Compliance with Dietary Guidelines and Relationship to Psychosocial Factors in Low-Income Women in Late Postpartum

RESEARCH Current Research

Compliance with Dietary Guidelines and Relationship to Psychosocial Factors in LowIncome Women in Late Postpartum GOLDY C. GEORGE, PhD; TRACEY J. MILANI, PhD; HENRY HANSS-NUSS; JEANNE H. FREELAND-GRAVES, PhD, RD

ABSTRACT Objectives The goals were to evaluate compliance with the Dietary Guidelines among low-income women during late postpartum and to examine the relationship between psychosocial variables and dietary compliance. Subjects/setting Participants were 146 triethnic, low-income women who were recruited 0 to 1 days after childbirth and who visited a clinic site at 1 year postpartum. Design At 1 year postpartum, multiple psychosocial characteristics were measured, and food choices and nutrient intakes were assessed via a validated food frequency questionnaire. Dietary guidelines index scores and measures of adherence to dietary recommendations were computed. Statistical analyses performed Descriptive statistics, analysis of variance with post-hoc Scheffe tests, ␹2 with follow-up tests of independent proportions, and Pearson correlation coefficients were utilized. Results For dietary compliance, 60% had adequate intakes of meat, but less than 30% met recommendations for grains, vegetables, fruits, dairy foods, total fat, and added sugar. Healthful weights (body mass index ⬍25) were observed in 37% of women. Those in the highest G. C. George is a National Cancer Institute Postdoctoral Research Fellow at the Center for Health Promotion and Prevention Research, The University of Texas School of Public Health at Houston; at the time of the study, she was a graduate student in the Division of Nutritional Sciences, The University of Texas at Austin. T. J. Milani is a Clinical Project Manager at MedLogix Communications, LLC, San Diego, CA; at the time of the study, she was a graduate student in the Division of Nutritional Sciences, The University of Texas at Austin. H. Hanss-Nuss is a doctoral candidate and J. H. FreelandGraves is the Bess Heflin Centennial Professor in the Division of Nutritional Sciences, The University of Texas at Austin. Address correspondence to: Jeanne H. FreelandGraves, PhD, RD, Division of Nutritional Sciences, 1 University Station, A2700, The University of Texas at Austin, Austin, TX 78712. E-mail: [email protected] Copyright © 2005 by the American Dietetic Association. 0002-8223/05/10506-0011$30.00/0 doi: 10.1016/j.jada.2005.03.009

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tertile of dietary compliance had a more positive body image than those in the lowest tertile, and less neglect of self-care, weight-related distress, stress, depressive symptoms, and perceived barriers to weight loss (P⬍.05). Dietary compliance and psychosocial scale scores did not vary by ethnicity. Conclusions Adherence to dietary guidelines was limited in the low-income, postpartum women. Psychosocial variables, such as neglect of self-care, weight-related distress, negative body image, stress, and depressive symptoms were associated with less healthful diets and lifestyle in late postpartum. Programs that target dietrelated behavior change in low-income women might be improved by inclusion of psychosocial assessment and counseling components. J Am Diet Assoc. 2005;105:916-926.

T

he Dietary Guidelines for Americans were created to provide nutritional guidance to promote health and reduce the risk of chronic disease (1,2). Eating patterns that are consistent with dietary guidance recommendations have been linked with increased nutrient adequacy (3); lower prevalence of heart disease (4), cancer (5,6), and age-related eye conditions (7); and reduced mortality (8). Unhealthful diets may be prevalent during postpartum as women adapt to the maternal role and face increased demands on their time (9). Low-income mothers, especially, may face unique stresses associated with finances (10), child care (11), and transportation (12) during this time. Thus, assessment of compliance with dietary guidelines in low-income women during late postpartum would help identify nutritional concerns. The postpartum period is characterized by rapidly changing life events that may influence psychosocial factors, such as neglect of self-care (13), weight-related distress (14), stress (15,16), depressive symptoms (10), negative body image (17), and a greater need for social support (18,19). For example, Horowitz and colleagues (20) reported that mild to moderate depressive symptoms may occur in more than 25% of postpartum women. It is plausible that psychosocial variables may impact compliance with dietary recommendations. Several indexes measure dietary quality and dietary behavior (21), including those that are exclusively nutrient- (22-24) or food-based (25,26), or both (5,27-31). The dietary guidelines index (5) was chosen for this study because it measures multiple aspects of diet and

