Within-Person Variation in Nutrient Intakes across Populations and Settings: Implications for the Use of External Estimates in Modeling Usual Nutrient Intake Distributions

Trends in Reported Calcium and Magnesium Intake from Diet and Supplements by Demographic Factors: National Health and Nutrition Examination Survey, 2003-2018

BACKGROUND

Calcium and magnesium are important micronutrients necessary for normal body functioning.

OBJECTIVE

The objective of the study was to approximate usual nutrient intakes and estimate proportion of adults meeting the Estimated Average Requirement (EAR) of calcium and magnesium from diet, and diet plus supplements (total intake). Trends in the proportion of adults meeting the EAR were estimated by sex, age, and race and ethnicity.

DESIGN

The study utilized data from the National Health and Nutrition Examination Survey, a cross-sectional survey of a nationally representative sample of the US civilian and noninstitutionalized population.

PARTICIPANTS AND SETTING

The continuous National Health and Nutrition Examination Survey survey data from 2003-2004 through 2017-2018 for dietary intake, and 2007-2008 through 2017-2018 for total intake were analyzed. The study sample included men and women (not lactating/pregnant) ages 19 years and older with 2 reliable 24-hour dietary recalls and energy intake >500 to <6,000 kcal/day (N = 35 037).

MAIN OUTCOME MEASURES

Mean daily intake and trends of proportion of adults meeting/exceeding the EAR for calcium and magnesium were estimated.

STATISTICAL ANALYSES PERFORMED

The National Cancer Institute's method was used to calculate daily intakes for calcium and magnesium by demographic subgroups. SAS SURVEYMEAN and SURVEYFREQ procedures were used to estimate means ± SE for continuous variables and frequencies and percentages for categorical variables, and 2-sample t test for P values. Trends were estimated with National Cancer Institute's Joinpoint trend analysis program.

RESULTS

Mean daily dietary calcium intake and proportions of adults meeting the EAR from both diet and supplements was lowest among women (859 mg [61.9%]), adults ages 71 years and older (865 mg [60.3%]) and non-Hispanic Black individuals (782 mg [48.6%]) compared with men, younger age groups, and other races and ethnicities. Magnesium intake reported from diet was lowest in adults ages 71 years and older (276 mg), whereas total magnesium intake and proportion of meeting the EAR from both diet and supplements was lowest in women (302 mg) and men (52%), respectively, adults ages 19 to 30 years (305 mg [48.5%]), and non-Hispanic Black individuals (274 mg [35.5%]). The trends in the proportion of women and non-Hispanic White adults meeting the EAR from total calcium intake decreased significantly (P < .05) by 2.9% and 2.0%, respectively.

CONCLUSIONS

Women and adults ages 71 years and older had the lowest reported mean daily dietary calcium intake and proportion meeting the EAR for calcium from diet and supplements. Men and adults ages 19 to 30 years had the lowest proportion meeting the EAR for magnesium from diet and supplements with adults ages 19 to 30 years also having the lowest reported total magnesium intake from diet and supplements. Non-Hispanic Black individuals had the lowest proportion of meeting the EARs for calcium and magnesium from reported total intake. The trends in the proportion of women and non-Hispanic White individuals meeting the EARs for calcium through total intake decreased over time and remained stable in other subpopulations and for magnesium.

Consumption of Milk Beverages Reduces Iron, Vitamin A, Vitamin C, Calcium, and B Vitamins Inadequacies in Pakistani School-Aged Children from Sindh and Punjab: A Diet Modeling Study

Background

Only 47% of households in Pakistan's Sindh and Punjab provinces are food secure. More than 80% of 5-9 y old children are below recommended intakes of calcium, iron, zinc, and vitamin A and vitamin D. Although 89% consume dairy products daily, only 3% comply with Pakistan's recommended dairy consumption of 2-3 servings/d.

Objectives

The objectives of this study were to evaluate the theoretical impact of substituting or adding fortified milk and/or buffalo milk in the diets of Pakistani school-aged children to address nutrient inadequacy.

Methods

Dairy consumption and nutrient intakes were calculated using dietary data collected from 5842 children via a 24-h diet recall in the School-age Children Health and Nutrition Survey conducted in Sindh and Punjab provinces of Pakistan between 2019 and 2020. Given daily intakes documented in the School-age Children Health and Nutrition Survey, 2 modeling scenarios were applied to test the impact on nutrient intakes of 1) substituting current milk (buffalo, cow, and goat) consumption (volume by volume) with a fortified milk beverage and 2) adding a fortified milk beverage or buffalo milk to current consumption to meet dairy consumption recommendations.

