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,**
* Department of Nutrition, Department of Maternal and Child Health, ** Carolina Population Center, School of Public Health, University of North Carolina, Chapel Hill, NC and Department of Human Development and Family Studies, Iowa State University, Ames, IA
2 To whom correspondence should be addressed. E-mail: blaraia{at}email.unc.edu.
ABSTRACT
Household food insecurity has been associated with several negative health outcomes, yet little is known about the prevalence and correlates of household food insecurity during pregnancy. This study was conducted as part of the Pregnancy, Infection, and Nutrition prospective cohort study to identify risk factors of preterm birth. The USDA 18-item scale was used to assess the prevalence of food insecurity among pregnant women with incomes 
400% of poverty. Descriptive statistics and logistic regression were used to identify socioeconomic, demographic, and psychosocial predictors of household food insecurity. Among 606 pregnant women, 75% were from fully food-secure, 15% from marginally food-secure, and 10% from food-insecure households. Women from marginally food-secure and food-insecure households had significantly less income, less education, and were older than women from fully food-secure households. In bivariate analysis, all psychosocial factors were significantly associated with household food insecurity and showed a dose-response relation with increasing food insecurity. Socioeconomic and demographic predictors for household food insecurity were income, black race, and age. After controlling for socioeconomic and demographic variables, psychosocial indicators of perceived stress, trait anxiety, and depressive symptoms, and a locus of control attributed to chance were positively associated with any household food insecurity. Conversely, self-esteem and mastery were inversely associated with any household food insecurity. Psychosocial factors as well as socioeconomic and demographic indicators are associated with household food insecurity among pregnant women; however, the direction of causation between psychosocial indicators and food insecurity cannot be determined in these data.
KEY WORDS: • household food security • pregnancy • psychosocial factors
A woman's nutritional status before and during pregnancy is an important environmental risk factor for adverse pregnancy outcomes (1–6). As a result, ensuring a nutritious food supply for pregnant women has been a primary focus of prenatal care and federal government interventions, with the latter concentrating efforts on low-income pregnant women. In recent years, the risk of experiencing food insecurity has been identified as a public health issue for low-income households. In 2003, 11.2% of all U.S. households, representing >36 million people, experienced food insecurity (7), defined as "whenever the availability of nutritionally adequate and safe food, or the ability to acquire acceptable foods in socially acceptable ways, is limited or uncertain" (8).
Food insecurity has many health consequences for women in low-income households. For example, food insecurity leads to reduced micronutrient intake among women of child-bearing age (9), overweight (10,11), and an inability, during peak weight-gaining years, to return to pregravid weight status (12). Maternal depression and decreased mental health status have been associated with food insecurity (13–15). Decreased mental health status may put low-income women at risk for household food insecurity because of job instability and associated decreased income, which contribute to food insecurity, or through poor coping skills rendering low-income women unable to acquire enough nutrient-dense foods (13).
Partly in response to the increased emphasis on food insecurity as a public health issue, an extensive literature on the predictors of food insecurity in the United States has emerged (16–24). However, far less is known about the predictors and correlates of food insecurity among pregnant women. There are 3 main reasons why predictors of food insecurity might be different for this population. First, the nutrient demands of pregnant women differ from those of nonpregnant women, with suggested increased intakes of most vitamins and minerals, and an additional 1.256 kJ/d on average for a woman of normal weight (25). To achieve optimal gestational weight gain, dietary requirements include nutrient-dense foods that are often more expensive (26). At a minimum, purchasing food to increase a woman's daily energy intake by 1.256 kJ means the household faces more constraints in their food budget. To address these problems during pregnancy, federal food programs such as the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) may be available to low-income women; however, the Food Stamp Program (a program with far higher monthly monetary benefits than WIC) does not increase benefit levels until after a child is born. Second, a pregnant woman may have more difficulty putting forth the effort to make nutritious food purchases, especially later in pregnancy when she is less mobile. In response, someone other than the pregnant woman may make food purchases. If this person is less experienced in food shopping, this may lead to purchases that are less nutritious; if this person is also less experienced in food preparation, more expensive purchases (e.g., fast food) may be made. These 2 factors together may strain a household's food budget. Third, a woman may exit the workforce during her pregnancy, decreasing the amount of money available for food. A sudden decrease may also present challenges to households that are not used to budgeting on a lower income (27,28). Although food stamps can help a family's financial situation, applying for and receiving food stamps is not an instantaneous process.
