Developing simple measures of women's diet quality in developing countries: overview

Food-based nutrition counselling and education intervention for improved diets of pregnant women in rural Malawi: a qualitative study of factors influencing dietary behaviour change

OBJECTIVE

We wanted to identify factors related to dietary behavioural change among impoverished pregnant women in the face of nutrition education and counselling, describing what creates an enabling environment and barriers for dietary change.

DESIGN

We used qualitative data from a cluster-randomised maternal education trial and conducted a thematic analysis using a social ecological framework to describe the factors that influenced dietary adherence.

SETTING

Mangochi district in rural Malawi.

PARTICIPANTS

We interviewed ten pregnant women and conducted four sets of focus group discussions with twenty-two significant family members (husbands and mothers-in-law) and twelve counsellors.

RESULTS

The participants' experiences showed that the main barriers of adherence to the intervention were taste, affordability and poverty. The use of powders and one-pot dishes, inclusion of both women and significant family members and a harmonisation with local food practices enabled adherence to the intervention. We found it crucial to focus the dietary education and counselling intervention on locally available ingredients and food processing methods.

CONCLUSIONS

Use of contextualised food-based solutions to combat maternal malnutrition was observed to be relatively cheap and sustainable. However, there is need for more research on local foods used as nutrition supplements. We suggest that investments need to be directed not only to nutrition education and counselling but also to the enabling factors that enhance adherence. The original cluster-randomised controlled trial was registered with Clinical trials.gov ID: NCT03136393.

Optimizing Maternal Nutrition: The Importance of a Tailored Approach

Improving nutritional status during pregnancy is a global interest. Frequently, women either fail to meet or exceed nutrient recommendations. Current strategies to improve maternal nutrition focus on a "one-size-fits-all" approach and fail to consider individual factors that affect the mother's overall nutritional status. The objectives of this review were to determine the importance of key nutrients for optimal maternal and fetal health, to explore to what extent current recommendations consider individual factors, and to explore novel strategies to close the gap between current guidelines and real-world challenges through more personalized approaches. This review intercalated different nutritional guidelines and recent scientific publications and research initiatives related to maternal nutrition. Based on that, an overview of current recommendations, challenges related to present approaches, and perspectives for future directions are described. Current guidelines are not optimally supporting adequate nutrient intake and health of expectant mothers and their offspring. Existing recommendations are not consistent and do not sufficiently take into account how interindividual variation leads to differences in nutrient status. Personalized nutrition offers women the opportunity to improve their health by using strategies that are tailored to their unique nutritional needs. Such strategies can include personalized supplementation, holistic lifestyle interventions, digital and application-based technologies, and dietary assessment through blood biomarker and genetic analysis. However, these approaches warrant further investigation and optimization. More personalized approaches have the potential to optimize mothers' and their offspring's health outcomes more appropriately to their nutritional needs before, during, and after pregnancy. Moving away from a generalized "one-size-fits-all" approach can be achieved through a variety of means. Future aims should be to provide supporting evidence to create customized subpopulation-based or individualized recommendations, improve nutrition education, and develop novel approaches to improve adherence to dietary and lifestyle interventions.

Association Between Nutrition Social Behavior Change Communication and Improved Caregiver Health and Nutrition Knowledge and Practices in Rural Tanzania

Background

Efforts to improve infant and young child feeding practices include the use of nutrition behavior change communication among caregivers of children under 5 years. We assessed the association between monthly participation in community-level nutrition group meetings on caregiver health and nutrition knowledge and practices (KPs).

Methods

Data from a community-based cross-sectional survey conducted in the Eastern and Southern Highland Zones of Tanzania were used. Indices were developed for caregivers' knowledge of nutrition, health and childcare, household (HDD) and young child dietary diversity (CDD), and vitamin A (VA) intakes. The comparison of means and proportions was assessed using Student's t-test and the Chi-square test, respectively, between the caregivers participating in nutrition group meetings and non-participants. The impact of the number of nutrition meeting attendance on caregiver KPs scores was examined using multiple regression.

Results

Of 547 caregivers surveyed, 49.7% attended nutrition group meetings and received information on nutrition social behavior change communication (SBCC). Overall, 28% of participating women had a moderate level of nutrition knowledge, 62% had a high level of VA knowledge, and 57% had a high level of health and childcare knowledge. Participation in nutrition group meetings was significantly associated with the health and childcare knowledge score (HKS), HDD and CDD scores, and household and young child VA intake; the magnitude of the associations was greater for caregivers who attended at least four meetings.

Conclusion

The findings emphasize the need for programs that seek to address the issues present in the use of nutrition SBCC at the community level to improve maternal or caregiver KPs and subsequently the nutrition status of infants and young children.

Predictors of Major Dietary Patterns Among Pregnant Women Attending Public Health Facilities in Eastern Ethiopia: A New Epidemiological Approach

Background

Dietary pattern analysis is a robust statistical procedure that efficiently characterize the dietary intakes of individuals. However, there is a lack of robust dietary intake evidence beyond nutrient intake in Ethiopia. This study was to answer, what are the major dietary consumption patterns and its predictors among pregnant women in Ethiopia.