Results

The hypothetical substitution of current milk consumption with fortified milk lowered nutrient inadequacies for vitamin C (by 86%), vitamin A (by 45%), thiamin (by 26%), riboflavin (by 14%), vitamin B6 (by 13%), calcium (by 8%), and iron (by 7%), compared to baseline (relative percent reduction). Among children consuming <2 dairy servings/d, theoretically adding buffalo milk had a positive contribution to calcium, phosphorous, zinc, vitamin A, vitamin C, riboflavin, niacin, and folate; theoretically adding fortified milk additionally reduced inadequacies of iron, thiamin, vitamin B6, and greatly reduced vitamin C inadequacy.

Conclusions

Buffalo milk and fortified milk each have their own value in closing nutrient gaps. Increasing their consumption can be integrated into a multi-pronged public health strategy (including fortified foods, ensuring food security, and diet diversity) to tackle nutrient inadequacies in children.

Modeling the Contribution of Multiple Micronutrient Fortification of Salt to Daily Nutrient Intake Among the Ethiopian Population

Background

Salt is an affordable commodity and has wide coverage regardless of economic and social status and, hence, could be suitable vehicle for multiple micronutrient fortification.

Objectives

This study aimed to simulate the contribution folic acid and zinc fortification of iodized salt to nutrient intake among the Ethiopian population.

Methods

The 2013 Ethiopian National Food Consumption Survey and various food composition tables were used to estimate baseline individual-level micronutrient intake. Usual intake was estimated using the Simulating Intake of Micronutrients for Policy Learning and Engagement macro tool. Discretionary salt consumption was calculated from total salt intake estimated using urinary sodium excretion. Fortificant addition rates were set to obtain maximum nutrient intake while simultaneously constraining that population with intake above the tolerable upper intake level to <5%. Addis Ababa and Somali (N = 2271), the regions with relatively the lowest and highest micronutrient deficiency prevalence in Ethiopia, were selected.

Result

Baseline median intake of Zn was below the estimated average requirement for all demographic groups. Inadequate Zn intake ranged from 73% to 99%, the highest prevalence being observed among women in lower class of wealth quintiles from Somali region. Dietary folate inadequacy was as low as 2% among men in Addis Ababa but almost all (99%) women from Somali region had inadequate folate intake. Calculated discretionary salt intake was 7.5 g/d for adult men and women and 3.4 g/d for children. With addition 0.8 mg Zn and 30 μg of folic acid per gram of salt, multiple salt fortification is estimated to reduce Zn inadequacy by 38 percentage points in urban areas and19 percentage points in rural areas. Modeled reduction in folate inadequacy were 18% in urban areas and 22% in rural areas.

Conclusions

Multiple salt fortification could be an effective approach to address micronutrient adequacy in Ethiopia given efficacious, technological, and economical feasibility.

Defining a Dichotomous Indicator for Population-Level Assessment of Dietary Diversity Among Pregnant Adolescent Girls and Women: A Secondary Analysis of Quantitative 24-h Recalls from Rural Settings in Bangladesh, Burkina Faso, India, and Nepal

Background

The Minimum Dietary Diversity for Women of Reproductive Age (MDD-W) indicator was validated as a proxy of micronutrient adequacy among nonpregnant women in low- and middle-income countries (LMICs). At that time, indeed, there was insufficient data to validate the indicator among pregnant women, who face higher micronutrient requirements.

Objective

This study aimed to validate a minimum food group consumption threshold, out of the 10 food groups used to construct MDD-W, to be used as a population-level indicator of higher micronutrient adequacy among pregnant women aged 15-49 y in LMICs.

Methods

We used secondary quantitative 24-h recall data from 6 surveys in 4 LMICs (Bangladesh, Burkina Faso, India, and Nepal, total n = 4909). We computed the 10-food group Women's Dietary Diversity Score (WDDS-10) and calculated the mean probability of adequacy (MPA) of 11 micronutrients. Linear regression models were fitted to assess the associations between WDDS-10 and MPA. Sensitivity, specificity, and proportion of individuals correctly classified were used to assess the performance of MDD-W in predicting an MPA of >0.60.

