Dietary Diversity Score Is A Useful Indicator of Micronutrient Intake in Non-Breast-Feeding Filipino Children
Dietary Diversity Score Is A Useful Indicator of Micronutrient Intake in Non-Breast-Feeding Filipino Children
Dietary Diversity Score Is A Useful Indicator of Micronutrient Intake in Non-Breast-Feeding Filipino Children
http://jn.nutrition.org/content/suppl/2007/01/22/137.2.472.DC
1.html
The Journal of Nutrition
Community and International Nutrition
Abstract
Micronutrient malnutrition remains a problem of public health concern in most developing countries, partly due to
monotonous, cereal-based diets that lack diversity. The study objective was to assess whether dietary diversity score
Introduction
recommended levels (2). Moving from a monotonous diet to one
Micronutrient malnutrition remains a serious nutritional con- containing a more diverse range of foods has been shown to
cern in developing countries. In the Philippines, 40% of children increase intake of energy as well as micronutrients in developing
6 mo–5 y of age have low or deficient serum retinol levels and countries (3–7). Intake of a diverse variety of foods has been a
29% of children 1–5 y of age are anemic (1). The prevalence of recommendation for achieving adequate nutrient intake and the
low serum retinol and anemia in Filipino children has increased recommendation appears in the dietary guidelines of many
over the past decade. The increase in low serum retinol has countries. The nutritional guidelines for the Philippines include a
occurred despite Department of Health biannual vitamin A number of recommendations on dietary diversity; 2 recommen-
capsule supplementation program for young children, most dations specify daily intake; 1) eat a variety of foods every day
probably as a result of low coverage and poor compliance with and 2) consume milk, milk products, and other calcium rich
biannual doses. The continuing high prevalence of anemia is foods such as small fish and dark green leafy vegetables every
attributed to low birth weight, low dietary iron intake, and day (8). Other recommendations encourage greater consump-
helminth infections (1). tion of certain food groups but do not specify how often these
Evidence from dietary intake research in the Philippines should be consumed (fish, lean meat, poultry, dried beans,
shows that the diets of a large percentage of young children are vegetables, fruits, and root crops). The precise number of foods
deficient in iron, vitamin A, and calcium. Intakes of vitamin C, or food groups that one should strive to consume over any given
niacin, riboflavin, and thiamin were found to be adequate. period is not commonly mentioned in most dietary guidelines.
Average energy intake of preschool age children was also below Japan advises consumption of 30 different food items per day (9)
and the US advocates consumption of a variety of nutrient-dense
foods and beverages within and among 5 basic food groups, with
1
Supported by the FAO of the United Nations. There are no known conflicts of an item from each food group consumed daily [the 5 USDA food
interest. groups are: cereals, vegetables, fruit, dairy, and protein source
2
Supplemental Tables 1 and 2 are available with the online posting of this paper
at jn.nutrition.org.
foods (meat, fish, poultry, eggs, nuts, beans)] (10).
* To whom correspondence should be addressed. E-mail: s_g_kennedy@yahoo. Despite many national nutritional guidelines recommending
com. consumption of a variety of foods to meet nutritional needs,
472 0022-3166/07 $8.00 ª 2007 American Society for Nutrition.
Manuscript received 6 May 2006. Initial review completed 19 June 2006. Revision accepted 20 November 2006.
including those in the Philippines, the question remains how to corresponding to intakes below 1607 kJ/d (384 kcal/d) and above 6632
operationalize this message for use as an indicator in the public kJ/d (1585 kcal/d) were discarded, leaving a total of 2805 records used in
health setting. The use of dietary diversity as an indicator of the analysis.
adequate nutrient intake remains under evaluation, particularly For the analysis using anthropometric data, only records with
complete information on age, gender, weight, and height were included.
in developing countries. In those settings where the importance
WHO fixed exclusion ranges were used as criteria for cleaning outlying
of dietary diversity to adequate nutrient intake has been anthropometric Z scores (17).