© 2005 by the American Dietetic Association

is based on lifestyle factors that are determined easily in low-income women. The purpose of this research was to evaluate compliance with dietary guidelines in late postpartum in lowincome women. A secondary purpose was to examine the impact of psychosocial variables on this dietary behavior. METHODS Study Design A triethnic sample of low-income women was recruited 0 to 1 days after delivery, by nursing staff employed at the hospital (32). Information on study procedures and participant requirements was provided to eligible new mothers. Women who agreed to participate gave written consent. Data on sociodemographic status (income, ethnicity, education) were obtained. Participants visited a clinic site at 1.5 months and at 1 year postpartum. Height was measured at the 1.5-month visit. At the 1-year postpartum visit, subjects brought in completed psychosocial questionnaires that had been mailed to them prior to the visit. The psychosocial questionnaires included the SelfCare Inventory (neglect of self-care), Weight Related Thoughts and Feelings (weight-related distress), Stress, Center for Epidemiologic Studies-Depression (CES-D) (depressive symptoms), Body Cathexis (body image), Postpartum Social Support, and Decisional Balance (pros and cons toward weight loss) scales. Weight also was measured at the 1-year postpartum visit, and participants completed a food frequency questionnaire of foods eaten during the previous 6 months. Subjects Participants were healthy, Medicaid-eligible women (family incomes ⱕ185% of poverty guidelines) who were not lactating at 1 year postpartum. Subject inclusion criteria included age 18 years or older; white, AfricanAmerican, or Hispanic ethnicity; parity ⱕ3; ability to read, write, and speak in English; and telephone access. Complete data on demographic, psychosocial, and food frequency questionnaires were obtained from 172 women. Twenty-one subjects were excluded as their energy intakes exceeded 4,500 kcal per day. Five subjects were excluded due to low energy intakes (⬍500 kcal per day). The final sample was 146 women (31.5% white, 30.1% African American, and 38.4% Hispanic), with a mean age of 22.2⫾0.31 years (mean⫾standard error of the mean [SEM]). The narrow age range reflected the population at the hospital who met study inclusion criteria. Sixty-two percent of participants were living with a spouse or partner. Parity more than 2 was reported by 64.4% of the sample and 61.6% had graduated high school. The Institutional Review Board of the University of Texas at Austin approved study procedures. Constructs and Instruments Food Frequency Questionnaire. Food choices and nutrient intakes were measured via a semiquantitative food frequency questionnaire (FFQ) tailored for multicultural populations in the southwestern United States (33). The questionnaire

contained 195 individual (eg, bananas) or closely related food items (eg, oranges and tangerines). It was based on the Block-National Cancer Institute Health, Habits, and History Questionnaire, and was modified to incorporate southwestern, new (eg, fat-modified foods, Slimfast [West Palm Beach, FL]), and ethnic food products. Examples of foods included were chorizo, chicken fried steak, and sopapillas. The reference period for the questionnaire was the previous 6 months. This instrument has been validated recently in an ethnically diverse sample of low-income postpartum women. Mean coefficients were 0.73 for reliability and 0.45 for validity (33). Subjects were instructed by a nutritionist or a nurse, both verbally and via written instructions, on how to fill out the FFQ and estimate portion sizes using food models and measuring cups and spoons. The FFQ was completed by participants at the visit, and the time taken was approximately 25 minutes. Portion size options were small, medium, large, and extra-large; frequency options varied from “never or less than once a month” to “2⫹ times per day.” The staff nutritionists and nurses had received extensive training in dietary data collection techniques using standardized protocols from a nutrition professor and dietetics professionals. All questionnaires were reviewed for missing items and ambiguous responses were clarified with participants. Dietary intake from the FFQ was analyzed in terms of foods and nutrients via DIETSYS, a computer program developed by Block and colleagues (34) that we modified to incorporate nutrient values for the added foods. Sample nutrients calculated by the program included total fat, saturated fat, cholesterol, and sodium intake. Analysis options in the DIETSYS program enabled fine-tuning of nutrient calculations based on responses of participants to summary questions. For example, the Vegetable Adjust option tallied the total of individual vegetable items selected with a summary question on how often vegetables were consumed. If the total of the individual servings of vegetables (group frequency) was 20% more than the frequency indicated by the summary question, then the frequencies of the individual vegetables would be decreased by the factor “summary frequency/group frequency” prior to the calculation of nutrient intakes (35). Energy cutoffs were applied for checking FFQ data. The lower limit was 500 kcal and the upper cutoff was 4,500 kcal. Similar cutoff values have been used in other studies in multiethnic (36-38) and low-income populations (39,40). The upper level cutoff was justified also by the fact that 63% of the women were overweight or obese at 1 year postpartum, suggesting excessive energy intakes. Anthropometric Measures. Height was measured to the nearest 0.1 cm via a mounted stadiometer (Perspective Enterprises, Portage, MI). Weight was measured with an accuracy up to 0.1 kg via an electronic scale (Fairbanks Portable Digital Scale, Kansas City, MO). Body mass index (BMI) was calculated as kg/m2. Dietary Guidelines Index. Dietary behavior was defined in terms of the dietary guidelines index (5), a composite measure of compliance with the 2000 Dietary Guidelines for Americans (1). This index has nine components that reflect each of the major recommendations in the guidelines. Food and nutrient data required for computation of

