Development of a Dichotomous Indicator for Population-Level Assessment of Dietary Diversity in Women of Reproductive Age

Abstract

Background: Dietary diversity is a key element of diet quality, but diets of women of reproductive age (WRA; aged 15–49 y) in resource-poor settings are often deficient in a range of micronutrients. Previous work showed associations between simple food-group diversity indicators (FGIs) and micronutrient adequacy among WRA. For operational and advocacy purposes, however, there is strong demand for a dichotomous indicator reflecting an acceptable level of dietary diversity. Objective: The aim of the study was to develop a dichotomous indicator of dietary diversity in WRA. Methods: We performed a secondary analysis of 9 data sets containing quantitative dietary data from WRA in resource-poor settings (total n = 4166). From the raw dietary data, we calculated an individual “mean probability of adequacy” (MPA) across 11 micronutrients. Several candidate FGIs were constructed. Indicator performance in predicting an MPA >0.60 was assessed within each data set by using receiver-operating characteristic analysis and sensitivity and specificity analysis at various FGI cutoffs. The analysis was performed separately for nonpregnant and nonlactating (NPNL) women and for lactating women. Results: We identified 2 “best candidate” dichotomous indicators on the basis of 9- or 10-point food-group scores (FGI-9 and FGI-10) with a cutoff of ≥5 food groups. Both were significantly correlated to MPA in each site (P < 0.001). Areas under the curve were moderate, ranging from 0.62 to 0.82 among NPNL women and from 0.56 to 0.90 among lactating women. Comparisons of results slightly favored FGI-10 for all women. Conclusions: When resource-intensive dietary methods are not feasible, a simple dichotomous indicator based on a cutoff of ≥5 of 10 defined food groups reflects “minimum dietary diversity for women of reproductive age.” According to the conclusions of a consensus meeting of experts, this indicator is well suited for population-level assessment, advocacy, and possibly also for tracking of change in dietary diversity across time.

Changes in women's dietary diversity before and during pregnancy in Southern Benin

“…Food items consumed were classified into 10 food groups according to recommended classifications (Food and Agriculture Organization [FAO] & Family Health International 360, ): (a) grains, white roots and tubers, and plantains (also known as starchy staples); (b) pulses (beans, peas, and lentils); (c) nuts and seeds; (d) dairy; (e) meat, poultry, and fish; (f) eggs; (g) dark green leafy vegetables; (h) other Vitamin A‐rich fruits and vegetables; (i) other fruits; and (j) other vegetables. The number of food groups consumed was summed up and dichotomised using a cut‐off at five food groups to compute the minimum dietary diversity for women (MDD‐W) indicator, which has been recently developed and validated as a proxy of micronutrient adequacy (FAO & Family Health International 360, ; Martin‐Prevel et al, ). We also used the number of food groups consumed as a continuous variable, namely the women's dietary diversity score (WDDS‐10), which ranged from 0 to 10 food groups.…”

“…For example, a randomised trial in Bangladesh showed that early multimicronutrient supplementation in pregnancy reduces the occurrence of stunting in boys during months 0-54, but not in girls (Khan et al, 2011). However, little attention has been paid to women's overall diet quality during preconception and gestation, particularly concerning dietary diversity, which has been shown to be associated with greater probability of micronutrient adequacy (Martin-Prevel et al, 2017). Poor dietary diversity during pregnancy has been documented in many contexts, particularly in low and middle-income countries (Lee, Talegawkar, Merialdi, & Caulfield, 2013).…”

Vitamin B12 is Low in Milk of Early Postpartum Women in Urban Tanzania, and was not Significantly Increased by High dose Supplementation

“…Vitamin B12 intake was energy-adjusted [12]. The minimum dietary diversity for women (MDD-W) score was calculated using 24-h recalls and later on categorized into those with score less than 5 and those with 5 or more groups [13]. The MDD-W is a population-level assessment indicator of the proportion of women (15-49 years) who consume a diet containing 5 or more food groups, which can be used as a proxy indicator of higher micronutrient adequacy [13].…”

“…The mean minimum dietary diversity for women (MDD-W) score during pregnancy was 2.86 (SD = 2.66). Only 6 (1.3%) of the women assessed had a mean score of MDD-W of at least 5 food groups, which is the FAO definition of minimum dietary diversity [13]. The median vitamin B12 intake was above the recommended dietary allowance (RDA) of 2.8 µg/d for lactating women in the multivitamin and placebo groups [15].…”

Why Food System Transformation Is Essential and How Nutrition Scientists Can Contribute

“…Widely agreed upon as an indicator for assessing diet diversity – a vital element of diet quality – the MDD-W is a dichotomous indicator that classifies women as having a high- or low-diet diversity based on the number of food groups consumed over 24 h [36]. Though unanimously endorsed by academia, international research institutes, the UN and donor agencies during its introduction in 2014 [37], the MDD-W remains underutilized in both government-led and independent assessments of nutrition and health [38]. Rigorous nutrition studies that use the MDD-W as a primary indicator or in tandem with biomarkers and other nutrition indicators are urgently needed to raise this metric’s visibility and application.…”