Dietary Quality and Diet-Related Factors Among Female Adults of Reproductive Age With and Without Disabilities Participating in the National Health and Nutrition Examination Surveys, 2013-2018



      Female adults of reproductive age (18 to 44 years) with disabilities have higher rates of health-risk behaviors and chronic conditions compared with their counterparts without disabilities; however, there is limited examination of diet.


      Our aim was to examine associations of self-reported disability status with diet quality and diet-related factors.


      Cross-sectional data were from the National Health and Nutrition Examination Surveys, 2013-2018.


      Female adults aged 18 through 44 years were included. Disability was defined as serious difficulty hearing, seeing, concentrating, walking, dressing, and/or running errands due to physical, mental, or emotional conditions.

      Main outcome measures

      The Healthy Eating Index-2015 assessed diet quality. Diet-related factors included self-rated diet healthfulness, meal characteristics, food security, and food assistance programs.

      Statistical analysis

      Multivariable linear regression estimated differences in Healthy Eating Index-2015 scores for a given day and multivariable Poisson regression estimated adjusted prevalence ratios and 95% CI of diet-related factors by disability status.


      Of 3,579 female adults, 557 (16%) reported any disabilities, 207 (6%) of whom reported having 2 or more types of disabilities. Differences in mean Healthy Eating Index-2015 scores for a given day were one-third to one-half a point lower for fruits, total protein foods, and seafood and plant proteins among female adults with 2 or more types of disabilities compared with those without disabilities. Female adults with any disabilities were more likely to rate their diet as poor, have low food security, participate in food-assistance programs, and consume frozen foods or pizza, compared with those without disabilities (adjusted prevalence ratio ranged from 1.35 to 1.93); they were less likely to be the main food planner or preparer or shopper for their households.


      Some indicators of diet quality and diet-related factors differed between female adults with and without disabilities. Additional investigation of dietary intakes and behaviors, as well as access to and availability of healthy foods, among female adults with disabilities is necessary.


