Correlates of Prenatal Diet Quality in Low-Income Hispanic Women

Abstract

Background

Low-income Hispanic women are at-risk of poor prenatal diet quality. Correlates associated with prenatal diet quality in this group of women are understudied.

Objective

The objective of this study was to examine the associations between financial, cultural, psychosocial, and lifestyle correlates and prenatal diet quality in low-income Hispanic women.

Design

This cross-sectional analysis used data from pregnant women enrolled in the Starting Early Trial, a randomized-controlled trial of a primary-care based child obesity prevention program beginning in pregnancy. The trial enrolled women from clinics affiliated with a large urban medical center in New York City from 2012 – 2014. Financial, cultural, psychosocial, and lifestyle variables were collected using a comprehensive baseline questionnaire. Usual dietary intakes over the past year were assessed using the Block Food Frequency Questionnaire 2005 bilingual version.

Participants

The study enrolled low-income Hispanic women between 28 and 32 gestational weeks (n=519).

Main outcome measures

Prenatal diet quality was measured by the Healthy Eating Index (HEI)-2015.

Statistical analyses performed

Unadjusted and adjusted multivariable linear regression analyses were performed to determine independent associations between financial, cultural, psychosocial, and lifestyle correlates and HEI-2015 total score.

Results

Overall prenatal diet quality was poor (mean HEI-2015 total score: 69.0 ± 9.4). Most women did not meet the maximum score for total vegetables (65.3%), whole grains (97.1%), dairy (74.8%), fatty acids (84.4%), refined grains (79.8%), sodium (97.5%), saturated fats (92.9%), and added sugars (66.5%). Women who reported screen time ≥2 hours/day, physical activity before and/or during pregnancy, and being born outside the US had higher mean HEI-2015 total score than women with screen time >2 hours/day, no physical activity, and those born in the US.

Conclusions

Prenatal diet quality of low-income pregnant Hispanic women was suboptimal. This cross-sectional study revealed associations between cultural and lifestyle factors and prenatal diet quality in low-income Hispanic women. Longitudinal studies are needed to determine long-term impacts and specific behaviors to target for effective intervention studies.

Introduction

Dietary intakes before conception and during pregnancy are important determinants of maternal, fetal, and child health.^1,2 Suboptimal diet quality during critical periods of pregnancy is a risk factor for adverse health outcomes for the mother, including excessive gestational weight gain³ and postpartum weight retention,⁴ and the child, including predisposition to obesity and other chronic diseases, such as cardiovascular and metabolic diseases.⁵ Although some evidence suggests that women who are pregnant or planning to become pregnant make healthy lifestyle changes, the average diet quality of pregnant women remains suboptimal.^6,7 Moreover, disparities in diet quality exist, particularly among low-income Hispanic women who have lower diet quality scores than their higher-income non-Hispanic white counterparts.^7-9

Hispanic women represent the largest minority group in the United States (US).¹⁰ Compared to women of other racial/ethnic groups, Hispanic families are more likely to experience poverty¹¹ and food insecurity,¹² placing them at-risk for poor prenatal diet quality.¹³ While protective factors, such as participation in supplemental nutrition assistance programs, may increase access to healthy foods, it is unclear whether these programs improve diet quality in Hispanic women.¹⁴ Psychosocial and lifestyle factors disproportionately affect low-income Hispanic women and may negatively influence their dietary intakes during pregnancy.^15-19 Low-income minority women report higher rates of depressive symptoms and absence of social support, which are associated with poor diet quality.^15,16 A study using the National Health and Nutrition Examination Survey (NHANES) data shows that a low percentage of Hispanic women meet physical activity guidelines for pregnancy,¹⁷ and studies suggest that inactivity and sedentary behaviors are inversely related to diet quality in pregnant women.^18,19

Correlates of prenatal diet quality are not well explored in low-income Hispanic women. This population is understudied in the literature and has high rates of child and adult obesity.²⁰ Identifying correlates of prenatal diet quality, some of which are modifiable, may be used to inform future research needs to improve dietary behaviors before and during pregnancy. The objective of the present study was to identify the contributions of financial, cultural, psychosocial, and lifestyle correlates to prenatal dietary quality among an urban cohort of pregnant, low-income Hispanic women.

Methods

Study Design

This study is a cross-sectional analysis of baseline data from pregnant, low-income Hispanic women enrolled in the Starting Early Trial, a randomized controlled trial of a primary-care based child obesity prevention program beginning in pregnancy.²¹ Women were recruited for Starting Early in the third trimester of pregnancy (baseline); the intervention continued until child age 3 years old. Bellevue Hospital Center, the New York City Health and Hospitals Corporation, and the institutional review boards of New York University School of Medicine and the Albert Einstein College of Medicine approved this study and it was registered on clinicaltrials.gov (NCT01541761).

