Food insecurity, dietary quality, & psychosocial factors among urban pregnant women

ABSTRACT

According to the USDA 10.9% of American households are food insecure. Current food insecurity rates are nearly twice the government's 2010 goal of under 6%. Given the importance of proper nutrition during pregnancy, rates of food insecurity among pregnant women is of particular public health concern. In preparation for the development of a nutritional intervention for pregnant women, this study had two objectives: (1) determine the prevalence of food insecurity in a population of women receiving care in a university-based urban prenatal clinic, and (2) determine if dietary quality and psychosocial factors are related to food insecurity. Women were approached during prenatal visits to complete an interview on maternal nutrition. Of the 107 women approached, 100 agreed to participate. Participants had a mean age of 22 years, 19% were Hispanic, 86% were Black, 43% were immigrants, 73% earned less than 30K annually, and 73% had a HS diploma. Twenty percent were found food insecure, 40% of whom were food insecure with hunger. Food insecure mothers had significantly lower scores on the HEI (t=-2.195, p=.031), significantly higher scores on the CES-D 10 (t=3.31, p=.001) and the stress scale (t=3.689, p<.001), and marginally lower scores on the self-esteem scale (t=1.743, p=.084) than food secure mothers. There was also a marginally significant association between being married/living with one's significant other and not experiencing food insecurity (χ²=3.603, p=.058). Findings suggest that food insecurity among this sample almost doubles national rates. This underscores the importance of nutritional support and program development for underprivileged pregnant women.

BACKGROUND

According to the United State Department of Agriculture's (USDA) Food Security Survey in 2006 approximately 10.9% (12.6 million) American households were unable to acquire enough food for all of their household members because of insufficient resources (United State Department of Agriculture [USDA], 2007). Despite modest nationwide declines over the past decade, current food insecurity rates are nearly twice the government's 2010 goal of a national rate of less than 6% (USDA, 2007).

Current data indicates that food insecurity is highest among households headed by low income black women, living in and around urban centers (USDA, 2007). Of particular concern is the presence of food insecurity in pregnant women, given the importance of proper nutrition both before and during pregnancy. Food insecurity is associated with an array of adverse reproductive outcomes (Carmichael, Wei, Herring et al., 2007; O'Scholl & Johnson, 2000; Adams, Grummer-Strawn & Chavez, 2003; George, Nanns-Nuss, Milani et al., 2005). In a study of maternal food insecurity and birth defects, food restriction was positively linked to elevated corticotropin releasing hormone, a teratogen associated with an increased risk of neural tube defects, clefts, and heart defects (Carmichael et al., 2007). Food insecure mothers also suffered insufficient folic acid and iron intake, which has been implicated in preterm delivery, low birth weight, and decreased fetal health (Carmichael et al., 2007; O'Scholl & Johnson, 2000; Allen, 2000). Furthermore, limited in utero nutrients has been found to affect the metabolic programming of fetuses, increasing future propensity towards heart disease, stroke, hyperlipidemia, decreased glucose tolerance, obstructive airway disease, and obesity (Painter, Roseboom & Bleker, 2005).

Food insecurity not only affects the nutritional status of the mother and child, but also has bearing on a mother's psychological and social wellbeing. Mothers from food insecure households had higher levels of perceived stress, depression, and anxiety than mothers of marginally food secure and food secure households (Laraia, Siega-Ritz, Gundersen et al., 2006). Furthermore, these mothers also harbored a lower self esteem and sense of mastery(Laraia et al., 2006).

While many investigations have been conducted on food insecurity among the general population, few studies have been conducted among pregnant women. Furthermore, no study to date has evaluated the relationship between dietary quality and food insecurity among this population. Data on these factors may provide valuable insight for the development of a nutritional intervention for pregnant women. The present study, therefore, had two objectives: (1) to determine the prevalence of food insecurity in a population of women receiving care in a university-based urban prenatal clinic, and (2) to determine if dietary quality and psychosocial factors are related to food insecurity status.

METHODS

Procedure:

A convenience sample of first time mothers was recruited from a university-based urban prenatal clinic. Potential participants were approached while they were waiting to be seen by their physicians. Only those who were in their second or third trimester were eligible to participate. One hundred and seven women were approached to participate in the study. One hundred women completed the survey, accounting for a 93.4% participation rate. Trained research assistants administered the survey in an interview-like format. Participants who completed the survey were given a small stipend for their time.

Instruments:

•Socio-demographics:

A socio-demographic form was developed to collect information on age, marital status, education, ethnicity, race, income, and country of birth.

•Dietary Habits:

To measure food intake we utilized the Block 98 Food Frequency Questionnaire (FFQ)(Siega-Ritz, Bodner & Savitz,2002). Participants recorded the frequency of consumption and portion size of 110 items from an array of food groups. As done in the Pregnancy, Infection, and Nutrition prospective cohort study, participants were asked to provide responses that reflect their consumption over the last 3 months, as opposed to 1 year, in order to ensure that the questionnaire captured intake during pregnancy only (Bodner & Siega-Ritz, 2002). The tool utilizes pictures reflecting different serving sizes in order to enhance the accuracy of participant responses. The Block 98 FFQ has been shown to be a valid measure of food intake in both the general population (Block, Thompson, Hartman et al., 1992) and pregnant women (Bodner & Siega-Ritz, 2002).

