The Global Diet Quality Score Is Inversely Associated with Nutrient Inadequacy, Low Midupper Arm Circumference, and Anemia in Rural Adults in Ten Sub-Saharan African Countries

The global diet quality score as an indicator of adequate nutrient intake and dietary quality - a nation-wide representative study

BACKGROUND

The Global Diet Quality Score (GDQS) was developed to be a simple, timely and cost-effective tool to track, simultaneously, nutritional deficiency and non-communicable disease risks from diet in diverse settings. The objective was to investigate the performance of GDQS as an indicator of adequate nutrient intake and dietary quality in a national-representative sample of the Brazilian population.

METHODS

Nationally-representative data from 44,744 men and non-pregnant and non-lactating women aging ≥ 10 years, from the Brazilian National Dietary Survey were used. Dietary data were collected through two 24-h recalls (24HR). The GDQS was calculated and compared to a proxy indicator of nutrient adequate intake (the Minimum Dietary Diversity for Women-MDD-W) and to an indicator of high-risk diet for non-communicable diseases (caloric contribution from ultra-processed foods-UPF). To estimate the odds for overall nutrient inadequacy across MDD-W and GDQS quintiles, a multiple logistic regression was applied, and the two metrics' performances were compared using Wald's post-test.

RESULTS

The mean GDQS for Brazilians was 14.5 (0-49 possible range), and only 1% of the population had a low-risk diet (GDQS ≥ 23). The GDQS mean was higher in women, elderly individuals and in higher-income households. An inverse correlation was found between the GDQS and UPF (rho (95% CI) = -0.20(-0.21;-0.19)). The odds for nutrient inadequacy were lower as quintiles of GDQS and MDD-W were higher (p-trend < 0.001), and MDD-W had a slightly better performance than GDQS (p-diff < 0.001). Having a low-risk GDQS (≥ 23) lowered the odds for nutrient inadequacy by 74% (95% CI:63%-81%).

CONCLUSION

The GDQS is a good indicator of overall nutrient adequacy, and correlates well with UPF in a nationally representative sample of Brazil. Future studies must investigate the relationship between the GDQS and clinical endpoints, strengthening the recommendation to use this metric to surveillance dietary risks.

Inverse Association between the Global Diet Quality Score and New-Onset Hypertension in Adults: A Nationwide Cohort Study

BACKGROUND

The Global Diet Quality Score (GDQS) is a simple and practical dietary metric associated with a number of chronic diseases. The GDQS included various foods related to blood pressure, especially diverse plant-based foods that have shown to lower blood pressure. However, studies on the role of the GDQS in reducing the risk of new-onset hypertension and whether its performance differs from that of other dietary metrics are lacking.

OBJECTIVE

We aimed to examine the association between the GDQS and new-onset hypertension and to compare its performance with that of other dietary patterns, including the Plant-based Diet Index (PDI), alternate Mediterranean diet (aMED) score, Alternative Healthy Eating Index-2010, and Dietary Approaches to Stop Hypertension (DASH) score in Chinese adults.

METHODS

We included a total of 12,002 participants (5644 males and 6358 females) aged >18 y from the China Health and Nutrition Survey (1997-2015). Dietary intake was estimated using average food intakes from 3 consecutive 24-h dietary recalls. Multivariable relative risks (RRs) were computed for hypertension using modified Poisson regression models.

RESULTS

With ≤18 y of follow-up (mean 8.7± 5.4 y), we ascertained 4232 incident cases of hypertension. Compared with participants with a low GDQS score (<15), the multivariable-adjusted RR of hypertension was 0.72 [95% confidence interval (CI): 0.62, 0.83] among participants with a high score (≥23). A 25% increment in the GDQS was associated with a 30% (RR, 0.70; 95% CI: 0.64, 0.76) lower risk of new-onset hypertension, which was comparable with the RRs of new-onset hypertension associated with every 25% increment in the PDI (RR, 0.84; 95% CI: 0.76, 0.93), DASH score (RR, 0.84; 95% CI: 0.78, 0.91), and aMED score (RR, 0.89; 95% CI: 0.84, 0.93).