Study Participants

From 2012 to 2014, researchers enrolled pregnant women at 28-32 weeks gestation during prenatal visits from clinics affiliated with a large urban medical center in New York City. Women were required to: 1) be 18 years of age or older, 2) self-report their ethnicity as Hispanic/Latina, 3) have a singleton uncomplicated pregnancy, 4) continue prenatal and pediatric care at the study sites, and 5) speak fluent English or Spanish. Women were excluded from the study if: 1) they had a history of severe medical or psychiatric illness or drug or alcohol abuse, 2) they did not have access to a phone, or 3) there was evidence that their infant would be born with severe medical problems that could affect feeding. Women were not excluded if they had pre-pregnancy diabetes or gestational diabetes. Trained bilingual English and Spanish speaking research assistants obtained written informed consent from all interested women and conducted baseline assessments in English or Spanish.

Baseline Assessments

Dietary assessment

At baseline (28 to 32 weeks gestational age), research assistants administered the Block Food Frequency Questionnaire (FFQ) 2005 bilingual version, which presents text in English and Spanish, to estimate usual dietary intake consumed in the past year, including during pregnancy.²² Previous studies show that dietary intake does not greatly change from before pregnancy to during pregnancy or between trimesters.^23,24 The Block FFQ has been validated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) population and in pregnant women from the Pregnancy, Infection, and Nutrition Study.^25,26 The FFQ included 118 food items based on the NHANES 1999 to 2002 dietary survey, as well as foods relevant to Latin American cuisine. Women self-reported the usual frequency of intake and quantity of these food items, with pictures available to choose appropriate portion sizes. The FFQ was analyzed using the United States Department of Agriculture (USDA) Food and Nutrient Database for Dietary Studies (FNDDS), version 1.0.²⁷ FFQ output provided information about the intake of specific nutrients (energy, macronutrients, micronutrients) and food groups using the My Pyramid Equivalents Database (MPED).²⁸

Diet Quality

Although several indexes are available to measure diet quality, the Healthy Eating Index (HEI)-2015 was chosen because it measures alignment to the current 2015-2020 Dietary Guidelines for Americans.^29,30 The content validity, construct validity, and reliability of the HEI-2015 has been previously evaluated.³¹ The HEI-2015 includes thirteen components that reflect the food choice recommendations of the Dietary Guidelines: nine adequacy (total fruits, whole fruits, total vegetables, greens and beans, whole grains, dairy, total protein foods, seafood and plant proteins, and fatty acids) and four moderation (refined grains, sodium, saturated fat, and added sugars).³⁰ The HEI-2015 uses least-restrictive standards to set maximum scores for individual components as those that are easiest to achieve by age and sex. Eight of the nine adequacy components (total fruits, whole fruits, total vegetables, greens and beans, whole grains, dairy, total protein foods, and seafood and plant proteins) and two of the four moderation components (refined grains and sodium) are scored based on nutrient density per 1,000 calories. The fatty acids score is based on the ratio of the sum of polyunsaturated fatty acids plus monounsaturated fatty acids to saturated fatty acids. Saturated fats and added sugars are scored based on the percentage of total energy intake. A higher score of an adequacy component indicates higher intake, while a higher score of a moderation component indicates lower intake. The HEI-2015 sums individual component scores for an overall total score between 0 and 100. A higher total score indicates better alignment with the 2015-2020 Dietary Guidelines for Americans. Using MPED food groups from the Block FFQ, HEI-2015 individual component scores and total scores were calculated following the HEI-2015 Statistical Analysis Software (SAS) Code for FFQ available from the National Cancer Institute.³² Average dietary intake of particularly important micronutrients during pregnancy, including folate, iron, and calcium, were assessed and compared to the Dietary Reference Intakes (DRIs).³³

Correlates of Diet Quality

Correlates of prenatal diet quality were chosen a priori based on findings from a recent systematic review and other relevant literature assessing prenatal dietary patterns.^34-36 In addition, correlates of dietary intake that were considered relevant to low-income Hispanic women were included in the analysis.³⁷ Correlates were grouped as financial, cultural, psychosocial and lifestyle-related.

Financial Correlates

Food security.

Women were asked the series of 10 questions from the U.S Adult Food Security Survey Module, a commonly used tool developed by the USDA.³⁸ The questions pertained to their ability to afford food over a 12-month period that included their pregnancy. Women who reported 2 or less food insecure conditions were categorized as food secure, while those who reported 3 or more food insecure conditions were categorized as food insecure.³⁸

Supplemental nutrition assistance.

WIC and the Supplemental Nutrition Assistance Program (SNAP) are food support programs that aim to improve nutrition and health outcomes of disadvantaged groups.¹⁴ Women reported SNAP and WIC participation, yes or no.