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        • Stephenson J.
        • Heslehurst N.
        • Hall J.
        • et al.
        Before the beginning: Nutrition and lifestyle in the preconception period and its importance for future health.
        Lancet. 2018; 391: 1830-1841
        • Hanson M.A.
        • Bardsley A.
        • De-Regil L.M.
        • et al.
        The International Federation of Gynecology and Obstetrics (FIGO) recommendations on adolescent, preconception, and maternal nutrition: “Think Nutrition First”.
        Int J Gynaecol Obstet. 2015; 131: S213-S253
        • Frey K.A.
        • Navarro S.M.
        • Kotelchuck M.
        • Lu M.C.
        The clinical content of preconception care: Preconception care for men.
        Am J Obstet Gynecol. 2008; 199: S389-S395
        • Kotelchuck M.
        • Lu M.
        Father’s role in preconception health.
        Matern Child Health J. 2017; 21: 2025-2039
        • Bodnar L.M.
        • Wisner K.L.
        Nutrition and depression: Implications for improving mental health among childbearing-aged women.
        Biol Psychiatry. 2005; 58: 679-685
        • Kumanyika S.
        Nutrition and chronic disease prevention: Priorities for US minority groups.
        Nutr Rev. 2006; 64: S9-S14
        • Decker D.
        • Flynn M.
        Food insecurity and chronic disease: Addressing food access as a healthcare issue.
        R I Med J. 2018; 101: 28-30
        • Schwartz N.
        • Buliung R.
        • Wilson K.
        Disability and food access and insecurity: A scoping review of the literature.
        Health Place. 2019; 57: 107-121
        • Okoro C.A.
        • Hollis N.D.
        • Cyrus A.C.
        • Griffin-Blake S.
        Prevalence of disabilities and health care access by disability status and type among adults—United States, 2016.
        MMWR Morb Mortal Wkly Rep. 2018; 67: 882-887
        • Mitra M.
        • Clements K.M.
        • Zhang J.
        • Smith L.D.
        Disparities in adverse preconception risk factors between women with and without disabilities.
        Matern Child Health J. 2016; 20: 507-515
        • Mitra M.
        • Clements K.M.
        • Zhang J.
        • Iezzoni L.I.
        • Smeltzer S.C.
        • Long-Bellil L.M.
        Maternal characteristics, pregnancy complications, and adverse birth outcomes among women with disabilities.
        Med Care. 2015; 53: 1027-1032
        • Mitra M.
        • Lu E.
        • Diop H.
        Smoking among pregnant women with disabilities.
        Womens Health Issues. 2012; 22: e233-239
        • Horner-Johnson W.
        • Akobirshoev I.
        • Amutah-Onukagha N.N.
        • Slaughter-Acey J.C.
        • Mitra M.
        Preconception health risks among U.S. women: Disparities at the Intersection of disability and race or ethnicity.
        Womens Health Issues. 2021; 31: 65-74
      1. National Health and Nutrition Examination Survey Data. Centers for Disease Control and Prevention, National Center for Health Statistics.
        Date accessed: February 1, 2021
        • Altman B.M.
        • Bernstein A.
        Disability and Health in the United States, 2001-2005.
        National Center for Health Statistics, 2008
        • Krebs-Smith S.M.
        • Pannucci T.E.
        • Subar A.F.
        • et al.
        Update of the healthy eating index: HEI-2015.
        J Acad Nutr Diet. 2018; 118: 1591-1602
        • Reedy J.
        • Lerman J.L.
        • Krebs-Smith S.M.
        • et al.
        Evaluation of the Healthy Eating Index-2015.
        J Acad Nutr Diet. 2018; 118: 1622-1633
      2. 2015-2020 Dietary Guidelines for Americans, 8th ed. US Department of Health and Human Services, US Department of Agriculture.
        (Published December 2015)
        • Panizza C.
        • Shvetsov Y.
        • Harmon B.
        • et al.
        Testing the predictive validity of the Healthy Eating Index-2015 in the multiethnic cohort: Is the score associated with a reduced risk of all-cause and cause-specific mortality?.
        Nutrients. 2018; 10: 452
      3. SAS Code. National Cancer Institute, Epidemiology and Genomics Research Program.
        • Kirkpatrick S.I.
        • Reedy J.
        • Krebs-Smith S.M.
        • et al.
        Applications of the Healthy Eating Index for surveillance, epidemiology, and intervention research: Considerations and caveats.
        J Acad Nutr Diet. 2018; 118: 1603-1621
        • Bickel G.
        • Nord M.
        • Price C.
        • Hamilton W.
        • Cook J.
        Guide to Measuring Household Food Security, Revised.
        USDA Food and Nutrition Service, 2000
        • Supplemental Nutrition Assistance Program (SNAP)
        US Department of Agriculture Food and Nutrition Service.
        • Weir C.B.
        • Jan A.
        BMI Classification Percentile and Cut Off Points.
        StatPearls Publishing, StatPearls2020
      4. Stata Statistical Software [computer program]. Release 15. StataCorp LLC, 2019
        • Deierlein A.L.
        • Litvak J.
        • Stein C.R.
        Preconception Health and disability status among women of reproductive age participating in the National Health and Nutrition Examination Surveys, 2013-2018 [published online ahead of print January 17, 2022]. J Womens Health (Larchmt).
        • Gamba R.
        • Leung C.W.
        • Guendelman S.
        • Lahiff M.
        • Laraia B.A.
        Household food insecurity is not associated with overall diet quality among pregnant women in NHANES 1999-2008.
        Matern Child Health J. 2016; 20: 2348-2356
        • Azarmanesh D.
        • Bertone-Johnson E.R.
        • Pearlman J.
        • Liu Z.
        • Carbone E.T.
        Association of the dietary inflammatory index with depressive symptoms among pre- and post-menopausal women: Findings from the National Health and Nutrition Examination Survey (NHANES) 2005-2010.
        Nutrients. 2022; 14: 1980
        • Greenland S.
        • Pearl J.
        • Robins J.M.
        Causal diagrams for epidemiologic research.
        Epidemiology. 1999; 10: 37-48
        • Brown M.C.
        • Marciniak C.M.
        • Garrett A.M.
        • Gaebler-Spira D.J.
        Diet quality in adults with cerebral palsy: A modifiable risk factor for cardiovascular disease prevention.
        Dev Med Child Neurol. 2021; 63: 1221-1228
        • Bertoli S.
        • Battezzati A.
        • Merati G.
        • et al.
        Nutritional status and dietary patterns in disabled people.
        Nutr Metab Cardiovasc Dis. 2006; 16: 100-112
        • Groce N.
        • Challenger E.
        • Berman-Bieler R.
        • et al.
        Malnutrition and disability: Unexplored opportunities for collaboration.
        Paediatr Int Child Health. 2014; 34: 308-314
        • Cruz-Jentoft A.J.
        • Kiesswetter E.
        • Drey M.
        • Sieber C.C.
        Nutrition, frailty, and sarcopenia.
        Aging Clin Exp Res. 2017; 29: 43-48
        • Feart C.
        Nutrition and frailty: Current knowledge.
        Prog Neuropsychopharmacol Biol Psychiatry. 2019; 95109703
        • Miller J.L.
        • Tan M.
        Dietary Management for adolescents with Prader-Willi syndrome.
        Adolesc Health Med Ther. 2020; 11: 113-118
        • Goswami J.N.
        • Sharma S.
        Current perspectives on the role of the ketogenic diet in epilepsy management.
        Neuropsychiatr Dis Treat. 2019; 15: 3273-3285
        • Gibson J.C.
        • Temple V.A.
        • Anholt J.P.
        • Gaul C.A.
        Nutrition needs assessment of young Special Olympics participants.
        J Intellect Dev Disabil. 2011; 36: 264-268
        • Ziegler J.
        • Spivack E.
        Nutritional and dental issues in patients with intellectual and developmental disabilities.
        J Am Dent Assoc. 2018; 149: 317-321
        • Koritsas S.
        • Iacono T.
        Weight, nutrition, food choice, and physical activity in adults with intellectual disability.
        J Intellect Disabil Res. 2016; 60: 355-364
        • Ptomey L.T.
        • Wittenbrook W.
        Position of the Academy of Nutrition and Dietetics: Nutrition services for individuals with intellectual and developmental disabilities and special health care needs.
        J Acad Nutr Diet. 2015; 115: 593-608
      5. Shulman HB, D’Angelo DV, Harrison L, Smith RA, Warner L. The Pregnancy Risk Assessment Monitoring System (PRAMS): Overview of design and methodology. Am J Public Health. Oct 2018;108(10):1305-1313.

