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

A review of the dietary diversity and micronutrient adequacy among the women of reproductive age in low- and middle-income countries

The dietary quality of women of reproductive age (WRA) is particularly important during preconception, conception, and pregnancy for themselves and their offspring. Poorly diversified diets resulting in inadequate micronutrient consumption may have adverse effects on their health. This narrative review summarizes the findings of studies reporting on dietary diversity and micronutrient intake by WRA in low- and middle-income countries (LMICs). Studies on WRA aged 15-49 years in LMICs, with a sample size of more than 150, report dietary diversity and multiple micronutrient intake based on 24-h dietary recall/food weighed record/food frequency questionnaire, and published between January 2011 and June 2021 were included. The results were compared to the Food and Agriculture Organization (FAO) recommended cut-off for dietary diversity and the Indian Council of Medical Research (ICMR) recommended age- and sex-specific estimated average requirements (EARs) for micronutrient intake. This review includes 35 articles, of which 21 focused on dietary diversity and 14 on micronutrient intake. The results showed that WRA in LMICs had inadequate dietary diversity, with mean food group consumption of only 3.0-4.84, and around 42.3%-90% of women consumed inadequately diversified diets (<5 food groups). Additionally, most studies found that WRA did not consume adequate amounts of essential micronutrients, particularly calcium, iron, zinc, vitamin A, thiamin, riboflavin, folate, and vitamin B12. However, the intake of vitamin C, niacin, and vitamin B6 was above the required levels. In conclusion, this review highlights the common inadequacy of dietary diversity and multiple micronutrient intake among WRA in most LMICs. Effective measures involving improving dietary diversity, food fortification with micronutrients, and supplementation programs could help improve the dietary quality and intake of optimal micronutrients by women in LMICs.

Factors associated with child and maternal dietary diversity in the urban areas of Bangladesh

Dietary diversity is an indicator of nutrition that has been found positively associated with diet quality, micronutrient adequacy, and improved maternal health and child growth. Due to the cultural responsibility of women in providing food at the household level, their status is very important to perform this role. Hence, this study has been conducted on the status of dietary diversity of the mother and child to understand how it relates to various factors of women in urban settings. Data were obtained from 1978 mother-child pairs living in different cities in Bangladesh. The foods taken by the women and children were categorized into 10 and 7 groups to measure women's dietary diversity (WDD) and children's dietary diversity (CDD), respectively. The study found that more than three-fourths of the mothers and half of the children had low dietary diversity. The household wealth holdings and access to resources by the women were found inadequate, while two-thirds of them had the lowest to medium level of nutritional knowledge. The binomial logistic regression model was used to measure the factors influencing WDD and CDD. The findings also indicated that children's dietary diversity was influenced by the mother's age, education, supportive attitude and behavior of husband, and access to and control over resources. While the household wealth index can enhance both child and mother's dietary variety, nutrition knowledge, dietary counseling, and access to and control over resources can improve maternal dietary diversity. This study recommends improving women's socioeconomic status by increasing their wealth and access to resources and enhancing their nutrition knowledge by providing food and nutrition counseling.

Dietary diversity and micronutrients adequacy among the women of reproductive age at St. Martin's island in Bangladesh

Minimum dietary diversity for women, an important dimension of diet quality, has been widely used as a proxy indicator for micronutrient adequacy. In low- and middle-income countries (LMICs), women of reproductive age (WRA) particularly are at high risk of inadequate micronutrient intake resulting from poor diversified diets. Therefore, the present study aimed to assess dietary diversity and micronutrients adequacy in the diets of WRA of St. Martin's island, along with their socio-economic determinants. A cross-sectional study was conducted on a representative sample of 201 WRA living at St. Martin's island. Utilizing the Estimated Average Requirement (EAR) cut-point approach, the adequacy of micronutrient intake was evaluated from observed 24-h recall dietary data. The recent guideline of FAO was employed to evaluate Minimum Dietary Diversity for Women (MDD-W). Binary logistic regression and multiple linear regression analyses were performed to identify socio-economic determinants of MDD-W and micronutrients adequacy. The mean (SD) dietary diversity score was 4.25 (1.17) and about 40.3% of the participants met the MDD-W cut-off. Starchy staples (100%), meat/poultry/fish (87%), and other vegetables (79%) were consumed more frequently, while, the least reported food groups were dairy (2%), nuts and seeds (11%), and vitamin A-rich fruits and vegetables (11%). Except for Niacin, intake of all micronutrients was inadequate, with an inadequacy prevalence of 36-100%. Educational level, and decision-making role of women were significantly related to their dietary diversity. On the other hand, age, decision-making role, and MDD-W were important determinants of micronutrient adequacy. In conclusion, the WRA of St. Martin's island consumed neither a sufficient amount of micronutrients nor an adequate diversity of foods. In addition, several socio-economic components are linked with dietary diversity and micronutrient adequacy. Therefore, attention is needed to decide on the best strategies to improve the quality of diet and dietary diversity for WRA in this setting.