Cultural Correlates

Country of birth.

Women identified their country of birth as Puerto Rico, Dominican Republic, Mexico, Ecuador, Colombia, US, or other. This variable was further categorized as continental US, Mexico or other Latin American countries.

Primary home language.

Women reported the main language spoken at home as all English, more English than Spanish, equally English and Spanish, more Spanish than English, all Spanish, or other. All English, more English than Spanish, and equally English and Spanish were aggregated into mostly/only English or equal English and Spanish, while more Spanish than English, all Spanish, and other were aggregated into mostly/only Spanish.

Years in the US.

Women born in countries other than the continental US reported the year they arrived in the US. Years in the US was calculated by subtracting the reported year from the baseline assessment year and categorized as <10 years or ≥10 years.

Psychosocial Correlates

Social support.

Women were asked how many people they could count on in times of need. Women who reported being able to count ≤1 person were considered to have no presence of a social support network, while women who reported being able to count on ≥2 people were considered to have the presence of a social support network in times of need.

Dietary support.

Women were asked whether they obtained information about diet during their pregnancy or a previous pregnancy from a doctor, nurse, or health professional; WIC food program; relative or friend; books or videos; newspaper or magazine; television or radio; or internet. Two categories were created: professional dietary support was considered when at least one source of support from a doctor, nurse, or health professional or the WIC food program was reported. Other dietary support was considered when at least one source of support from a relative or friend; books or videos; a newspaper or magazine; television or radio; or the internet was reported. Professional and other dietary support were dichotomized as received dietary support or did not receive dietary support.

Depressive symptoms.

The Patient Health Questionnaire-9 (PHQ-9), a subscale of the Patient Health Questionnaire, was used to measure depressive symptoms. The PHQ-9 is a validated tool that includes 9 questions related to depression and is scored on a scale of 0 to 27, with higher PHQ-9 total score indicating greater depressive symptoms.³⁹ PHQ-9 scores can be categorized as mild (5-9), moderate (10-14), moderately severe (15-19), or severe (≥20). PHQ-9 score was dichotomized to indicate no depressive symptoms (total score 0-4) or mild or greater depressive symptoms (total score 5-27).

Lifestyle Correlates

Physical activity.

Questions from the 2011 Behavioral Risk Factor Surveillance System (BRFSS) Physical Activity Rotating Core (PARC) were used to assess physical activity before and during pregnancy.⁴⁰ Questions were modified to ask specifically about any physical activity before and during pregnancy because research suggests that physical activity differs during these time periods.^41,42 Activities were also modified to include activities relevant to the study population (running, exercise classes, dancing, gardening, soccer, other sports, or walking for exercise). Only a small number of women (n=49, 9.4%) reported physical activity during but not before pregnancy; therefore, physical activity was categorized as no exercise, exercise before or during pregnancy, or exercise before and during pregnancy.

Screen time.

Women were asked how much time they spend on a typical weekday and on a typical weekend day watching TV, video/DVD, or movies; using the computer or playing video or handheld games (aside from work); and using social media sites. A weighted daily average of weekday and weekend minutes of media use was calculated from the responses. Based on research that found that risk of obesity and type 2 diabetes mellitus increased in women with every 2-hour increment of daily TV watching, the weighted weekly media average was categorized as 0 to 2 hours/day, >2 to 4 hours/day, or >4 hours/day.⁴³

Socio-demographic Covariates

Covariates included maternal age (years), marital status (single or married/living with partner), nulliparous (yes or no), employment status (employed or not employed), and highest level of education completed (less than high school or high school or greater). Pre-pregnancy body mass index (BMI, kg/m²) was calculated using pre-pregnancy weight (measured at ≤13 weeks’ gestation) and height collected from women’s medical records. Self-reported measurements were used if medical record data was missing (n=1). Pre-pregnancy BMI was categorized as underweight (<18.5 kg/m²), normal weight (18.5-24.9 kg/m²), overweight (25.0-29.9 kg/m²), and obese (≥30 kg/m²).⁴⁴

