Download Psychosocial Influences in Dietary Patterns During Pregnancy

RESEARCH
Research and Professional Briefs
Psychosocial Influences in Dietary Patterns
During Pregnancy
KRISTEN M. HURLEY, MPH; LAURA E. CAULFIELD, PhD; LISA M. SACCO, PhD; KATHLEEN A. COSTIGAN, MPH; JANET A. DIPIETRO, PhD
ABSTRACT
There is increasing evidence that psychosocial factors may
affect dietary intakes and health. The current analysis examined the association of six indices of psychosocial wellbeing with dietary intake during pregnancy. One hundred
thirty-four women with low-risk, normal pregnancies participated in a cross-sectional, observational study that assessed dietary intake at 28 weeks’ gestation. Psychosocial
characteristics, including anxiety, depressed mood, anger,
fatigue, social support, and stress were assessed between 24
and 32 weeks’ gestation. Pearson product-moment correlations were calculated to determine the relationships between psychosocial factors and diet. Findings suggest that
pregnant women who were more fatigued, stressed, and
anxious consumed more foods, as evidenced by their increased macronutrient intakes, while appearing to have
decreased intakes of some micronutrients. Psychosocial factors should be considered when counseling women regarding diet during pregnancy.
J Am Diet Assoc. 2005;105:963-966.
T
here is increasing evidence that psychosocial factors
may affect health through both biological effects and
changes in health behaviors (1). Among these, food
choices and dietary intakes could be affected by psycho-
K. M. Hurley is a doctoral candidate and L. E. Caulfield is an associate professor at the Center for Human
Nutrition, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. L. M. Sacco is a postdoctoral
fellow, Carolina Population Center, Department of Nutrition, School of Public Health, University of North
Carolina, Chapel Hill; at the time of the study, she was
a doctoral candidate in the Center for Human Nutrition,
The Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD. K. A. Costigan is a research coordinator
in the Division of Maternal-Fetal Medicine and J. A.
DiPietro is a professor of Population and Family Health
Sciences, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
Address correspondence to: Laura E. Caulfield, PhD,
Center for Human Nutrition, The Johns Hopkins
Bloomberg School of Public Health, 615 N Wolfe St,
Room W2517, Baltimore, MD 21205. E-mail: lcaulfie@
jhsph.edu
Copyright © 2005 by the American Dietetic
Association.
0002-8223/05/10506-0007$30.00/0
doi: 10.1016/j.jada.2005.03.007
© 2005 by the American Dietetic Association
social factors and lead to poor nutritional status and
health. While psychological distress is associated with
biological changes that might be expected to reduce food
intake (1), experimental studies yield inconsistent results
(1-3).
Pregnancy is a period that presents unique stresses
that challenge overall psychological adaptation in
women. Pregnancy is also a time in which variation in
dietary intakes affect health outcomes for both the
mother and fetus (4,5). To our knowledge, no studies have
examined in a comprehensive manner whether psychosocial factors affect dietary patterns and intakes during
pregnancy, although a few have examined how psychosocial factors affect weight gain during pregnancy. While
some of these studies suggest that women with negative
attitudes or a history of dieting gain excess weight because pregnancy can disinhibit restraint (6,7), others find
that higher anxiety, depression, and fewer personal resources are associated with poorer weight gain in adolescents and low-income white, but not African-American,
women (8,9).
We have previously reported that well-educated, middle-class women who reported more weight-restrictive
behaviors during pregnancy were more anxious, stressed,
depressed, angry, and felt less uplifted about their pregnancies (5). Here we conduct further analyses with this
same population to determine whether features of psychosocial functioning, including anxiety, depressed mood,
stress, anger, fatigue, and social support, are associated
with variations in dietary patterns during pregnancy.
Findings from these analyses may provide fresh insights
about factors related to dietary intake during pregnancy
and open new avenues for increasing the effectiveness of
nutrition programs.
METHODS
The current analysis included 134 nonsmoking, predominantly white (85%), married (94.7%), well-educated
women (mean⫽16.7, range⫽12 to 20 years in school) with
low-risk, uncomplicated, singleton pregnancies. These
characteristics provided an opportunity to assess relationships independent of significant social and medical
risks. A total of 185 participants began the study; 48 were
excluded due to development of pregnancy complications,
premature delivery, or conditions in the neonate of fetal
origin. Dietary data were unavailable for three cases.
According to Institute of Medicine guidelines for weight
gain, 11% of women in this sample undergained
(mean⫽14.5 lb), 47% overgained (mean⫽42 lb), and 42%
gained the amount of weight recommended for their
prepregnancy body mass index (BMI) (mean⫽29.1 lb).
