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Dietary behaviors, physical activity, and cigarette smoking among pregnant Puerto Rican women ^1,2,3

¹ From the Division of Biostatistics and Epidemiology, the Department of Public Health, the School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA (AG, PP, LC-T); the Baystate Medical Center, Springfield, MA (PP, GM); and the Jean Mayer US Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, MA (KLT)

² Supported by an American Diabetes Association Career Development Award 7-00-CD-02.

³ Address reprint requests and correspondence to L Chasan-Taber, Division of Biostatistics and Epidemiology, School of Public Health and Health Sciences, 405 Arnold House, University of Massachusetts, 715 North Pleasant Street, Amherst, MA 01003-9304. E-mail: lct{at}schoolph.umass.edu.

	ABSTRACT

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION REFERENCES

 
Background: Few studies have examined predictors of meeting health guidelines in pregnancy among Latina women.

Objective: We assessed dietary behaviors, physical activity, and cigarette smoking in the Latina Gestational Diabetes Mellitus Study, a prospective cohort of 1231 prenatal care patients.

Design: Self-reported information on lifestyle factors, demographics, medical history, and physical activity was collected by bilingual interviewers during pregnancy. Fruit/vegetable intake was determined by summing the reported consumption of specific fruit and vegetables on a food-frequency questionnaire designed for this population and then adjusted for reported total daily servings.

Results: Approximately 13% of women met physical activity guidelines [10 metabolic equivalents (MET)-h/wk], 19% met fruit/vegetable guidelines (7 servings/d), 21% of women smoked, and 1.4% consumed alcohol during pregnancy. In multivariate analyses, Spanish-language preference, an indicator of less acculturation, was associated with an approximately 40% less likelihood of both smoking [odds ratio (OR): 0.6; 95% CI: 0.4, 0.8] and meeting physical activity guidelines (OR: 0.6; 95% CI: 0.3, 1.0). College education was associated with a 2-fold greater likelihood of meeting fruit/vegetable guidelines (OR: 2.2; 95% CI: 1.1, 4.3) and a lower likelihood of smoking (OR: 0.2; 95% CI: 0.1, 0.4). A history of adverse pregnancy outcome was associated with a >4-fold greater likelihood of meeting physical activity guidelines. Smoking in pregnancy was associated with a decreased likelihood of meeting the fruit/vegetable guidelines (RR: 0.5; 95% CI: 0.3, 0.9).

Conclusion: Factors related to engagement in prenatal health behaviors should be addressed in the design of targeted intervention strategies in this underserved and rapidly growing population.

	INTRODUCTION

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Increasing evidence suggests that health behaviors during pregnancy such as dietary intake, physical activity, weight gain, and substance use can affect the health of both the mother and fetus (1-7). For example, physical activity in pregnancy has been associated with a reduced risk of gestational diabetes mellitus (GDM) (3, 8), preeclampsia (4, 9), and excessive maternal weight gain, whereas inadequate maternal nutrition has been linked with preterm delivery and intrauterine growth restriction (10-12). However, little is known regarding prenatal health behaviors and factors associated with these behaviors in Latina women. Latina women have 2–4 times the risk of developing GDM compared with non-Latina white women (13). Although Latinas have been reported to have a low risk of adverse fetal outcomes (termed the epidemiologic paradox) (14, 15), this has been noted mainly among Mexican Americans. Indeed, Latinas of Puerto Rican descent have an elevated risk of low birth weight and poor neonatal health outcomes compared with other Latina groups (16-19), suggesting that the epidemiologic paradox may not hold true for Puerto Rican women (14, 15).