Assessment of nutrient adequacy and associated factors among lactating women of rural Bangladesh using observed intake: Findings from Bangladesh Integrated Household Survey 2018-2019

Lactating women of low- and middle-income countries are prone to develop deficiencies in essential nutrients due to various demographic and socioeconomic components. This study aimed to estimate the adequacy of dietary intake and the determinants of diet quality of lactating women in rural Bangladesh. One-day dietary recall (24-Hour recall) data of 973 lactating women were obtained from the Bangladesh Integrated Household Survey (BIHS) 2018-2019. Nutrient adequacy was determined using the Estimated Average Requirement (EAR) cut-point approach. The molar ratios of phytate to zinc, calcium, and iron were calculated. Mean Adequacy Ratio (MAR) was calculated to measure diet quality, and multiple linear regression analysis was performed to assess the sociodemographic determinants of MAR. While the intakes of protein and carbohydrate were equal to/above the Acceptable Macronutrient Distribution Range (AMDR) among most of the subjects, intakes of total energy and fat were below the reference intakes for 74.4% and 98.3%, respectively. Nutrient adequacy remained unmet for riboflavin, calcium, vitamin A, and folate among most (87.2%-97.6%) of the study population, and the mean (SD) MAR was 0.72 (0.12). Cereals were the major contributor of energy and B vitamins, while protein and iron mainly came from plant-based sources. The molar ratio of phytate to iron was greater than the critical limit among most respondents. Maternal Body Mass Index (BMI) (beta = 0.003, p = .014) and education level (beta = 0.017, p = .038) were associated with their diet quality. The diet of most lactating women in rural Bangladesh indicates the inadequacy of several micronutrients. This can lead to a worsening of the double burden of malnutrition in women. Lactating women should be given special consideration when designing food and nutrition programs for reproductive women in rural Bangladesh.

Trends and Inequities in Food, Energy, Protein, Fat, and Carbohydrate Intakes in Rural Bangladesh

BACKGROUND

Tracking dietary changes can inform strategies to improve nutrition, yet there is limited evidence on food consumption patterns and how disparities in food and nutrient intakes have changed in Bangladesh.

OBJECTIVES

We assessed trends and adequacies in energy and macronutrient intakes and evaluated changes in inequities by age group, sex, and expenditure quintile.

METHODS

We used panel data from the 2011 and 2018 Bangladesh Integrated Household Survey (n = 20,339 and 19,818 household members aged ≥2 y, respectively). Dietary intakes were collected using 24-h recall and food-weighing methods. Changes in energy and macronutrient intakes were assessed using generalized linear models and adjusted Wald tests. Inequities in outcomes were examined by age group, sex, and expenditure quintile using the Slope Index of Inequality and Concentration Index.

RESULTS

Between 2011 and 2018, dietary diversity improved across sex and age groups (30-46% in children, 60-65% in adolescents, 37-87% in adults), but diets remain imbalanced with ∼70% of energy coming from carbohydrates. There were declines in intakes of energy (3-8%), protein (3-9%), and carbohydrate (9-16%) for all age groups (except children aged 2-5 y), but an increase in fat intake (57-68% in children and 22-40% in adults). Insufficient intake remained high for protein (>50% among adults) and fat (>80%), whereas excessive carbohydrate intake was >70%. Insufficient energy, protein, and fat intakes, and excessive carbohydrate intakes, were more prevalent among poor households across survey years. Inequity gaps decreased for insufficient energy intake in most age groups, remained stable for insufficient protein intake, and increased for insufficient fat and excessive carbohydrate intakes.