CONCLUSION

A higher GDQS was associated with a lower risk of new-onset hypertension, with comparable associations of new-onset hypertension with PDI, DASH, and aMED scores in Chinese adults.

Association between diet quality and risk of stunting among school-aged children in Schistosoma mansoni endemic area of western Kenya: a cross-sectional study

BACKGROUND

Healthy eating habits are essential for improving nutritional status and strengthening immunity against infectious diseases. This study examined the relationship between diet quality and stunting in school-aged children in an infectious disease-endemic area of western Kenya.

METHODS

This cross-sectional study included 260 school-aged children (age 9-17 years) enrolled in primary schools in Mbita Sub-county, western Kenya. The nutritional status was assessed using anthropometric measurements. Dietary intake was measured using food frequency questionnaires and evaluated using the Food Pyramid (FP) score, which indicates adherence to the Kenyan food-based dietary guideline. Information on the children's age, sex, maternal education, and household wealth index was collected using a household-based questionnaire. Infections with the predominant parasites, such as Schistosoma (S.) mansoni, were detected via microscopy. The trend associations of the FP score with food group intake were examined to characterize the dietary intake of this population. Logistic regression analysis was performed to investigate the relationship between stunting and FP score tertiles, adjusted for sociodemographic and economic indicators and parasitic infection status.

RESULTS

Among the studied schoolchildren, 15.0% exhibited stunting, while 76.2% were infected with S. mansoni. The mean FP score was 25.6 out of 50 points. A higher FP score was characterized by a high intake of roots and tubers, dairy products, pulses, and fruits and a low intake of cereals and animal-source foods. The analysis revealed a trend: a lower risk of stunting was evident in groups with elevated FP scores (p for trend = 0.065). However, these trend associations were observable among subjects with either negative or light S. mansoni infection (p for trend = 0.016).

CONCLUSIONS

A higher quality diet, as evaluated by FP scores, was associated with a low risk of stunting among school-aged children. Notably, this association seemed to weaken in the presence of a high burden of S. mansoni infection. It highlights the importance of enhancing dietary quality through the promotion of diverse nutrient-dense foods alongside effective S. mansoni infection control for improved growth. This study contributes fundamental knowledge for understanding the diet-malnutrition relationship in areas endemic for S. mansoni infection.

Performance of the Global Diet Quality Score (GDQS) App in Predicting Nutrient Adequacy and Metabolic Risk Factors among Thai Adults

BACKGROUND

The Global Diet Quality Score (GDQS) was developed for monitoring nutrient adequacy and diet-related noncommunicable disease risk in diverse populations. A software application (GDQS app) was recently developed for the standardized collection of GDQS data. The application involves a simplified 24-h dietary recall (24HR) where foods are matched to GDQS-food groups using an onboard database, portion sizes are estimated at the food group level using cubic models, and the GDQS is computed.

OBJECTIVES

The study aimed to estimate associations between GDQS scores collected using the GDQS app and nutrient adequacy and metabolic risks.

METHODS

In this cross-sectional study of 600 Thai males and nonpregnant/nonlactating females (40-60 y), we collected 2 d of GDQS app and paper-based 24HR, food-frequency questionnaires (FFQs), anthropometry, body composition, blood pressure, and biomarkers. Associations between application scores and outcomes were estimated using multiple regression, and application performance was compared with that of metrics scored using 24HR and FFQ data: GDQS, Minimum Dietary Diversity-Women, Alternative Healthy Eating Index-2010, and Global Dietary Recommendations score.

