Original Research

Food and Nutrition Bulletin

1-11
ª The Author(s) 2022
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Maternal Socioeconomic DOI: 10.1177/03795721221077723
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Factors and Adequacy

of Energy and Macronutrient
Intakes in Pregnant Women
From Yucatan, Mexico

Dulce Romero-Villanueva, MSc1, Federico Dickinson, PhD1,

José Luis Batún, PhD2, Marı́a Teresa Castillo-Burguete, PhD1,
and Hugo Azcorra, PhD3

Abstract
Background: Socioeconomic factors influence diet quality during pregnancy. However, dearth of
evidence about the influence on energy and macronutrients adequacy calls for research.
Objective: To analyze the association between socioeconomic factors and adequacy rates of energy
and macronutrients intakes in pregnant women from Merida, Yucatan, Mexico.
Methods: During September to December 2019, we applied a socioeconomic questionnaire and
three 24-hour dietary recalls to 83 pregnant females resident in Merida, Yucatan. Energy and mac-
ronutrient intakes were compared with the estimated trimester-specific energy and macronutrient
requirements to calculate adequacies (%). Outcome variables were average adequacy of energy,
carbohydrates, total fat, and protein intakes and the main predictors were maternal education,
monthly family income, working status, and marital status. Descriptive statistics of adequacy were
calculated for each category of predictors. The association between socioeconomic factors and
outcome variables was analyzed through simple and multiple linear regression models.
Results: Adequacy rates of energy and macronutrients decreased as education and familial income
levels increased, as well as among unemployed women. Consistently with these results, simple linear
regressions showed that years of education, family income, and working status (i.e., women working to
earn money), were negatively associated with adequacy rates of energy and macronutrients intakes.
When all predictors and covariates were included in a multiple linear regression model, only having a
job was significantly associated with adequacy rates. Marital status was not associated with outcomes.

1
Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, Mérida, Yucatán, México
2
Universidad Autónoma de Yucatán, Mérida, Yucatán, México
3
Universidad Modelo, Mérida, Yucatán, México