Methods

A facility-based survey among 380 randomly selected pregnant women using a contextualized food frequency questionnaire (FFQ) over 1 month recall was used. The frequency of food consumption was standardized to daily frequency equivalents, and a sequential exploratory factor analysis was used to derive major dietary patterns. A multivariable ordinary logistic regression model was fitted with all its assumptions.

Results

Three major dietary patterns (“fruits and animal-source foods,” “cereals, tubers, and sweet foods,” “legumes and vegetables”), explaining 65% of the total variation were identified. Women snacks (AOR = 1.93; 1.23–2.75), without food aversion (AOR = 1.59; 1.08–2.35), non-fasting (AOR = 0.75; 1.12–2.12), and receiving nutritional counseling (AOR = 1.96; 1.25–3.07) were significantly positively associated with a higher tercile of fruits and animal-source food consumption. Non-working mothers (AOR = 1.8;1.23–2.76), chronic disease (AOR = 1.88; 1.14–3.09), or received nutritional counseling (AOR = 1.33; 0.88–2.01), were fasting (AOR = 1.33;0.88–2.01), and no food cravings (AOR = 4.27;2.67–6.84), and aversion (AOR = 1.60;1.04–2.44) had significantly higher odds of consuming cereals, tubers, and sweet foods. Literacy (AOR = 1.87; 1.14–3.09), urban residence (AOR = 2.10; 1.10–3.93), low socioeconomic class (AOR = 2.68; 1.30–5.23), and skipping meals (AOR = 1.73; 1.15–2.62) were associated with higher odds of legume and vegetable consumption.

Conclusion

Socioeconomic class, literacy, occupation, getting nutritional counseling, habits of food craving, food aversion, and fasting can predict a woman’s dietary pattern.

Strengthening Vegetable Production and Consumption in a Kenyan Informal Settlement: A Feasibility and Preliminary Impact Assessment of a Sack Garden Intervention

Background

Over 85% of Kibera's population, an informal settlement in Nairobi, Kenya, is food insecure. Nutrition-sensitive agriculture interventions, such as sack gardens, have the potential to diversify diets-in turn, improving household food security and diet quality. Furthermore, the sale of extra vegetables may provide an income for program participants.

Objectives

The aim of this paper was to conduct a feasibility assessment and preliminary impact assessment of a nutrition-sensitive urban agriculture intervention that used sack gardens for women in Kibera.

Methods

Women, from a women's empowerment program, in Kibera (n = 36; n = 21 full program participants, n = 11 withdrawn, n = 4 new members) were engaged in a sack garden intervention in June 2018. A mixed-method approach was used to assess the feasibility and preliminary impact of the program. Qualitative semi-structured interviews (n = 25; n = 18 full program participants, n = 5 withdrawn, n = 2 new members), administered at the end of the pilot phase (March 2019), identified barriers and facilitators (e.g., preferences, inputs, group dynamics) to the production, consumption, and sale of self-produced vegetables. Quantitative surveys (n = 21 full program participants), administered in June 2018 and March 2019, were conducted to evaluate preliminary intervention impact on food security and diet quality through analysis of the Household Hunger Scale (HHS) and Minimum Dietary Diversity for Women (MDD-W).

Results

Key barriers included insufficient inputs and group work difficulties, particularly around communication. Facilitators included positive intervention feedback, social bonds and teamwork, participants' self-sufficiency, and preference for sack garden vegetables over market vegetables. Post-intervention, participants reported reduced household food insecurity. Recommendations for program scale-up include investment in additional inputs, a water-collection/irrigation system, additional training, and placing sack gardens closer to women's homes to reduce time constraints.

Conclusions

This study suggests that sack gardens may provide partial solutions to improve diet quality; however, further research is needed to assess any impact on household income.

Can Anganwadi services strengthening improve the association between maternal and child dietary diversity? Evidence from Project Spotlight implemented in tribal dominated Gadchiroli and Chandrapur districts of Maharashtra, India

Dietary intake is a fundamental determinant of maternal and child nutrition. This paper presents evidence on whether maternal and child dietary diversity can be improved with systemic improvements focused on strengthening training, capacity building, and behavior change communication among frontline workers to encourage improved nutritional practices among mothers and children in the intervention area. The evidence is derived from Project Spotlight intervention that was jointly implemented by Department of Women and Child Development, Government of Maharashtra and Tata Trusts in tribal dominated Gadchiroli and Chandrapur districts in Maharashtra. Based on a pre-post comparison of baseline (2019) and endline (2021) household survey data it is confirmed that there is a significant association between maternal and child dietary diversity in the study area. Notably, dietary diversity in mother-child dyads is marked with a higher consumption of fruits and vegetables as well as eggs and flesh foods. Econometric analysis further reveals that the association between maternal and child dietary diversity has improved after the systems strengthening interventions. The paper concludes that local interventions such as Project Spotlight for strengthening counselling services and coverage by frontline workers and enhancing knowledge and awareness on maternal and child dietary diversity among communities are important for improving maternal and child nutrition.

