Eating and drinking are part of the daily activities that humans engage in. Despite their ordinary na-ture, “they are complex behaviors that are determined by many factors and their interactions” (Köster 2009). Diet-related behaviors may change in pregnancy due to interactions between different deter-minants of eating behaviors. These deterdeter-minants are personal values and beliefs about the ideal diet in pregnancy, advice from professionals, personal preferences, time, money and physical and physio-logical changes (Forbes et al. 2018).
Typical dietary changes that women make during pregnancy are reduction and elimination of certain foods. When women’s reasons for these changes have been studied, health of the baby, concern, aversions and nausea are listed as the most common reasons for making these changes. On the con-trary, when pregnant women’s choices for adding certain foods into their diet have been studied, the most frequent responses are concerning cravings, nutritional content, health, enjoyment, and efforts to decrease the chances of illness (Forbes et al. 2018).
Despite the vast amount of evidence emphasizing the importance of a healthy diet in pregnancy, not all women see the need to make dietary modifications when they get pregnant. Researchers have found that social and biological factors impact the dietary choices that pregnant women make. For example, a compliance with public health recommendations for pregnancy is notable especially among older and more educated women (Crozier et al. 2009). Whereas, younger, less educated women, who have a higher pre-pregnancy weight and who have more children, are more likely to
have poorer quality diets in pregnancy (Rifas-Shiman et al. 2009). Table 5 lists some general determi-nants of food choice according to the DONE framework categorization structure (Stok et al. 2017).
Table 5. Determinants of food choice. Source: This table was modified from the original DONE framework (figure 3) categorization structure: Determinants of nutrition and eating (Stok et al. 2017).
Main levels Stem-categories Leaf-categories
Individual Biological 1 Brain and oral function
2 Food related physiology
The following sections will focus on some of the determinants listed in Table 5 that pertain especially to pregnant women’s dietary choices.
Biological determinants
Pregnancy related nausea, aversions, cravings and changes in olfaction are some of the factors that may alter dietary behavior during pregnancy (Fessler et al. 2002). One of the common foods, that pregnant women often find offensive, is meat (Flaxman and Sherman 2000). Traditionally, meat has been the food most likely to carry pathogens, and it is not until recently that humans have found ef-fective hygienic methods to ensure the elimination of pathogens in meat. A study from an evolution-ary perspective on the topic of pregnancy sickness and meat consumption suggests that these biolog-ical mechanisms are in place for a reason during a time of vulnerability (Fessler et al. 2002). Indeed, morning sickness has been found to have a positive effect on pregnancy outcome, including a de-creased risk for miscarriage, preterm birth, LBW and perinatal death. Furthermore, dede-creased intake of calories during early pregnancy is associated with a higher placental weight (Huxley 2000). Section 2.2.8 discusses cravings and aversions during pregnancy more in depth.
Another biological factor that impacts a pregnant woman’s food choices is her pre-pregnancy weight.
One study found that the dietary quality decreases during pregnancy for overweight and obese women (Moran et al. 2012). Whereas women who are underweight or of normal bodyweight have been found to have a better dietary quality during pregnancy (Tsigga et al. 2011). Studies have also shown that obese pregnant women are less likely to follow the guidelines for fruit and vegetable con-sumption or for meal/snack patterns. Moreover, fiber and folate intake has been reported to be lower among women with a higher prepregnancy BMI (Laraia et al. 2012).
Age is another biological factor that impacts the nutritional choices that women make during preg-nancy. Research has shown that younger women tend to have a lower dietary quality in pregnancy (Rifas-Shiman et al. 2009). A Finnish study found that healthy food choices are common among preg-nant Finnish women and these choices have a positive correlation with age and education (Arkkola et al. 2006). Additionally, the most influential characteristic that impacts a woman’s adherence to nutri-tional guidelines in pregnancy is her ethnicity (Morton et al. 2014). Studies based in the United States have reported that there are racial-ethnic differences for maternal and health outcomes, and energy intake and diet quality during pregnancy are one of the possible risk factors for these differences (Headen et al. 2012).
Finally, a major determinant of food choice and purchasing behavior is taste (Renzaho and Burns 2006). Generally, it is understood that taste changes take place during the course of a pregnancy, however, more scientific evidence is needed to support this claim (Faas et al. 2010). So far, there is evi-dence suggesting that sex steroids are elevated during pregnancy, and as a result, the taste responses and sensation would be impacted by it (Bhatia and Puri 1991).