Journal of the AMERICAN DIETETIC ASSOCIATION
963
Subjects were recruited through advertisements placed
in local university publications and word-of-mouth to participate in a larger study of factors that influence fetal
neurobehavioral development. Psychosocial data collection commenced at 24 weeks’ gestation and continued at
monthly intervals. Assessment of different features of
psychosocial functioning took place at each visit, a schedule designed to minimize participant burden. A food frequency questionnaire was administered at 28 weeks to
assess dietary patterns and intakes. The study was observational and thus did not bias maternal attitudes
about dietary intake during pregnancy. Study approval
was obtained from the Johns Hopkins Institutional Review Board and written consent was obtained at enrollment.
The following instruments were used:
●
Health Habits and History Questionnaire (HHHQ)
(10), which includes a food frequency questionnaire to
estimate usual dietary intake. Its reliability and validity, while not tested in our sample, have been established in a wide range of similar adult populations
(10-12). Women were asked about dietary intake with
the question, “Since the beginning of your pregnancy,
how often have often have you eaten. . . ?” Respondents
reported frequency as daily, weekly, monthly, or during
pregnancy, and portion size was recorded as small,
medium, or large. Using the HHHQ dietary analysis
software, we quantified average daily intakes for 30
nutrients; energy intake from sweets, protein, carbohydrates, fats, and alcohol; and average weekly frequencies for seven food groups.
Psychosocial Measures:
●
●
●
●
●
●
Spielberger State-Trait Anxiety Inventory (13) is a
widely validated measure of anxiety. It was administered at 28 weeks’ gestation; higher scores reflect
higher levels of anxiety.
Social support specific to pregnancy (14) was assessed
at 28 weeks. An 18-item, 5-point scale was employed to
evaluate support; higher scores reflect greater levels of
support.
Pregnancy Experience Scale measures maternal assessment of exposures to potential hassles and uplifts
specific to pregnancy. The reliability and validity of this
instrument have been established (15). A 4-point scale
was used to appraise each item as a hassle and/or an
uplift at 32 weeks’ gestation; a ratio variable comparing
the frequency was derived to evaluate the relative emotional valence of the pregnancy.
Profile of Mood States (16) administered at 24 weeks’
gestation measures mood. Three negative affect subscales were used, including depression, anger, and fatigue and were administered at 24 weeks’ gestation;
higher scores represent greater negative mood.
Perceived Stress Scale (17) is one of the most widely
used psychological instruments for measuring the perception of stress. It was administered at 28 weeks’
gestation; higher scores reflect higher degrees of perceived stress.
Marlowe-Crowne Social Desirability Scale (18) measures an individual’s tendency to respond to question-
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June 2005 Volume 105 Number 6
naires in a socially desirable way through true-false
questions that describe both acceptable but improbable
behaviors and those deemed unacceptable but probable. It was administered at 36 weeks’ gestation to assess whether this response tendency affected reported
psychosocial functioning and dietary intake.
Statistical Analysis
Pearson product-moment correlations were calculated to
determine the relationships among psychosocial and dietary factors. We also examined the correlations after
adjusting for maternal age, parity, BMI, and education
using a residual approach. A probability of P⬍.05 was
considered statistically significant.
RESULTS
According to pregnancy-specific dietary recommendations (19), the majority of participants in this study reported inadequate intakes of iron, folate, and fiber, and
excessive intakes of proteins and fats. No significant associations with the Marlowe-Crowne scale were detected
(r values ranged from ⫺.14 to .13), indicating that reported dietary intake was not systematically confounded
by maternal perception of social desirability of certain
food choices.
Two sociodemographic characteristics were significantly associated with psychosocial factors. Increased
maternal age was associated with more stress and hassles relative to uplifts during pregnancy. Higher parity
was associated with depressed mood, stress, and hassles
relative to uplifts during pregnancy, and was negatively
associated with social support and partner support. Maternal education and BMI did not correlate significantly
with any psychosocial factors.
Variations in dietary intakes were associated with fatigue, stress, and, to a lesser extent, anxiety (Table 1).
Women who were more fatigued reported higher intakes
of energy, carbohydrates, fats, proteins, and zinc. Conversely, after adjusting for total energy intake, women
who reported greater fatigue also reported lower intakes
of folate. Stress was associated with higher intakes of
energy, fats, proteins, iron, and zinc. Anxiety was negatively associated with intakes of vitamin C, after adjusting for energy intake. Women who were more hassled
than uplifted by the pregnancy reported lower intakes of
protein.
Associations were also found with intakes by food
groups (Table 2). Stress was associated with higher intakes of breads and foods from the fats, oils, sweets, and
snack group. Anxiety was associated with higher intakes
of foods from the fats, oils, sweets, and snack group.
Women who were more hassled than uplifted by the pregnancy reported lower consumption of foods in the meat
group.
Findings remained significant after adjusting for maternal age, parity, BMI, and education. No significant
relationships were detected for depressed mood, anger, or
social support (results not shown).