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index scores were obtained from FFQs. BMI at 1 year postpartum was used to estimate compliance with the weight guideline. Physical activity was assessed via a questionnaire (41) that incorporated the frequency of time spent in exercising vigorously during the past month. Certain index components, such as those relating to adherence to the Food Guide Pyramid, dietary variety, and fat intake, were divided into subcomponents (Table 1). Total possible scores on this index range from 0 to 18, and higher scores indicate greater compliance with the dietary guidelines (5). The choice of this multidimensional index reflects the suggestion that diet should be examined in terms of overall dietary patterns (8,42) rather than in terms of individual nutrients or food groups (43-45). Psychosocial Measures. The psychosocial questionnaires were mailed to the participants to complete at home and bring to the clinic site because these instruments took approximately 25 minutes to complete. At the clinic site, psychosocial questionnaires were reviewed and missing items completed. Self-Care Inventory. The tendency of participants to neglect self-care by engaging in negative health behaviors such as inadequate sleep, unhealthy dietary practices, and substance abuse, was assessed via this 40-item measure (41). Two questions on use of alcohol were added (46). The items on this questionnaire had a 4-point Likert format, with responses ranging from “rarely/never” to “very often.” Higher scores indicate greater neglect of self-care. Internal consistency was determined via Cronbach ␣ and was .85 for the present sample. Construct validity for this instrument was demonstrated by significant positive relationships between neglect of self-care scores and the presence of illness (path coefficient⫽0.33, P⬍.01) (47). Feelings and Thoughts about Weight Scale. This 14-item scale measured weight-related distress in postpartum, with higher scores indicating greater weight-related distress (48). Responses were coded on a 7-point Likert scale, ranging from “disagree strongly” to “agree strongly.” Internal consistency reliability via Cronbach ␣ was .94 at 1 year postpartum. Stress Scale. An 11-item scale measured stress experienced from different sources, such as financial or family problems, or the presence of a young infant (49). The Likert-type scale had responses ranging from 1 (no stress) to 4 (severe stressor/hassle). Cronbach ␣ value in this sample was .8 at 1 year postpartum. Depressive Symptoms Scale. Depressive symptoms were assessed via the CES-D (50). This 20-item instrument has been used previously to measure depression in postpartum women (51-53). Responses to questions 4, 8, 12, and 16 were reverse-coded prior to the calculation of total scale scores. Cutoffs on total scores that indicate mild and severe depression were 11 and 16, respectively (54). The Cronbach ␣ value for the CES-D scale in this sample of 146 women was .92. Body Cathexis Scale. This 30-item instrument that measured dissatisfaction with specific parts (eg, waist, hips, face) or functions (eg, digestion) of the body was an abbreviated version of the original scale developed by Secord and Jourard (55). The validity of the scale was estab-

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lished because negative body image as measured by this instrument was related to lower self-esteem and to higher body weight (56). The Cronbach ␣ value in the present study was .97 at 1 year postpartum. Social Support Scale. This 6-item scale measured the degree of support a new mother received from her family, primarily her partner. This instrument is pertinent to the period following childbirth and had a Cronbach ␣ value of .90 in the present sample. Decisional Balance Inventory. This 20-item measure evaluated the predisposition of participants toward weight loss. The “pro” subscale identified the degree to which participants desired to lose weight; “con” queried on perceived barriers to weight loss. Cronbach ␣ values for this scale in the present study were .94 for the “pro” subscale and .91 for the “con” subscale. Statistical Methods. Descriptives such as ranges and means were used to describe characteristics of participants with respect to demographics and components of the diet guidelines index. Frequencies were computed to estimate the number of people who complied with each of the dietary guidelines. To establish construct validity, analysis of variance with post-hoc Scheffe tests was used to test for significant differences in nutrient intakes and Food Guide Pyramid patterns among persons classified into different tertiles of diet index scores. ␹2 analyses with follow-up via tests of independent proportions were conducted to determine statistically significant differences among tertiles for categorical variables. Construct validity is obtained when a construct (in this case, compliance with dietary guidelines) varies with related variables (in this case, aspects of diet) in expected ways, consistent with established theory (57-59). A similar method was used previously to demonstrate the usefulness of the dietary guidelines index in a sample of older women (5). Internal consistency reliability of psychosocial instruments was evaluated using Cronbach ␣ for each scale. Reliability coefficients exceeding .7 were considered acceptable (59). Variations in psychosocial factors across tertiles of the diet guidelines index were examined using analysis of variance with post-hoc Scheffe tests. Differences in demographic factors such as age, ethnicity, and parity by tertiles of index scores were assessed using analysis of variance for continuous and ␹2 tests for categorical variables. Variation in psychosocial factors among ethnic groups was evaluated using analyses of variance. Associations between individual items on the psychosocial scales and overall diet index scores were assessed via Pearson correlation coefficients. The Bonferroni analysis was applied to aid in interpretation of comparisons. Because this technique is widely recognized as being highly conservative and may cause one to overlook truly significant findings (60,61), items with unadjusted P⬍.05 were reported. RESULTS Compliance with the dietary guidelines index was less than optimal in this sample of low-income women (Table 1). Weight recommendations were not followed by the majority of the sample; 37% were obese (BMI ⱖ30) and 25.3% were overweight (BMI ⱖ25 and ⬍30). More than