RESULTS

In covariate-adjusted models, application scores were significantly (P < 0.05) associated with higher energy-adjusted mean micronutrient adequacy computed using 24HR (range in estimated mean adequacy between score quintiles 1 and 5: 36.3%-44.5%) and FFQ (Q1-Q5: 40.6%-44.2%), and probability of protein adequacy from 24HR (Q1-Q5: 63%-72.5%). Application scores were inversely associated with BMI kg/m2 (Q1-Q5: 26.3-24.9), body fat percentage (Q1-Q5: 31.7%-29.1%), diastolic blood pressure (Q1-Q5: 84-81 mm Hg), and a locally-developed sodium intake score (Q1-Q5: 27.5-24.0 points out of 100); positively associated with high-density lipoprotein cholesterol (Q1-Q5: 49-53 mg/dL) and 24-h urinary potassium (Q1-Q5: 1385-1646 mg); and inversely associated with high midupper arm circumference (Q5/Q1 odds ratio: 0.52) and abdominal obesity (Q5/Q1 odds ratio: 0.51). Significant associations for the application outnumbered those for metrics computed using 24HR or FFQ.

CONCLUSIONS

The GDQS app effectively assesses nutrient adequacy and metabolic risk in population surveys.

The Global Diet Quality Score predicts diet quality of women of reproductive age in Addis Ababa, Ethiopia

Improving diet quality is recognised as a double-duty action that can simultaneously address multiple forms of malnutrition. This study aimed to assess diet quality among non-pregnant non-lactating women of reproductive age (WRA) in Addis Ababa, Ethiopia. A 1-d quantitative 24 h recall was conducted among 653 non-pregnant/non-lactating women. Diet quality, assessed using the women dietary diversity score (WDDS), the Global Diet Quality Score (GDQS) and the Nova 4 classification reflecting consumption of ultra-processed foods (UPF), was compared. The proportion that meets the minimum dietary diversity for women (MDD-W) was estimated. The average MDD-W score was 2·6 (sd 0·9), with only 3 % of women meeting the MDD-W (≥ 5 food groups). Consumption of wholegrain and legumes was high, but UPF were also consumed by 9 % of the women. GDQS was positively associated with WDDS, age and skipping breakfast and was negatively associated with eating out of home and UPF consumption (P < 0·05). The multivariate regression model showed that GDQS (total) was not associated with wealth but was significantly associated with both UPF and WDDS (P < 0·001). Unlike UPF and WDDS alone, GDQS was able to predict both nutrient adequacy and unhealthy dietary practices. The diet quality of WRA in Addis Ababa is low in diversity, possibly exposing them to higher risk of nutrient inadequacy and non-communicable diseases as reflected by the low GDQS. Understanding what drives food and dietary choices in urban settings is urgently needed.

Diet Quality and Consumption of Healthy and Unhealthy Foods Measured via the Global Diet Quality Score in Relation to Cardiometabolic Outcomes in Apparently Healthy Adults from the Mediterranean Region: The ATTICA Epidemiological Cohort Study (2002-2022)

The Global Diet Quality Score (GDQS) is a novel food-based score that assesses both nutrient adequacy and chronic disease risk, by evaluating healthy (GDQS+) and unhealthy foods (GDQS-). The aim of this study was to evaluate the association among GDQS, GDQS+, and GDQS- against the 20-year risk of cardiometabolic outcomes in a Mediterranean population. The sample was n = 2169 initially free of cardiovascular disease (CVD) participants of the ATTICA study (2002-2022) that participated in the 20-year follow-up. The incidence of CVD, hypertension, hypercholesterolemia, and type 2 diabetes mellitus (T2DM) was defined according to WHO-ICD-10 criteria. The GDQS was computed based on previously published instructions. In multivariate analyses, a higher diet quality, per 1/49 of the GDQS, was associated with an 8% [95% Confidence Interval-CI: 6-9%] and 2% [95% CI: 1-3%] lower CVD and T2DM risk, respectively. A higher consumption of healthy foods, per 1/32 of GDQS+, was associated with a 9% [95% CI: 7-11%] and 2% [95% CI: 1-3%] lower CVD and T2DM risk, respectively. Contrarily, a lower consumption of unhealthy foods (GDQS-) was not associated with cardiometabolic events in the adjusted models (all p value< 0.05). In clinical practice or future public health actions to ameliorate dietary habits and prevent CVD and T2DM, more attention should be focused on healthy foods that should be included in our diets.