Statistical Analysis

Statistical analyses were performed using the STATA Data Analysis and Statistical Software Version 15.0.⁴⁵ Study size for Starting Early was estimated using a power analysis that determined that 500 pregnant women needed to be enrolled to achieve 80% power to detect a 15% reduction in childhood obesity prevalence at 3 years, assuming 30% loss to follow-up and alpha of 0.05. For the current study, women with usual energy intake of less than 500 kcal or more than 5000 kcal were excluded from analysis to remove implausible energy intakes. These cutpoints were modified from what is considered plausible energy intake in women (500 kcal to 3500 kcal)⁴⁶ and what has been used in the Nurses’ Health Study.⁴⁷ The higher cutpoint accounts for the increased energy needs during the second and third trimesters of pregnancy. HEI-2015 individual component and total score variables, correlate variables, and covariates were analyzed descriptively as means and standard deviations (for continuous variables) or frequencies (for categorical variables). Unadjusted bivariate analyses estimating mean HEI-2015 total scores for the correlate variables were performed using independent t-tests or one-way analysis of variance. Linear regression was performed to estimate the mean differences in HEI-2015 total score for the correlate variables. Years in US was not included in the regression model because the variable only considered women born outside of the US (n=417). Two models were used: the first model (Model 1) included all of the a priori correlate variables. The backward solution regression method was used to identify variables that contributed to the model (p<0.10).⁴⁸ The second model (Model 2) included the correlate variables identified in Model 1 and additionally controlled for confounding variables (maternal age). Variance inflation factor (VIF) values were generated for regression models to assess multicollinearity, and mean VIF <4 was considered acceptable (mean VIF for Model 1: 1.15).⁴⁹ Significant correlate variables (p≤0.05) identified in Model 2 were placed into linear regressions to examine associations with HEI-2015 individual components and were adjusted for maternal age.

Results

Study Sample

There were 933 low-income Hispanic pregnant women who were eligible to participate in Starting Early; 559 women completed baseline assessments, and 541 fully completed the food frequency questionnaire. Of those 541, 519 (95.9%) had plausible energy intakes between 500 kcal and 5000 kcal and were included in analyses. Women with implausible energy intakes (n=22) were younger than women with plausible energy intake (24 ± 5 vs 28 ± 6 years, respectively, p=0.001) and had lower HEI-2015 total score (62.7 ± 10.4 vs 69.0 ± 9.4, respectively, p=0.002), lower total vegetables, greens and beans, dairy, whole grains, and saturated fats individual scores (p<0.05). There were no differences in financial, cultural, psychosocial, or lifestyle correlates, or other covariates between the analyzed sample and those with implausible energy intakes. Table 1 presents characteristics of the women included in analysis. On average, women were 28 ± 6 years old and had a pre-pregnancy BMI of 27.5 ± 5.5 kg/m². Most women were classified as overweight or obese before pregnancy, married, and had a high school education or greater. A small percentage of women were diagnosed with pre-pregnancy diabetes or gestational diabetes, and prenatal diet quality did not differ between women with diagnosed pre-pregnancy or gestational diabetes and women without. About a third reported household food insecurity and most participated in WIC but not SNAP. One-third reported mild or greater depressive symptoms, with 8% reporting moderate or severe symptoms. Almost half of women were born in Mexico, while one-third were from other Latin American countries, including 16% from Ecuador, 6% from the Dominican Republic, and the remainder from 12 countries in South and Central America and the Caribbean. Most women reported at >2 hours of daily screen time, and less than half reported engaging in physical activity before and during pregnancy, usually walking.

Table 1.

Characteristics of Low-Income Pregnant Hispanic Women Participating in the Starting Early Trial, 2012 – 2014 (N=519)

	Mean ± Standard Deviation or n (%)
Socio-demographic Covariates
Maternal Age (years)	28 ± 6
Pre-Pregnancy Body Mass Index (kg/m2)	27.5 ± 5.5
Pre-Pregnancy Weight Category
Underweight	8 (1.5)
Normal	177 (34.1)
Overweight	178 (34.3)
Obese	156 (30.1)
Pre-Pregnancy Diabetes	12 (2.3)
Gestational Diabetes	19 (3.8)
Marital Status
Single/Separated/Divorced	149 (28.7)
Legally/Living as Married	370 (71.3)
First Child	191 (36.8)
Employed	131 (25.2)
Education
Less Than High School	172 (33.1)
High School or Greater	347 (66.9)
Financial Correlates
Household Food Insecurea	161 (31.0)
WICb Participation	451 (86.9)
SNAPc Participation	192 (37.0)
Cultural Correlates
Years Lived in USd	9.6 ± 5.9
<10 years	223 (53.5)
≥10 years	194 (46.5)
Country of Birth
United States	102 (19.7)
Mexico	245 (47.2)
Other Latin Americane	172 (33.1)
Primary Home Language
Mostly/Only English or Equalf	121 (23.2)
Mostly/Only Spanish	398 (76.7)
Psychosocial Correlates
Presence of Social Support Network	413 (79.6)
Professional Dietary Support	454 (87.5)
Other Dietary Supportg	393 (75.7)
Patient Health Questionnaire-9 Scoreh	4.0 ± 3.6
Depressive Symptomsi	175 (33.7)
Lifestyle Correlates
Physical Activity
None Before or During Pregnancy	102 (19.7)
Before or During Pregnancy	198 (38.2)
Before and During Pregnancy	219 (42.2)
Daily Screen Time Use
0-2 hours/day	119 (22.9)
>2-4 hours/day	177 (34.1)
>4 hours/day	223 (43.0)