In response to mounting evidence regarding the effects of substance use, diet, and physical activity on perinatal morbidity and mortality, the Institute of Medicine (IOM), the American College of Obstetricians and Gynecologists (ACOG), and the American Dietetic Association (ADA) have set forth guidelines for health-promoting behaviors in the prenatal period (1, 20, 21). Specifically, the IOM recommends that physicians prioritize prevention or cessation of use of cigarettes, alcohol, and drugs during pregnancy (21). Similarly, the ADA and ACOG recommend that pregnant women consume 7 servings of fruits and vegetables per day for optimal nutrition (1, 22). ACOG also suggests that, in the absence of either medical or obstetric contraindications, pregnant women adopt the guideline of the Centers for Disease Control and Prevention of 30 min of moderate-intensity physical activity on most and preferably all days of the week (20, 23).

Few studies have examined predictors of meeting health guidelines in pregnancy among Latina women, and those that have been conducted were largely restricted to Latinas of Mexican descent (24-26). Therefore, our goals were to 1) estimate the prevalence of meeting guidelines for pregnancy health behaviors set by the IOM, ACOG, and ADA among Latina women of predominantly Puerto Rican descent and 2) to identify demographic, acculturation, medical, and behavioral factors associated with meeting guidelines in this ethnic group.

	SUBJECTS AND METHODS

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Study design and subjects
Participants were self-identified Latinas enrolled in prenatal care in the public obstetrics, gynecology, and midwifery practice of a large tertiary care facility in Western Massachusetts, Baystate Medical Center. The study design and methods of the Latina Gestational Diabetes Mellitus Study have been described elsewhere (27, 28). In brief, participants at prenatal care visits up to 24 wk of gestation (mean: 15 wk of gestation) were recruited by bilingual interviewers from September 2000 to December 2003. Eligibility criteria included Latina ethnicity, age 16–40 y, <24 wk gestational age at first interview, singleton pregnancy, no prior diagnosis of hypertension, chronic renal disease, or type 2 diabetes, and no prior participation in the study. Interviewers obtained informed consent from participants approved by the institutional review boards of the University of Massachusetts–Amherst and Baystate Medical Center.

Interviewers collected information on substance use, medical and obstetric history, physical activity, and sociodemographic factors at the time of recruitment. Dietary information was assessed in midpregnancy (mean: 23 wk). Medical and obstetric history and clinical characteristics of the pregnancy were collected from medical records by trained medical abstractors. A subgroup of participants (n = 750) were interviewed a second time, later in pregnancy, to update information on substance use and physical activity (mean: 28 wk of gestation). Women not reached for this second interview did not deliver at Baystate Medical Center (n = 157), had a miscarriage, pregnancy termination, or preterm birth at <28 wk (n = 34), or failed to attend a prenatal care visit or were not located by the interviewer at the clinic or by telephone (n = 300).

Fruit and vegetable consumption
Diet during pregnancy was assessed with use of a food frequency questionnaire (FFQ) adapted from the National Cancer Institute FFQ designed for Latinos (of mainly Puerto Rican and Dominican heritage) in the Northeastern United States (29). This questionnaire, adapted from the Block FFQ designed for non-Latino whites, was validated in a population of Latinos and non-Latino whites by using 24-h recalls (29). When 24-h recalls were coded into the original Block and adapted FFQs, intraclass correlation coefficients between the adapted FFQ and 24-h recalls were generally greater than that of the Block FFQ, ranging from 0.84 for vitamin E to 0.97 for energy (kcal) and 0.98 for protein (g) (29).

Total servings of fruit and vegetables were calculated by summing the reported daily number of fruits and vegetables listed on the FFQ and adjusting by a summary measure of usual number of servings. On the basis of ADA and ACOG recommendations for daily consumption of fruit and vegetables during pregnancy, those who consumed 7 servings/d were considered to be meeting dietary guidelines during pregnancy.

Physical activity participation
Physical activity in pregnancy was measured with use of a modified version of the Kaiser Physical Activity Survey (KPAS) (30). The modified KPAS was validated among a sample of 54 pregnant women at Baystate Medical Center by using 7 days of accelerometer measurements (31). Intraclass correlation coefficients used to measure the reproducibility of the KPAS ranged from r = 0.76 to 0.86 and Spearman correlation coefficients between the KPAS and 3 published cut points used to classify accelerometer data ranged from r = 0.49 to 0.59.

