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Relationship between food insecurity and the risk of pregnancy-induced hypertension: a prospective cohort study

BMC Pregnancy and Childbirth volume 25, Article number: 318 (2025) Cite this article

Abstract

Background

Pregnancy-induced hypertension (PIH) is a major cause of maternal and fetal mortality. Various risk factors contribute to this condition. This study aimed to investigate the association between food insecurity and the risk of pregnancy-induced hypertension among pregnant women referred to health centers.

Method

In this study, a prospective cohort design was employed. A total of 600 pregnant mothers covered by the Isfahan Health Network were randomly included in the study. Demographic questionnaires, DASS-21, HFIAS, and IPAQ were administered through interviews. Blood pressure data after the 20th week of pregnancy, were collected. Mothers were considered hypertensive patients whose blood pressure was above 140 (systolic) or above 90 (diastolic) or both, for the first time after the 20th week of pregnancy after two measurements. Data analysis was performed using chi-square, independent t, and binary logistic regression tests.

Result

The incidence of PIH was estimated to be 5.2%. The mean age of pregnant mothers was 30.24 ± 5.84 years, and 43% had university education. Food insecurity showed a significant association with PIH, even after controlling for confounding variables (P < 0.05). Additionally, an increase in pre-pregnancy BMI was associated with increased risk of PIH (ORA = 1.16, CI95%: 1.07–1.25). Larger household size increased the likelihood of hypertension by 51%, while having more than two pregnancies reduced the risk by 30%.

Conclusion

The Incidence of high blood pressure during pregnancy and its association with food insecurity and pre-pregnancy BMI emphasizes the need for interventions to improve food security in pregnant women and control pre-pregnancy BMI, ultimately preventing pregnancy related complications.

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Background

Gestational hypertension is defined as a systolic blood pressure 140 mm Hg or more or a diastolic blood pressure of 90 mm Hg or more, or both, on two occasions at least 4 h apart after 20 weeks of gestation, in a woman with a previously normal blood pressure [1]. This condition is one of the leading causes of maternal and fetal mortality worldwide, accounting for approximately 14% of maternal deaths [2]. The global prevalence of this disorder is 116.4 per 100,000 women of reproductive age [3]. In a study conducted in Isfahan, the prevalence of this condition was estimated to be 6% [4]. High blood pressure during pregnancy also increases the likelihood of complications for both the mother and the fetus. Maternal complications include chronic hypertension, cardiovascular disease, and kidney disease [5, 6]. Infants born to these mothers are at increased risk of preterm birth, low birth weight, small for gestational age (SGA), obesity, and type 2 diabetes in adulthood [7].

Various studies have identified numerous risk factors for increasing the likelihood of developing this condition. These include advanced maternal age, pre-pregnancy overweight and obesity, excessive weight gain during pregnancy, multiple pregnancies, ethnicity, and a history of hypertension in previous pregnancies [8,9,10,11,12,13]. Additionally, some studies have suggested other risk factors such as socioeconomic, psychological, lifestyle, and food insecurity factors [14,15,16,17].

Food insecurity refers to limited or uncertain access to adequate and nutritious food, or limited ability to acquire food in socially acceptable ways [18]. In Iran, various factors contribute to food insecurity, including age, spouse’s education, socio-economic status, lack of stable employment, job loss, single parenthood, family size, and loss of food assistance [19, 20]. According to reports from the Food and Agriculture Organization (FAO) and the World Health Organization (WHO), women in Africa, Asia, and Latin America are more severely affected by food insecurity [21]. Among women, pregnant women are a vulnerable group for whom food insecurity can be an independent risk factor for pregnancy complications [20]. In a meta-analysis study, the results showed that no consistent pattern was observed for the association between food insecurity and gestational hypertension. Seven studies examined the relationship between food insecurity and hypertension in various forms, including pre-eclampsia, gestational hypertension, and chronic hypertension. Among these, only one study demonstrated a significant relationship between pre-eclampsia and food insecurity [22], one study showed a positive but not significant association between food insecurity and gestational hypertension [23], and the remaining studies reported no association between food insecurity and hypertension [24,25,26]. Therefore, considering the lack of a clear pattern in the association between food insecurity and gestational hypertension, and given that limited studies have considered gestational hypertension as an outcome in the early stages without symptoms of pre-eclampsia and eclampsia, the present study examined the relationship between food insecurity and gestational hypertension, without considering the symptoms of pre-eclampsia and eclampsia, in pregnant women under the health centers of Esfahan city, with and without controlling for confounding variables.