^aMeasured by reporting ≥3 food insecure conditions on the series of 10 questions from the U.S Adult Food Security Survey Module

^bSpecial Supplemental Nutrition Program for Women, Infants, and Children

^cSupplemental Nutrition Assistance Program

^dN=417

^eThe 33.1% from other Latin American countries includes 16% from Ecuador, 6% from the Dominican Republic, and the remainder from 12 countries in South and Central America and the Caribbean

^fEqual English and Spanish

^gAnother source includes relative, book, news, TV, internet, or other

^hQuestionnaire to measure depressive symptoms measured on scale of 0 to 27, with scores ≥5 indicating mild or greater depressive symptoms

ⁱMeasured by scoring 5-27 on the Patient Health Questionnaire-9

Prenatal Diet Quality

Table 2 shows the standards for minimum and maximum scores for the individual HEI-2015 components, as well as average individual component and total scores for the study population. The average HEI-2015 total score was 69.0 ± 9.4, and individual total scores ranged from 44.1 to 96.0. Over half of women met recommended intake levels of total fruits (54.5%), whole fruits (51.6%), greens and beans (65.5%), total protein foods (62.4%), and seafood and plant proteins (61.5%). However, most women did not meet the maximum score for the remaining adequacy components and had inadequate intake of total vegetables (65.3%), whole grains (97.1%), dairy (74.8%), and fatty acids (84.4%). In addition, most women did not meet the maximum score for all moderation components and over consumed refined grains (79.8%), sodium (97.5%), saturated fats (92.9%), and added sugars (66.5%). Figure 1 illustrates the mean score for each individual component as a percentage of the maximum score for that component. Mean scores were <80% of the maximum component score for whole grains, dairy, fatty acids, refined grains, sodium, and saturated fats. Mean reported usual energy intake was 2128 ± 890 kcal, with 50% of kcal from carbohydrate, 16% of kcal from protein, and 35% of kcal from fat. On average, women reported consuming 327 ± 153 mcg/d of folate (compare to the Recommended Dietary Allowance, RDA: 600 mcg), 16 ± 8 mg/d of iron (RDA: 27 mg), and 1122 ± 455 mg/d of calcium (RDA: 1000 mg/d) from dietary sources, and 94.4% of women reported taking a prenatal multivitamin (data not shown).³³

Table 2.

HEI-2015 Individual Component and Total Scores and Standards for Low-Income Pregnant Hispanic Women in the Starting Early Trial, 2012 – 2014 (N=519)³¹

Component (Score Range)	Standard for Maximum Score	Standard for Minimum Score	Women That Met Maximum Score, n (%)	Mean Score ± Standard Deviation
Adequacy (higher score indicates higher consumption)
Total Fruits (0-5)	≥0.8 cup eqa/1,000 kcal	No fruit	283 (54.5)	4.2 ± 1.2
Whole Fruits (0-5)	≥0.4 cup eq/1,000 kcal	No whole fruit	268 (51.6)	3.9 ± 1.4
Total Vegetables (0-5)	≥1.1 cup eq/1,000 kcal	No vegetables	180 (34.7)	3.9 ± 1.1
Greens and Beans (0-5)	≥ 0.2 cup eq/1,000 kcal	No dark green vegetables or beans	340 (65.5)	4.4 ± 1.1
Whole Grains (0-10)	≥1.5 oz eq/1,000 kcal	No whole grains	15 (2.9)	3.7 ± 2.4
Dairy (0-10)	≥1.3 cup eq/1,000 kcal	No dairy	131 (25.2)	7.1 ± 2.5
Total Protein Foods (0-5)	≥2.5 oz eq/1,000 kcal	No protein foods	324 (62.4)	4.6 ± 0.7
Seafood and Plant Proteins (0-5)	≥0.8 oz eq/1,000 kcal	No seafood or plant proteins	319 (61.5)	4.4 ± 1.0
Fatty Acids (0-10)	(PUFAsb + MUFAsc)/SFAsd ≥2.5	(PUFAsb + MUFAsc)/SFAsd ≤1.2	81 (15.6)	6.5 ± 2.5
Moderation (higher score indicates lower consumption)
Refined Grains (0-10)	≤1.8 oz eq/1,000 kcal	≥4.3 oz equiv/1,000 kcal	105 (20.2)	6.4 ± 3.1
Sodium (0-10)	≤1.1 gram/1,000 kcal	≥2.0 grams/1,000 kcal	13 (2.5)	4.4 ± 2.5
Saturated Fats (0-10)	≤8% of energy	≥16% of energy	37 (7.1)	6.7 ± 2.1
Added Sugars (0-10)	≤6.5% of energy	≥26% of energy	174 (33.5)	8.6 ± 1.8
Total Score (0-100; higher score indicates better diet quality)			0 (0.0)	69.0 ± 9.4e

^aEq: Equivalents

^bPUFAs: Polyunsaturated fatty acids

^cMUFAs: Monounsaturated fatty acids

^dSFAs: Saturated fatty acids

^eRange: 44.1-96.0

Figure 1. Mean Scores for HEI-2015 Components as a Percentage of the Maximum Component Score in Low-Income Pregnant Hispanic Women in the Starting Early Trial, 2012 – 2014 (N=519).