Corresponding Author:
Hugo Azcorra, Centro de Investigaciones Silvio Zavala, Universidad Modelo, Mérida, Yucatán, México.
Email: hugoazpe@hotmail.com
2 Food and Nutrition Bulletin XX(X)
Conclusions: Women in disadvantaged socioeconomic conditions (unemployed and low levels of
education and familial income) show greater energy and macronutrient intakes.
Keywords
pregnancy, nutritional adequacy, socioeconomic factors, Yucatan, Mexico
Introduction
Food intake in individuals is the result of complex
interactions between physical environmental,
biological, and socioeconomic factors.1 Socioe-
conomic status includes variables, mainly educa-
tion, income, and occupation, which together
describe living conditions and social inequality
among members of a given population.2 Socio-
economic conditions may influence food intake
and diet quality increasing or decreasing the
access to foods and promoting individuals to
make decisions regarding food choices.3,4 Preg-
nant women are not exempt from the influence of
socioeconomic conditions on their diet character-
istics and nutritional quality.
The influence of socioeconomic factors on food
intake and diet quality is particularly relevant dur-
ing pregnancy given the potential effects not only
on mothers’ but also on their offspring’s health and
well-being.5,6 Negative nutritional balance during
pregnancy may increase the risk of several adverse
birth outcomes including preterm birth, low birth
weight, and intrauterine growth restriction, partic-
ularly in populations that experience adverse
socioeconomic conditions.7 Furthermore, nutri-
tional excesses may increase the risk for excessive
maternal weight gain8-10 which, in turn, has been
associated with several adverse neonatal outcomes
including low Apgar score, hypoglycemia, poly-
cythemia, meconium aspiration syndrome, and
large-for-gestational age.11,12
Studies in several countries and socioeconomic
backgrounds have shown that women with higher
income and education levels tend to have a healthy
dietary pattern, which comprises of the intake of
green leafy vegetables, legumes, fruits, milk and
dairy products, red meat, and chicken.13-18 In the
United Kingdom and New Zealand, results from
the Avon Longitudinal Study of Parents and Chil-
dren (ALSPAC) and the Growing Up studies
showed that low maternal schooling was related
with higher consumption of processed food.19,20
Marital status also seems to have some influence
of food intake during pregnancy; studies underta-
ken in Ethiopia, Canada, and Brazil show that
women with a partner tend to have a high-quality
diet.15,17,21 Most of these studies use principal
component analysis (PCA) or diet quality indexes
to assess food consumption in pregnant women.
Principal component analysis analyzes the associ-
ation between many foods and identifies the com-
ponents of population-specific dietary patterns and
diet quality indexes score dietary intakes, orga-
nized in several components, whose sum or total
amount of points quantifies dietary quality.
Energy and macronutrients adequacy, defined
as the relationship between intake and individual
requirements and quantified as the rates of cov-
ered requirements, is also an important compo-
nent in the assessment of dietary quality. 22
Adequacy is relatively easy to obtain and allows
the assessment of both energy deficiency and
excess and how energy intake is distributed
between carbohydrates, fats, and proteins in
populations. An intake of macronutrients within
the adequate distribution range is associated with
reduced risk of chronic disease.23 However, the
number of studies that has analyzed the influence
of socioeconomic factors on energy and macro-
nutrients adequacy is limited.24-26
The analysis of the influence of socioeco-
nomic factors on diet adequacy in pregnant
women is relevant in populations found in low-
and middle-income nations where inequalities in
income and access to education and health ser-
vices and healthy foods are deep. In their review
of 62 studies about dietary intake in pregnant
women from low- and middle-income countries
in Asia, Africa, the Caribbean, and Central/South
America, Lee et al27 found that in 44% of studies
included in the review macronutrient intakes
Romero-Villanueva et al
were not within the recommended ranges. Mex-
ico is a country with high socioeconomic inequal-
ity among its population; northern and central
states show the highest levels of economic growth
and well-being, while the southern states have
been historically characterized by poor economic
development and have the highest levels of pov-
erty and social inequality.28 The state of Yucatan,
located in the southeast of the country, has about
2.3 million inhabitants, distributed among 106
municipalities; 42% of the state’s population live
in Merida, its capital.29 Socioeconomic segrega-
tion is a distinctive characteristic of the popula-
tion of Merida and contributes to noticeable
differences in income and access to basic services
such as health and education. Socioeconomic dis-
parities in this city have shown their impact on
several components of individuals’ phenotype
and population’s epidemiological profile.30,31
Factors experienced by individuals during the
early stages of development, including diet dur-
ing pregnancy, may be playing an important role.
In this study, we analyze the association between
socioeconomic factors and adequacy rates of
energy and macronutrients intake in pregnant
women from the municipality of Merida.
Methods
The Study Location
This observational and cross-sectional study was
carried out in the municipality of Merida, which
includes the capital city and 14 comisarı́as, small
localities near to Merida. Nine localities were
selected for this study based on the presence of
health units that provide services for pregnant
women. All these localities are less than 5 km
from Merida, which results in an intense relation-
ship in terms of commerce, employment, and
education and health services.
Sample
The sample size was calculated considering that
the study had to compare categorical variables
using chi-square tests, as well as verify the exis-
tence of associations (correlations) between
them. To guarantee the existence of at least 5
3
observations in each combination of categories
of the variables, it was required to work with at
