Rural-urban differences in dietary intake across pregnancy trimesters: A multisite prospective cohort study.

PURPOSE: Poor diet during pregnancy compromises maternal-fetal health and may reflect broader environmental and structural inequities. This study investigated differences in dietary intake across pregnancy among rural and urban women in the United States and assessed whether socioeconomic status (SES) modified rural-urban differences. METHODS: In this prospective study, pregnant women (n = 495; 22.4% rural) from three sites (Iowa, Pennsylvania, West Virginia) had dietary intake estimated via the 26-item Dietary Screener Questionnaire (DSQ) during each trimester. Rural was defined as Rural-Urban Commuting Area (RUCA) code ≥ 4. A SES score was derived using Principal Component Analysis of education, annual household income, and insurance type. Adjusted robust linear mixed-effects models (controlled for site, age, minority status, pre-pregnancy BMI) compared dietary intakes between rural and urban participants, with trimester and SES interactions. FINDINGS: Compared to their urban counterparts, rural participants had higher predicted intakes of added sugars from sugar-sweetened beverages (SSBs) in the first (0.61 tsp eq/day; 95% CI: [0.04, 1.18]) and second trimesters (0.62 tsp eq/day [0.05, 1.21]), and less fiber across all trimesters (ranging from -0.90 g/day [-1.7, -0.1] to -1.2 g/day [-2.0, -0.3]). Women in the high-SES urban group had higher intakes of fiber and calcium, and lower intakes of SSBs compared to their low-SES counterparts in both rural and urban settings. CONCLUSIONS: Although rurality was associated with greater SSBs and lower fiber intake, differences were modest. Low-SES was related to a poorer diet regardless of geography, highlighting the need for targeted interventions for both rural and urban low-SES pregnant women.