Correlates of Prenatal Diet Quality

Table 3 shows the results of the bivariate analyses, linear regression Model 1, and linear regression Model 2. Associations between some of the financial, cultural and lifestyle correlates and prenatal diet quality were found. Women who participated in WIC had a higher mean HEI-2015 total score than those who did not participate in WIC, but these results were not significant after controlling for maternal age. Similarly, women who spoke a home language of mostly/only Spanish had a higher mean HEI-2015 total score than those who spoke mostly/only English or equal English and Spanish, but these results did not remain significant in the regression analysis. Being born outside the continental US was associated with a higher mean HEI-2015 total score. After controlling for maternal age, being born in Mexico was associated with a 2.4-point increase in HEI-2015 total score (95% CI: 0.3, 4.9) and being born in other Latin American countries was associated with a 6.4-point (95% CI: 3.7, 8.4) higher score compared to being born in the US. Reporting physical activity (before and/or during pregnancy) and lower daily screen time were also independently associated with a higher mean HEI-2015 total score. Compared to no physical activity, physical activity before or during pregnancy was associated with a 2.1-point increase in HEI-2015 total score (95% CI: 0.1, 4.2) and physical activity before and during pregnancy was associated with a 3.9-point increase (95% CI: 1.9, 5.9). Greater than 4 hours of daily screen time was associated with a 3.6-point decrease in HEI-2015 total score (95% CI: −5.6, −1.5) and 2-4 hours of daily screen time was associated with a 2.1 -point decrease (95% CI: −4.1, 0.0) compared to women who watched 0-2 hours of screen time daily. The adjusted R² of the linear regression model adjusted for maternal age was 0.16, with small effect sizes of physical activity, daily screen time, and participation in WIC and medium effect sizes of country of birth.⁵⁰ None of the other correlate variables were associated with HEI-2015 total score.

Table 3.

Bivariate and Linear Regression Analyses Examining Associations between Financial, Cultural, Psychosocial, and Lifestyle Correlates and HEI-2015 Total Score in Low-Income Pregnant Hispanic Women from the Starting Early Trial, 2012 – 2014 (N=519)

			Model 1			Model 2a
	HEI-2015 Mean ± SD	pb	B	95% CI	p	B	95% CI	p
Financial Correlates
Household Food Insecure		0.821
Yes	68.8 ± 9.6		−1.2	−2.9, 0.5	0.173
No	69.0 ± 9.3		ref
WICc Participation		0.004
Yes	69.4 ± 9.3		2.2	−0.1, 4.5	0.055	2.1	−0.1, 4.4	0.060
No	65.9 ± 9.5		ref			ref
SNAPd Participation		0.403
Yes	68.5 ± 9.8		−0.3	−1.9, 1.3	0.730
No	69.2 ± 9.1		ref
Cultural Correlates
Country of Birth		<0.001
United States	63.9 ± 9.2		ref			ref
Mexico	68.8 ± 9.1		3.2	0.6, 5.7	0.014	2.4	0.3, 4.9	0.034
Other Latin American	72.2 ± 8.5		7.1	4.6, 9.6	<0.001	6.4	3.7, 8.4	<0.001
Primary Home Language		0.001
Mostly/Only English or Equale	66.4 ± 9.6		ref
Mostly/Only Spanish	69.7 ± 9.2		0.5	−1.8, 2.8	0.671
Psychosocial Correlates
Presence of Social Support Network		0.725
Yes	68.9 ± 9.5		−0.1	−2.1, 1.8	0.912
No	69.2 ± 8.9		ref
Professional Dietary Support		0.314
Yes	69.1 ± 9.4		0.5	−2.0, 2.9	0.693
No	67.9 ± 9.0		ref
Other Dietary Support		0.126
Yes	69.3 ± 9.2		0.8	−1.1, 2.7	0.408
No	67.8 ± 9.7		ref
Depressive Symptoms		0.135
Yes	68.1 ± 9.0		−0.5	−2.1, 1.2	0.589
No	69.4 ± 9.5		ref
Lifestyle Correlates
Physical Activity		<0.001
None Before or During Pregnancy	66.2 ± 9.0		ref			ref
Before or During Pregnancy	68.6 ± 9.1		2.0	−0.1, 4.1	0.058	2.1	0.1, 4.2	0.041
Before and During Pregnancy	70.6 ± 9.5		3.7	1.6, 5.8	0.001	3.9	1.9, 5.9	<0.001
Daily Screen Time Use		<0.001
0-2 hours/day	72.3 ± 8.5		ref			ref
>2-4 hours/day	69.5 ± 9.2		−2.5	−4.5, −0.4	0.018	−2.1	−4.1, 0.0	0.046
>4 hours/day	66.8 ± 9.3		−4.3	−6.3, −2.2	<0.001	−3.6	−5.6, −1.5	0.001
Adjusted R2				0.15			0.16