Results

In the pooled sample, median values (interquartile range) of WDDS-10 and MPA were 3 (1) and 0.20 (0.34), respectively, whereas the proportion of pregnant women with an MPA of >0.60 was 9.6%. The WDDS-10 was significantly positively associated with MPA in each survey. Although the acceptable food group consumption threshold varied between 4 and 6 food groups across surveys, the threshold of 5 showed the highest performance in the pooled sample with good sensitivity (62%), very good specificity (81%), and percentage of correctly classified individuals (79%).

Conclusions

The WDDS-10 is a good predictor of dietary micronutrient adequacy among pregnant women aged 15-49 y in LMICs. Moreover, the threshold of 5 or more food groups for the MDD-W indicator may be extended to all women of reproductive age, regardless of their physiologic status.

Comparison of Published Estimates of the National Prevalence of Iron, Vitamin A, and Zinc Deficiency and Sources of Inconsistencies

Micronutrient deficiencies result in a broad range of adverse health and functional consequences, but the true prevalence of specific deficiencies remains uncertain because limited information is available from nationally representative surveys using recommended biomarkers. The present review compares various reported national deficiency prevalence estimates for nutrients and years where the estimates overlap for individual countries that conducted nationally representative surveys and explores possible reasons for any discrepancies discovered. Nationally representative micronutrient status surveys that were conducted since 2000 among preschool-aged children or women of reproductive age and included assessment of iron, vitamin A, or zinc status based on recognized biomarkers were considered eligible for inclusion, along with any modeled deficiency prevalence estimates for these same countries and years. There was considerable variation across different published prevalence estimates, with larger inconsistencies when the prevalence estimate was based on proxies, such as hemoglobin for iron deficiency and dietary zinc availability for zinc deficiency. Numerous additional methodological issues affected the prevalence estimates, such as which biomarker and what cutoff was used to define deficiency, whether the biomarker was adjusted for inflammation, and what adjustment method was used. For some country-years, the various approaches resulted in fairly consistent prevalence estimates. For other country-years, however, the results differed markedly and changed the conclusions regarding the existence and severity of the micronutrient deficiency as a public health concern. In conclusion, to determine micronutrient status, we consider the assessment of one of the recommended biomarkers in a population representative survey as the best available information. If indicated, results should be adjusted for inflammation and generally acceptable cutoffs should be applied to facilitate comparisons, although individual countries may also apply nationally defined cutoffs to determine when and where to intervene. Global consensus is needed on best practices for presenting survey results and defining the prevalence of deficiency.

Assessing Repeated Urinary Proline Betaine Measures as a Biomarker of Usual Citrus Intake during Pregnancy: Sources of Within-Person Variation and Correlation with Reported Intake

Proline betaine (Pro-B) has been identified as a biomarker of dietary citrus intake, yet gaps remain in its validation as a quantitative predictor of intake during various physiological states. This study quantified sources of within-individual variation (WIV) in urinary Pro-B concentration during pregnancy and assessed its correlation with the reported usual intake of citrus fruit and juice. Pro-B concentrations were determined by 1H-NMR spectroscopy in spot and 24-h urine specimens (n = 255) collected throughout pregnancy from women participating in the MARBLES cohort study. Adjusted linear or log mixed effects models quantified WIV and tested potential temporal predictors of continuous or elevated Pro-B concentration. Pearson or Spearman correlations assessed the relationship between averaged repeated biomarker measures and usual citrus intake reported by food frequency questionnaires. The proportion of variance in urinary Pro-B attributable to WIV ranged from 0.69 to 0.74 in unadjusted and adjusted models. Citrus season was a significant predictor of Pro-B in most analyses (e.g., adjusted β [95% CI]: 0.52 [0.16, 0.88] for non-normalized Pro-B), while gestational age predicted only non-normalized Pro-B (adjusted β [95% CI]: -0.093 [-0.18, -0.0038]). Moderate correlations (rs of 0.40 to 0.42) were found between reported usual citrus intake and averaged repeated biomarker measurements, which were stronger compared to using a single measurement. Given the high degree of WIV observed in urinary Pro-B, multiple samples per participant are likely needed to assess associations between citrus consumption and health outcomes.

Estimating national and subnational nutrient intake distributions of global diets

BACKGROUND

Access to high-quality dietary intake data is central to many nutrition, epidemiology, economic, environmental, and policy applications. When data on individual nutrient intakes are available, they have not been consistently disaggregated by sex and age groups, and their parameters and full distributions are often not publicly available.