Women who reported participating in sports or exercise in pregnancy listed the activity type, frequency, and duration for up to 3 activities. Metabolic equivalents (MET)-hr/wk were calculated for each activity based on the Compendium of Physical Activities (32) and summed to create a total measure of sports/exercise energy output. Pregnant women are advised to participate in 30 min of moderate activity on most days of the week, which corresponds to a total of 2.5 h/wk. Moderate activities range from 4 to 6 METs. Therefore, we multiplied 4 METs by 2.5 h to obtain a minimum of 10 MET-hr/wk as our definition of meeting the physical activity guidelines.

Cigarette smoking and alcohol consumption
Cigarette smoking was assessed with the use of questions designed by the Pregnancy Risk Assessment Monitoring System (PRAMS), a surveillance project of the Centers for Disease Control and Prevention. Participants were asked to self-report the number of cigarettes/packs of cigarettes smoked on an average day. Participants were also asked to report the average number of days that alcohol was consumed per week or month and the average number of drinks consumed per session.

Covariates
We collected information on sociodemographic variables including age, education level, employment, and parity. Medical factors including pregnancy weight gain, prepregnancy body mass index, personal history of gestational diabetes, history of adverse pregnancy outcome (a prior preterm birth, low birth weight neonate, infant with congenital anomalies, or stillbirth) and family history of type 2 diabetes were abstracted from medical records. Acculturation measures included language preference for speaking, reading, and writing along with place of birth (United States compared with Puerto Rico or foreign born). Because cigarette smoking, alcohol consumption, and illicit drug use may be highly correlated, we created a variable defined as engagement in 0, 1, 2, or 3 risky behaviors (ie, smoking, drinking, or use of illicit drugs) in pregnancy.

Statistical analysis
Statistical analysis was performed with use of SAS 9.1.3 software (SAS Institute Inc, Cary, NC). Dichotomous variables for meeting each guideline in pregnancy were evaluated as outcomes in separate multiple logistic regression models. The likelihood of alcohol consumption was not modeled because of low prevalence in this population (1.6%).

Sociodemographic, acculturation, and medical factors were assessed as predictors of meeting health behavior guidelines in these models. Predictors that showed significant (P < 0.05) or borderline significant (P < 0.2) association with outcomes at the bivariate level were added to the multivariable models along with maternal age. Those predictors that were not borderline significant at the bivariate level were added singly to the model to determine additional improvement in model fit. Compliance with each health behavior guideline was also considered as a potential predictor of meeting the other health behavior guidelines. The likelihood ratio test was used to determine the best fitting model for the data. Final multivariate logistic models were used to calculate adjusted odds ratios (ORs) and 95% CIs. Tests for linear trend were calculated by modeling ordinal categories as continuous variables (ie, 1, 2, or 3). Interactions by age, education, smoking, and drug use were evaluated by inspection of stratum-specific ORs and by including multiplicative interaction terms in the multivariable models and assessing their statistical significance with use of likelihood ratio chi-square tests. For the assessment of acculturation, only language preference was used in multivariable models as language preference and birth place were highly correlated (P < 0.0001). We evaluated history of GDM and history of adverse pregnancy outcome as predictors of health behaviors in analyses restricted to parous women. We evaluated the correlation between smoking, alcohol, and illicit drug use using Spearman rank-order correlation coefficients.

	RESULTS

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The population has been described elsewhere (27, 28). In brief, 70% of the population was younger than age 25 y and 55% had not completed high school. Nearly 90% of participants born in the continental United States had at least one parent born in Puerto Rico with the remaining 10% having parents born in Central or South America. Among those born outside the continental United States, 84.5% were born in Puerto Rico with the remainder born in Mexico (2.4%) and the Dominican Republic (2.0%) and smaller proportions born in Central and South America. With regard to medical factors, >60% of participants were parous, >60% had a family history of diabetes, and >40% were considered overweight or obese by prepregnancy body mass index standards.