The nutritional demands and the existing psychological state during the major life event of pregnancy pose challenges for all women to eat well. Women from vulnerable households may face additional challenges if they are food insecure. The purpose of this study was to investigate the prevalence and predictors of food insecurity among pregnant women from medium- and low-income households.
SUBJECTS AND METHODS
Study sample.
This study used data from the Pregnancy, Infection, and Nutrition (PIN) cohort, a prospective study that examines the influence of infection, physical activity, nutrition, food security, and stress on preterm birth. Between 2000 and 2004, 1510 women were recruited though the University of North Carolina Hospitals residents' and private physicians' obstetrics clinics before 20 wk gestation. Women were excluded from these analyses if they had incomplete food insecurity and delivery information (n = 270). Women excluded had a lower mean age (27.6 vs. 29.1 y), education (13.8 vs. 15.5 y), and income (307 vs. 402% poverty), and a higher proportion were black (P = 0.001 for each). From the 1240 women who had completed the study and had complete information on household food security status, we limited the analysis to women from households with incomes 400% of the poverty line, n = 606. The household income restriction allowed better comparison among households that might be food insecure due to financial and material constraints and purposefully excluded any households with higher incomes. The procedures followed for this study were in accordance with the ethical standards of the Institutional Review Board of the University of North Carolina School of Medicine.
Food security—main outcome.
The USDA food security module is comprised of 18 questions posed in increasing levels of severity by measuring the dimensions of concern about food quantity and food quality over the last 12 mo (29). Examples of these questions and their level of severity include "How often was the following statement true? I worried whether our food would run out before we got money to buy more" (the least severe question), "Did you or the other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food?", "Were you ever hungry but did not eat because you couldn't afford enough food?", and "Did a child in the household ever not eat for a full day because you couldn't afford enough food?" (the most severe question). In this analysis we used 3 categories of food insecurity. We defined a household as "fully food secure" if all questions were answered negatively. Because of the importance that nutrition plays during pregnancy for both maternal health and fetal growth, we investigated the prevalence and predictors of food insecurity to include "marginal food security." We defined a household as "marginally food secure" if 1 or 2 questions were answered in the affirmative (30). We defined a household as food insecure (with or without hunger) if 
3 questions were answered in the affirmative. The marginally food-secure and food-insecure categories were combined for logistical regression because women from these categories had similar socioeconomic and demographic characteristics that were distinct from those of women from fully food-secure households.
Candidate predictor variables.
Exploratory analyses included the following socioeconomic and demographic variables previously identified as associated with household food security status: maternal age in years, number of children, household income (indicator for at or below 100% poverty, 101–200% poverty compared to over 201% of poverty), education (dichotomized as 12 y or >12 y), race (indicator for black and other race compared with white), and marital status (dichotomized as married or not married).
Along with this set of traditional socioeconomic and demographic variables, we included several psychosocial measures. Inclusion was based on a determination that food insecurity might be influenced by personal psychological states such as anxiety, depression symptoms, and perceived stress. In addition, one's personal dispositions may influence how a person copes with household food security issues in a protective fashion through self-esteem, mastery, or internal locus of control, or in a negative fashion through the belief that one's locus of control is subject to chance or powerful others. A description of these measures and how they were constructed follows.
were excellent, ranging from 0.83 to 0.92. Neugebauer et al. (35) found that two-thirds of women with scores 30 would be expected to meet diagnostic criteria for major depressive disorders. ranging from 0.77 to 0.88 (37). Levenson's IPC Locus of Control is a 24-item questionnaire that has 3 subscales:
Previous research demonstrated that 7 of these scales are markers of long-standing characteristics. Thus, these 7 scales are unlikely to be affected by a household's food insecurity status. The only scale that is more episodic is the CES-D. We used the Z-scores for each psychosocial measure, with a change of 1 SD as the unit of interpretation.
Statistical analysis.