OBJECTIVES

We sought to derive usual intake distributions for as many nutrients and population subgroups as possible, use these distributions to estimate nutrient intake inadequacy, compare these distributions and evaluate the implications of their shapes on the estimation of inadequacy, and make these distributions publicly available.

METHODS

We compiled dietary data sets from 31 geographically diverse countries, modeled usual intake distributions for 32 micronutrients and 21 macronutrients, and disaggregated these distributions by sex and age groups. We compared the variability and skewness of the distributions and evaluated their similarity across countries, sex, and age groups. We estimated intake inadequacy for 16 nutrients based on a harmonized set of nutrient requirements and bioavailability estimates. Last, we created an R package-nutriR-to make these distributions freely available for users to apply in their own analyses.

RESULTS

Usual intake distributions were rarely symmetric and differed widely in variability and skewness across nutrients and countries. Vitamin intake distributions were more variable and skewed and exhibited less similarity among countries than other nutrients. Inadequate intakes were high and geographically concentrated, as well as generally higher for females than males. We found that the shape of usual intake distributions strongly affects estimates of the prevalence of inadequate intakes.

CONCLUSIONS

The shape of nutrient intake distributions differs based on nutrient and subgroup and strongly influences estimates of nutrient intake inadequacy. This research represents an important contribution to the availability and application of dietary intake data for diverse subpopulations around the world.

Assessment of zinc inadequacy among tribal adolescent population of central India - A cross-sectional study

Background & objectives

Zinc is a crucial micronutrient in adolescence, required for promoting growth and sexual maturation. Adolescents of some tribes may be at high risk of zinc deficiency due to dietary inadequacy and poor bioavailability of zinc from plant-based diets. This study aimed to evaluate the risk of zinc deficiency by estimating prevalence of inadequate zinc intake, prevalence of low serum zinc and stunting among tribal adolescents.

Methods

A cross-sectional community-based survey was conducted among adolescents (10-19 yr) in three purposively selected districts where Bhil, Korku and Gond tribes were in majority. Structured data collection instrument comprising information about sociodemographic characteristics and dietary recall data was used. Anthropometric assessment was conducted by standardized weighing scales and anthropometry tapes, and blood sample was collected from antecubital vein into trace element-free vacutainers. Serum zinc was estimated using an atomic absorption spectrophotometer.

Results

A total of 2310 households were approached for participation in the study, of which 2224 households having 5151 adolescents participated. Out of these enlisted adolescents, 4673 responded to dietary recall (90.7% response rate). Anthropometry of 2437 participants was carried out, and serum zinc was analyzed in 844 adolescents. The overall prevalence of dietary zinc inadequacy was 42.6 per cent [95% confidence interval (CI) 41.2 to 44.1] with reference to the estimated average requirement suggested by International Zinc Nutrition Consultative Group (IZiNCG) and 64.8 per cent (95% CI 63.4 to 66.2) with Indian Council of Medical Research-recommended requirements. Stunting was observed in 29 per cent (95% CI 27.2 to 30.8) participants. According to IZiNCG cut-offs, low serum zinc was detected in 57.5 per cent (95% CI 54.1 to 60.8) of adolescents, whereas it was 34.4 per cent (95% CI: 31.2-37.5) according to the national level cut-off.

Interpretation & conclusions

Risk of dietary zinc inadequacy and low serum zinc concentration amongst adolescents of the Gond, Bhil and Korku tribes is a public health concern.

A Preliminary Study on a Form of the 24-h Recall That Balances Survey Cost and Accuracy, Based on the NCI Method