least 60 sampling units. The final sample con-
sisted of 83 pregnant women older than 18 years
of age.
Participants were recruited from 6 public hos-
pitals or health units (3 belonging to Mexican
Institute of Social Security and 3 from the
Ministry of Health of Yucatan State) with 3 being
private institutions. Initially, we met representa-
tives of these institutions to obtain their formal
authorization to undertake the study. Then, we
organized informative meetings with pregnant
women attending their prenatal care checkups.
During these meetings, potential participants
received detailed information about the aims of
the study, their participation, potential benefits,
and rights as participants. Those women who
agreed to participate provided us with their
address and phone number to make an appoint-
ment to begin the process of obtaining data. Our
inclusion criteria were (1) being pregnant,
(2) older than 18 years of age, and (3) resided
in the municipality of Merida. We excluded from
the analysis women with a medical diagnosis of
diabetes and/or hypertension.
Data Collection
Between September and December 2019, we col-
lected data on socioeconomic, pregnancy and diet
characteristics, and anthropometric measures of
women during 3 household visits. During the first
visit, we applied a questionnaire developed in the
Laboratory of Somatology at Cinvestav-Merida
which obtained information about the women’s
age, family composition, marital status, educa-
tion, occupation and income of all family
members, number of offspring, and gestational
age. Age was classified into 3 groups at tertile
points: (1) 18 to 24 years, (2) 25 to 29 years, and
(3) >30 years, while education was referenced to
years of schooling and then for descriptive pur-
poses was categorized in 3 levels: (1) low: pri-
mary and junior high school), (2) medium: high
school, and (3) high: university or more, respec-
tively. Regarding marital and working status,
women were grouped in (1) with partner and
(2) without partner and (1) working women and
4 Food and Nutrition Bulletin XX(X)
(2) nonworking women, respectively; here
“working” means carrying an activity to earn
money. More than 90% of mothers with a job
were employees in public and private institutions.
Income of all family members was obtained in
Mexican pesos (MXP) and then used to calculate
total family income. Family income was con-
verted into 3 categories at tertile points (Low,
medium, and high).
During our first visit, we measured women’s
height and weight and asked them to provide us
with their weight prior to pregnancy. We calcu-
lated pregestational body mass index (BMI ¼
weight [kg]/height [m2]) and classified women
as normal weight (18.5-24.9 kg/m2), overweight
(25-29.9 kg/m2), and obese (>30 kg/m2). Preges-
tational and pregnancy anthropometric data are
used in this article only for descriptive purposes.
Two qualified nutritionists applied 24-hour
dietary recalls 3 times during a 7-day period,
twice during the week and once at the weekend.
The surveyors followed the multiple-step
method,32 because of its precision in obtaining
data and reducing bias in the reported foods. This
procedure consists of 5 steps: (1) to list of all
foods consumed in the day, (2) to list forgotten
foods, (3) to record schedules and meal times,
(4) to obtain meal details, and (5) final review.
Standardized kitchen utensils (spoons, cups,
plates, and glasses) were used to register food
quantities in order to increase the accuracy of
consumption measurement. For foods made with
more than one ingredient, each ingredient was
register, except for fast food, packaged food, and
beverages. The 24-hour dietary recalls were ana-
lyzed using the software Nutrium to estimate
energy (kcal/day) and macronutrient (g/day)
intake rates. Energy and macronutrient consump-
tion rates were compared with the estimated
trimester-specific energy and macronutrient
requirements33 to calculate adequacies (percen-
tages) for each day of consumption. The energy
distribution in macronutrients was based on the
recommendation of the Food and Agriculture
Organization of the United Nations33 as follows:
55% for carbohydrates, 30% for fat, and 15% for
protein. For descriptive purposes, intake rates of
energy and macronutrients were defined accord-
ing to the percentage of requirement as below
normal: <90%, normal: 90% to 110%, and above
normal or high: >110%, as proposed by Suverza
and Haua. 34 Dietary data were extensively
reviewed by a nutritionist to identify possible aty-
pical consumptions and adequacies.
Data Analyses
Descriptive statistics of maternal sociodemo-
graphic characteristics and energy and macronu-
trients intake are presented for the total sample.
Mean and standard deviations (SD) of energy and
macronutrients adequacy were calculated for
each category of independent variable; Student t
tests were used to compare dietetic adequacy
between categories of marital and working status,
and one-way analysis of variance tests we applied
to compare dietetic parameters between cate-
gories of education level and familial income.
The relationship between socioeconomic factors
and diet characteristics was analyzed through
simple and multiple linear regression models.
Outcome variables were average adequacy of
energy, carbohydrates, total fat, and protein
intake. The main independent variables were
family income (numerical), women’s years of
education (numerical), marital status (categori-
cal), and working status (categorical). Since obe-
sity may alter food behavior, multiple linear
regression models were also adjusted for the pres-
ence of prepregnancy excess body weight (BMI >
24.9 kg/m2). Several diagnostic tests were applied
to determine the regression models validity. All
models met the assumptions of normality of resi-
duals, homogeneity of variance, and the variance
inflation factor. Data entry and analysis were
made with Stata/IC 11.1 for Windows statistical
package (StataCorp LP, 2010). The significance
level for statistical tests was a ¼ 0.05.
Ethical Clearance
This study was approved (057/2019) by the
Bioethics Committee for the Study of Human
Beings of the Centre for Research and
Advanced Studies of the National Polytechnic
Institute (Cinvestav-IPN) of México. Partici-
pant women signed consent forms during the
first household visit.
Romero-Villanueva et al 5