Overall, 21.1% of participants reported cigarette smoking, 1.4% used alcohol, and 5.5% reported illicit drug use during pregnancy, whereas 13.1% met the physical activity guidelines and 18.5% met the fruit/vegetable consumption guidelines (Table 1). Overall, <1% of participants engaged in all 3 risky behaviors (defined as cigarette smoking, alcohol use, or illicit drug in pregnancy), 4% engaged in 2 risky behaviors, and 18% engaged in 1 risky behavior only.

Table 2

Table 3

Table 4

Table 5

	DISCUSSION

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION REFERENCES

 
In this prospective cohort of predominantly Puerto Rican pregnant Latinas, we found that behavioral, medical, acculturation, and demographic factors were predictive of meeting prenatal health behavior guidelines. Although few studies have examined predictors of meeting physical activity guidelines in pregnant women, our findings are, in general, consistent with prior studies. Using data from 6528 participants in the Behavioral Risk Factor Surveillance System in 1994, 1996, 1998, and 2000 of which 18% were Latina, Petersen et al (34) found that 16–20% of pregnant women met the physical activity guidelines. These women were more likely to be younger, more educated, unmarried, and nonsmokers and to have higher incomes. Similarly, in the current study, we observed that 13% of pregnant women met the activity guidelines, and these women were more likely to be younger and have higher education. In contrast, we did not observe an association between cigarette smoking and meeting these guidelines. This lack of association may be due, in part, to differences in smoking patterns between our predominantly Puerto Rican population and the largely non-Latina white population of the Behavioral Risk Factor Surveillance System. In a second study examining predictors of meeting physical activity guidelines among 1979 pregnant women using 2000 Behavioral Risk Factor Surveillance System data, Evenson et al (35) observed that 16% of pregnant women met the physical activity guidelines. Consistent with our findings, meeting guidelines was associated with younger age, higher education, and excellent or very good health. Marital status, employment, and number of children were unassociated with the likelihood of meeting these guidelines (35).

Predictors of smoking have been widely studied among pregnant women but less so among Latinas. In general, lower education, white race, age <25 y, unmarried status, and greater parity have been associated with smoking during pregnancy (36). Among studies that included Latinas, predictors were similar (26, 37). These studies showed that increasing time in the United States and poorer health behaviors in pregnancy, including drug use, were associated with an increased likelihood of smoking (26, 37). Using nationally representative data from 20 large US cities in the Fragile Families and Child Wellbeing Study (n = 3301), Perreira and Cortes (37) observed that foreign-born Latina women were >80% less likely to smoke than their US-born counterparts and that smoking was increased among poor and less educated women. Similarly, we observed an association between Spanish language preference, a measure of lower acculturation, and decreased likelihood of smoking compared with those who preferred English.

Studies examining predictors for meeting fruit/vegetable intake guidelines in pregnancy are sparse. In a study of Mexican-origin pregnant women, Harley et al (38) observed that Mexican-born immigrants consumed more fruit and vegetables than US-born Mexican American pregnant women, whereas we did not observe differences in meeting the guidelines by place of birth or language preference. This difference in findings may result from cultural differences between the Mexican and Puerto Rican native diets. In a nonpregnant, 80% white population of women, Kieffer et al (39) found that those with greater than a high school education who met physical activity guidelines and were nonsmokers were more likely to meet fruit/vegetable guidelines. These findings are consistent with those of the present study.