Table 1. Compliance with dietary guidelines recommendationsa in low-income women at 1 year postpartum (N⫽146) Recommendation Index component Aim for fitness Weight Physical activity Build a healthy base Food Guide Pyramid recommendations Breads, grains, cereal, rice, and pasta Vegetable Fruit Milk, yogurt, and cheese Meat, fish, poultry, dry beans, eggs, and nuts Variety of grains and whole grains Grains Whole grains Variety of fruits and vegetables Fruits Vegetables Choose sensibly Amounts and types of fat Total fat Saturated fat Cholesterol Sweets and sugar-sweetened beverages Sodium Alcoholic beverages Total score

Score

Criteria

Compliance (%)

Possible Range

MeanⴞSEMc

BMId ⬍25 Often/fairly often

37.7 21.3

0-2 0-2

0.99⫾0.07 0.27⫾0.05

ⱖ6 servings/d

23.3

0-0.4

0.09⫾0.01

ⱖ3 ⱖ2 ⱖ2 ⱖ2

16.4 25.3 19.9 65.1

0-0.4 0-0.4 0-0.4 0-0.4

0.07⫾0.01 0.10⫾0.01 0.08⫾0.01 0.26⫾0.02

ⱖ4 different types of grain items/wk ⬎1 serving/d

35.0

0-1

0.25⫾0.03

14.4

0-1

0.08⫾0.02

ⱖ5 different types of fruits/wk ⱖ7 different types of vegetables/wk

25.3

0-1

0.21⫾0.03

35.0

0-1

0.25⫾0.03

6.8

0-0.67

0.05⫾0.01

6.2

0-0.67

0.04⫾0.01

58.9

0-0.67

0.39⫾0.03

28.8

0-2

0.95⫾0.07

22.6 97.9 —

0-2 0-2 0-18

0.45⫾0.07 2.0⫾0.02 6.5⫾0.17

servings/d servings/d servings/d servings/d

ⱕ30% energy from fat/d ⱕ10% energy from saturated fat/d ⱕ300 mg cholesterol/d ⱕ3 servings/d ⱕ2,400 mg sodium/d ⱕ1 drink/d —

b

a

Comparisons are based on the 2000 Dietary Guidelines for Americans (1) and the dietary guidelines index (5). Failure to meet stated criterion for an index component results in a score of zero. c SEM⫽standard error of mean. d BMI⫽body mass index. b

75% of the sample did not engage in vigorous physical activity often or fairly often. Conformity with guidelines for food groups such as grains, vegetable, fruit, and dairy was low (⬍25%). Yet, over 60% of the sample did meet the recommendations for the meat, fish, poultry, dry beans, eggs, and nuts group. Almost everyone (99.3%) reported intakes of ⬍3 servings of whole-grain foods each day. In terms of variety, vegetables had the greatest diversity, with 35% of the sample consuming at least seven different items each week. The least variety was found for fruits, with only 25.3% of the participants consuming ⬎5 types/week. The mean percentage of total energy from fat was 38.8%⫾0.52%, ranging from 19.2% to 54.4%. Mean daily intakes of saturated fat and cholesterol were 13.6%⫾0.19% of total energy and 325.1⫾16.9 g, respectively. Sodium intake averaged 3,600⫾128.6 mg/day. Use

of alcoholic beverages was not prevalent in this population; less than 3% drank more than one alcoholic beverage each day. Construct validity for the dietary guidelines index was provided by expected variations of index scores with dietary variables (Table 2). Those classified into the highest tertile of compliance consumed more servings of vegetables and fruits, and less cholesterol, sodium, and alcohol than those in the lowest tertile. Dietary variety of grains, vegetables, and fruits also was greater in those with higher scores on the dietary guidelines index. Table 3 shows psychosocial scale scores across tertiles of the dietary guidelines index. Greater compliance with dietary guidelines was associated with lower neglect of self-care, weight-related distress, stress, depressive symptoms, and perceived barriers to weight