Table 1. Sociodemographic and Pregnancy Characteristics of Participant Women.a

Characteristic Mean (SD)/%

Sociodemographic
Age (years) 27.6 (5.2)
Age categories (%)
18-24 28 (34%)
25-29 29 (35%)
>30 26 (31%)
Total years of education 13.1 (3.7)
Levels of education attained (%)
Low: Primary and junior high school 23 (28%)
Medium: High school 25 (30%)
High: University and more 35 (42%)
Marital status
Without partner 9 (11%)
With partner 74 (89%)
Working status
With a job 49 (59%)
Without a job 34 (41%)
Monthly familial income (MXP/US$) Median ¼ MXP 15 000 (IR ¼ 7650-22 000)/
Median ¼ US$793 (IR ¼ 404-1163)
Tertiles of familial income
Tertile 1 MXP 3200-9600/US$169-507
Tertile 2 MXP 10000-19000/US$527-1004
Tertile 3 MXP 20000-150000/US$1057-7928
Pregnancy
Gestational age (months) 22.6 (8.3)
Trimester of pregnancy (%)
First 13 (16%)
Second 44 (53%)
Third 26 (31%)
Number of offspring (%)
None 44 (53%)
One 26 (31%)
Two or more 13 (16%)
Anthropometric
Height (cm) 153.2 (6.5)
Pregestational weight (kg) 60.6 (12.8)
Pregestational BMI (kg/m2) 25.6 (4.8)
Pregnant weight (kg) 65.5 (12.1)
Pregestational weight status (%)
Normal 40 (48%)
Overweight 26 (31%)
Obesity 17 (21%)

Abbreviations: BMI, body mass index; IR, interquartile range; MXP, Mexican pesos; SD, standard deviation; US$, US dollars.
a
Descriptive statistics for familial income corresponds to medians and interquartile ranges. 1 US$ ¼ 18.92 Mexican pesos; rate
of exchange on October 31, 2019, according to the Bank of Mexico (https://www.banxico.org.mx/tipcamb/main.do?
page¼tas&idioma¼sp#).