^aAdjusted for maternal age

^bOne-way ANOVAs and independent t-tests

^cSpecial Supplemental Nutrition Program for Women, Infants, and Children

^dSupplemental Nutrition Assistance Program

^eEqual English and Spanish

Of those variables that were significantly associated with HEI-2015 total score, country of birth outside of the continental US was associated with higher scores of total vegetables, greens and beans, seafood and plant proteins, fatty acids, and added sugars (p<0.001) compared to continental US-born women. Being born in other Latin American countries was also associated with higher score of refined grains (p<0.01). Compared to 0 – 2 hours of daily screen time, >4 hours of daily screen time was associated with lower score of total vegetables (p=0.01), total fruits, whole fruits, and dairy (p<0.05). Physical activity before and during pregnancy was associated with higher score of total fruits, total vegetables, greens and beans, refined grains (p<0.05), and whole grains (p<0.01) compared to no physical activity (data not shown).

Discussion

Prenatal diet quality of low-income pregnant Hispanic women was suboptimal and did not align with the 2015-2020 Dietary Guidelines for Americans.²⁹ Unhealthy dietary behaviors during pregnancy place mothers and children at-risk of adverse health outcomes, including obesity and other chronic diseases.¹ Moreover, most women did not meet the recommended intakes of total vegetables, whole grains, dairy, and fatty acids, dietary components that supply key nutrients needed during pregnancy and exceeded the recommended intakes of refined grains, sodium, saturated fats, and added sugars, components that are associated with low nutrient value foods. Prenatal diet quality was associated with some of the financial, cultural, and lifestyle correlates, but none of the psychosocial correlates.

Consistent with these findings, previous studies that used versions of the HEI and other diet quality indexes showed that prenatal diet quality and consumption of individual dietary components did not align with dietary recommendations, with disparities apparent by race/ethnicity and socioeconomic status.^7,19,51,52 Inadequate whole grains was the largest contributor to poor diet quality in this group, followed by overconsumption of sodium. Other research found that low-income women reported consuming inadequate amounts of fruits and vegetables, whole grains, low-fat dairy, lean meats, and fish and excess refined grains and added fats.⁹ These may be potential food components to target in intervention studies to low-income women. Among studies assessing pregnant low-income minority women, including Hispanic, non-Hispanic black, and Native American, mean HEI total scores ranged from 40 to 61.^7,19,51 In comparison, mean total HEI-2015 score of the general population, based on NHANES 2011 – 2012, was 56.6 overall and 59.7 in women.³¹ Though the mean HEI total score of the current study was substantially higher than what has been reported for other populations of pregnant low-income minority women and the general population, prenatal diet quality in the current study was poor, which may have implications for maternal and child health.

In the literature, associations between diet quality and financial correlates have been inconsistent between nonpregnant adults and pregnant women. Studies in low-income adults suggested that food insecurity was associated with characteristics of poor diet quality.^53,54 However, similar to findings in the current study, research in low-income pregnant women found that food security was not related to diet quality.⁵⁵ The differences in the observed associations between these populations may be partially explained by participation in supplemental nutrition assistance programs. Low-income adults can participate in SNAP, which aims to alleviate food insecurity without nutritional requirements,⁵⁶ while low-income pregnant women are also eligible to participate in WIC, which focuses on improving diet quality.^57,58 Though research found SNAP to be effective in reducing food insecurity, it may not improve diet quality.⁵⁹ In contrast, studies showed that WIC participation provided greater accessibility to healthy foods and beverages and improved dietary intakes⁶⁰ and was positively associated with HEI total score in children.⁶¹ WIC provides nutrition education and food packages to promote healthy dietary intake in pregnant women and their children.⁵⁸ In the current study, nearly 90% of women participated in WIC and participants had a higher mean HEI-2015 total score than non-participants, though it was not statistically significant after controlling for other socio-demographic covariates. In contrast, less than 40% of women participated in SNAP, and there was no association between SNAP participation and diet quality.