DISCUSSION
Our results indicate that stress, fatigue, and anxiety during pregnancy are associated with increased consump-
Table 1. Pearson correlations for nutrient intakes of pregnant women with psychosocial measures (N⫽134)
Nutrient
Fatigue
(POMS)a
Stress
(PSS)b
Energy
Carbohydrates
Fats
Proteins
Iron
Folate
Zinc
Calcium
Vitamin A
Vitamin C
Fiber
.24**
.18*
.23**
.23**
.06
⫺.05
.21*
.13
.002
⫺.01
.14
.22*
.12
.24**
.24**
.21*
.02
.24**
.15
.15
.02
.002
Anxiety
(STAI)c
Pregnancy hassles/
uplifts (Pregnancy
Experience Scale)
Fatigue
(POMS)d
Stress
(PSS)d
Anxiety
(STAI)d
Pregnancy hassles/
uplifts (Pregnancy
Experience Scale)d
.10
.04
.16
.01
.12
⫺.03
.06
⫺.02
.03
⫺.09
.02
⫺.12
⫺.07
⫺.14
⫺.19*
.09
.06
⫺.01
⫺.05
.05
⫺.13
.08
⫺.07
.05
.04
⫺.12
⫺.22*
.05
⫺.002
⫺.16
⫺.17
.008
⫺.16
.10
.11
.10
⫺.12
.12
.04
.03
⫺.11
⫺.15
⫺.11
.15
⫺.14
.07
⫺.10
⫺.02
⫺.09
⫺.03
⫺.17*
⫺.05
.10
⫺.07
⫺.15
.21*
.15
.10
.03
.14
⫺.07
.18*
a
POMS⫽Profile of Mood States.
PSS⫽Perceived Stress Scale.
c
STAI⫽Spielberger State-Trait Anxiety Inventory.
d
Adjusted for total energy intake.
*P⬍.05.
**P⬍.01.
b
Table 2. Pearson correlations for food group intakes of pregnant women with psychosocial measures (N⫽134)
Food group
Fatigue (POMS)a
Stress (PSS)b
Anxiety (STAI)c
Pregnancy hassles/uplifts
(Pregnancy Experience Scale)
Vegetables
Fruits
Breads
Milks
Meats
Fats, oils, sweets, snacks
.12
.07
.12
.05
.16
.04
.02
⫺.02
.23**
.14
.08
.18*
⫺.02
⫺.14
.10
.02
⫺.02
.22*
.03
⫺.08
⫺.04
⫺.06
⫺.31**
⫺.06
a
POMS⫽Profile of Mood States.
PSS⫽Perceived Stress Scale.
STAI⫽Spielberger State-Trait Anxiety Inventory.
*P⬍.05.
**P⬍.01.
b
c
tion, particularly in terms of carbohydrates, fats, and
protein. Byproducts of this increased consumption include higher intakes of some micronutrients, including
iron and zinc. There is some evidence that negative affect
is associated with lower folate and vitamin C intake,
perhaps mediated by a trend toward lower fruit consumption. Thus, the relation between dietary intake and psychosocial factors during pregnancy is not unlike that previously described for adults in general (1-3,20).
Pregnancy-specific stress was associated with only a single dietary pattern—reduced protein and meat intake.
This suggests that the psychosocial effects on diet during
pregnancy may be mediated not by stresses particular to
pregnancy but reflect more chronic patterns of individual
women. However, a caution to this interpretation involves the consistent role that fatigue exerted on intake.
Fatigue is a common physical symptom of pregnancy and
it is not known whether this measure reflects a transient
response or a more persistent characteristic associated
with maternal personality.
This study extends knowledge regarding the link between psychosocial factors and eating patterns to pregnancy. The physiologic changes associated with pregnancy may provide additional mechanisms that foster
this relationship, in that pregnancy-induced hormones
may intensify the relationship between dietary intake
and stress. While progesterone increases appetite and
enables women to gain needed fat stores early in pregnancy (21), the addition of elevated stress-induced cortisol might lead to higher intakes of energy and sweets
(20).
We believe that our findings may underestimate the
associations between psychosocial factors and dietary intake. A questionnaire-based approach to ascertain maternal psychological functioning, although common, may
generate a variety of response biases. The presence of
measurement error in these, as well as the food frequency
questionnaire, can produce conservative findings (22). In
addition, it is also likely stronger associations would be
June 2005 ● Journal of the AMERICAN DIETETIC ASSOCIATION
965
found in more heterogeneous populations than the one
studied, including low-income populations that often
have poorer diets (23) and experience higher levels of
stressful life events.
CONCLUSIONS
●
●
The impact of psychosocial characteristics on dietary
intake should be discussed during nutrition counseling
in pregnant and nonpregnant individuals. Practitioners might use these findings to advocate for better
collaboration between health disciplines.
Our findings suggest that better measures are needed
to study the influence of psychosocial functioning on
dietary intake. Researchers can use these findings to
justify the application of longitudinal designs and non–
self-report methods of dietary intake and psychosocial
functioning in future studies.
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