The ultimate goal of the changes that may occur in pregnancy in the area of food behavior should serve the needs of the developing baby. According to a review on how pregnancy and sex hormones interfere with taste and food intake: “Many physiological and behavioral changes take place during pregnancy, including changes in taste and an increase in food intake. These changes are necessary to ensure growth and development of a healthy fetus” (Faas et al. 2009).
Demographic determinants
Another significant factor, related to the dietary intake and adequacy in pregnancy, is the country of origin (Rodriguez-Bernal et al. 2012). In Brazil, women do not comply with nutritional guidelines in pregnancy (Dos Santos et al. 2014). Researchers in New Zealand have made the same finding about pregnant women in New Zealand. Likewise, recent data from Australia and Canada show that the level of adherence to nutritional guidelines in pregnancy is low in those countries as well (Morton et al.
2014). Whereas, in Belgium, pregnant women tend to adhere to nutritional recommendations
(Verbeke and Bourdeaudhuij 2007). These cross-country variations pertaining to following dietary rec-ommendations in pregnancy, are also true for alcohol consumption in pregnancy, as section 2.2.5 pointed out (Mårdby et al. 2017).
Psychological determinants
Besides biological and demographic determinants of dietary choices, also psychological factors have been linked with pregnant women’s food intake (Bowen 1992). Some psychological determinants that can impact the dietary choices of a person are mood and emotions, health cognitions, food
knowledge, skills and abilities (Stok et al. 2017). This section will focus on these psychological determi-nants in food choices specifically from a pregnant woman’s perspective.
Pregnancy is a season in life when women tend to be particularly interested in finding dietary infor-mation concerning pregnancy, in order to protect their growing babies (Szwajcer et al. 2005).
Knowledge about food, nutritional attitudes and actions, seem to have a direct link to nutrition aware-ness (Eze et al. 2017), which is one of the factors that impacts the dietary choices that pregnant women make (Szwajcer et al. 2007). Also, the level of nutritional knowledge and food practices have been found to have a significant association (Mirsanjari et al. 2016). Especially, the knowledge of basic dietary principles and the nutrient values of foods during the first trimester, may have an influence on dietary intake (Fowles et al. 2011).
Research has shown that education plays an essential role in a woman’s knowledge about food during pregnancy. A cross-sectional study on the dietary quality of pregnant low-income women found that pregnant women who were less educated, had poorer nutritional knowledge and lower dietary quality (Fowles et al. 2011). Although, adequate knowledge towards nutritional guidelines does not automati-cally convert into corresponding behavior (Okunaiya et al. 2016). An example of this is a study that was investigating how cultural factors may impact the diet in pregnancy among Mexican American adolescents. The study found that there was no relationship between a person’s knowledge of nutri-tion and the adequacy of her diet in pregnancy. The foods chosen, were tradinutri-tional foods, perceived as healthy by parents and family members (Gutierrez 1999).
One study that was investigating the link between nutrition awareness and pregnancy, found that there were three groups that pregnant women would fall into in their nutrition awareness. In one group, the women would follow all the health guidelines recommended for pregnant women and would “live by the book”. Another group of women would have a more flexible approach to the cur-rent nutritional guidelines and feel the freedom to occasionally not abide by the recommendations.
The last group of pregnant women did not make lifestyle adjustments but continued to live their life the same way as before getting pregnant. Additionally, the study found that there are three types of motivations linked to nutrition awareness, the interest of the child-, the mother-, and the social envi-ronment (Szwajcer et al. 2007).
One important determinant for nutrition awareness is seeking information about diet (Szwajcer et al.
2005). A logical place to find information about pregnancy and diet is a health care clinic. It is a com-mon practice around the world to have antenatal care guidelines, that are used in a clinical setting, to educate pregnant women on nutrition- and health issues. Most healthcare providers believe in the im-portance of nutrition education in pregnancy, but many factors get in the way of pregnant women re-ceiving adequate dietary education during their pregnancy (Lucas et al. 2014). One study found that women in Ghana gather their dietary knowledge for pregnancy from a variety of sources, including lay and expert knowledge, and form their opinions based on these sources of information (de-Graft Ai-kins 2014).
Significant differences about nutritional knowledge in pregnancy have been found between different socio-demographic groups. It has been proposed that those, within the lower socio-demographic group, would have poorer knowledge of nutrition (Inglis et al. 2005). However, this proposition has been challenged by various studies (Fowles 2002, Fowles et al. 2011, Okunaiya et al. 2016). Other sig-nificant factors that impact a person’s nutritional knowledge during pregnancy are monthly income, level of education, number of pregnancies, and her attitude (Tenaw at al. 2018).