Dietary diversity (DD) and associated factors among Lactating women (LW) in Pawie district, Northwest, Ethiopia, 2019: community-based cross-sectional study

Background

Low Dietary Diversity (DD) result in severe problem among the vulnerable group in low-income countries (LICs), whose diets are predominantly starchy staples. Lactating Women (LW) from LICs are considered a nutritionally vulnerable group. It results in many consequences on the health and well-being of children, households, communities, and the nation. However, there is little empirical evidence on factors contributing to low DD among LW in Ethiopia and the proposed study site. Therefore, this study aimed at assessing the DD and associated factors among LW in Pawie district, Northwest Ethiopia.

Methods

A Community-based cross-sectional study was conducted among 806 LW from March to May 2019 G.C. DD assessed using 24 h dietary recall methods with structured questionnaires.

A mean dietary diversity score (DDS) was computed for ten food groups. Food insecurity measured using a 9-item Household Food Insecurity Access Scale (HFIAS). The multivariable logistic regression model was used to see the relevant associations. The variables which have a significant association with DD were identified based on AOR, P-value ≤ 0.05, and 95% Cl.

Results

A total of 806 LW aged 15–49 years were interviewed with a response rate of 100%. About two-third of LW had low DD (<5 food groups). Fathers occupation being daily laborer [AOR = 1.82, 95% CI (.339, 9.784)], birth interval less than 24 months [AOR = 3.7, 95 % CI (1.743, 7.885)], family size greater than six members [AOR = 1.55, 95 % CI (1.046, 2.313)] and food insecurity [AOR = 2.23, 95 % CI (1.626, 3.066)] were more likely associated with the low DD among LW compared to their counterpart.

Conclusion

The DD among LW was low. Low Dietary Diversity was statistically associated with low birth intervals, large family sizes, and food insecurity. Hence, attention should be paid to the identified factors of low DD of LW to improve their health, and that of their children as well as their family.

Enhancing nutrition knowledge and dietary diversity among rural pregnant women in Malawi: a randomized controlled trial

Background

In many sub-Saharan African countries, such as Malawi, antenatal care (ANC) services do not deliver sufficient nutrition awareness to improve adequate dietary intake in pregnancy. We therefore compared the effects of supplementary nutrition education and dietary counselling with routine ANC service on nutrition knowledge and dietary intakes among Malawian pregnant women.

Methods

We used data from a two-armed cluster randomised controlled trial (RCT) of which the intervention group received supplementary nutrition education, dietary counselling and routine ANC services whereas the controls received only routine ANC services. The RCT was conducted in 10 control and 10 intervention villages in Mangochi, Southern Malawi and included pregnant women between their 9^th and 16^th gestational weeks. We examined the changes in nutrition knowledge and dietary diversity from enrolment (baseline) to study end-point of the RCT (two weeks before expected delivery). We used three linear multilevel regression models with random effects at village level (cluster) to examine the associations between indicators of nutrition knowledge and diet consumption adjusted for selected explanatory variables.

Results

Among 257 pregnant women enrolled to the RCT, 195 (76%) were available for the current study. The supplementary nutrition education and counselling led to significant improvements in nutrition knowledge, dietary diversity and nutrition behaviour in the intervention group compared with controls. Most women from both study groups had a moderate consumption of diversified foods at study end-point. A significant positive association between nutrition knowledge and consumption of a diversified diet was only observed in the intervention group.

Conclusions

Nutrition knowledge and dietary diversity improved in both study groups, but higher in the intervention group. Increased nutrition knowledge was associated with improved dietary diversity only in the intervention women, who also improved their nutrition perceptions and behaviour. Antenatal nutrition education needs strengthening to improve dietary intakes in pregnancy in this low resource-setting.

Trial registration

Clinical trials.gov ID: NCT03136393 (registered on 02/05/2017).

Associations between hurricane exposure, food insecurity, and microfinance; a cross-sectional study in Haiti

Natural disaster and food insecurity are prevalent in Haiti. Natural disasters may cause long-term food insecurity. Microfinance programs may provide resilience against this outcome. The objectives of this study were 1) to assess the association between the impact of Hurricane Matthew and long-term food insecurity and 2) to understand whether this association varies by participants' membership in a microfinance program. In 2017-2018, we interviewed 304 Haitian female microfinance clients. We used log-binomial regression to evaluate the association between hurricane Matthew impact and long-term food insecurity, with evaluation of effect modification by timing of microfinance exposure. We found that one year after the hurricane, participants who were severely impacted by the hurricane were more likely to report poor dietary diversity and moderate to severe household hunger, compared to the less severely impacted participants. Both associations became insignificant among those who received their first microfinance loan before the hurricane. Natural disasters like hurricanes are associated with long-term food insecurity at individual and household levels. Microfinance programs might improve post-hurricane long-term food security.

