in the non-adequacy group (<5 food groups). MDD-W adequacy was not associated with adverse pregnancy outcomes(OR = 0.90, 95% CI: 0.69–1.17). Although the main differencein dietary intake between groups was predominantly plant-based, the adequacy group had greater environmental impacts, even after adjustment per 1,000 kcal, in terms of the ecological footprint(eco-score/day), carbon emissions (g/day) and water use (L/day). The MDD-W is a useful indicator of adequate micronutrient intake. However, dietary intake ofcalcium, iron, folate, and vitamin A was below the recommended levelin approximately 80% of individuals in both groups. Conclusions: Our findings suggest that although MDD-W adherence is a useful tool for dietary micronutrient intake, it is not associated with pregnancy outcomes and that achieving dietary diversity may entail a greaterenvironmental footprint, revealing trade-offs between nutritional adequacy indicators and sustainability goals. This underscores the need for integrated food and nutrition policies that simultaneously address maternal health and environmental sustainability. Pregnant women sit at the nexus of human and planetary futures, highlighting the need for a “double future” perspective linking maternal health and planetary boundaries.