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Background  Although global nutrition/dietary transition resulting from industrialisation and urbanisation has been identified as a major contributor to widespread trends of obesity, there is limited data in pregnant women, including those living with HIV in South Africa. We examined food-based dietary intake in pregnant women with and without HIV at first antenatal care (ANC) visit, and associations with maternal overweight/obesity and gestational weight gain (GWG).    Methods  In an urban South African community, consecutive women living with ( n  = 479) and without ( n  = 510) HIV were enrolled and prospectively followed to delivery. Interviewer-administered non-quantitative food frequency questionnaire was used to assess dietary intake (starch, protein, dairy, fruits, vegetables, legumes, oils/fats) at enrolment. Associations with maternal body mass index (BMI) and GWG were examined using logistic regression models.    Results  Among women (median age 29 years, IQR 25–34), the prevalence of obesity (BMI ≥ 30 kg/m 2 ) at first ANC was 43% and that of excessive GWG (per IOM guidelines) was 37% overall; HIV prevalence was 48%. In women without HIV, consumption of potato (any preparation) (aOR 1.98, 95% CI 1.02–3.84) and pumpkin/butternut (aOR 2.13, 95% CI 1.29–3.49) for 1–3 days a week increased the odds of overweight/obesity compared to not consuming any; milk in tea/coffee (aOR 6.04, 95% CI 1.37–26.50) increased the odds of excessive GWG. Consumption of eggs (any) (aOR 0.52, 95% CI 0.32–0.86) for 1–3 days a week reduced the odds of overweight/obesity while peanut and nuts consumption for 4–7 days a week reduced the odds (aOR 0.34, 95% CI 0.14–0.80) of excessive GWG.  In women with HIV, consumption of milk/yoghurt/maas to drink/on cereals (aOR 0.35, 95% CI 0.18–0.68), tomato (raw/cooked) (aOR 0.50, 95% CI 0.30–0.84), green beans (aOR 0.41, 95% CI 0.20–0.86), mixed vegetables (aOR 0.49, 95% CI 0.29–0.84) and legumes e.g. baked beans, lentils (aOR 0.50, 95% CI 0.28–0.86) for 4–7 days a week reduced the odds of overweight/obesity; tomato (raw/cooked) (aOR 0.48, 95% CI 0.24–0.96) and mixed vegetables (aOR 0.38, 95% CI 0.18–0.78) also reduced the odds of excessive GWG.    Conclusions  Diet modification may promote healthy weight in pregnant women living with and without HIV.    Supplementary Information  The online version contains supplementary material available at 10.1186/s12889-021-11566-2.

Association between food intake and obesity in pregnant women living with and without HIV in Cape Town, South Africa: a prospective cohort study