Given the heterogeneity of dietary intakes among Hispanic populations, the current study considered several cultural correlates. Being born outside of the continental US and speaking mostly/only Spanish at home were associated with higher mean HEI-2015 total score, which was consistent with previous studies.^62-64 Women born outside of the continental US had higher intakes of vegetables, greens and beans, and seafood and plant proteins, and lower intake of added sugars compared to women born in the US. Other studies confirm that women born outside the US had greater intake of vegetables and legumes.^62-64 There was no association between years living in the US and diet quality. More time spent in the US increases the likelihood of adopting common US dietary behaviors and has been inversely related to diet quality;^65-67 however, this observation may be dependent on the communities in which individuals live within the US. For example, among a cohort of pregnant Mexican immigrants, years living in the US was not associated with dietary intakes, but these women lived in largely Hispanic-based communities that may have helped them to maintain dietary behaviors consistent with their country of birth.⁶⁸

Psychosocial correlates were not associated with prenatal diet quality in this sample; however, most women with depressive symptoms reported mild symptoms, and the majority of women reported having both social and dietary support. Associations between depressive symptoms and diet quality in the literature are mixed, and causal mechanisms underlying the association are unclear.^15,69 Studies that examined social support and dietary behaviors in low-income pregnant women found that women with more social support reported healthier dietary behaviors.^16,35 Research regarding the role of dietary support is limited. While nutrition education given in multiple sessions by registered dietitian nutritionists and health educators improved dietary behaviors during pregnancy,⁷⁰ the contribution of dietary support from other sources on diet quality remains to be investigated.

Lifestyle correlates, including physical activity (before and/or during pregnancy) and limited screen time (<4 hours/day), were associated with higher mean HEI-2015 total scores. Positive associations of diet quality with physical activity and inverse associations of diet quality with screen time in children and adults have been reported.^71,72 Similar to the current study, other research find that individuals who are more physically active consume more fruits and vegetables, while increased sedentary time is associated with decreased fruit and vegetable intake.^73,74 Additionally, physical inactivity places women at greater risk for excess gestational weight gain and adverse pregnancy outcomes.⁷⁵ Guidelines are available for physical activity during pregnancy;⁷⁶ however, qualitative studies found that low-income Hispanic women lack resources and information to be physically active during pregnancy.^77-80 Given that physical activity and screen time are modifiable correlates that contribute to prenatal diet quality and overall healthy lifestyle behaviors, healthcare providers should assess these correlates and discuss recommendations for activity during pregnancy.

Strengths of this study included assessing important correlates of prenatal diet quality in an understudied and underserved high-risk group of women. In addition, this study used validated questionnaires to survey women about certain financial, psychosocial, and dietary variables. This study also had several limitations. Analyses were cross-sectional and no causal relationships between financial, cultural, psychosocial, or lifestyle correlates and prenatal diet quality could be determined. The Starting Early assessment questionnaires were self-reported and interviewer-administered, and social support and dietary support variables were based on a single question and may not accurately capture these complex psychosocial correlates. Questions about dietary support did not specifically ask whether women obtained information about diet during their pregnancy or a previous pregnancy from a registered dietitian nutritionist. The study did not repeatedly measure dietary intake during pregnancy or use a second dietary assessment measure (e.g. a 24-hour recall), and the Block 2005 FFQ required women to accurately report their average diet and portions consumed over the past year. If women made changes to their dietary behaviors during pregnancy, the FFQ may not have accurately captured usual dietary intake of the entire year. The FFQ may have omitted foods that are common in diets of certain Hispanic ethnicities. Given that the FFQ was interviewer-administered, recall bias may exist.⁸¹ Finally, the HEI-2015 was not specifically designed for pregnancy, and weights individual dietary components equally. Certain dietary components during the prenatal period may be more influential to maternal and child health outcomes than others.

Conclusions

Study findings suggest that low-income Hispanic women had poor prenatal diet quality, which may put them at greater risk of diet-associated pregnancy complications or adverse health outcomes. These findings support the importance of screening low-income Hispanic women for diet quality and providing counseling based on individual areas of concern. Dietary interventions for low-income Hispanic women should be culturally appropriate as well as promote healthy lifestyle behaviors during pregnancy. Future research is needed to investigate optimal strategies to support healthful eating in this population.

Research Snapshot.

Research Question: Low-income Hispanic women are at increased risk of poor prenatal diet quality. How are financial, cultural, psychosocial, and lifestyle correlates associated with prenatal diet quality in these women?

Key Findings: Low-income Hispanic pregnant women do not meet the recommendations for important dietary components, and overall prenatal diet quality is poor. Country of birth outside of the US, physical activity before and/or during pregnancy, and screen time ≤2 hours/day was associated with higher prenatal diet quality.