Anemia and frailty in the aging population: implications of dietary fiber intake (findings of the US NHANES from 2007-2018)

BACKGROUND

Frailty has long been seen as an indicator of reduced physical functions in the elderly, which may be caused by a variety of chronic illnesses or cancerous tumors. Dietary fiber was connected with anemia and frailty, whereas it was uncertain if dietary fiber consumption modifies the impact of anemia on frailty in elderly adults.

METHODS

We performed a secondary analysis using older adults aged 60 years and over from the National Health and Nutrition Examination Survey (NHANES) 2007-2018 cycles. Dietary fiber intake was estimated using two 24-h dietary recalls. Participants were dichotomized as frail or non-frail based on a modified Fried physical frailty phenotype from previous NHANES studies. The weighted logistic regression was used to estimate the odds ratio (OR) and confidence interval (CI) for the associations between hemoglobin levels and frailty at high- and low-dietary fiber intake levels.

RESULTS

A total of 9644 older adults were included in this study, and the weighted sample was 56,403,031, of whom 3,569,186 (6.3%) were deemed to be frail, and the remainder were deemed to be non-frail. Among the low dietary fiber intake group, higher hemoglobin was significantly associated with a lower risk of frailty (OR = 0.79, 95% CI: 0.71-0.87), and anemia was associated with an almost threefold elevated risk of frailty (OR = 3.24, 95% CI:1.98-5.29) in the fully adjusted model. However, this phenomenon was not observed in groups with high dietary fiber intake. In addition, L-shaped dose response relationship was found in the high dietary fiber intake group (P overall association < 0.001; P non-linear association = 0.076). Whereas the dose response relationship was not significant in the high dietary fiber intake group (P overall association 0.752; P non-linear association = 0.734).

CONCLUSIONS

Frailty was positively associated with the severity of anemia in older adults with low, but not high, dietary fiber intake. Adequate fiber intake may be an innovative dietary strategy to reduce frailty in older adults.

Effect of an action-research nutrition intervention on the Global Diet Quality Score of Colombian adolescents

Strategies to address the nutritional needs of adolescent girls and young women often focus on supplementation. In this study, an action-research approach involving a nutrition education and entrepreneurship intervention was carried out among adolescent girls and young women in poor neighborhoods of Medellín, Colombia. The intervention group significantly increased its intake of several nutrients, including energy, protein, total fat, saturated fat, monounsaturated fat, polyunsaturated fat, cholesterol, dietary fiber, calcium, zinc, and vitamins A, B2, B3, B9, and C. A significant increase was observed in the intake of the Global Diet Quality Score (GDQS) healthy food groups (other fruits, other vegetables, legumes, high-fat dairy products), accompanied by a decrease in the consumption of some unhealthy food groups (sweets and ice creams). A multivariate regression controlling for age, socioeconomic status, occupation, Household Hunger Scale, mean probability of adequacy, physical activity, and body self-perception showed that the nutrition intervention improved the total GDQS by 33% in the intervention group-a substantial improvement notwithstanding the study group's precarious social and economic conditions. We conclude that nutrition education and entrepreneurship models based on this approach may improve the dietary profile of this population and reduce future pressures from nutrition-related chronic diseases.

The Global Diet Quality Score is associated with nutrient adequacy and depression among Vietnamese youths

The Global Diet Quality Score (GDQS) has been recommended as a simple diet quality metric that is reflective of both nutrient adequacy and noncommunicable disease outcomes. It has been validated among women of reproductive age (15-49 years) in diverse settings but not specifically among younger women. This paper examines the relationship between the GDQS and nutrient adequacy, anthropometric outcomes, and depressive symptoms among 1001 Vietnamese young women aged 16-22 years. In energy-adjusted models, the GDQS was significantly (p < 0.05) and positively correlated with intakes of protein (ρ = 0.23), total fat (ρ = 0.06), nine micronutrients (calcium, iron, zinc, vitamin C, riboflavin, niacin, vitamin B6, folate, and vitamin A) (ρ = 0.12-0.35), and the mean probability of adequacy of micronutrients (ρ = 0.28). Compared to young women with optimal GDQS, those with low and very low GDQS were two to five times more likely to have a mean probability of nutrient adequacy less than 50% and showed two to three times higher odds for depression. No association was observed for GDQS and anthropometric outcomes. In conclusion, the GDQS performed well in capturing nutrient adequacy and depressive symptoms among Vietnamese young women. Further research is warranted to explore the relationship between diet quality and depression in other settings.

