JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION

1. Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain and pregnancy complications Barbara A. Laraia: University of California, San Francisco Anna Maria Siega-Riz: University of North Carolina Craig Gundersen: University of Illinois JOURNAL OFTHE AMERICAN DIETETICASSOCIATION Laraia et al.J Am Diet Assoc. 2010; Volume 110 (May).

2. Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain and pregnancy complications What is Household Food Insecurity? • A household is defined as food insecure if it faces limited or uncertain availability of nutritionally adequate and safe foods or uncertain ability to acquire acceptable foods in socially acceptable ways. • Anderson SA. Core Indicators of Nutritional State for Difficult-to-Sample Populations. J Nutr. 1990;120:1559S-1600S. JOURNAL OFTHE AMERICAN DIETETICASSOCIATION Laraia et al.J Am Diet Assoc. 2010; Volume 110 (May).

3. Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain and pregnancy complications U.S. Prevalence of Household Food Insecurity: from 1997 to 2008 Source: http://www.ers.usda.gov/publications/ JOURNAL OFTHE AMERICAN DIETETICASSOCIATION Laraia et al.J Am Diet Assoc. 2010; Volume 110 (May).

4. Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain and pregnancy complications Scoring for Household Food Insecurity • Assessed using the 18 item Core Food Security Model • Household was fully food secure if no question was answered in the affirmative • Household was marginally food secure if 1 or 2 questions were answered in the affirmative • Household was food insecure if 3 or more questions were answered in the affirmative JOURNAL OFTHE AMERICAN DIETETICASSOCIATION Laraia et al.J Am Diet Assoc. 2010; Volume 110 (May).

5. Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain and pregnancy complications Influence of Household Food Insecurity on Weight Status and Pregnancy Complications • Individual Characteristics • Age • Education • Race/ethnicity • Income • Marital Status Weight Status • Pregnancy Complications • PIHa • Anemia • GDMb • Pregravid Weight status HOUSEHOLD FOOD INSECURITY • Gestational Weight Gain • Individual Behaviors (Mediators) • Diet • Physical Activity • Smoking a Pregnancy-Induced Hypertension b Gestational Diabetes Mellitus JOURNAL OFTHE AMERICAN DIETETICASSOCIATION Laraia et al.J Am Diet Assoc. 2010; Volume 110 (May).

6. Pregnancy, Infection and Nutrition Study:Design Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain and pregnancy complications Study Design • Prospective cohort study, n= 2,006 pregnant women enrolled between 2001-2006 • Assessed: • Pre-pregnancy weight and height • Measured height, self-reported weight converted to body mass index (BMI: kg/m2) • Household food insecurity status at 26-32 weeks’ gestation • USDA 18 Item Core Food Security Module • Total weight gain and ratio of observed to recommended weight gain • 1990 Institute of Medicine recommendation for weight gain based on pre-pregnancy BMI • Pregnancy induced hypertension-high blood pressure after 20 weeks’ gestation • Second trimester anemia-Hgb <10.5 g/dl during 2nd trimester • Gestational diabetes mellitus-based on universal screening • All models restricted the sample to women with incomes ≤ 400% of the income/poverty ratio (n=810) • Covariate adjusted for age, race, education, income, marital status and number of children JOURNAL OFTHE AMERICAN DIETETICASSOCIATION Laraia et al.J Am Diet Assoc. 2010; Volume 110 (May).

7. Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain and pregnancy complications Sample Population • Among 810 women • Average age was 27.3 years (standard deviation=5.5) • Average education was 14.2 years (sd=2.9) • Average income was 212.5% income/poverty ratio (sd=113.0) • 68% were white, 31.2% were black • 61.4% were married, 38.6% were not married JOURNAL OFTHE AMERICAN DIETETICASSOCIATION Laraia et al.J Am Diet Assoc. 2010; Volume 110 (May).

8. Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain and pregnancy complications Methods • Multivariate regression (continuous outcomes) • Kilograms of weight gain • Observed (actual)-to-recommended weight gain ratio • <1 = inadequate weight gain • 1 = adequate weight gain • >1 = excessive weight gain • Logistic regression (dichotomous outcomes for rare events) • Gestational diabetes mellitus (yes/no) • Poisson Regression (dichotomous outcomes for common events) • Pregravid weight status (underweight, normal, overweight, obesity class I, obesity class II) • Pregnancy induced hypertension (yes/no) • 2nd trimester anemia (yes/no) • Covariates • All models adjusted for age, children, education, income, race, and marital status JOURNAL OFTHE AMERICAN DIETETICASSOCIATION Laraia et al.J Am Diet Assoc. 2010; Volume 110 (May).

9. Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain and pregnancy complications Results • Pregravid weight status • 13.1% underweight • 41.9% normal weight • 11.6% overweight • 16.9% class I obesity • 16.5% class II obesity • Household food insecurity status • 76% were from fully food secure • 14% were from marginally food secure • 10% were from food insecure households JOURNAL OFTHE AMERICAN DIETETICASSOCIATION Laraia et al.J Am Diet Assoc. 2010; Volume 110 (May).

10. Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain and pregnancy complications Prevalence of Outcomes by Household Food Security Status * * * * * * * Significant at p<0.05 level compared to food secure group JOURNAL OFTHE AMERICAN DIETETICASSOCIATION Laraia et al.J Am Diet Assoc. 2010; Volume 110 (May).

11. Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain and pregnancy complications Null Results from Adjusted Models • Household food insecurity was not associated with: • Pre-pregnancy underweight, overweight or obesity • Although there was an association with pregravid overweight in unadjusted models, after adjusting for covariates the association was attenuated • 2nd trimester anemia* • Pregnancy-induced hypertension (PIH)* • Although there was an association with PIH unadjusted models, after adjusting for covariates the association was attenuated * Covariate adjusted models controlling for age, children, education, income, race, and marital status, pregravid weight status, physical activity, smoking status JOURNAL OFTHE AMERICAN DIETETICASSOCIATION Laraia et al.J Am Diet Assoc. 2010; Volume 110 (May).

12. Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain and pregnancy complications Positive Results from Adjusted Models • Household Food Insecurity was Associated with Severe Obesity • Higher Risk of Severe Pregravid Obesity [RRR=2.97, 95% CI: 1.44, 6.14] • Women with Class II Obesity (BMI≥35) were at 3 time greater risk of reporting household food insecurity • Household Food Insecurity was Associated with: • Greater Gestational Weight Gain* [β = 1.87 95% CI: 0.13, 3.62] • Women from food insecure households gained on average 1.87 kilograms more than women from food secure household after adjusting for covariates • Higher Weight Gain Ratio* [β = 0.25, 95% CI: 0.01, 0.49] • Women from food insecure households had on average a 25% higher actual-to-recommended weight gain ratio compared to food secure household after adjusting for covariates • Gestational Diabetes Mellitus* [OR 2.38, 95% CI: 0.99, 5.73, p = 0.05] • Women from food insecure households had two times greater odds of developing gestational diabetes compared to women from food secure household after adjusting for covariates JOURNAL OFTHE AMERICAN DIETETICASSOCIATION Laraia et al.J Am Diet Assoc. 2010; Volume 110 (May).

13. Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain and pregnancy complications Conclusion • Household food insecurity was associated with heavier pre-pregnancy weight, greater weight gain during pregnancy and risk for gestational diabetes • Finding that household food insecurity was associated with pre-pregnancy weight status and weight gain is consistent with research regarding non-pregnant women • Food insecurity may strongly influences weight gain among women throughout the life cycle • How can society decrease food insecurity, among concurrent negative consequences, since it has implications for the next generation? • Fetal exposure to excessive weight gain and gestational diabetes may have intergenerational effects. JOURNAL OFTHE AMERICAN DIETETICASSOCIATION Laraia et al.J Am Diet Assoc. 2010; Volume 110 (May).