Whether pregnant women need more dietary knowledge about nutrition in pregnancy, is debatable. A study from India came to a conclusion that pregnant women would not benefit from additional
knowledge, but instead, should receive nutritional guidance and counseling during pregnancy (Gupta et al. 2016). Another study concluded that since pregnant women failed to understand nutritional guidelines accurately and their dietary intake was not meeting current standards, there should be reg-ular, individualized dietary counseling to help establish life-long, health-promoting eating habits (Fowles 2002). Furthermore, having proper dietary knowledge is not sufficient enough if a person is lacking the required skills in cooking and food preparation. One study found that pregnant women’s lack of cooking skills and information about healthy eating practices in pregnancy impacted their die-tary quality (Johnson et al. 2013).
Besides dietary knowledge being a factor that influences the food choices in pregnancy, studies have shown that also maternal psychosocial stress and nutritional state are interconnected to dietary be-havior during pregnancy (Lindsay et al. 2017). Pregnant women who are more fatigued, stressed and
anxious consume more overall calories, but yet, have less than an ideal number of micronutrients in their diet (Hurley et al. 2005). Also, distress in pregnancy has been found to have a direct effect on eating habits and an indirect effect on dietary quality among low-income women (Fowles et al. 2011).
Moreover, stress about outward appearance may be of medical and psychiatric significance in preg-nancy. According to a study, women who have a previous history of being worried about their shape, weight, and eating, tend to have a different reaction toward pregnancy when compared to women who have not dealt with such issues (Fairburn and Welch 1990).
So far, researchers have presented forthcoming evidence proposing that omega-3 fatty acids could be able to debilitate psychosocial maternal stress. They have also found that high pre-pregnancy BMI could lead to unhealthy dietary behavior under elevated stress. Despite the preliminary findings about the connection between stress and diet in pregnancy, more longitudinal studies are needed in order to understand the relationship between these two factors better (Lindsay et al. 2017).
Another area that researches have been trying to comprehend for decades, is the link between atti-tudes and behavior. Initially, a presumption that attitude leads to corresponding behavior was prevail-ing (Guyer and Fabrigar 2015). In 1934, a researcher named LaPierre (McLeod 2018) published a study on racial prejudice that challenged this idea (Guyer and Fabrigar 2015). Although, attitudes can lead to changes in behavior, it is important to note that positive attitude towards good nutrition does not au-tomatically convert into good dietary practices (Fasola et al. 2018). This phenomenon was confirmed by a study in Nigerian slums, where pregnant women had positive attitudes toward nutritional guide-lines, yet, failed to follow good dietary practices (Okunaiya et al. 2016).
Pregnant women’s attitudes toward nutrition and related topics have been repeatedly researched with various outcomes. One study found that the level of education has an impact on the person’s attitude toward good nutrition. According to the same study, there was a significant association between the participant’s knowledge and attitude towards good nutrition (Fasola et al. 2018). Other studies have confirmed the link between knowledge and positive nutritional attitude (Tenaw at al. 2018).
Another study examined pregnant women’s attitudes toward environmental chemicals and how their attitudes may influence the different choices that they make during pregnancy. The study found that
educated women were more likely to believe that environmental chemicals are dangerous, and their attitude was associated with certain behaviors, such as choosing organic foods, choosing foods in safe plastics and reducing fast-food consumption (Barrett et al. 2014). Conversely, one study found that it is not education, but religion, that is significantly associated with a person’s attitude towards good nu-trition (Fasola et al. 2018).
Finally, attitude is not a predictor of behavior, as stated above. Even when surrounding factors are ideal, the expected behavior does not always take place. One study found that even when pregnant women have a positive attitude and sufficient knowledge about a nutrition topic (in this case iron de-ficiency in pregnancy), it still does not automatically translate into action (Habib et al. 2018).
Finally, perceptions of having a healthy diet can lead to health-promoting dietary acts. One study found that women who perceived their diet as healthy were more inclined to adhere to the recom-mendations about consuming servings of fruit and dairy on daily basis. However, despite reaching sta-tistical significance, the association between perception and the dietary practice was weak in this par-ticular study (Malek et al. 2016).