assessed, researchers have used different food group classifica-
tion systems, as well as diverse reference periods, cut-off points, DDS. DDS were calculated for each child using a set of 10 food groups
and age groups (11). There is need for a set of comparable (cereals and tubers; meat, poultry and fish; dairy; eggs; pulses and nuts;
validation studies using the same methodology for creating a vitamin A-rich fruits and vegetables; other fruit; other vegetables; oils
dietary diversity score (DDS)7 to predict adequate micronutrient and fats; and other). The choice of the 10 food groups was based on the
intake. outcome of discussions held during a workshop on validation methods
The purpose of this study is to validate dietary diversity as an for dietary diversity held in Rome, Italy in October 2004. The decision
indicator of micronutrient adequacy in the diet of Filipino was based on previous experience and testing of the usefulness of
children 24–71 mo of age and to quantify the appropriate DDS different food groupings (5) and is reflected in a set of basic guidelines for
validating DDS in non-breast-feeding children 24–83 mo of age (18) and
cut-off point for use as an indicator of inadequate micronutrient
also in validation guidelines for children 0–24 mo of age (19). The food
intake. The results of this study will aid in the development and
group ‘‘other,’’ consisting of sugar, non-juice or dairy beverages, and
promotion of rapid assessment tools for measuring diversity of condiments and spices, was used in descriptive statistics but was not used
the diet and further understanding of the utility of a measure of for tests of correlation, because this group does not contribute sub-
dietary diversity as part of a set of indicators used to monitor stantially to micronutrient intake. The majority of the analysis presented
food and nutrition security. is based on the 9 food groups, excluding the ‘‘other’’ category.
DDS were calculated by summing the number of unique food groups
consumed by the child in the 24-h period. An all inclusive DDS was
%
1 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
2 100.0 89.2 0.6 4.5 1.3 1.3 2.5 0.6 0.0
3 100.0 90.7 26.1 19.5 16.0 19.7 14.7 7.2 6.1
4 100.0 94.5 45.0 36.6 35.6 31.1 21.1 19.8 16.1
5 99.9 97.1 52.6 50.6 52.2 50.2 38.0 33.6 25.7
6 100.0 98.4 64.7 63.7 64.3 64.9 54.2 49.4 40.3
7 100.0 99.7 82.1 72.1 72.4 80.0 70.0 69.3 54.5
8 100.0 100.0 88.4 87.0 86.2 87.0 86.2 87.7 77.5
9 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
child (data not shown). The mean MPA was 0.33. Only children not at risk of nutrient inadequacy (high MPA) and who
1 nutrient, niacin, had an average probability of adequate are correctly classified by high DDS. Using an MPA of 0.50, the
intake above 50%. The next highest intakes were for vitamin best DDS cut-off point (where the sensitivity and specificity
B-6, iron, and vitamin A. Intakes of absorbed calcium, absorbed curves meet) is 5 food groups. Increasing the MPA to 0.75
zinc, and folate had the lowest probability of adequacy. increased the DDS cut-off point to 6 food groups (Fig. 2).
DDS/DDS 10g 0.0451* 0.0022 0.0618* 0.0024 0.0219* 0.0019 0.0333* 0.0021
Male 0.0107 0.0069 0.0102 0.0067 20.0023 0.0056 20.0019 0.0054
Age, mo 20.0026* 0.0005 20.0025* 0.0004 20.0030* 0.0004 20.0029* 0.0004
Weight, kg 0.0104* 0.0032 0.0093* 0.0031 20.0000 0.0026 20.0000 0.0025
Height, m 0.0008 0.0010 0.0007 0.0010 0.0011 0.0008 0.0010 0.0008
Energy, kcal 0.0004* 0.0000 0.0004* 0.0000
Constant 0.0084 0.0585 20.0022 0.0565 20.1195 0.0469 20.1219 0.0460
Adj. R2 0.150 0.205 0.460 0.475
1
*P , 0.05.
The nutrients with the lowest adequacy ratios were iron, In our study, 2 nutrients, calcium and vitamin B-12, were not
calcium, and zinc. In Mali, the mean DDS was 5.8 (based on 8 significantly correlated with DDS. Vitamin B-12 is found only in
food groups), with a mean MAR of 0.77 (4). The nutrients with animal source foods, particularly liver, dairy products, and eggs.
the lowest nutrient adequacy ratio were riboflavin, calcium, The best sources of calcium are dairy products, some legumes,
vitamin A, and vitamin C. green leafy vegetables, and small fish species, particularly if the
The low intake of thiamin and riboflavin in this study was bones are consumed. Dairy, eggs, and legumes were the least