The 24-h recall (24HR) is a short-term dietary assessment instrument that is widely used in large-scale nutrition surveys. The number of survey days is critical in the accuracy of estimates. The multiple, repeated collection of 24HRs can yield reliable dietary intakes, whereas that is not always feasible due to staffing, equipment, financial, and temporal constraints. The NCI (National Cancer Institute) method was developed to address this limitation by using only within-person variance to calculate usual dietary intake. However, the performance of different forms of 24HRs based on the NCI method remains unclear. The aim of this study was to explore a form of 24HR based on the NCI method that can balance accuracy and survey cost. A total of 595 subjects completed 7 consecutive 24HRs in each season, for a total of 28 24HRs. The averages of the 28 collection days were defined as the reference value to compare the performance of 24HRs for two consecutive days (C2), three consecutive days (C3), two non-consecutive days (NC2), and three non-consecutive days (NC3) for estimating the dietary intakes of Chinese adults. The equivalence test was used to evaluate whether the estimates of scenarios NC2 and NC3 were equivalent. Additionally, the accuracy of a scenario of NC2 which included a weekend was compared to that of a scenario of NC2 which included two weekdays. All results of the 24HRs in each scenario were corrected by the NCI method. Bias/relative bias and mean bias/mean relative bias were used as measures of precision and accuracy, respectively. The results showed that the precision was similar among the four scenarios, while the accuracy relationship varied among the different dietary components. In general, scenario NC3 was the most accurate, followed by scenario NC2, which was close to the former. The form using non-consecutive days was more accurate than that using consecutive days, and the main factor affecting the accuracy of the 24HRs was the continuity between multiple survey days rather than the number of days. The means and major percentiles of energy, nutrients, and frequently consumed food in scenarios NC2 and NC3 were functionally identical. The accuracy of the scenario of NC2 which included a weekend was higher than that of scenario NC2, which consisted of only weekdays. The above results indicated that the adoption of two, non-consecutive 24HRs consisting of a weekend and a weekday to collect dietary data prior to correction by the NCI method, is a feasible approach to balancing survey costs and accuracy in large-scale nutrition surveys.

Prepregnancy adherence to plant-based diet indices and exploratory dietary patterns in relation to fecundability

BACKGROUND

Modest associations have been reported between specific food groups or nutrients and fecundability [measured by time to pregnancy (TTP)]. Examining overall diets provides a more holistic approach towards understanding their associations with fecundability. It is not known whether plant-based diets indices or exploratory dietary patterns are associated with fecundability.

OBJECTIVES

We examine the associations between adherence to 1) plant-based diet indices; and 2) exploratory dietary patterns and fecundability among women planning pregnancy.

METHODS

Data were analyzed from the Singapore Preconception Study of Long-Term Maternal and Child Outcomes (S-PRESTO) study. Prepregnancy diet was assessed using a semi-quantitative FFQ from which the overall, healthful, and unhealthful plant-based diet indices (oPDI, hPDI, and uPDI, respectively) were calculated. Exploratory dietary patterns were derived using factor analysis based on 44 predefined food groups. Participants were categorized into quintiles based on their dietary pattern scores. TTP (expressed in menstrual cycles) was ascertained within a year from the prepregnancy dietary assessment. Discrete-time proportional hazard models, adjusted for confounders, were used to estimate fecundability ratios (FRs) and 95% CIs, with FR > 1 indicating a shorter TTP.

RESULTS

Among 805 women, 383 pregnancies were confirmed by ultrasound scans. Compared with women in the lowest quintile, those in the highest quintile of the uPDI had reduced fecundability (FR of Q5 compared with Q1, 0.65; 95% CI, 0.46-0.91; P trend, 0.009). Conversely, greater adherence to the hPDI was associated with increased fecundability (1.46; 95% CI, 1.02-2.07; P trend, 0.036). The oPDI was not associated with fecundability. Among the 3 exploratory dietary patterns, only greater adherence to the Fast Food and Sweetened Beverages (FFSB) pattern was associated with reduced fecundability (0.61; 95% CI, 0.40-0.91; P trend, 0.018).

CONCLUSIONS

Greater adherence to the uPDI or the FFSB dietary pattern was associated with reduced fecundability among Asian women. Greater adherence to the hPDI may be beneficial for fecundability, though this requires confirmation by future studies.

Fortified Balanced Energy-Protein Supplements Increase Nutrient Adequacy without Displacing Food Intake in Pregnant Women in Rural Burkina Faso

BACKGROUND

In many low- and middle-income countries, the prevalence of energy and nutrient deficiencies is high among pregnant women. Balanced energy-protein (BEP) supplements are a promising strategy to cover nutritional requirements during pregnancy and improve birth outcomes. However, the displacement of nutrient-dense foods by BEP might attenuate the efficacy of supplementation.

OBJECTIVE

This cross-sectional study of participants in a randomized controlled trial evaluated the difference in energy and macro- and micronutrient intakes, food groups, and nutrient adequacy between a control and intervention group receiving either a daily iron-folic acid (IFA) tablet or IFA and BEP supplement during pregnancy, respectively.