Validating a semi-quantitative food frequency questionnaire to assess regional diet in a study of cancer in South West Nigeria

PURPOSE

Cancer burden is rising rapidly in Nigeria, the most populous country in sub-Saharan Africa; this trend may in part be attributable to diet. We developed and validated a semi-quantitative food frequency questionnaire (FFQ) to assess regional diet in Nigeria.

METHODS

We recruited 68 adult participants from rural and urban settings in South West Nigeria. We developed an FFQ administered at baseline and assessed its validity using 3 dietary recalls (baseline, 7 days post baseline, 3 months post baseline). We calculated Spearman's rank correlation coefficients and energy-adjusted de-attenuated correlation coefficients for food items and macronutrients. We evaluated cross-classification using quartiles of macronutrient intake.

RESULTS

Energy-adjusted de-attenuated food item correlations between the FFQ and dietary recalls ranged from -0.08 (smoked beef/goat) to 0.73 (fried snacks) for the average intake from the first 2 recalls (2DR) and from -0.05 (smoked beef/goat) to 0.75 (smoked fish) for the average of all 3 recalls (3DR). Macronutrient correlations ranged from 0.15 (fat) to 0.37 (fiber) for the 2DR and from 0.08 (fat) to 0.41 (carbohydrates) for the 3DR. The percent of participants classified in the same quartile ranged from 16.4% (fat) to 32.8% (fiber, protein) for the 2DR and from 25.6% (fat) to 34.9% (carbohydrates) for the 3DR. Agreement improved when including adjacent quartiles, from 65.5% (carbohydrates) to 70.5% (fat, fiber) for the 2DR and from 62.8% (protein) to 76.8% (carbohydrate) for the 3DR.

CONCLUSION

Our semi-quantitative FFQ was reasonably valid for ranking intake of certain foods and macronutrients in adults in South West Nigeria.

Integrated Spreadsheets for Nutritional Analysis of Population Diet Surveys

It can be challenging to calculate nutrient intakes in population diet surveys because existing nutritional analysis software is generally oriented toward analyzing intakes of individuals and may not allow users to input or easily modify the food composition data used in the analysis. These are drawbacks that are more problematic in low- and middle-income country settings. While there are numerous software-assisted dietary assessment platforms that conduct onboard nutritional analysis and are appropriate for use in large surveys, they are often similarly limited, and further restrict users to specific assessment modalities. This paper presents a multifunctional system of integrated spreadsheets for nutritional analysis of population diet surveys (ISNAPDS) that provides a solution for situations in which data have been collected but cannot be adequately analyzed with existing software. The protocol involves supplying the system with fully customizable data on food composition, food group classifications, and food intake (food intake in g/day may be entered directly or calculated based on user-supplied intake frequencies and either standard or variable serving sizes). Following data entry, the user modifies a set of simple pre-populated formulas to match them to the structure of the input data and the system applies these formulas to calculate nutrient and food group intakes, and the contributions of food groups to nutrient intakes for all members of the survey population. The flexibility of the ISNAPDS system allows it to accommodate the global diversity of foods consumed and analyze quantitative, semiquantitative, and nonquantitative food consumption data collected using prospective and retrospective assessment methods employing different reference periods and portion size estimation methods. To date, the system has been applied in published and ongoing analyses of 24 h recall, diet record, food frequency, and disaggregated household consumption data from population surveys in China, Ethiopia, India, Mongolia, Thailand, and a multi-country analysis of 10 sub-Saharan African countries.

Development and Validation of a Novel Food-Based Global Diet Quality Score (GDQS)

BACKGROUND

Poor diet quality is a major driver of both classical malnutrition and noncommunicable disease (NCD) and was responsible for 22% of adult deaths in 2017. Most countries face dual burdens of undernutrition and NCDs, yet no simple global standard metric exists for monitoring diet quality in populations and population subgroups.