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Table 2. Parameters of dietary behavior according to tertiles of diet index scores in low-income women at 1 year postpartum (N⫽146) Tertiles of Dietary Guidelines Index Scoresab Dietary parameters

Range

1 (lowest)

2

3 (highest)

P value

4™™™™™™™™™™™™™™™™™ mean⫾SEM c ™™™™™™™™™™™™3 Food categories Grains (servings/d) Vegetables (servings/d) Fruits (servings/d) Dairy (servings/d) Meat (servings/d) Sweets and sugar-sweetened beverages (servings/d) Dietary variety Grains (servings/wk) Vegetables (servings/wk) Fruits (servings/wk) Nutrient intakes Total fat (g/d) Saturated fat (g/d) Cholesterol ⬎300 mg/d Sodium ⬎2,400 mg/d Alcohol ⬎1 drink/d

0-16.2 0-7.7 0-14.3 0-6.2 0.4-7.2

4.3⫾0.40x 1.4⫾0.12x 0.89⫾0.13x 1.5⫾0.18x 2.9⫾0.20x

4.7⫾0.36x 1.9⫾0.16xy 1.5⫾0.18xy 1.3⫾0.12x 3.1⫾0.21x

4.7⫾0.42x 2.5⫾0.25yz 2.6⫾0.37yz 1.2⫾0.11x 2.8⫾0.24x

.724 .001 .001 .273 .598

0-24.1

5.5⫾0.63x

3.3⫾0.30y

2.5⫾0.28yz

.001

0-11 0-18 0-19

2.5⫾0.20x 3.5⫾0.40x 1.9⫾0.41x

2.8⫾0.28x 5.3⫾0.51x 2.8⫾0.35x

4.0⫾0.38y 7.7⫾0.67y 5.6⫾0.56y

.001 .001 .001

100.9⫾6.0x 89.4⫾5.5x 84.1⫾5.6x 35.9⫾2.2x 31.2⫾2.0x 29.7⫾2.1x 4™™™™™™™™™™™™™™™™™™™™™™ % ™™™™™™™™™™™™™™™3 52.1x 44.9x 26.5x x x 87.5 81.6 63.3x 6.3x 0.0x 0.0x

.088 .073

20-196 7.2-75.3 44.7-1,321 822-8,339 0-2

.031 .013 .045

a

Indicates compliance with dietary guidelines as measured by the dietary guidelines index score (5). Subjects were classified into tertiles based on total dietary guidelines index scores. c SEM⫽standard error of the mean. xyz Different superscript letters indicate significant differences in anthropometric and dietary variables among tertiles of diet index scores as indicated by the post-hoc Scheffe test for continuous variables, and by the test of independent proportions for categories, Pⱕ.05. b

Table 3. Distribution of psychosocial scale scores by tertiles of diet index scores in low-income women at 1 year postpartum (N⫽146) Scores Tertiles of Dietary Guidelines Index Scoresa 2

Range

1 (lowest)

Neglect of self-cared Weight-related distressd Stress scaled Depressive symptomsd Negative body imaged Social support Decisional balance inventory Pro subscalee Con subscalef

7-72 14-96 11-38 0-50 30-132 6-54

4™™™™™™™™™™™™™™™™™ mean⫾SEM c ™™™™™™™™™™™™™™™3 40.9⫾2.1x 33.4⫾1.5y 30.4⫾1.3y x y 52.4⫾3.1 39.8⫾2.5 42.6⫾2.9xy 22.9⫾0.89x 19.2⫾0.78y 20.3⫾0.70xy x xy 21.2⫾1.9 15.1⫾1.6 15.0⫾1.5y 83.9⫾3.6x 72.1⫾3.3x 73.9⫾3.5x x x 32.9⫾1.8 35.1⫾1.9 34.7⫾2.0x

.001 .006 .009 .020 .041 .753

10-50 10-48

32.0⫾1.6x 24.8⫾1.3x

.059 .039

25.8⫾1.6x 20.3⫾1.3x

3 (highest)

P valueb

Scale

28.0⫾1.7x 20.3⫾1.3x

a

Subjects were classified into tertiles based on total dietary guidelines index scores. Analysis of variance used to determine statistically significant differences among tertiles. SEM⫽standard error of the mean. d Higher scores indicate greater negativity in psychosocial factors. e Higher scores indicate greater disposition towards weight loss. f Higher scores indicate greater disinclination towards weight loss. xy Different superscript letters indicate significant differences in psychosocial variables across tertiles of diet index scores as indicated by the post-hoc Scheffe test. b c

loss (decisional balance-con scale), and less negative body image (P⬍.05). Surprisingly, social support did not differ across tertiles of diet index scores. Demographic factors such as age and parity did not vary

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across categories of dietary guidelines index scores. Psychosocial factors and overall compliance with dietary guidelines (dietary guidelines index scores) did not vary by ethnicity.