To measure dietary quality, the Healthy Eating Index (HEI) was calculated based on the responses to the FFQ. The HEI assesses 10 dietary components that included whether participants met the recommended serving sizes of the five major food groups, total fat consumption, total cholesterol intake, sodium intake, and variety in diet. Each component is evaluated on a scale of 0 to 10, 10 being the highest, giving a combined score of 100 (USDA, 2000). HEI scores over 80 imply good dietary quality, scores between 51-80 imply dietary quality that needs improvement, and scores under 51 imply poor dietary quality (USDA, 2000). The HEI has been shown to be a valid measure of dietary quality (Hann, Block & King, 2001).

•Psychosocial Factors:

The Prenatal Psychosocial Profile (PPP) is composed of three psychological scales that have been slightly modified and validated on a pregnant population (Curry, Burton & Fields, 1998). The Perceived Stress Scale, which consists of 11 items, evaluates the stress associated with financial worries, recent moves, losses, and problems at work. Women indicated the extent of the stress associated with each statement using a Likert scale ranging from “no stress” = 1 to “severe stress” = 4. The Support Behaviors Inventory, composed of 11 items, assesses support received from the participant's partner and other individuals in her life. Satisfaction with the support received was evaluated on a Likert scale ranging from “very dissatisfied” = 1 to “very satisfied” = 6. Finally, the Rosenberg Self-Esteem Scale included 11 items measuring self-acceptance on a Likert scale ranging from “strongly disagree” = 1 to “strongly agree” = 4. Responses from each scale were totaled and 3 separate scores derived.

In addition, the short form of the Center for Epidemiological Studies Depression Scale (CES-D 10) was used to assess depressive mood (Cole, Rabin, Smith et al., 2004). This measure asks participants to indicate on a scale from 0 = rarely, to 3 = all of the time, the frequency they have experienced a particular feeling during the past week. Statements included “I felt depressed” and “I felt fearful.” Items are totaled to provide an overall depressive mood score.

•Food Security Scale:

The USDA Food Security Scale was used to evaluate the level of concern participants experienced regarding the availability of food over the last 12 months (Carlson, Andrews & Bickel, 1999). The scale consists of 10 questions pertaining to food conditions in the household, such as: “We are worried whether food would run out before we got money to buy more” and “In the last 12 months did you or others in your household ever not eat for a whole day because there wasn't enough money for food.” Depending on the item, answers included “never,” “sometimes,” and “often,” or “yes” and “no.” As suggested by the USDA report on determining household food security in the US ¹ participants were considered food insecure if 3 or more statements were answered with a yes, often, or sometimes. Again using the USDA guidelines (USDA, 2007) participants were considered food insecure with hunger if 6 or more statements were answered with a yes, often, or sometimes.

RESULTS

The women had a mean age of 22 years, 19% were Hispanic, 86% were Black, 34% were married or living with a partner, and 43% were foreign born. Seventy-three percent of the women had an annual household income less than 30K, and 73% had at least a High School diploma. Twenty percent of the women were found to be food insecure, of which 40% were found food insecure with hunger. Mothers who were food insecure had a mean score of 55.35 on the Healthy Eating Index while food secure mothers scored an average of 61.68 points (t=2.195, p=.031). Food insecure mothers also had significantly higher scores on the CES-D 10 (t=3.31, p=.001) and the stress scale (t=3.689, p<.001) and were marginally more likely to be unmarried (χ²=3.603, p=.058) and to suffer from lower self esteem (t=1.743, p=.084). Food insecure mothers were not different from food secure mothers in terms of age, education, immigration status, race, ethnicity, and income.

CONCLUSION

Pregnancy is a time during which appropriate nutrition is critical for the developing fetus. This has become increasingly true in light of recent studies that support the fetal programming hypothesis (Vickers, Breier & Cutfield et al., 2000; Breier, Vickers, & Ikenasio, 2001; Woodall, Johnston & Breier et al., 2001). Evidence showing maternal nutrition guides future health-related behaviors of offspring (e.g., appetitite ) and is correlated with increased risk for metabolic and cardiovascular disorders during adulthood, has been demonstrated in epidemiological studies (Painter et al., 2005) and has been replicated in animal models (Vickers et al., 2000; Woodall et al., 2001). Given the alarming rate of food insecurity reported in our sample and the associated poorer dietary quality reported among this group, we need to be addressing nutrition issues during pregnancy very aggressively, particularly among inner-city populations. Furthermore, the CDC and the American Heart Association have reported that over 34% and 37% of Americans suffer from obesity and cardiovascular disease respectively (Center of Disease Control and Prevention, 2008; American Heart Association, 2008). These statistics mark the necessity for novel research on uncovering new pathways in prevention and support the development of programs that promote proper nutrition during pregnancy.