Our study has several limitations. We used an FFQ designed and validated for northeastern United States, Puerto Rican, and Dominican Latina groups and administered during midpregnancy to assess usual pregnancy diet. However, diet may change over the course of pregnancy. In the only study to date to assess the change in maternal dietary intake between trimesters, Rifas-Shiman et al (40) showed no appreciable change in mean food group intake between trimesters. The authors observed the highest correlations for fruit and vegetable intake between the first and second trimesters (r = 0.68), suggesting that our measure of dietary intake in midpregnancy may be sufficient to characterize compliance with fruit/vegetable guidelines in this population.

As in any study relying on self-reported smoking information, some degree of misclassification of smoking status is possible. Several recent studies demonstrated that pregnant women can accurately self-report prenatal smoking behaviors when compared with urinary cotinine measurements (41-43). In addition, studies evaluating smoking among Latina women demonstrate that Puerto Rican women tend to report higher smoking and substance use rates than other Latina subgroups (33, 44-46). The Puerto Rican Maternal and Infant Health Study showed that 16.5% of US-born Puerto Rican women self-reported smoking during pregnancy (33), whereas another study showed that 17.9% of US-born Hispanic women smoked during pregnancy (37). We found that 21% of our participants (23% of US-born and 16.7% of foreign-born) self-reported smoking in pregnancy, making it unlikely that smoking was substantially underestimated.

A second measure of pregnancy behavior, later in pregnancy, was available for a subgroup (62%) of the sample. Women with this second measure did not differ significantly from women missing this measure in terms of the majority of factors, but this group was older, more highly educated, and less likely to have a history of GDM. However, after controls for level of education, there were no significant differences between the groups in terms of age and history of GDM. The finding that the majority of predictors of meeting health behavior guidelines were similar in the first and second time period reduces the likelihood of this sample representing a select group.

The association between reported illicit drug use in pregnancy and the increased likelihood of meeting physical activity and fruit/vegetable guidelines was unexpected, but studies of these behaviors among pregnant and nonpregnant women are sparse. Indeed, patterns of perinatal drug use among predominantly Puerto Rican Latinas have not been adequately described. Among nonpregnant women, smoking and alcohol consumption, often gateways to illicit drug use, have been inconsistently related to physical activity with some studies among multiethnic populations indicating that current smokers are less active, whereas others have found no relation, and one study among black women found the reverse (47). Similarly, studies of correlates of fruit/vegetable consumption have been inconsistent and limited to nonpregnant populations, with 2 studies showing that marijuana use is associated with greater caloric intake explained by greater intake of all macronutrients but with lower fruit intake and no difference in vegetable intake (48, 49) and a third study among college students finding that marijuana use was not associated with diet (50). In our study, women who used drugs during pregnancy were predominately users of marijuana (89%) and were more likely to be young in age. Although we controlled for age, it is possible that confounding by other factors associated with drug use may be responsible for these findings. Because of the sensitive nature of illicit drug use reporting, it is also likely that some misclassification of this variable occurred.

Findings of this study may be generalized to behaviors of pregnant Puerto Rican women, a subgroup of Latina women who report worse overall health and have higher rates of substance use and adverse birth outcomes compared with other Latina groups (16-19, 45, 46). Indeed, there is substantial heterogeneity between and within the various Latina subgroups in terms of genetics, acculturation, and health disparities (46, 51-54), and such differences should be addressed in culturally specific intervention programs.

In summary, in our cohort of predominantly Puerto Rican Latinas, we prospectively identified a number of modifiable predictors of smoking and meeting physical activity and fruit/vegetable intake guidelines in pregnancy. Factors related to engagement in prenatal health behaviors should be addressed in the design of targeted intervention strategies in this underserved and rapidly growing population.

	ACKNOWLEDGMENTS

 
The authors' responsibilities were as follows—AG: was responsible for the data analysis and data management; AG, PP, KT, and GM: were responsible for the draft of the manuscript; PP, GM, and KT: contributed to the study design; PP and KT: were responsible for the statistical analysis; LC-T: was responsible for the study design, data collection, and analysis plan. All authors read and contributed to the final version of the manuscript. None of the authors had a personal or financial conflict of interest.

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