Descriptive statistics were conducted to test for significance between food security status and each of the candidate predictor variables using t tests for the continuous variables of maternal age, number of children and all psychosocial variables, and 
2 tests for the categorical variables of poverty, maternal race, maternal education, and marital status. A 2 test was also used to test for significance between food security status, food coping, and federal food assistance programs. Interactions were tested between categorical variables using a 2 statistic with a cut-off point for significance at P 0.1; however, no interactions were identified. Logistic regression models were used to model the predictors of household food security status, controlling for other factors. Two dependent variables were modeled, a combined marginal food secure/food insecure compared with fully food secure and food insecure compared with all others. First, socioeconomic and demographic variables that were assumed exogenous, in other words, variables that would not be caused by household food insecurity status, were modeled as predictors of food security status. Then, due to the high correlation coefficients (>0.70) among most psychosocial factors, each psychosocial factor was modeled separately, adjusting for all of the selected socioeconomic variables. Finally, we modeled all socioeconomic and psychosocial variables in a fully adjusted model to identify the joint significance of the psychosocial variables on both food security outcomes using a Wald 2 test. Stata software (41) was used for data management and statistical calculations.
RESULTS
Household food security status.
Among 606 pregnant women from households at 400% of the poverty line, 75% were from fully food-secure households, 15% were from marginally food-secure households, and 10% were from food-insecure households.
Characteristics of the study population by food security status. The final sample was composed of 606 low- and middle-income pregnant women. A greater proportion of women from marginally food-secure and food-insecure households had incomes <100% of the poverty line, had the equivalent of a high school education or less, were black and were single compared with women from fully food-secure households (Table 1). Women from marginally food-secure households were significantly younger than women from either fully food-secure or food-insecure households.
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400% of the poverty line participated in at least one of these coping behaviors. The food assistance and food coping variables were not entered into the final model because they are endogenous to the food security status of a household. Psychosocial indicators varied by household food security status and were all significantly associated with food insecurity status (Table 2). Women from food-insecure households had higher measures for psychological states (perceived stress, depression symptoms, and trait anxiety) than women from both marginally food-secure and fully food-secure households. As perceived stress, trait anxiety and depression symptoms increased, household food security status worsened. This suggests a dose-response relation. Similarly, women from food-insecure households scored lower on the protective personal disposition scales (self-esteem, mastery) and higher on the locus of control indicators that were more fatalistic (powerful others and chance), than women from both marginally food-secure and fully food-secure households.
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2 test used to identify the joint significance of the set of psychosocial indicators (excluding depression because it was not a stable indicator of one's psychological state) on combined marginal food security/insecurity and food insecurity was significant (2 = 32.25, P = 0.001 for both models), suggesting that the psychosocial indicators have joint influence on either outcome while controlling for socioeconomic and demographic variables. However, perceived stress was the predominant psychosocial indicator; it was the only one independently associated with combined marginal food secure/insecurity (adjusted odds ratio 1.84, 95% CI 1.27, 2.68) and with food insecurity (adjusted odds ratio 2.31, 95% CI 1.37, 3.91) in these models. Perceived stress also had larger point estimates compared with the other psychosocial variables (results not shown), suggesting that women who perceived more stress in their lives were more likely to experience food insecurity.
DISCUSSION
A limited amount of previous work examined the food insecurity status of pregnant women (42,43). Ours is the first study to measure food insecurity during pregnancy with a substantial sample size and a wide variety of relevant covariates. In particular, our data include a wide variety of covariates reflecting the psychological state and personal disposition of pregnant women. Rates of marginal food security (15%) and food insecurity (10%) among low- and moderate-income pregnant women were lower compared with the broader North Carolina population; between 2001 and 2003, North Carolina had a prevalence of 13.7% food-insecure households for the total population (7).
In initial descriptive analyses, we found that the population of pregnant women who experience food insecurity had significantly lower income levels, less education, and were more likely to be single and black, than women from fully food-secure households. These findings are consistent with findings for the general population (16–24). In addition, a number of psychosocial measures were consistently associated with household food insecurity in bivariate analysis, with evidence of a dose-response relation with increasing levels of food insecurity.