Situational determinants
Situational elements also impact the nutrition choices of an individual. One particular situational de-terminant of food choice is a constraint on time (Stok et al. 2017). A lack of time can be a barrier to eating healthfully during pregnancy, and family and work reasons can contribute to the feelings of lacking time in food preparation (Sui et al. 2013).
Social determinants
The daily dietary decisions that an individual makes can serve other purposes beyond nutrition. By fol-lowing certain dietary patterns, a person can represent their participation in a social group or a life stage, such as pregnancy. One study found a link between what was perceived as “good mothering”
and nutrition choices. The researcher describes her findings on the topic: “Good mothers are sup-posed to be altruistic by placing the needs of their children above their own wants, and mothers-to-be are expected to do the same... Consuming a nutritious diet in pregnancy, then, mothers-to-becomes part of the cultural expectations of the good mother and women construct positive identities as good mothers by attempting to manage their prenatal diets” (Copelton 2006).
Studies have shown that social support from partners, family and friends is associated with more nu-tritious diets in diverse populations (Fowles et al. 2011). One study found that the most impactful fac-tors, that had an effect on healthy eating practices among pregnant Mexican American adolescents, were the maternal concern for the baby’s well-being, the role of the motherhood and having a family support system in place (Gutierrez 1999). Another study found that Latina women who received emo-tional support from their husbands and female relatives were maintaining healthy diets in pregnancy.
Among low-income women, social support has led to healthier meals and higher vegetable consump-tion during pregnancy (Fowles et al. 2011). Moreover, influence of others is another aspect that may impact the nutritional choices that women make during pregnancy. These other people may include health professionals and peers. Additionally, pregnant women can receive and adopt advice from edu-cational resources (Forbes et al. 2018).
In many communities, it is the older, the more experienced women, who are the key influencers in maternal and child health issues. Having this on mind, one study decided to explore the concept of educating the senior women of a community, in order to make positive health changes for the younger women of reproductive age. The study found that educating the grandmothers on healthy dietary practices during pregnancy advanced the health of the pregnant women of the community.
According to the study, within 12 months there were significant improvements made in the grand-mothers’ knowledge, practices and the level of advice they would give on nutrition-related practices in pregnancy. This improvement had positive consequences for the pregnant women of the community (Aubel et al. 2004).
Pregnant women may also take into consideration their partner’s food preferences when they make dietary choices. A study conducted in India found that 71 % of the reported food purchasing behavior by the participants, was made on the basis of her family member’s choices (Ajantha et al. 2015).
Sometimes these preferences can act as a barrier for making health-promoting dietary choices during the course of the pregnancy. One study found that pregnant women struggled to reduce the fat con-tent of their traditional cooking due to their consideration of their partner’s food preferences (John-son et al. 2013). On the same topic, a qualitative Canadian study reported that it was the sociocultural and physical factors that served as barriers for pregnant women to reduce their dietary sugar intake (Lucas et al. 2014).
Many factors impact the eating behavior and diet of an individual and the current evidence suggests that some of the influences are socio-economically patterned (Inglis et al. 2005). One strong and inde-pendent predictor for nutrient intake and BMI during pregnancy is education (Freisling et al. 2006). A cross-sectional study on the dietary quality of pregnant low-income women found that pregnant women who were less educated had poorer nutritional knowledge and lower dietary quality (Fowles et al. 2011). Other studies have made the same observation (Rifas-Shiman et al. 2009, Haste et al. 1990).
Many studies have found that the people who are of lower socioeconomic status have a higher risk for having a diet-related disease and overall poor health due to their intake of nutrients and the diet as a whole. When people have limited financial resources, healthier foods like produce, may be over-passed if more calorie dense foods are available at lower cost (Inglis et al. 2005). A person’s socio-eco-nomic situation can be challenged by the process of migration. A qualitative study on Iranian immi-grant women residing in Sweden reported that migration had an impact on their economic condition.
As a result, certain nutritious foods that they had frequently consumed in their country of origin were now less available to them because of the high cost associated with buying these foods (Ahlqvist and Wirfält 2000).
Cultural factors
Cultural factors, along with household food security situation, have been found to be the elemental influencers of the nutritional status of an individual. Traditional food habits, rooted in the local culture, can keep pregnant women around the world from eating nutritious foods widely available to them (Okunaiya et al. 2016). In some cultures, social- and gender roles may also determine the access to
food and the order of eating within the family. Especially in situations when food is scarce, these roles
food and the order of eating within the family. Especially in situations when food is scarce, these roles