CONCLUSIONS

Despite improvements in dietary diversity, diets remain imbalanced and inequities in insufficient energy, protein, and fat intakes persist. Our findings call for coherent sets of policies and investments toward a well-functioning food system and social protection to promote healthier, more equitable diets in rural Bangladesh.

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.

Comparison of the 24 h Dietary Recall of Two Consecutive Days, Two Non-Consecutive Days, Three Consecutive Days, and Three Non-Consecutive Days for Estimating Dietary Intake of Chinese Adult

The specific forms of 24 h dietary recall used by national nutrition surveys differ, such as two non-consecutive days and three consecutive days. However, it is unclear which form of 24 h dietary recall is more accurate in the Chinese population. The purpose of this study was to compare the performance of 24 h recalls on two consecutive days (C2), three consecutive days (C3), two non-consecutive days (NC2), and three non-consecutive days (NC3) in estimating Chinese adult dietary intake. A total of 595 participants completed more than twenty-three 24 h recalls. The average of all completed 24 h recalls of each subject was defined as the individual’s true dietary intake. The dietary intake in the four scenarios of 24 h recalls was calculated using the within-person mean (WPM) method and National Cancer Institute (NCI) method and compared with the true values. Equivalent testing was used to evaluate whether scenarios NC2 and C3 were equivalent. Bias and mean bias were used as a measure of precision and accuracy, respectively. For the WPM method, the precision between the four scenarios was similar. For mean, the accuracy between the four scenarios was similar, yielding estimates that were close to the true intakes. However, for percentiles, the accuracy in descending order was scenario NC3, C3, NC2, and C2. Furthermore, the difference between two and three days was greater than that between consecutive and non-consecutive days. In most case, the distribution of dietary intakes calculated from scenarios NC2 and C3 was equivalent with equivalence margins of 5% (p < 0.05). Usually, the NCI method was significantly more accurate than the WPM method. We concluded that three non-consecutive 24 h recalls relative to three consecutive days increases accuracy. Two non-consecutive days can be substituted to some extent for three consecutive days. The new form of 24 h recall needs to be used with caution when applied practically in the China nutrition surveys. Furthermore, using the NCI method to calculate dietary intake from 24 h recall may be a way to reduce costs and increase accuracy.

Consumption of animal source foods, especially fish, is associated with better nutritional status among women of reproductive age in rural Bangladesh

In rural Bangladesh, intake of nutrient-rich foods, such as animal source foods (ASFs), is generally suboptimal. Diets low in nutrients and lacking in diversity put women of reproductive age (WRA) at risk of malnutrition as well as adverse birth outcomes. The objective of this study was to assess the relationship between maternal dietary diversity, consumption of specific food groups and markers of nutritional status, including underweight [body mass index (BMI) < 18.5 kg/m² ], overweight (BMI ≥ 23 kg/m² ) and anaemia (haemoglobin < 120 g/dl) among WRA in Bangladesh. This analysis used data from the third round of a longitudinal observational study, collected from February through May of 2017. Dietary data were collected with a questionnaire, and Women's Dietary Diversity Score (WDDS) was calculated. Associations between WDDS, food group consumption and markers of nutritional status were assessed with separate adjusted logistic regression models. Among WRA, the prevalence of underweight, overweight and anaemia was 13.38%, 40.94% and 39.99%, respectively. Women who consumed dark green leafy vegetables (DGLV) or eggs were less likely to be anaemic or underweight, respectively, and women who consumed ASFs, particularly fish, were less likely to be underweight compared with women who did not consume these foods. WDDS did not show any consistent relationship with WRA outcomes. Interventions that focus on promoting optimal nutritional status among WRA in Bangladesh should emphasise increasing consumption of specific nutrient-rich foods, including ASFs, DGLV and eggs, rather than solely focusing on improving diet diversity in general.

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.