Results The mean of total years of education was 13.1

The age of participant women ranged from 18 to (SD ¼ 3.7) and 42% finished university or held
40 years (Mean ¼ 27.6 years, SD ¼ 5.2; Table 1). a technical qualification. Most of the participants
6 Food and Nutrition Bulletin XX(X)
Table 2. Descriptive Statistics of Energy and Macronutrients Intake and Adequacy Rates of Pregnant Women.
Nutrient Average intake (kcal/g)
Energy 2085 (SD ¼ 544)
Carbohydrates 1188 (SD ¼ 371)
297 g (SD ¼ 92)
Total fat 637 (SD ¼ 237)
71 g (SD ¼ 26)
Protein 308 (SD ¼ 81)
77 g (20)
Abbreviation: SD, standard deviation.
a
Low: <90%, normal: 90%-110%, high: >110%.
(89%) reported having a partner at the moment
of the study and 59% reported having a job.
Monthly family income ranged from MXP 3200
to 63 000 (US$169 to US$3330) with a median
of MXP 15 000 (interquartile range [IR] ¼ MXP
7650-22 000) (Median ¼ US$793, IR ¼ 404-1163).
Working women had more years of educa-
tion (Mean ¼ 15, SD ¼ 0.56 vs Mean ¼ 11,
SD ¼ 0.42; P < .001) and familial income
(Median ¼ MXP 18 500, IR ¼ 14 000-24 000 vs
Median ¼ MXP 8825, IR ¼ 6000-16 000, P < .001)
than nonworking women. The mean gestational age
was 22.6 (SD ¼ 8.3) weeks and 53% and 31% of
women were in the second and third trimesters of
pregnancy, respectively.
Descriptive statistics of energy and macronu-
trients intake and adequacy rates are presented in
Table 2. The means of adequacy rates for energy
and macronutrients fell between the recommend-
able ranges in the overall sample. However, 45%
of women did not meet their energy requirements
(below 90% adequacy) and 57% exceeded their
intake of carbohydrates (above 110% adequacy).
Adequacy rates of energy, carbohydrates, and
fat significantly decreased as education and
familial income levels increased (Table 3).
Women with a job at the time of the study showed
25%, 29%, 31% and 16% points less in energy,
carbohydrates, total fat, and protein adequacy
rates, respectively, than women without a job.
Women with and without a partner showed
similar adequacy rates. These findings were
Adequacy rate (%) Categories of adequacya
95 (SD ¼ 31) Low: 37 (45%)
Normal: 25 (30%)
High: 21 (25%)
99 (SD ¼ 36) Low: 2 (2%)
Normal: 34 (41%)
High: 47 (57%)
98 (SD ¼ 41) Low: 2 (2%)
Normal: 68 (82%)
High: 13 (16%)
93 (SD ¼ 29) Normal: 43 (52%)
High: 40 (48%)
consistent with results obtained in simple linear
regressions.
Simple linear regression analyses showed that
having a job was associated with decreases in
adequacy rates of 21%, 24%, 26%, and 13% in
energy, carbohydrates, lipids, and proteins intake,
respectively (Table 4). Family income was nega-
tively associated with adequacy rates of energy
and carbohydrates intake, but effects were sub-
stantially lower (0.3% and 0.4%, per each
MXP 1000 increase in family income, respec-
tively). Each additional year of education was
associated with decreases of 2% to 3% in ade-
quacy rates of energy, carbohydrates, and lipids
intake. When all socioeconomic variables and
prepregnancy excess body weight were included
in a multiple linear regression model (not pre-
sented in tables), we found that having a job was
significantly associated with higher adequacy
rates of energy (B ¼ 15.31 [SE ¼ 6.83],
P < .05) and lipids (B ¼ 25.22 [SE ¼ 10.83],
P < .05) rates. The rest of sociodemographic pre-
dictors were not associated with the outcome
variables.
Discussion
In this sample of Yucatecan women, we found
that working status (i.e., women working to earn
money), years of education, and family income
were negatively associated with energy and
macronutrients adequacy rates during pregnancy.
Romero-Villanueva et al 7

Table 3. Descriptive Statistics and Comparisons of Energy and Macronutrients Adequacy Between Categories of
Socioeconomic Variables.a

Variables Energy mean (SD) Carbohydrates mean (SD) Fat mean (SD) Protein mean (SD)

Having a partner
No 94 (34)b 102 (37)b 101 (62)b 93 (26)b
Yes 96 (35) 99 (36) 97 (39) 95 (30)
Having a job
No 110 (33)c 116 (38)c 116 (49)c 103 (29)d
Yes 85 (25) 87 (31) 85 (30) 87 (27)
Education level
Low 108 (35)d 113 (41)d 113 (56)d 102 (32)b
Medium 96 (33) 104 (35) 95 (41) 95 (29)
High 87 (24) 80 (25) 89 (27) 85 (25)
Familial income
Tertile 1 (low) 106 (36)d 115 (39)d 102 (46)b 102 (31)b
Tertile 2 (medium) 98 (31) 101 (35) 99 (41) 90 (26)
Tertile 3 (high) 83 (22) 86 (31) 91 (37) 90 (29)

Abbreviation: SD, standard deviation.

a
Student t tests were used to compare dietetic adequacy between categories of marital and working status, and one-way analysis
of variance tests we applied to compare dietetic parameters between categories of education level and familial income.
b
Nonsignificant.
c
P < .001.