Methods

Study design and study population

This prospective cohort study was conducted on pregnant mother’s city of Isfahan. The study population included pregnant mothers, who were eligible to receive prenatal care under the coverage of the Isfahan Health Network from 10 May, 2023 to 21 June, 2024ed. The inclusion criteria consisted of: (1) maximum gestational age of 14 weeks, and (2) coverage by the Isfahan Health Network. The exclusion criteria included: (1) chronic diseases such as cardiovascular diseases and hypertension, (2) incomplete data, (3) Mothers who experienced intentional or unintentional abortion during the study and (4) refusal to participate.

Sample size and sampling method

Initially, considering the prevalence of food insecurity of 34.8 in previous studies [27], 600 pregnant mothers were enrolled in the study to assess food security status. Subsequently, the incidence of PIH in food secure and food insecure groups was determined based on previous studies [27]. Considering a 95% confidence level and an 80% study power, a minimum of 207 participants in each group was required for comparing pregnancy hypertension between the two groups.

The values of each parameter in the formula: P = 34.8 (prevalence of food insecurity), P1 = 14.3%, P2 = 8.8%, q1 = 85.7, q2 = 91.2, α = 0.05 (Z1- \(\:\frac{\alpha\:}{2\:}=1.96\)), β = 0.2 (Z1-β = 0.85).

$$\:n = \frac{{{{\left[ {{Z_{1 - \alpha \:/2}}\sqrt {2\bar P(1 - \bar P)} + {Z_{1 - \beta \:}}\:\sqrt {{p_1}{q_1} + {p_2}{q_2}} } \right]}^2}}}{{\:{{\left( {{P_2} - {P_1}} \right)}^2}}}$$

The sampling method was conducted in multiple stages. Pregnant women were covered by 12 health centers, which were divided by region into 6 centers in Esfahan 1 and 6 centers in Esfahan 2, We randomly selected three centers from Esfahan 1 and three centers from Esfahan 2 equally. Subsequently, in each health center, pregnant women with a maximum gestational age of 14 weeks were randomly selected from the list and invited via telephone call to complete the questionnaires, either in person or over the phone.

Assessment tools and their validity and reliability

To collect information, we first used a checklist to record demographic and maternal characteristics, as well as three questionnaires: the Depression, Anxiety, and Stress Scale (DASS-21), the Household Food Insecurity Access Scale (HFIAS-9), and the International Physical Activity Questionnaire (IPAQ). We extracted outcome data from the electronic health system.

  1. 1.

    HFIAS-9: This 9-item questionnaire assesses food security using a 4-point Likert scale across various dimensions. the score range is from 0 to 27, where scores of 0 to 1 indicate food security, and scores of 2 to 27 indicate food insecurity. the validity of this questionnaire was assessed through concordance with household ranking from both the HFIAS and the Food Frequency Questionnaire (FFQ). the Pearson’s correlation coefficient exceeded 0.60. For reliability assessment, we used Cronbach’s alpha, which yielded a value of 0.95 [28].

  2. 2.

    DASS-21: This questionnaire consists of 21 items that measures three components: depression, anxiety, and stress. the final score for each component is obtained by summing the scores of relevant questions. Scoring is done using a 4-category Likert scale from 0 to 3. the validity of this questionnaire was confirmed by Lovibond 0.77, and its reliability was assessed using Cronbach’s alpha 0.83 [29]. The validity and reliability of the questionnaire were examined in Iran by Samani and Jokar [30].

  3. 3.

    IPAQ: Developed by an international expert group in 1988, the IPAQ assesses three categories of physical activity: vigorous, moderate, and walking during the past week. The validity and reliability of this questionnaire have been confirmed in 12 countries [31]. Scoring involves assigning an 8-fold weight to vigorous activity, a 4-fold weight to moderate activity, and a 3.3-fold weight to walking. The final activity level is calculated by multiplying the duration of each activity by the number of days performed. This questionnaire has also been utilized in various studies within Iran, and its validity and reliability have been confirmed [32, 33].