The results from the logistic regression models confirmed the critical importance of income as an indicator of risk for food insecurity among pregnant women. As suspected, maternal age and race were also predictors of household food insecurity. In separate logistic models, 7 of the 8 psychosocial measures were associated with household food insecurity status, adjusting for individual socioeconomic and demographic characteristics.
Consistent with the literature on household food insecurity and depression (13,14,44,45), our measure of depressive symptoms was associated with household food insecurity. Often the association between depression and food insufficiency or food insecurity is modeled with depression as the dependent variable using either a depression screener (13) or the diagnostic criteria for major depression (44,45); this suggests that alleviating household food insecurity could treat depression. Our use of this depression measure as an independent variable is consistent with Gundersen et al. (14) who found that women having at least one mental health disorder predicted household food insecurity among a sample of homeless and housed female-headed households.
Although valid arguments that can likely be made for modeling episodic mental health problems such as depression as either a dependent or an independent variable, we believe that a subset of our measures can be thought of as more permanent measures of psychosocial status. For these more permanent measures, there should be very little question that these variables should be considered independent rather than dependent variables. In addition to depressive symptoms, we found that perceived stress, trait anxiety, fatalistic perceptions (e.g., locus of control attributed to chance) and protective personal dispositions (e.g., self-esteem and mastery) used in these analyses were all associated with either measure of household food insecurity.
Overall, our results suggest that low-income pregnant women may be in need of psychological counseling in addition to increased access to optimal nutrition. Clearly, the full context of life stress and coping behaviors may be as important as income in determining an individual's risk for food insecurity. Previous research found that a high proportion of pregnant and postpartum women who are eligible for WIC but not receiving benefits are food insecure (43). Outreach to these women may be especially vital. In our study, 60% of participants with household income <185% of poverty participated in WIC.
Our results highlight an important issue concerning the measurement of food insecurity. Responses to the 18-item food security module can indicate either "food insecurity" (3 positive responses) or "marginal food security" (1–2 positive responses). The USDA has typically included respondents with "marginal food security" with the fully food-secure population for purposes of estimating prevalence and analysis. We found, however, that several socioeconomic and demographic variables were associated with both marginal food security and food insecurity in the same population, and that most of the psychosocial factors displayed a dose-response relation with household food security status. These results indicate that households answering affirmatively to 1 or 2 of the food security core questions are different from households answering negatively to all of the food security questions.
The study was limited by several factors. First, our sample is a cohort of women obtaining prenatal care at UNC hospital clinics and cannot be generalized to all pregnant women. The sample may be representative of women in the U.S. south who seek prenatal care at community and state-funded hospitals. Second, although many of the psychosocial measures used in this analysis have been characterized as stable measures of one's psychological disposition, the direction of causality between psychological state and household food insecurity cannot be established. For example, an acute or chronic episode of food insecurity could influence a woman's psychological state or personal disposition, and therefore influence how she answers a survey. However, the finding that many measures were consistently associated in the suspected direction strengthens the notion that food insecurity may be influenced by one's perceived stress and personal dispositions. Finally, the cross-sectional dataset and the analysis techniques that we used limit our ability to draw causal inferences.
The findings of this study suggest that income level is the household characteristic that is most predictive of household food security status. However, psychosocial indicators are consistently associated with food security status with evidence of a dose-response relation. Women who perceived more stress in their lives, or who had poorer scores on psychological state evaluations, may be more likely to experience food insecurity, whereas women who have higher scores on personal disposition indices such as self-esteem and mastery may be less likely to experience food insecurity during pregnancy. These findings suggest preventive measures to decrease food insecurity among pregnant women must remain a priority, and that referrals to psychological counseling might help assist women in coping during this vulnerable time in their lives.
ACKNOWLEDGMENTS
We greatly appreciated the work and assistance given to us by Diane Kaczor.
FOOTNOTES
1 Supported by the U.S. Department of Agriculture grant 43-3AEM-0-80086, entitled "Effects of Food Security on Pregnancy Outcomes"; by grants HD28684 from the National Institute of Child Health and Human Development, National Institutes of Health; and funding from the National Institutes of Health, General Clinical Research Centers program of the Division of Research Resources (grant # RR00046). 
Manuscript received 19 August 2005. Initial review completed 24 September 2005. Revision accepted 19 October 2005.
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