Table 4. Associations Between Adequacy Rates and Socioeconomic Variables, Through Simple Linear Regression
Models.

Energy Total fat Carbohydrates Proteins

Variables b (SE) P value b (SE) P value b (SE) P value b (SE) P value

Having a 0.18 (9.56) .985 7.06 (13.13) .592 5.59 (11.43) .626 10.41 (9.10) .256
partner
Having a job 20.68 (5.64) <.001 26.06 (7.86) <.001 24.30 (6.77) <.001 12.72 (5.67) .028
Familial 0.30 (0.10) .032 0.30 (0.20) .142 0.40 (0.10) .018 0.10 (0.10) .323
incomea
Education 2.34 (0.76) .003 2.25 (1.08) .041 3.44 (0.89) <.001 1.10 (0.76) .153
(years)
Abbreviation: SE, standard error.
a
Income: thousands of Mexican Pesos.

Women experiencing more disadvantageous in our sample show, on average, an intake of

socioeconomic conditions, that is, lower levels
of education and family income and unemploy-
ment, show greater energy and macronutrient
intakes.
Energy and macronutrient intakes of pregnant
women in this study are comparable with intakes
of women residing in low- and middle-income
countries from Asia, Africa, and Latin America,
including Mexico.27 On the other hand, women
60 kcal/day of energy and 15 g/day of total fat
less than women from developed countries,
including the United States, Canada, the United
Kingdom, Denmark, Norway, Australia, and
Japan.35 However, women participating in our
study show a slightly greater intake of carbohy-
drates than women from these developed
countries (297 vs 269 g/day). Overall, these dif-
ferences and likenesses may reflect the effect of
8 Food and Nutrition Bulletin XX(X)
macro-level socioeconomic disparities that in-
fluence availability, access, and selection of
food choices and shape dietary patterns in
populations.36
We found that energy and macronutrients ade-
quacy rates decreased as the levels of education
and familial income increased, which is consis-
tent with the results obtained by Blumfield and
collaborators35 in their systematic review of stud-
ies with pregnant women from developed coun-
tries. In our sample, energy intake in the lowest
level of education was 2374 kcal (SD ¼ 589),
2068 kcal (SD ¼ 563) for the medium, and
1906 kcal (SD ¼ 482) for the highest. Corre-
sponding values by tertiles of familial income
were tertile 1: 2284 kcal (SD ¼ 557), tertile 2:
2136 kcal (SD ¼ 548), and tertile 3: 1841 kcal
(SD ¼ 443). Women in the highest levels of edu-
cation and income tended to be near to the lower
limit of the normal range of energy and macro-
nutrient adequacy. In contrast, adequacy rates of
carbohydrates of women in the lowest levels of
education and income were above the upper limit
of the normal range. The negative association
found in this study between education, income,
and energy and macronutrient intakes through
simple linear regressions is consistent with what
has been found in nonpregnant women, adult
men, and children from different populations.37-41
Working status of women was also associated
with nutritional adequacy in our sample of preg-
nant women. Adequacy rates for energy and total
fat were significantly higher in nonworking
mothers than in working mothers. Differences
in energy and macronutrients intakes between
these two groups correspond to 242 kcal/day and
15 g/day of fat. Additionally, we found that the
proportion of women with high adequacy of
energy intake (>110%) was greater in nonwork-
ing women than in working women (38% vs
16%). Adequacy rates of working mothers
closely resemble those of women with the highest
levels of education and income. Few studies have
analyzed the influence of working status on diet
quality during pregnancy.19,42 In the ALSPAC,
Northstone, Emmett, and Rogers19 found that
working pregnant women tended to have a
health-conscious dietary pattern, which was char-
acterized by the high consumption of salads, fruit,
rice, pasta, oat, fish, fruit juices, and nonwhite
bread. In the Study of Food Intake and Eating
Behavior during Pregnancy undertaken in Brazil
during 2006 to 2007, Hoffmann et al42 found that
being a working woman was associated with the
consumption of a more varied dietary pattern,
while nonworking women showed a restricted
pattern which is characterized by a higher con-
sumption of energy-dense foods.
The higher levels of formal education and
familial income found in working women allow