Data collection method

Pregnant mothers who were in the first trimester of pregnancy and met the inclusion criteria were enrolled in the study in 2023. Participants were followed until the 20th week of pregnancy. The duration of follow-up varied for each individual based on their entry time into the study, give the duration range collected up to June 2024. The questionnaires were completed by the researcher at the beginning of the study, and information related to pregnancy blood pressure was collected through the electronic health system. The researcher and the midwives at the health centers completed the questionnaires. The method of completing the questionnaire was explained to the midwives. The questionnaire was given to the pregnant mother, and general explanations about how to fill in the questionnaire questions were provided. Participants could also contact the researcher if they had any questions.

Study variables and definition

In this study, the primary outcome was the incidence of gestational hypertension in mothers after the 20th week of pregnancy, defined as a systolic blood pressure of ≥ 140 and a diastolic blood pressure of ≥ 90, without symptoms of pre-eclampsia or eclampsia. After the 20th week of pregnancy, mothers visited the health center where their blood pressure was measured using an electronic sphygmomanometer. If the pregnant mother’s blood pressure was ≥ 140 (systolic) and ≥ 90 (diastolic) after at least two measurements, she was considered hypertensive.

The main independent variable in this study was food insecurity. Pregnant women with an HFAIS questionnaire score above 2 were considered to have food insecurity.

The demographic and clinical information examined in this study included the age of the pregnant mother, the number of family members, the educational level of the pregnant woman and her husband, the interval between pregnancies, the mother’s pre-pregnancy BMI, gravidity and the history of gestational hypertension disorders in previous pregnancies.

Statistical analysis

After collecting data from questionnaires and the electronic health system, the information was entered into a computer database. Subsequently, statistical analysis was performed using SPSS version 21. The calculated statistics were reported with a 95% confidence interval. For data description, measures such as frequency, percentage, mean, and standard deviation were used. To measure relationship between quantitative variables, the t-test was employed, while the chi-square test was used to assess relationships between categorical variables. Data normality was assessed using the Kolmogorov-Smirnov test. Predictive variables and confounders were evaluated using binary logistic regression test.

Results

Demographic and clinical characteristics of pregnant mothers under study

Table 1. illustrates the distribution of demographic and clinical characteristics of pregnant mothers covered by the health network in Isfahan city, categorized by food security. In this study, 600 pregnant women were included. Their mean age was 30.24 ± 5.84 years, and the mean BMI before pregnancy was 25.84 ± 4.53. Most participants had university education (43.7%), and more than two pregnancies (62%). The incidence of PIH in the overall population was estimated at 5.2%. A higher percentage of mothers with PIH were in the food-insecure group (P = 0.004). Food-insecure individuals had a higher average household size compared to food-secure individuals (P < 0.001). In the food-secure group, a higher percentage of pregnant mothers and their spouses had university education (P < 0.001). primigravida mothers were more prevalent in the food-secure group than the food-insecure group (P < 0.001). Depressive symptoms were also reported more frequently among food-secure mothers compared to those without food security (P = 0.001). Anxiety and stress were higher in the food-secure group (P < 0.05). Smoking and first-degree relatives with hypertension did not show significant differences between the food-secure and food-insecure groups (P > 0.05).

Table 1 Demographic and clinical characteristics of pregnant mothers in Isfahan city, 2023
Full size table

In Table 2 Food insecurity did not show a significant difference across different age groups (P = 0.502). Similarly, food insecurity did not show a significant difference across the four BMI categories before pregnancy (P = 0.758). In examining the association between gestational hypertension and different age groups, no significant relationship was observed (P = 0.210). Pregnant women with overweight and obese pre-pregnancy BMI were significantly more likely to develop gestational hypertension compared to those with normal and underweight BMI (P = 0.006).

Table 2 Distribution of age groups and pre-pregnancy BMI in pregnant women by outcome and independent study variables
Full size table

Incidence of pregnancy-induced hypertension and associated factors

Table 3. shows the frequency of demographic and clinical variables of pregnant women, categorized by the presence of PIH. The mean age did not differ between the hypertensive and non-hypertensive groups (P = 0.501). The mean pre-pregnancy BMI was higher in the hypertensive group (P < 0.001). There was no significant difference in smoking habits and the incidence of PIH among first-degree relatives between the hypertensive and non-hypertensive groups (P > 0.05).