OBJECTIVES

We aimed to develop an easy-to-use metric for nutrient adequacy and diet related NCD risk in diverse settings.

METHODS

Using cross-sectional and cohort data from nonpregnant, nonlactating women of reproductive age in 10 African countries as well as China, India, Mexico, and the United States, we undertook secondary analyses to develop novel metrics of diet quality and to evaluate associations between metrics and nutrient intakes and adequacy, anthropometry, biomarkers, type 2 diabetes, and iteratively modified metric design to improve performance and to compare novel metric performance to that of existing metrics.

RESULTS

We developed the Global Diet Quality Score (GDQS), a food-based metric incorporating a more comprehensive list of food groups than most existing diet metrics, and a simple means of scoring consumed amounts. In secondary analyses, the GDQS performed comparably with the Minimum Dietary Diversity - Women indicator in predicting an energy-adjusted aggregate measure of dietary protein, fiber, calcium, iron, zinc, vitamin A, folate, and vitamin B12 adequacy and with anthropometric and biochemical indicators of undernutrition (including underweight, anemia, and serum folate deficiency), and the GDQS also performed comparably or better than the Alternative Healthy Eating Index - 2010 in capturing NCD-related outcomes (including metabolic syndrome, change in weight and waist circumference, and incident type 2 diabetes).

CONCLUSIONS

The simplicity of the GDQS and its ability to capture both nutrient adequacy and diet-related NCD risk render it a promising candidate for global monitoring platforms. Research is warranted to validate methods to operationalize GDQS assessment in population surveys, including a novel application-based 24-h recall system developed as part of this project.

The Global Diet Quality Score is Associated with Higher Nutrient Adequacy, Midupper Arm Circumference, Venous Hemoglobin, and Serum Folate Among Urban and Rural Ethiopian Adults

BACKGROUND

Nutritionally inadequate diets in Ethiopia contribute to a persisting national burden of adult undernutrition, while the prevalence of noncommunicable diseases (NCDs) is rising.

OBJECTIVES

To evaluate performance of a novel Global Diet Quality Score (GDQS) in capturing diet quality outcomes among Ethiopian adults.

METHODS

We scored the GDQS and a suite of comparison metrics in secondary analyses of FFQ and 24-hour recall (24HR) data from a population-based cross-sectional survey of nonpregnant, nonlactating women of reproductive age and men (15-49 years) in Addis Ababa and 5 predominately rural regions. We evaluated Spearman correlations between metrics and energy-adjusted nutrient adequacy, and associations between metrics and anthropometric/biomarker outcomes in covariate-adjusted regression models.

RESULTS

In the FFQ analysis, correlations between the GDQS and an energy-adjusted aggregate measure of dietary protein, fiber, calcium, iron, zinc, vitamin A, folate, and vitamin B12 adequacy were 0.32 in men and 0.26 in women. GDQS scores were inversely associated with folate deficiency in men and women (GDQS Quintile 5 compared with Quintile 1 OR in women, 0.50; 95% CI: 0.31-0.79); inversely associated with underweight (OR, 0.63; 95% CI: 0.44-0.90), low midupper arm circumference (OR, 0.61; 95% CI: 0.45-0.84), and anemia (OR, 0.59; 95% CI: 0.38-0.91) in women; and positively associated with hypertension in men (OR: 1.77, 95% CI: 1.12-2.80). For comparison, the Minimum Dietary Diversity-Women (MDD-W) was associated more positively (P < 0.05) with overall nutrient adequacy in men and women, but also associated with low ferritin in men, overweight/obesity in women, and hypertension in men and women. In the 24HR analysis (restricted to women), the MDD-W was associated more positively (P < 0.05) with nutrient adequacy than the GDQS, but also associated with low ferritin, while the GDQS was associated inversely with anemia.

CONCLUSIONS

The GDQS performed capably in capturing nutrient adequacy-related outcomes in Ethiopian adults. Prospective studies are warranted to assess the GDQS' performance in capturing NCD outcomes in sub-Saharan Africa.