        • Centers for Disease Control and Prevention
        Behavioral Risk Factor Surveillance System Survey Data.
        US Department of Health and Human Services, Centers for Disease Control and Prevention, 2020
        • Kim M.
        • Kim H.J.
        • Hong S.
        • Fredriksen-Goldsen K.I.
        Health disparities among childrearing women with disabilities.
        Matern Child Health J. 2013; 17: 1260-1268
        • Schrager S.
        Osteoporosis in women with disabilities.
        J Womens Health (Larchmt). 2004; 13: 431-437
        • Millward D.J.
        • Layman D.K.
        • Tomé D.
        • Schaafsma G.
        Protein quality assessment: Impact of expanding understanding of protein and amino acid needs for optimal health.
        Am J Clin Nutr. 2008; 87: 1576s-1581s
        • Calder P.C.
        Functional roles of fatty acids and their effects on human health.
        JPEN J Parenter Enteral Nutr. 2015; 39: 18s-32s
        • Godswill A.G.
        • Somtochukwu I.V.
        • Ikechukwu A.O.
        • Kate E.C.
        Health benefits of micronutrients (vitamins and minerals) and their associated deficiency diseases: A Systematic Review.
        Int J Food Sci. 2020; 3: 1-32
        • Social determinants of health (SDOH)
        NEJM Catalyst.
        • Herman D.R.
        • Taylor Baer M.
        • Adams E.
        • et al.
        Life course perspective: Evidence for the role of nutrition.
        Matern Child Health J. 2014; 18: 450-461
        • Hadgkiss E.J.
        • Jelinek G.A.
        • Weiland T.J.
        • Pereira N.G.
        • Marck C.H.
        • van der Meer D.M.
        The association of diet with quality of life, disability, and relapse rate in an international sample of people with multiple sclerosis.
        Nutr Neurosci. 2015; 18: 125-136
        • Fitzgerald K.C.
        • Tyry T.
        • Salter A.
        • et al.
        Diet quality is associated with disability and symptom severity in multiple sclerosis.
        Neurology. 2018; 90: e1-e11
        • Rimmer J.H.
        • Wang E.
        • Pellegrini C.A.
        • Lullo C.
        • Gerber B.S.
        Telehealth weight management intervention for adults with physical disabilities: A randomized controlled trial.
        Am J Phys Med Rehabil. 2013; 92: 1084-1094
        • Vadiveloo M.
        • Lichtenstein A.H.
        • Anderson C.
        • et al.
        Rapid diet assessment screening tools for cardiovascular disease risk reduction across healthcare settings: A Scientific Statement From the American Heart Association.
        Circ Cardiovasc Qual Outcomes. 2020; 13e000094
        • Crowley J.
        • Ball L.
        • Hiddink G.J.
        Nutrition in medical education: A systematic review.
        Lancet Planet Health. 2019; 3: e379-e389
        • Rotoli J.
        • Backster A.
        • Sapp R.W.
        • et al.
        Emergency medicine resident education on caring for patients with disabilities: A call to action.
        AEM Educ Train. 2020; 4: 450-462
        • Taouk L.H.
        • Fialkow M.F.
        • Schulkin J.A.
        Provision of reproductive healthcare to women with disabilities: A survey of obstetrician-gynecologists’ training, practices, and perceived barriers.
        Health Equity. 2018; 2: 207-215
        • Madans J.H.
        • Loeb M.E.
        • Altman B.M.
        Measuring disability and monitoring the UN Convention on the Rights of Persons with Disabilities: The work of the Washington Group on Disability Statistics.
        BMC Public Health. 2011; 11: S4
        • Anderson M.L.
        • Chang B.H.
        • Kini N.
        Alcohol and drug use among deaf and hard-of-hearing individuals: A secondary analysis of NHANES 2013-2014.
        Subst Abus. 2018; 39: 390-397
        • Kirkpatrick S.I.
        • Dodd K.W.
        • Potischman N.
        • et al.
        Healthy Eating Index-2015 scores among adults based on observed vs recalled dietary intake.
        J Acad Nutr Diet. 2021; 121: 2233-2241.e1
        • Ahluwalia N.
        • Dwyer J.
        • Terry A.
        • Moshfegh A.
        • Johnson C.
        Update on NHANES Dietary Data: Focus on collection, release, analytical considerations, and uses to inform public policy.
        Adv Nutr. 2016; 7: 121-134


      A. L. Deierlein is an associate professor of public health nutrition, School of Global Public Health, New York University, New York.


      J. Litvak is a doctoral student, School of Global Public Health, New York University, New York.


      C. R. Stein is a research associate professor, Department of Child and Adolescent Psychiatry, New York University, Grossman School of Medicine, New York.