Table 4. Relationships between selected significant items on psychosocial questionnaires and diet index scores in low-income women at 1 year postpartum (N⫽146) Relationship to Dietary Guidelines Index Score Selected items on questionnaires Self-care inventory (neglect of self-care) How often did you substitute junk food (candy, potato chips, soda) or fast food (Burger Kingb) for a regular meal? How often did you drink a lot of coffee or cola beverages in one day? How often did you take time to perform exercises that enhance muscle tone (yoga, running in place, calisthenics/ weight training)? How often did you eat a nutritious breakfast? Weight-related distress I feel like a failure when I think about my weight I feel ashamed of myself because of my weight I prefer to wear clothes that hide my weight Stress scale Degree of stress from work or school problems such as being laid off, failing a class, etc Degree of stress from money problems such as paying bills Center for Epidemiological Studies Depression Scale (CES-D) I felt that I could not shake off the blues even with help from my family or friends I thought my life had been a failure Body cathexis scale (body image) Negative feelings about health Negative feelings about age Negative feelings about weight Decisional balance inventory Others would have more respect for me if I lost weight I would be able to accomplish more if I carried fewer pounds

Mean scoreⴞSEMa

Pearson correlation (r)

P value*

1.46⫾0.08

⫺0.303

.001c

0.34⫾0.05

⫺0.223

.008

1.20⫾0.07

0.192

.021

1.73⫾0.07

0.187

.025

2.72⫾0.15

⫺0.212

.011

2.79⫾0.16

⫺0.203

.015

3.82⫾0.17

⫺0.182

.029

1.59⫾0.08

⫺0.183

.028

2.77⫾0.08

⫺0.181

.029

0.81⫾0.09 0.53⫾0.07

⫺0.197 ⫺0.177

.018 .034

2.34⫾0.10 2.02⫾0.09 3.00⫾0.12

⫺0.188 ⫺0.176 ⫺0.166

.024 .035 .046

1.98⫾0.11

⫺0.222

.008

2.72⫾0.13

⫺0.173

.038

a

SEM⫽standard error of the mean. Burger King, Miami, FL. c Significant following Bonferroni adjustment. *Correlations are significant at P⬍.05. b

Individual items on the psychosocial questionnaires that showed highly significant relationships with diet index scores are shown in Table 4. Specific items that showed the strongest associations with dietary guidelines compliance were substituting junk foods for a meal, drinking a lot of coffee or cola, and lack of respect and feeling like a failure due to weight.

DISCUSSION The ensuing discussion of the results is based on the 2000 dietary guidelines (1), which were current at the time of analysis, and comparisons are made as appropriate to the recently released 2005 dietary recommendations (62). Compliance with the dietary guidelines recommenda-