Table 3 Factors related to PIH among pregnant women in Isfahan city, 2023
Full size table

Examining the relationship between food insecurity and pregnancy-induced hypertension

The findings in Table 4 show the risk factors associated with PIH. In the univariate analysis, pregnant women with food insecurity had a 3.01-fold increased risk of developing PIH (P = 0.006). Pre-pregnancy BMI increased the risk of PIH by 1.14 times (P < 0.001). The adjusted odds ratio, controlling for confounding factors, indicated that the risk of PIH in food-insecure individuals was 3.45 times higher than in food-secure individuals (P = 0.004). Pre-pregnancy BMI increased the risk of pregnancy-induced hypertension by 1.16 times (P < 0.001). A larger household size increased the risk of PIH by 1.51 times (P = 0.038). Having more than two pregnancies reduced the risk of PIH by 0.30 times (P = 0.021).

Table 4 Logistic regression model to examine the association between FI &PIH among pregnant women, 2023
Full size table

Discussion

In this study, the incidence of pregnancy-induced hypertension (PIH) was estimated at 5.2%. A significant relationship was reported between food insecurity and the risk of PIH, even after controlling for confounding variables. Pregnant women experiencing food insecurity had a higher likelihood of developing PIH. Pre-pregnancy BMI was identified as an independent risk factor for the occurrence of PIH, with higher pre-pregnancy BMI increasing the risk of pregnancy-induced hypertension.

In the study by Magee et al., the incidence of pregnancy hypertension was reported in less developed countries as follows: 6.9% in India, 6.5% in Pakistan, 8.4% in Mozambique, and 7.1% in Nigeria [34]. Another study conducted in Minnesota assessed pregnancy hypertension incidence per woman and per pregnancy. The estimated prevalence was 6% per woman and 3% per pregnancy [35]. There is a slight difference between the findings of the aforementioned studies and the incidence in our study; it can be attributed to racial and geographical differences.

In our study, the risk of developing PIH was three times higher in individuals with food insecurity compared to those with food security. In a study by Hojaji et al., the odds of hypertension in food-insecure individuals were estimated 1.25 times higher than in food-secure individuals, although this association was not statistically significant [36]. Another study by Kazemi et al., did not find any significant relationship between the likelihood of PIH/ preeclampsia and food insecurity [37]. In a separate study conducted in Qazvin, Hoseini et al., observed a 24% higher risk of pregnancy-induced hypertension in the food-insecure group compared to the food-secure group, however, this difference was not statistically significant [38]. The difference in these findings with our study can be attributed to the different methodology. Our current study follows a prospective cohort design, collecting information on food security first and then assessing the risk of PIH. However, the three mentioned studies were cross-sectional, collecting information on food insecurity and PIH simultaneously. In the cohort study by Laraia, the crude odds ratio showed that mothers experiencing food insecurity were significantly 1.53 times more likely to develop gestational hypertension compared to food-secure mothers, which it appeared to align with our study; however, after controlling the confounding effects, it did not remain significant and was not consistent with the results of our study [39]. In the cohort study conducted by Chehab et al., the results showed that the risk of pre-eclampsia increased by 26% in pregnant women with food insecurity. However, no significant association was observed between food insecurity and the risk of gestational hypertension [40]. In a case-control study conducted in Iran, the results showed that mothers in the pre-eclampsia group experienced food insecurity significantly six times more than healthy mothers [41]. In another cohort study, food-insecure mothers were 91% more likely to exhibit symptoms of pre-eclampsia compared to food-secure mothers, and this association was statistically significant [22]. In a cross-sectional study conducted by Joseph et al., no significant association was reported between food insecurity and pre-eclampsia with or without symptoms after controlling for confounding variables [24]. The possible mechanism explaining the association between food insecurity and gestational hypertension can be attributed to irregular eating patterns, consumption of high-energy and obesity-inducing foods, and the lack or insufficient intake of preventive foods such as fruits and vegetables [42,43,44,45,46].

In the present study, pre-pregnancy BMI increased the risk of PIH by 14%. In the study by Sun et al., the risk of PIH significantly increased with higher pre-pregnancy BMI [8]. These findings are consistent with our study. The mechanism by which BMI affects blood pressure can be explained as follows: with increased body weight and fat, estrogen accumulates in the body. This leads to the secretion of aldosterone, which retains sodium in the renal tubules, resulting in high blood pressure [47]. Additionally, with increased body fat, lipid metabolism in the blood becomes abnormal, leading to elevated blood pressure [48].