Dietary diversity and its correlates among pregnant adolescent girls in Ghana

BACKGROUND

Dietary diversity, a qualitative measure of dietary intake, which reflects the variety of foods consumed has been recommended to assuage nutritional problems related to insufficient micronutrients, and food insecurity. To better understand the underlying factors for poor birth outcomes in Ghana, we assessed factors associated with dietary diversity among rural and urban pregnant adolescents in the Ashanti Region of Ghana.

METHODS

As part of a larger longitudinal cohort of 416 pregnant adolescents, the FAO minimum dietary diversity for women index was used to determine the dietary diversity score (DDS) of the participants from a previous days' 24-hour dietary recall data. The household hunger scale (HHS) and lived poverty index (LPI) were used to determine hunger and socioeconomic status. Eating behavior and socio-demographic data were gathered using interviewer-administered questionnaires.

RESULTS

The mean age of the participants was 17.5 (±1.4) years with an MDD-W of 4.4 and 56% recording inadequate MDD score. More rural (63.6%) than urban dwellers (50.6%) had inadequate DDS (p = 0.008). Among all the multiple variables tests of associations on dietary diversity, only hunger status (p = 0.028) and both food aversion and poverty status (p = 0.003) had a significant effect on the adolescents' dietary diversity. Rural dwelling adolescents (AOR = 1.7, p = 0.035, 95% CI = 1.0-2.6) recorded higher odds for inadequate DD compared with the urban respondents. Pregnant adolescents with severe hunger had higher odds (Unadjusted OR = 1.9, p = 0.053, 95% CI 1.1-3.8) for inadequate dietary diversity compared with those with no hunger.

CONCLUSIONS

Inadequate DD is common among pregnant adolescents in this study and is associated with rural living, food insecurity, poverty, and food craving. Livelihood support for pregnant teenagers and nutrition education are recommended interventions to improve dietary quality and limit the consequences of poor dietary diversity.

Assessing statistical similarity in dietary intakes of women of reproductive age in Bangladesh

Women of reproductive age (WRA) need adequate nutrient intakes to sustain a healthy pregnancy, support fetal growth, and breastfeed after childbirth. However, data on women's dietary intake in low‐ and middle‐income countries (LMICs) are limited, and assessment of differences between dietary intakes of pregnant or lactating women compared with that of nonpregnant, nonlactating (NPNL) women is untested. Using single, multiple‐pass 24‐h dietary recall data from a sample of WRA residing in rural Bangladesh, we examined women's dietary intakes for energy, protein, calcium, iron, vitamin A, and dietary diversity for three groups: NPNL (n = 2,903), pregnant (n = 197), and lactating women (n = 944). We used equivalence testing to examine similarity in adjusted intakes for pregnant versus NPNL women and lactating versus NPNL women with a predetermined equivalence threshold based on recommendations specific for each reproductive stage. On average, both pregnant and lactating women had insufficient intakes for all dietary measures. Although statistically significant differences were observed between pregnant and NPNL women for energy intake and dietary diversity and between lactating and NPNL women for energy and protein intake, the magnitudes of these differences were too small to reject equivalence. Statistical similarity was also evident in all micronutrients and dietary diversity for both two‐group comparisons. Understanding statistical differences and similarities between dietary measures of women in distinct reproductive stages has important implications for the relevance, appropriateness, and evaluation of maternal diet‐enhancing interventions in LMICs, especially during pregnancy and lactation, when demand for macronutrients and micronutrients is elevated.

Dietary Diversity and Associated Factors among Children Aged 6-59 Months in Ethiopia: Analysis of Ethiopian Demographic and Health Survey 2016 (EDHS 2016)

Background

Dietary diversity is one of the key elements of diet quality. Even though different measures were taken to increase dietary diversity feeding practice in Ethiopia, the problem still remains high. Therefore, this study was done to identify determinants of inadequate minimum dietary practice among children aged 6-59 months in Ethiopia.

Method

Secondary analysis of the data from the 2016 Ethiopian Demographic and Health Survey was done on a weighted sample of 5161 children aged 6-59 months. Data analysis was done using STATA v.14. Variables with P value < 0.05 in the bivariable analysis were candidates for the multivariable analysis to identify independent determinants of dietary diversity. Odds ratios (OR) were calculated at 95% confidence interval (CI).

Results

A total of 5161 children aged 6 to 59 months were enrolled in the study. Only 8.5% of the children had the recommended minimum dietary diversity. Mother's education (adjusted odds ratio (AOR) = 2.51 (1.65, 3.83)), mothers currently working (adjusted odds ratio (AOR) = 1.83 (1.47, 2.29)), mother's wealth index (adjusted odds ratio (AOR) = 4.75 (3.31, 6.81)), age of a child (adjusted odds ratio (AOR) = 1.72 (1.24, 2.39)), and number of under-five children (adjusted odds ratio (AOR) = 1.49 (1.12, 2.00)) were significantly associated with the minimum dietary diversity.