us to suggest that this group experience better
socioeconomic conditions, which could make
them more likely to access and select less
energy-dense foods including fruits, vegetables,
and grains, which would contribute decreasing
the energy and macronutrient adequacy rates.
Marital status was not associated with nutritional
adequacy rates in this sample, which may be
explained by the fact that a minor proportion
(n ¼ 9, 11%) of participant women reported not
having a partner at the moment of the study.
Our results indicate that the energy intake of
an important proportion (45%) of women in this
sample was lower than recommended, as has
been reported in pregnant women residing in
urban contexts in Mexico43,44 and countries that
experience better socioeconomic conditions.35 In
this regard, Dufour et al45 have proposed that
deliberate changes in physical activity during
pregnancy, particularly more time allocated to
energy-saving activities and less time to more
energy-demanding activities, may be an impor-
tant way to meet energy demands during preg-
nancy. Blumfield et al 35 also proposed that
energy homeostasis during pregnancy can be
achieved by relative reductions in the women’s
basal metabolic rate as have been reported in
some populations46,47 and by women’s weight
status at the beginning of pregnancy. In this
respect, some studies have reported that women
who enter pregnancy with higher values of BMI
tend to have less healthy dietary patterns during
pregnancy 14,48-50 ; though few studies have
focused on nutritional intakes and adequacies in
relation to prepregnancy BMI.51,52 Overall, these
results suggest that physiological adaptations
experienced by women during pregnancy may
Romero-Villanueva et al
buffer low energy intake during pregnancy driven
by socioeconomic factors.
Limitations
The percentage of women with high level of edu-
cation (42%) and the median of monthly familial
(MXP 15 000 [US$793]) indicate that the sample
of this study tend to overrepresent the population
of medium socioeconomic level from the munici-
pality of Merida, thus our results should inter-
preted only in the context of the sample. More
research that includes the more disadvantaged
socioeconomic groups in this geographical region
is needed. Also, the small sample size limited us
to include other important socioeconomic vari-
ables in the analyses.
Conclusions
This study found energy and macronutrient
inadequacies (deficiencies and excesses) in this
sample of pregnant women from Merida, Yuca-
tan, Mexico. Women under disadvantageous
socioeconomic conditions, namely, those with
lower levels of education and family income and
without a job, show greater energy and macronu-
trient intakes. From a public health point of view,
these findings are important in delineating the
groups at risk in terms of their socioeconomic
circumstances.
Acknowledgments
The authors thank their colleagues who participated in
the fieldwork and research, especially Graciela Valen-
tin, Niky Searle, Patricia Kantun, Gabriela Solı́s, and
Erika Karter, who made anthropometric measurements
and applied dietary recalls to women. The authors also
thank the authorities of institutions where participant
women were recruited: the IMSS, the Ministry of
Health of Yucatan, the Maternal Connection psycho-
prophylactic center, the Mothers Love center, and to
the authorities in Cholul, Chablekal, San José Tzal,
Oncan, and Dzununcan. The authors thank all the
women who participated in this study, for trusting us,
allowing us to enter their homes, and giving us the
necessary time to obtain all the information.
9
Author Contributions
DRV, HA, and FD: Conceptualized the research proj-
ect; JLB: Supervised the sample size calculation and
the statistical analyses of the data. HA: Wrote the first
draft of the manuscript and all coauthors read, revised,
and added intellectual content to the manuscript.
MTCB: Collaborated in the project development, and
for this article read, revised, and added intellectual
content.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publi-
cation of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
ORCID iD
Hugo Azcorra, PhD https://orcid.org/0000-0002-
3381-9341
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