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tions in late postpartum was less than expected. Specifically, these low-income women were not in compliance for guidelines related to weight, physical activity, grains, vegetables, fruit, dairy, and dietary variety. A significant proportion of the sample also reported excessive intakes of total fat, saturated fat, sweets/sugar-sweetened beverages, and sodium. Adherence to the weight guideline in the present study (37%) was less than that seen in a national sample of 20to 34-year-old women from the 1999-2000 National Health and Nutrition Examination Survey (63) (48.5%) and in low-income women in the same age group by Gibson (64) (50.4%). The lower proportion of healthful weight persons in the present sample may reflect the large proportion (⬎60%) of minority women who exhibit higher rates of obesity (65) and postpartum weight retention (66) than whites. In this study, the majority of women (79.2%) retained weight gained during pregnancy and the mean BMI was 26⫾0.5 at prepregnancy and 28.9⫾0.6 at 1 year postpartum. The high degree of noncompliance with the weight guideline is of concern because excess body weight increases risk for type 2 diabetes (67,68), heart disease (69), gallstone formation (70), certain types of cancer (71), and depression (72); reduces immune competence (73); and negatively impacts quality of life (1). The frequency of vigorous physical activity in this cohort is less than that found in research by Hinton and Olson (74) in 622 women at 1 year postpartum. In their study, 42% of participants exercised regularly and 15% reported doing so often. Our lower figures may be due to differences in socioeconomic composition or a limited ability to capture physical activity adequately. The 2005 guidelines for physical activity are even more stringent than those laid out in the 2000 edition and emphasize increased physical activity for prevention of chronic disease and weight management. The minimal physical activity seen in the present sample is problematic, as Rooney and Schauberger (75) found that participation in aerobic exercises during postpartum was associated with less weight gain 8 to 10 years later. Postpartum physical activity also has been linked with improved overall fitness, serum lipid profiles, insulin sensitivity, and psychological well-being (76). Reasons for limited exercise in this group of low-income postpartum women may include the responsibility of caring for a newborn infant; lack of time, financial resources and transportation (74); negative body image; lack of easy access to exercise facilities; safety concerns; and social isolation (77). The percentage of women meeting the 2000 dietary guideline recommendations for specific food groups was less than those reported in a national sample of 20- to 29-year-old women (78) for grains (23.3% vs 32%) and vegetables (16.4% vs 35%), but higher for fruits (25.3% vs 18%), dairy (19.9% vs 17%), and meats (65.1% vs 29%). The proportions of low-income women consuming at least five different fruits (25.3% vs 63.6%) or seven vegetables (35% vs 63.2%) weekly were less than those observed in postmenopausal women of primarily high socioeconomic status (5). Only 6.8% and 3.4% of women met the 2005 recommendations for fruits (ⱖ4 servings/day) and vegetables (ⱖ5 servings/day), respectively. The almost complete lack of alcohol consumption is surprising, but this

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absence may be a reflection of economic pressures, priority of needs, or the cultural norms of the society in which these women live. In late postpartum, our women had high intakes of total fat, saturated fat, and cholesterol, which increase the risk of cardiovascular and other chronic diseases. The percentage of energy from fat in the present study (38.8%) was slightly higher than that seen in other samples of low-income postpartum women (32% to 37%) (79), as well as US women older than 20 years of age (32.4%) (80). Trans fat intake, a component of the 2005 dietary guidelines, was not measured in this study. Energy ingested from added sugar in soft drinks was more in these low-income women than in a national sample of adults from the Continuing Survey of Food Intake by Individuals (195 vs 107 kcal) (81). The increased consumption of fat and added sugar in this population is of concern because these dietary components may enhance weight gain and obesity (82). Mean daily sodium intakes in the low-income women were higher than those reported for a national sample of females aged 20 to 39 years (83) (3,600 mg vs 3,161 mg). The percentages of women meeting the 2005 recommendations for sodium (⬍2,300 mg/day) and potassium (⬎4,700 mg/day) was low at 18.5% and 3.4%, respectively. Reasons for compromised dietary behavior in women of limited economic means may include lower costs of highfat foods and higher expense for more nutritious foods such as fruits and vegetables (84); economic constraints (85-87); insufficient food shopping (88) and cooking (89,90) skills; and lack of nutrition knowledge (91-93). Recent evidence also suggests that foods containing sugar and fat are highly preferred by adults in general (94). Dietary practices during postpartum may be influenced further by insufficient time (9), weight concerns (95), disinterest in eating, and meal skipping followed by the consumption of high-fat snacks (79). The construct validity of the dietary guidelines index was verified by the distribution of dietary guidelines index scores in expected directions with individual food and nutrient variables. For example, the fact that actual consumption of fruits and vegetables was higher in those subjects classified into the higher tertiles of the dietary guidelines index than in those classified into the lower tertiles confirms validity of this method. The psychosocial variables measured in this study were associated with lower compliance with dietary guidelines at 1 year postpartum. Previously, depression and environmental stresses have been reported to influence health behaviors during pregnancy (46). It is interesting to note from the present study that the influence of psychosocial factors on dietary behavior continues into postpartum. The association of lower dietary compliance with inattention to taking care of oneself is not surprising. The majority of these low-income women was overweight or obese and did not exercise on a regular basis. The relationship between eating at fast-food restaurants and lower dietary compliance in our study parallels that of a national sample of 17,370 by Paeratakul and colleagues (96), who showed concordance between fast-food consumption and poor-quality diets. Weight-related distress was associated with low com-

