Examining the Relationships Between Stress, Depressive Symptoms, and the Neighborhood Food Environment on Diet Quality Among Racially-Diverse Pregnant Women in South Carolina

Background Women’s diet quality during pregnancy often falls short of U.S. Dietary Guidelines and poor mental health and poor access to healthy food may be important barriers to improving diet quality during pregnancy. The purpose of this study was to 1) synthesize existing literature on the relationship between mental health and diet quality during pregnancy, 2) examine the relationship between mental health and diet quality in pregnancy, and 3) examine the relationship between healthy food density and diet quality in pregnancy. Methods For Aim 1 (systematic review), articles were obtained from five databases; study characteristics and findings were extracted and synthesized. For Aims 2 & 3, a cross- sectional analysis was conducted on baseline demographic, mental health, food environment, and dietary data from African-American (AA) and White overweight/obese pregnant women participating in the Health in Pregnancy and Postpartum (HIPP) study. Assessments were conducted from January 2015 to March 2018 by research staff. Data from self-administered 24-hour dietary recalls were used to calculate Healthy Eating Index (HEI)-2015 total and component scores. Food retailer data were obtained from ReferenceUSA. Food retailer locations and participants’ home addresses were geocoded to the point or street-address level in ArcGIS Pro. Healthy food density scores (via the Modified Retail Food Environment Index) were calculated based on a 5-mile network buffer around each participant’s home. For Aim 2, the associations between stress and depressive symptoms on HEI total scores and meeting HEI component recommendations were examined. For Aim 3, the associations between 5-mile healthy food density on HEI total scores and meeting HEI component recommendations were examined. Multiple linear and logistic regression models were conducted in SAS 9.4. Results Findings from the systematic review (n=24 studies) show that stress and depressive symptoms were generally related to unhealthy dietary patterns and lower diet quality scores in pregnancy. There were conflicting findings regarding the relationship between mental health and food group consumption in pregnancy. The review identified the following important gaps in the literature: 1) limited use of longitudinal and randomized designs, 2) few studies used comprehensive diet quality indices, 3) an underrepresentation of racial/ethnic minority women, and 4) a lack of multi-theoretical frameworks that informed the studies. For Aims 2 & 3, women (n=169) were racially-diverse (40% AA), young (M=29.6+5.1 years), primarily married (67%), well-educated (61% earned a college degree or higher), almost a quarter (23%) were enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children, most were in early pregnancy (M=10.1+2.4 weeks), and most lived in urban areas (82%). Women had low levels of stress (M=4.8+3.3, range 0-14) and depressive symptoms (M=5.8+4.3, range 0-20), along with poor diet quality (M=55.9+10.6, range 28-76). As hypothesized, as stress and depressive symptoms increased, HEI total scores tended to decrease; alternatively, as healthy food density increased, HEI total scores tended to increase, but contrary to hypotheses, associations did not reach statistical significance. As hypothesized, a one-unit increase in stress was associated with a 14% decrease in the odds of meeting Seafood and Plant Protein recommendations [adjusted (adj) OR: 0.86 (95% CI=0.77, 0.96)]. The association between healthy food density and HEI total scores was in the expected direction but contrary to the hypothesis, did not reach statistical significance. As hypothesized, residential location moderated the relationship between healthy food density and meeting the Whole Fruit recommendation such that a one-unit increase in healthy food density was associated a 21% increase in the odds of meeting the Whole Fruit recommendation for participants living in an urban area (adj OR: 1.21 [95% CI=1.04, 1.40]) compared to those living in a rural area (adj OR: 0.97 [95% CI=0.91, 1.03]). Conclusions Overall, previous literature shows that stress and depressive symptoms are associated with unhealthy dietary patterns and lower diet quality scores in pregnancy; however, there is a need for prospective studies, standardization in diet quality assessment, greater representation of minority women, and the use of multi-level theoretical frameworks in future studies. HIPP participants’ diet quality was poor overall. Mental health and healthy food density were not associated with overall diet quality; however, AA women seemed to have healthier diets related to unsaturated fatty acid consumption and limited refined grains consumption compared to White women. Additionally, having better access to healthy food was associated with greater whole fruit consumption among urban but not rural women. Future studies should examine the efficacy of interventions that incorporate stress management and nutrition education and investigate aspects of the consumer food environment to identify barriers to improving diet quality in pregnancy