METHODS

We collected a single multiple-pass 24-h recall from 470 pregnant women from the MIcronutriments pour la SAnté de la Mère et de l'Enfant (MISAME) III study that investigates the efficacy of BEP supplementation on birth outcomes and infant growth. Dietary intake (median and IQR) and nutrient adequacy were assessed using individual recipes and preparation methods of mixed dishes for each participant. Linear regression models were fitted to compare energy and nutrient intakes.

RESULTS

Dietary energy, and macro- and micronutrient intakes were significantly higher among women in the intervention group when including BEP [2329 kcal/d (1855, 3008 kcal/d) compared with 1942 kcal/d (1575, 2405 kcal/d) in the control group (all P < 0.001)]. The difference in median energy intake (448 kcal/d; 95% CI: 291, 605 kcal/d) was approximately equivalent to a daily dose of the BEP supplement (393 kcal). Nutrient adequacy ratios for both groups were low for all micronutrients (between 0.02 and 0.66), when excluding BEP (except iron and folic acid, due to standard supplemental doses) from analysis. However, nutrient intakes increased to the Estimated Average Requirement for pregnant women when including BEP supplements.

CONCLUSIONS

BEP supplementation increases energy and macro- and micronutrient intakes among pregnant women and fills nutrient gaps without displacing food intake. This trial was registered at clinicaltrials.gov as NCT03533712 (https://clinicaltrials.gov/ct2/show/NCT03533712).

Challenges for Estimating the Global Prevalence of Micronutrient Deficiencies and Related Disease Burden: A Case Study of the Global Burden of Disease Study

Information on the prevalence of micronutrient deficiencies is needed to determine related disease burden; underpin evidence-based advocacy; and design, deliver, and monitor safe, effective interventions. Assessing the global prevalence of deficiency requires a valid micronutrient status biomarker with an appropriate cutoff to define deficiency and relevant data from representative surveys across multiple locations and years. The Global Burden of Disease Study includes prevalence estimates for iodine, iron, zinc, and vitamin A deficiencies, for which recommended biomarkers and appropriate deficiency cutoffs exist. Because representative survey data are lacking, only retinol concentration is used to model vitamin A deficiency, and proxy indicators are used for the other micronutrients (goiter for iodine, hemoglobin for iron, and dietary food adequacy for zinc). Because of data limitations, complex statistical modeling is required to produce current estimates, relying on assumptions and proxies that likely understate the extent of micronutrient deficiencies and the consequent global health burden.

Introduction to the SIMPLE Macro, a Tool to Increase the Accessibility of 24-Hour Dietary Recall Analysis and Modeling

BACKGROUND

Information on long-term dietary intake is often required for research or program planning, but surveys routinely use short-term assessments such as 24-h recalls (24HRs). Methods to reduce the impact of within-person variation in 24HRs, such as the National Cancer Institute (NCI) method, typically require extensive training and skill.

OBJECTIVES

We introduce the Simulating Intake of Micronutrients for Policy Learning and Engagement (SIMPLE) macro, a new tool to increase the accessibility of 24HR analysis. We explain the underlying theory behind the tool and provide examples of potential applications.

METHODS

The SIMPLE macro connects the core NCI statistical code to estimate usual intake distributions and includes additional code to enable advanced analyses such as predictive modeling. The related SIMPLE-Iron macro applies the full probability method to estimate inadequate iron intake, and the SIMPLE-1D macro is used for descriptive or modeling analyses of data with a single 24HR per person. The macros and associated documentations are freely available. We analyzed data from the US National Health and Nutrition Examination Survey (NHANES) and the Cameroon National Micronutrient Survey to compare the SIMPLE macro to 1) the core NCI code using the Estimated Average Requirement cut point method, and 2) the IMAPP software for iron only, and to demonstrate the applications of the SIMPLE macro for estimating usual intake and predictive modeling.

RESULTS

The SIMPLE macro generates identical results to the core NCI code. The SIMPLE-Iron macro also produces estimates of inadequate iron intake comparable to the IMAPP software. The examples demonstrate application of the SIMPLE macro to 1) descriptive analyses of nutrient intake from food and supplements (NHANES), and 2) analyses accounting for breast-milk nutrient intake and modeling fortification and supplementation programs (Cameroon).

CONCLUSIONS

The SIMPLE macros may facilitate the analysis and modeling of dietary data to inform nutrition research, programs, and policy.