Conclusion

The minimum dietary diversity was not achieved by most children 6-59 months of age in Ethiopia. Ensuring large-scale interventions that focus on the identified factors should be considered by concerned bodies to improve the dietary diversity practice.

Nutrient Adequacy Is Low among Both Self-Declared Lacto-Vegetarian and Non-Vegetarian Pregnant Women in Uttar Pradesh

Poor dietary intake during pregnancy remains a significant public health concern, affecting the health of the mother and fetus. This study examines the adequacy of energy, macronutrient, and micronutrient intakes among self-declared lacto-vegetarian and non-vegetarian pregnant women. We analyzed dietary data from 627 pregnant women in Uttar Pradesh, India, using a multiple-pass 24 h diet recall. Compared to non-vegetarians, lacto-vegetarians (~46%) were less likely to report excessive carbohydrate (78% vs. 63%) and inadequate fat intakes (70% vs. 52%). In unadjusted analyses, lacto-vegetarians had a slightly higher mean PA for micronutrients (20% vs. 17%), but these differences were no longer significant after controlling for caste, education, and other demographic characteristics. In both groups, the median intake of 9 out of 11 micronutrients was below the Estimated Average Requirement. In conclusion, the energy and micronutrient intakes were inadequate, and the macronutrient intakes were imbalanced, regardless of stated dietary preferences. Since diets are poor across the board, a range of policies and interventions that address the household food environment, nutrition counseling, behavior change, and supplementation are needed in order to achieve adequate nutrient intake for pregnant women in this population.

Minimum Dietary Diversity for Women of Reproductive Age (MDD-W) Data Collection: Validity of the List-Based and Open Recall Methods as Compared to Weighed Food Record

Minimum dietary diversity for women of reproductive age (MDD-W) was validated as a population-level proxy of micronutrient adequacy, with indicator data collection proposed as either list-based or open recall. No study has assessed the validity of these two non-quantitative proxy methods against weighed food records (WFR). We assessed the measurement agreement of list-based and open recall methods as compared to WFR (i.e., reference method of individual quantitative dietary assessment) for achieving MDD-W and an ordinal food group diversity score. Applying a non-inferiority design, data were collected from non-pregnant women of reproductive age in Cambodia (n = 430), Ethiopia (n = 431), and Zambia (n = 476). For the pooled sample (n = 1337), proportions achieving MDD-W from both proxy methods were compared to WFR proportion by McNemar's chi-square tests, Cohen's kappa, and receiver operating characteristic (ROC) analysis. Ordinal food group diversity (0-10) was compared by Wilcoxon matched-pairs signed-rank tests, intraclass correlation coefficients (ICC), and weighted kappa. MDD-W food groups that were most frequently misreported (i.e., type I and II errors) by the proxy methods were determined. Our findings indicate statistically significant differences in proportions achieving MDD-W, ordinal food group diversity scores, and ROC curves between both proxy methods and WFR (p < 0.001). List-based and open recall methods overreported women achieving MDD-W by 16 and 10 percentage points, respectively, as compared to WFR (proportion achieving MDD-W: 30%). ICC values between list-based or open recall and WFR were 0.50 and 0.55, respectively. Simple and weighted kappa values both indicated moderate agreement between list-based or open recall against WFR. Food groups most likely to be misreported using proxy methods were beans and peas, dark green leafy vegetables, vitamin A-rich fruit and vegetables, and other fruits. Our study provides statistical evidence for overreporting of both list-based and open recall methods for assessing prevalence of MDD-W or ordinal food group diversity score in women of reproductive age in low- and middle-income countries. Operationalizing MDD-W through qualitative recall methods should consider potential trade-offs between accuracy and simplicity.

Assessing Dietary Diversity in Pregnant Women: Relative Validity of the List-Based and Open Recall Methods

BACKGROUND

The Minimum Dietary Diversity for Women (MMD-W) was validated as a proxy of micronutrient adequacy for nonpregnant women, with proposed data collection being either a list-based or a qualitative open recall method. Few studies have compared the performance of these 2 methods.

OBJECTIVES

We compared performance in predicting micronutrient adequacy of food group indicators (FGIs) measured by the list-based and the quantitative open recall methods using varying quantity cut-offs. We also examined the agreement between list-based and open recall FGIs.

METHODS

Data were collected in Bangladesh (n = 600 pregnant women) and India (n = 655). The performance of different indicators to predict micronutrient adequacy was compared using receiver operating characteristic (ROC) analysis. Correlations between list-based and open recall FGIs were calculated using Spearman's rank test; agreement was assessed by the intraclass correlation coefficient (ICC) and kappa statistics. Food groups that were most often misreported by the list-based method were identified.