Our study demonstrated a significant relationship between the number of family members and the risk of PIH. Specifically, with an increase in household size, the risk of PIH increased by 51%. In the study by Gabal et al., a significant association between household size and pregnancy-induced hypertension was reported [49]. These findings are consistent with our study. In the study by Hojaji et al., the risk of PIH increased by 28% with an increase in family size, but this association was not statistically significant [36]. One of the indicators of socioeconomic status is the number of household members. It can be stated that a higher number of household members indicates a lower socioeconomic status, which is associated with an increased risk of PIH [50]. In the present study, socioeconomic status was not examined as an independent variable. which could be an area for future research.

This study found that primigravida pregnant women have an increased risk of PIH. Lakhute et al. also reported that women in their first pregnancy are at higher risk of PIH [51]. Another study showed that a higher percentage of primigravida women develop preeclampsia compared to multigravida women [52]. Immunological factors, such as maternal incompatibility with fetal or paternal alloantigens, may indirectly cause uteroplacental perfusion disorders, leading to increased blood pressure and preeclampsia [53]. Additionally, primigravida women experience higher circulating levels of sFlt1 and a higher sFlt1/PlGF ratio, contributing to angiogenic imbalance and potentially leading to preeclampsia [54].

A key strength of our study is its prospective cohort design with an adequate sample size. This design allows for the examination and control of confounding variables and facilitates causal inference. The findings of this study are generalizable to pregnant women in the city of Isfahan.

Like other studies, our research has limitations. The limitations include: (1) Not considering preeclampsia and eclampsia as outcomes. Only gestational hypertension (GH) was considered as an outcome within the category of hypertensive disorders of pregnancy (HDP). Although the practical aim was primary prevention by identifying and controlling risk factors to prevent GH, future studies should follow up with women who develop GH and separately examine preeclampsia and eclampsia. (2) Family history of hypertension in first-degree relatives was collected through self-reporting, which may be subject to recall bias.

Conclusion

This study demonstrated that food insecurity and high pre-pregnancy BMI independently increase the risk of gestational hypertension in pregnant women. Therefore, intervening to control BMI before pregnancy and considering a proper food basket for food-insecure mothers can prevent pregnancy complications such as gestational hypertension and its subsequent issues.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

PIH:

Pregnancy induce hypertension

GH:

Gestational hypertension

HDP:

Hypertensive disorders of pregnancy

FI:

Food insecurity

BMI:

Body mass index

SGA:

Small for gestational age

FAO:

Food and Agriculture Organization

WHO:

World Health Organization

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Acknowledgements

We sincerely thank all participants. We express our gratitude for the collaboration of the midwifery units of Isfahan Health Network 1 and Isfahan Health Network 2, as well as the midwives of comprehensive health service centers.

Funding

The authors received funding from the Research Deputy of Isfahan University of Medical Sciences for the implementation of this study.

Author information

Authors and Affiliations

  1. Student Research Committee and Department of Epidemiology and Biostatistics, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran

    Neda Yaghobieh

  2. Department of Clinical Nutrition, School of Nutrition and Food Sciences, Professor of Nutritional, Isfahan University of Medical Sciences, Isfahan, Iran

    Reza Amani

  3. Department of Epidemiology and Biostatistics, School of Public Health, Associate Professor of Epidemiology Sciences, Isfahan University of Medical Sciences, Isfahan, Iran

    Mohammad Javad Tarrahi

Authors
  1. Neda Yaghobieh
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  2. Mohammad Javad Tarrahi
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  3. Reza Amani
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Contributions

M.T and R.A and N.Y contributed to designing the study and literature review. They are also involved in study design. The article was written by all authors. Data collection was performed by N.Y. The data was analyzed by N.Y and M.T. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Mohammad Javad Tarrahi.

Ethics declarations

Ethics approval and consent to participate

This study was conducted in full compliance with ethical principles and with the approval by the Ethics Committee of Isfahan University of Medical Sciences (Ethics code: IR.MUI.RESEARCH.REC.1402.004). All participants received comprehensive information about the objectives and methods of the research before the study began and gave their consent to participate. Participants were also assured that their personal information would be kept confidential and used solely for research purposes. At any stage of the research, participants had the right to withdraw from the study. All methods used in this research were in accordance with the Declaration of Helsinki.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Yaghobieh, N., Tarrahi, M.J. & Amani, R. Relationship between food insecurity and the risk of pregnancy-induced hypertension: a prospective cohort study. BMC Pregnancy Childbirth 25, 318 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07340-6

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07340-6

Keywords

BMC Pregnancy and Childbirth

ISSN: 1471-2393

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