Adherence to the Healthy Food Pyramid Among Pregnant and Lactating Women and the Impact of Socioeconomic Status in Pakistan: An Analytical Cross-Sectional Study

Abstract

Background: Maternal nutrition during pregnancy and lactation is a critical determinant of maternal and neonatal health, yet adherence to balanced dietary patterns remains suboptimal in low- and middle-income settings. In Pakistan, nutritional counseling is frequently supplementation-focused, and the influence of socioeconomic status (SES) on comprehensive dietary adherence during these physiologically demanding periods remains insufficiently characterized. Objective: To assess adherence to the Healthy Food Pyramid (HFP) among pregnant and lactating women attending tertiary care hospitals in Pakistan and to examine its association with socioeconomic indicators and maternal body mass index (BMI). Methods: In this analytical cross-sectional study, 204 women aged 18–42 years (pregnant, lactating, or dual-status) were recruited consecutively from tertiary hospitals. Adherence was measured using a culturally adapted Adherence to Pyramid Questionnaire (AP-Q; 0–10 scale). Sociodemographic data and anthropometric measurements were collected using standardized procedures. Group comparisons were performed using ANOVA, and multivariable linear regression was conducted to adjust for potential confounders. Results: The mean AP-Q score was 5.71 ± 0.96, indicating moderate adherence. No significant differences were observed across reproductive status groups (p = 0.62). Higher adherence was associated with normal BMI (p = 0.003), higher monthly income (p = 0.001), and husband’s graduate-level education (p = 0.004). In adjusted analysis, high income (β = 0.52; 95% CI: 0.24–0.80) and obesity (β = −0.61; 95% CI: −0.94 to −0.28) remained independent predictors. Conclusion: Adherence to HFP principles among pregnant and lactating women in Pakistan is moderate and significantly influenced by socioeconomic gradients and BMI. Integrating culturally tailored, household-oriented dietary interventions into maternal care may improve nutritional quality and mitigate long-term cardiometabolic risk.