RESULTS

There were no statistically significant differences in ROC curves between list-based and open recall FGIs in either country. In Bangladesh, correlations between list-based and open recall FGIs varied between 0.6 and 0.8; ICC values were 0.43-0.75; kappa values were 0.51-0.53 when using a cut-off of any quantity or 15 g for open recall, but were lower (k = 0.24) with the cut-off of 1 portion. In India, these values were lower: ∼0.4 for correlation, 0.32-0.37 for ICCs, and 0.17-0.22 for kappas. Food groups most susceptible to misreporting using the list-based method were beans/peas in Bangladesh and other vegetables in India.

CONCLUSIONS

Our study provides initial support for the use of list-based questionnaires in assessing food group diversity or prevalence of MDD-W in pregnant women. Additional and context-specific work may be required to understand the potential of simple methodologies to assess consumption of specific food groups. This trial was registered at clinicaltrials.gov as NCT02745249 (Bangladesh) and NCT03378141 (India).

The Relationship Between Dietary Diversity Among Women of Reproductive Age and Agricultural Diversity in Rural Tanzania

BACKGROUND

Agriculture can influence diets through consumption of home-produced foods or increased purchasing power derived from sale of agricultural commodities.

OBJECTIVE

This article explores cross-sectional relationships between agricultural diversification and dietary diversity (a proxy for micronutrient adequacy) among women of reproductive age in rural Tanzania.

METHODS

Dietary diversity was measured using the women's minimum dietary diversity score indicator. Data were analyzed from the baseline survey of a cluster randomized control trial in Rufiji, Tanzania. One woman of reproductive age was randomly surveyed from each eligible household, totaling 1006 individuals. Generalized linear mixed-effects models were used to estimate the relationship between agricultural indicators and dietary diversity.

RESULTS

Median dietary diversity score for women was 3.00 (interquartile range: 2-3). Approximately 73% of households grew at least 1 crop in the previous year. Women's dietary diversity score was positively associated with cropping diversity (P for trend = .04), ownership of livestock (adjusted coefficient: 0.30; 95% confidence interval [CI]: 0.08-0.44; P = .005), cash crop production (adjusted coefficient: 0.22; 95% CI: 0.03-0.41; P = .02), and production of pulses (adjusted coefficient: 0.50; 95% CI: 0.27-0.74; P < .0001) and other vegetables (adjusted coefficient: 0.64; 95% CI: 0.11-1.17; P = .02).

CONCLUSIONS

Average dietary diversity is well below the recommended 5 food groups per day, a widely used indicator of micronutrient adequacy. Since the majority of households participate in agriculture, the efforts to promote agricultural diversification and/or specialization and sale of agricultural goods may positively influence dietary diversity and associated health and nutrition outcomes.

Seasonality in associations between dietary diversity scores and nutrient adequacy ratios among pregnant women in rural Malawi - a cross-sectional study

Background

Dietary diversity scores (DDS) are simple indicators often used as proxies for nutrient adequacy. A 10-food group indicator is proposed by the Food and Agriculture Organization of the United Nations as a global standard for measuring dietary diversity among women in low-resource settings. However, its validity as a proxy for nutrient adequacy across different agricultural seasons for pregnant women has not been determined.

Objective

We studied associations between DDS and nutrient adequacy ratios (NAR) across two different agricultural seasons (pre- and post-harvest seasons) for pregnant women in rural Malawi and assessed whether a 1-day DDS or a 3-day DDS would be the best indicator of nutrient adequacy.

Design

Dietary intakes of 330 pregnant women were assessed between gestational weeks 28 and 35. Intakes of energy, macronutrients, and 11 micronutrients were estimated using three repeated interactive 24-h diet recalls, and DDS were also calculated from these days. Correlation coefficients (r) between DDS, NAR, and mean adequacy ratio (MAR) of the 11 micronutrients were determined.

Results

After energy adjustments, we found significant correlations between DDS and MAR with both DDS indicators in the preharvest season (r = 0.22–0.23; p < 0.001) but not in the post-harvest season (p > 0.05). For individual energy-adjusted NARs, correlations were not consistently significant across the two seasons and the two DDS indicators.

Conclusions

Our results suggest that DDS could be used to predict overall nutrient adequacy during the preharvest season. As similar correlations were found using both the 1- and 3-day indicators, we recommend using a 1-day DDS, for simplicity. However, as the indicators are sensitive to seasonality they should be used with care in this study setting.

Women's Empowerment in Agriculture and Dietary Quality Across the Life Course: Evidence from Bangladesh

Using nationally-representative survey data from rural Bangladesh, we examine the relationship between women's empowerment in agriculture and indicators of individual dietary quality. Our findings suggest that women's empowerment is associated with better dietary quality of individuals within the household, but the strength of this association varies across the life course. Women's empowerment is correlated with more diverse diets of children under five, but empowerment measures are not consistently associated with increases in nutrient intake for this age group. Rather, maternal schooling and household socio-economic status play a more important role for younger children. Women's empowerment is positively and significantly associated with adult men's and women's dietary diversity and nutrient intakes. Empowerment does not benefit all individuals within the household equally, with gender bias emerging in adolescence. Variations in the strength of the association between women's empowerment and different individuals' dietary quality across the life course has implications for the design and targeting of interventions to improve dietary quality, particularly of women, children, and adolescent girls.

