This is one of the first studies to examine dietary quality in low-income women who were in the early weeks of their pregnancy, prior to enrolling in prenatal care or receiving food vouchers through the United States Special Supplemental Nutrition Program for Women, Infants and Children Program. Most of the women in this study did not have adequate dietary quality to ensure that they were meeting the nutritional recommendations for pregnancy in the US. These findings are similar to others that low-income pregnant women have inadequate intakes of iron, folate, fruits, and vegetables (Siega-Riz, Evenson, & Dole, 2004
). Although Siega-Riz et al. did not compute a dietary quality index, nutrients and food that were examined are consistent with the DQI-P, and inadequate intake could have a negative impact on birth outcomes for these women.
The finding that stress and depression, elements of distress in this study, had a negative direct relationship with eating habits and overall dietary quality, is not surprising. Depression and stress together have been found to relate negatively to dietary quality and eating habits in low-income women during pregnancy (Larson, Story, Wall, & Neumark-Sztainer, 2006
; Ma et. al., 2003
; Tuffery & Scriven, 2005
). The negative relationship between maternal mental stress and dietary quality is similar to others reporting poor dietary quality in stressed pregnant women (Borders et al., 2007
; Larson et al., 2006
Overall dietary quality among low-income women in the current study was related positively to support and is consistent with previous research (Fowles et al., 2005
). The finding that support from a partner seemed to be more influential on improving dietary quality during early pregnancy than support from other family and friends is consistent with the works of Fowles et al. (2010)
; however, these results conflict with Thorton et al. (2006)
, who noted that support from female family friends or from a partner improved dietary intake in pregnant Latina women. Social support may serve to buffer the negative influence that psychosocial distress has on dietary quality. The influence of different types of social support on improving or hindering dietary quality during pregnancy requires further study.
As anticipated, poor eating habits, such as meal skipping and eating at fast food restaurants, had a very significant influence on dietary quality. This finding is similar to others reporting lower dietary quality in pregnant women who had poor eating habits by consuming less fruits and a high percent of total calories coming from fat (Siega-Riz et al., 2004
Age and education were related independently to nutritional knowledge and to dietary quality, such that older women had more nutritional knowledge and a higher dietary quality score but less educated women had less nutritional knowledge and lower dietary quality scores. These findings are similar to those noted in a U.S. prospective cohort study (n
= 1,777), in which Rifas-Shiman et al. (2009)
noted that dietary quality in pregnancy differed by age and level of education. Also, the importance of nutritional knowledge on dietary quality supports previous research that suggests pregnancy may be an opportune time for health care providers to target nutrition education programs designed to improve maternal health and birth outcomes (Fowles & Gabrielson, 2005
The current study has several limitations. First, the focus on low-income women in this study may limit the application of these findings to wealthier women. However, focusing on low-income women may be important since they are more vulnerable to experiencing adverse pregnancy outcomes. Understanding factors that influence their dietary intake may inform the development of food-based interventions designed to improve birth outcomes. Second, limitations to using dietary recalls include the under- or overreporting of intake, variations between foods eaten on weekends versus weekdays, and the possibility of participants providing socially desirable responses (Siega-Riz et al., 2004
). Nonetheless, utilizing the multiple-pass method to obtain more complete intake amounts (Moshfegh et al., 2001
) may minimize inherent dietary recall problems (Willett, 1998
) by incorporating multiple, unannounced, nonconsecutive 24-hour recalls.
Findings from this study should be viewed with caution for several reasons. Although the sample size was adequate based on power analysis projections, responses from a larger number of women might alter the findings. Finally, the coefficient of internal consistency for the stress scale is just below the accepted value of .70; this may reflect lack of variability in participant responses to questions about stress following adverse life events (recent move, work difficulties, or drug abuse) that they have experienced.
Evaluating a woman’s dietary intake is an important component of the initial prenatal visit and dietary intake should be assessed frequently throughout pregnancy. In addition, health care providers should assess for factors that may enhance or pose as barriers to healthy eating, such as depression, presence of stressors, and eating habits, to identify women needing more intensive dietary monitoring and intervention throughout pregnancy. Frequent assessment of women’s dietary quality during pregnancy provides an opportunity to facilitate improvements in women’s dietary quality that could enhance maternal and fetal outcomes.
The lack of dietary quality in this sample supports the notion that low-income women are indeed a vulnerable, high-risk population. This requires further study to determine what contextual, behavioral, and psychosocial characteristics influence dietary quality so that evidenced-based, targeted interventions to promote dietary quality can be developed, potentially leading to improved birth outcomes.