pliance with dietary guidelines in the present sample. Feelings of inadequacy linked to weight may accompany overweight status (14). In a cohort of 622 women at 1 year postpartum, Hinton and Olson (74) found that 56% reported dissatisfaction with body weight and/or shape. Previous studies also have shown that feelings of shame and guilt relating to weight may result in attempts by participants to avoid social activities (48) and to lose self-esteem (97). These feelings also were associated with lower adherence to nutrition recommendations in the present research. We found that degree of stress from work or school problems, financial issues such as paying bills, and recent loss of loved ones were associated with limited compliance with dietary guidelines. Dixon and colleagues (98) also observed that economic hardship negatively impacted dietary quality. A high incidence of depressive symptoms among lowincome minority women has been reported (99). In the present study, we found an inverse association between depression and dietary quality in these women. Previously, depression has been linked with lower intakes of fruits and vegetables (100) and reduced physical activity (101) in adolescents; increased diabetes risk in persons with low education levels (102); diminished quality of life in patients with chronic disease (103); and folate deficiency (104), weight gain, and cardiovascular disease in the general population (105). To the best of our knowledge, the present study is the first to explore the relationship between depressive symptoms and dietary behavior in a low-income postpartum sample. A limitation may be the wording of questions. For example, respondents may have answered a query related to consumption of a nutritious breakfast based on how they interpret the term “nutritious” or what they perceived to be “junk food.” Although this study provides insight about the dietary patterns of low-income women during late postpartum, a measure of prepregnancy behavior was not available. It is conceivable that compliance with dietary guidelines was less than optimal before pregnancy; thus, it is possible that the responses are not unique to postpartum. In summary, compliance with dietary guidelines was minimal in the low-income women. Psychosocial variables, such as neglect of self-care, weight-related distress, body image, stress, and depressive symptoms were associated with reduced compliance at 1 year postpartum. Thus, programs that target diet-related behavior change in low-income women might be improved by inclusion of psychosocial assessment and counseling components. Similarly, it is plausible that these psychosocial factors may be improved by healthful eating patterns. CONCLUSIONS Significant proportions of young, ethnically diverse, lowincome women may not comply with dietary guideline recommendations for weight, physical activity, grains, vegetables, fruits, dairy foods, fats, and added sugar in late postpartum. Thus, programs and policies are needed to improve these areas of diet and lifestyle that may be compromised in this population. Mechanisms by which this education may be incorporated include the postpar-

tum visits that are currently part of the health care system and governmental assistance programs. Dietetics professionals should be cognizant that psychosocial factors such as neglect of self-care, weightrelated distress, negative body image, stress, and depressive symptoms may be associated with less healthful diets in late postpartum. It is unclear whether psychosocial factors that were tested influenced eating patterns or whether the diet impacted psychosocial factors. Nonetheless, clinical efforts that target dietary behavior in these low-income women should incorporate counseling components related to psychosocial issues. The authors acknowledge Lorraine Walker, PhD, RN, for her role on the National Institutes of Health (NIH) grant and for reviewing the manuscript, and Thomas Bohman, PhD, for statistical advice. This research was supported by NIH grant RO1 NR04679. There have been no financial arrangements, organizational affiliations, or other relationships that may constitute a conflict of interest regarding the subject matter of the manuscript. References 1. US Department of Agriculture, US Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans, 2000. Available at: http://www.health.gov/dietaryguidelines/ dga2000/document/frontcover.htm. Accessed on August 1, 2004. 2. McMurry KY. Setting dietary guidelines: The US process. J Am Diet Assoc. 2003;103(suppl 2):S10S16. 3. Foote JA, Murphy SP, Wilkens LR, Basiotis PP, Carlson A. Dietary variety increases the probability of nutrient adequacy among adults. J Nutr. 2004; 134:1779-1785. 4. Millen BE, Quatromoni PA, Nam B, O’Horo CE, Polak JF, Wolf PA, D’Agostino RB. Dietary patterns, smoking and subclinical heart disease in women: Opportunities for primary prevention from the Framingham Nutrition Studies. J Am Diet Assoc. 2004; 104:208-214. 5. Harnack L, Nicodemus K, Jacobs DR, Folsom AR. An evaluation of the Dietary Guidelines for Americans in relation to cancer occurrence. Am J Clin Nutr. 2002;76:889-896. 6. Jansen MC, McKenna D, Bueno-De-Mesquita HB, Feskens EJ, Streppel MT, Kok FJ, Kromhout D. Reports: Quantity and Variety of Fruit and Vegetable Consumption and Cancer Risk. Nutr Cancer. 2004;48:142-148. 7. Moeller SM, Taylor A, Tucker KL, McCullough ML, Chylack LT, Hankinson SE, Willett WC, Jacques PF. Overall adherence to the Dietary Guidelines for Americans is associated with reduced prevalence of early age-related nuclear lens opacities in women. J Nutr. 2004;134:1812-1819. 8. Kant AK, Graubard BI, Schatzkin A. Dietary patterns predict mortality in a national cohort: The National Health Interview Surveys, 1987 and 1992. J Nutr. 2004;134:1793-1799. 9. Devine CM, Bove CF, Olson CM. Continuity and

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