Mother's dietary diversity and association with stunting among children <2 years old in a low socio-economic environment: A case-control study in an urban care setting in Dhaka, Bangladesh

Mothers are often responsible for preparing nutritious foods in their households. However, the quality of mother's diets is often neglected, which may affect both mother's and child's nutrition. Because no single food contains all necessary nutrients, diversity in dietary sources is needed to ensure a quality diet. We aimed to study the association between mother's dietary diversity and stunting in children <2 years attending Dhaka Hospital of icddr,b, a diarrhoeal disease hospital in Dhaka, Bangladesh. A case-control study (n = 296) was conducted from November 2016 to February 2017. Data were collected from mothers of stunted children <2 years (length-for-age z score [LAZ] < -2) as "cases" and nonstunted (LAZ ≥ -1) children <2 years as "controls." Mothers were asked to recall consumption of 10 defined food groups 24 hr prior to the interview as per Guidelines for Minimum Dietary Diversity for Women. Among the mothers of cases, 58% consumed <5 food groups during the last 24 hr, compared with 45% in control mothers (P = 0.03). Children whose mothers consumed <5 food groups were 1.7 times more likely to be stunted than children whose mothers consumed ≥5 food groups (P = 0.04). Intake of food groups such as pulses, dairy, eggs, and vitamin A rich fruit was higher in control mothers. Proportion of mother's illiteracy, short stature, monthly family income <BDT 11,480, absence of bank account, and poor sanitation was also found to be higher in stunted group. Further study particularly intervention or longitudinal study to see the causality of mother's dietary diversity with child stunting is recommended.

Dietary Diversity Predicts the Adequacy of Micronutrient Intake in Pregnant Adolescent Girls and Women in Bangladesh, but Use of the 5-Group Cutoff Poorly Identifies Individuals with Inadequate Intake

Background

The Minimum Dietary Diversity for Women (MDD-W) indicator based on a 10-food group women dietary diversity score (WDDS-10) has been validated to assess dietary quality in nonpregnant women. Little is known about its applicability in pregnant women, and specifically pregnant adolescent girls with higher nutrient requirements.

Objectives

This study aimed to 1) compare the adequacy of micronutrient intakes between pregnant adolescent girls and women, 2) examine the performance of WDDS-10 in predicting the mean probability of adequacy (MPA) of 11 micronutrients, and 3) assess how well the MDD-W cutoff of 5 groups performed in pregnant adolescent girls and women.

Methods

We used data from a 2015 household survey in Bangladesh (n = 600). Nutrient intakes were estimated with a multiple-pass 24-h recall and WDDS-10 was assessed through the use of a list-based method. Multiple linear regression models adjusted for geographical clustering assessed the association between WDDS-10 and MPA. Sensitivity and specificity analysis assessed the accuracy of MDD-W in correctly classifying individuals into high (MPA >0.6) or low MPA.

Results

Dietary intakes of pregnant adolescent girls and women were similar in energy intake, WDDS-10 (5.1 ± 1.4), MPA (0.40 ± 0.12), and micronutrient intakes. Probabilities of adequacy were ∼0.30 for riboflavin, vitamin B-12, calcium, and zinc; 0.12-0.15 for folate; 0.16-0.19 for vitamin A; and extremely low for iron at 0.01. The WDDS-10 was significantly associated with MPA in both groups and predicted MPA equally well at population level (SD of residuals 0.11 for both). Use of the 5-food groups cutoff for MDD-W to classify individuals' diets into MPA >0.6, however, resulted in a low correct classification (∼40%). A cutoff of 6 food groups markedly improved correct classification.

Conclusions

The WDDS-10 predicted MPA equally well for pregnant adolescent girls and women at population level. The MDD-W indicator performed poorly in classifying individuals with MPA >0.6.

Food security in the context of HIV: towards harmonized definitions and indicators

Integration of HIV and food security services is imperative to improving the health and well-being of people living with HIV. However, consensus does not exist on definitions and measures of food security to guide service delivery and evaluation in the context of HIV. This paper reviews definitions and indicators of food security used by key agencies; outlines their relevance in the context of HIV; highlights opportunities for harmonized monitoring and evaluation indicators; and discusses promising developments in data collection and management. In addition to the commonly used dimensions of food availability, access, utilization and stability, we identify three components of food security-food sufficiency, dietary quality, and food safety-that are useful for understanding and measuring food security needs of HIV-affected and other vulnerable people. Harmonization across agencies of food security indicators in the context of HIV offers opportunities to improve measurement and tracking, strengthen coordination, and inform evidence-based programming.

Health and nutrition knowledge, attitudes and practices of pregnant women attending and not-attending ANC clinics in Western Kenya: a cross-sectional analysis

Background

Antenatal care (ANC) is a key strategy to decreasing maternal mortality in low-resource settings. ANC clinics provide resources to improve nutrition and health knowledge and promote preventive health practices. We sought to compare the knowledge, attitude and practices (KAP) among women seeking and not-seeking ANC in rural Kenya.

Methods

Data from a community-based cross-sectional survey conducted in Western Province, Kenya were used. Nutrition knowledge (NKS), health knowledge (HKS), attitude score (AS), and dietary diversity score (DDS) were constructed indices. χ² test and Student’s t-test were used to compare proportions and means, respectively, to assess the difference in KAP among pregnant women attending and not-attending ANC clinics. Multiple regression analyses were used to assess the impact of the number of ANC visits (none, <4, ≥4) on knowledge and practice scores, adjusting for maternal socio-demographic confounders, such as age, gestational age, education level and household wealth index.

Results

Among the 979 pregnant women in the survey, 59% had attended ANC clinics while 39% had not. The mean (±SD) NKS was 4.6 (1.9) out of 11, HKS was 6.2 (1.7) out of 12, DDS was 4.9 (1.4) out of 12, and AS was 7.4 (2.2) out of 10. Nutrition knowledge, attitudes, and DDS were not significantly different between ANC clinic attending and non-attending women. Among women who attended ANC clinics, 82.6% received malaria and/or antihelmintic treatment, compared to 29.6% of ANC clinic non-attendees. Higher number of ANC clinic visits and higher maternal education level were significantly positively associated with maternal health knowledge.

Conclusions

Substantial opportunities exist for antenatal KAP improvement among women in Western Kenya, some of which could occur with greater ANC attendance. Further research is needed to understand multi-level factors that may affect maternal knowledge and practices.

Still waiting for Godot? Improving Household Consumption and Expenditures Surveys (HCES) to enable more evidence-based nutrition policies

BACKGROUND

The constrained evidence base of food and nutrition policy-making compromises nutrition programs. Nutrition policy-making must do better than relying exclusively on Food and Agriculture Organization Food Balance Sheets. The strategy of relying on observed-weighed food record or 24-hour recall surveys has not proven practical either; they remain few in number, generally not nationally representative, and of dubious external validity. Although Household Consumption and Expenditures Surveys (HCES) have shortcomings, they are increasingly being used to address this information gap.

OBJECTIVE

To promote dialog within the nutrition community, and between it and the greater community of HCES stakeholders, in order to identify their shared agenda and develop a strategy to improve HCES for analyzing food and nutrition issues.

METHODS

The diverse origins and objectives of HCES are described, the evolution of their use in addressing food and nutrition issues is traced, and their shortcomings are identified.

RESULTS

The causes, relative importance, some potential solutions, and the strategic implications of three distinct categories of shortcomings are discussed. Elements of a possible approach and process for strengthening the surveys are outlined, including identifying best practices, developing guidelines and more rigorously analyzing the tradeoffs involved in common, key survey design and implementation decisions.

CONCLUSIONS

To date, the nutrition community's role in most HCES has been as a passive user of secondary data. The nutrition community must become more involved in the design, implementation, and analysis of HCES by identifying criteria for prioritizing countries, establishing assessment criteria, applying the criteria in retrospective assessments, identifying key shortcomings, and recommending alternatives to ameliorate the shortcomings. Several trends suggest that this is a propitious time for improving the relevance and reliability of HCES.

Dietary intakes of women during pregnancy in low- and middle-income countries

OBJECTIVE

To provide a better understanding of dietary intakes of pregnant women in low- and middle-income countries.

DESIGN

Systematic review was performed to identify relevant studies which reported nutrient intakes or food consumption of pregnant women in developing countries. Macronutrient and micronutrient intakes were compared by region and the FAO/WHO Estimated Average Requirements. Food consumption was summarized by region.

SETTING

Developing countries in Africa, Asia, and the Caribbean and Central/South America.

SUBJECTS

Pregnant women in the second or third trimester of their pregnancies.

RESULTS

From a total of 1499 retrieved articles, sixty-two relevant studies were analysed. The ranges of mean/median intakes of energy, fat, protein and carbohydrate were relatively higher in women residing in the Caribbean and Central/South America than in Africa and Asia. Percentages of energy from carbohydrate and fat varied inversely across studies in all regions, whereas percentage of energy from protein was relatively stable. Among selected micronutrients, folate and Fe intakes were most frequently below the Estimated Average Requirements, followed by Ca and Zn. Usual dietary patterns were heavily cereal based across regions.

CONCLUSIONS

Imbalanced macronutrients, inadequate micronutrient intakes and predominantly plant-based diets were common features of the diet of pregnant women in developing countries. Cohesive public health efforts involving improving access to nutrient-rich local foods, micronutrient supplementation and fortification are needed to improve the nutrition of pregnant women in developing countries.