Global Dietary Surveillance: Data Gaps and Challenges

The Impact of Malnutrition on the Developing Lung and Long-Term Lung Health: A Narrative Review of Global Literature

Worldwide, over 2 billion children under the age of 5 experience stunting, wasting, or are underweight. Malnutrition contributes to 45% of all deaths in this age group (approximately 3.1 million deaths) [1]. Poverty, food insecurity, suboptimal feeding practices, climate change, and conflict are all contributing factors. Malnutrition causes significant respiratory problems, including increased risk of respiratory infections, impaired lung function, and increased risk of subsequent adult respiratory disease, including asthma, COPD, and lung cancer. Childhood malnutrition not only has serious consequences for children's health but it also has numerous consequences on wellbeing and educational attainment. Childhood malnutrition is a complex and multifaceted problem. However, by understanding and addressing the underlying causes, and investing in prevention and treatment programs, it is possible to maximize children's health and wellbeing on a global scale. This narrative review will focus on the impact of childhood malnutrition on lung development, the consequent respiratory disease, and what actions can be taken to reduce the burden of malnutrition on lung health.

FoodEx2 Harmonization of the Food Consumption Database from the Italian IV SCAI Children's Survey

Estimating the habitual food and nutrient intakes of a population is based on dietary assessment methods that collect detailed information on food consumption. Establishing the list of foods to be used for collecting data in dietary surveys is central to standardizing data collection. Comparing foods across different data sources is always challenging. Nomenclatures, detail, and classification into broad food groups and sub-groups can vary considerably. The use of a common system for classifying and describing foods is an important prerequisite for analyzing data from different sources. At the European level, EFSA has addressed this need through the development and maintenance of the FoodEx2 classification system. The aim of this work is to present the FoodEx2 harmonization of foods, beverages, and food supplements consumed in the IV SCAI children's survey carried out in Italy. Classifying foods into representative food categories predefined at European level for intake and exposure assessment may lead to a loss of information. On the other hand, a major advantage is the comparability of data from different national databases. The FoodEx2 classification of the national food consumption database represented a step forward in the standardization of the data collection and registration. The large use of FoodEx2 categories at a high level of detail (core and extended terms) combined with the use of descriptors (facets) has minimized information loss and made the reference food categories at country level comparable with different food databases at national and international level.

Measuring dietary intake in low-and middle-income countries: a systematic review of the methods and tools for estimating fish and seafood intake

CONTEXT

Fish and seafood consumption makes an important but often under-recognized contribution to dietary patterns and nutrition, particularly in low- and middle-income countries (LMICs). Therefore, valid, and reliable dietary assessment tools (DATs) and methods to measure seafood consumption in resource-poor settings are needed.

OBJECTIVE

To review the available DATs that have been used to measure fish and seafood consumption in LMICs and to assess their quality.

DATA SOURCES

A systematic search of the electronic databases Scopus, Embase, and Medline was conducted, identifying 1541 initial articles, of which 122 eligible full-text articles were reviewed.

DATA EXTRACTION

Data extraction focused on the purpose of dietary assessment, setting, target population group, DAT type, administration mode, type of fish and seafood assessed, specific measure of food intake, use of a portion-size-estimation aid, and details of validity, reliability, and pilot testing of the DATs.

DATA ANALYSIS

The most common DATs used were food frequency questionnaires (n = 80; 58%), of which 36 (25%) were semi-quantitative. The majority of tools (n = 107; 78%) included measurement of consumption frequency; only 41 studies (30%) measured frequency, quantity, and type of seafood consumed. Only 41 DATs (30%) solely focused on fish or seafood intake. Most DATs were interviewer administered (n = 80; 58%), 23 (16%) mentioned the use of a portion-size-estimation aid, and validity was tested for only 13% of DATs (n = 18).

CONCLUSION

This systematic review reveals a lack of sufficient detail in the use of standard DATs to fully capture the contribution of fish and seafood to diets in LMICs. Consequently, the need to develop or adapt existing DATs to capture frequency, quantity, and type of fish and seafood intake with consideration of cultural eating practices has been highlighted. This is essential for informing appropriate interventions to leverage the nutritional benefits of seafood consumption in LMICs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021253607.

Exploring Diet and Nutrient Insufficiencies across Age Groups: Insights from a Population-Based Study of Brazilian Adults

Assessing dietary inadequacies can contribute to understanding the nutritional vulnerabilities of a country. This study aimed to investigate nutrient intakes and micronutrient inadequacies in the Brazilian adult population, with an interest in different age subgroups. We conducted a cross-sectional study with 1812 individuals aged 19 to 65 years from a population-based study with a representative sample of Brazilian adults. Dietary intake was assessed by two 24 h food recalls, and the probabilities of inadequate intake were estimated using the Dietary Reference Intake targets. Adequate macronutrient intake was over 99% for proteins, 84.7% for carbohydrates, and 80.7% for total fats. There was a high probability of inadequacy (above 90%) for vitamins D and E, but vitamin D inadequacy was very similar between the sexes. In contrast, vitamin E was more likely to be inadequately consumed among women. A high probability of inadequacies (above 85%) of calcium and magnesium were found in the population, regardless of age group. Except for iron, the probability of an inadequacy of other minerals increased with age. The results showed a relevant proportion of nutrient inadequacies, with those most at risk being women and older individuals, helping with the better targeting and monitoring of public-health policies that address nutritional problems in the population.

Current perspectives and challenges in the estimation of fruit juice consumption across the lifecycle in Europe

Fruit juice (FJ) is typically low in energy, contains natural sugars, important amounts of micronutrients and is not permitted to have added sugars/sweeteners. However, its role in a healthy diet is under scrutiny partly due to the wider adoption of the definition for free sugars in nutrition policy. This review aimed to identify data on FJ consumption from national food consumption surveys across Europe, to examine current intakes, percent consumers and its contribution to intakes of energy, total sugars, free sugars, vitamin C, folate and potassium. Data were extracted on the population mean intake of FJ and its contribution to nutrient intakes across the lifecycle and crude estimates of population mean intakes across countries were reported for the total population and for consumers only. This review highlighted significant gaps/challenges regarding the availability of country-specific national food consumption surveys across Europe and specifically data on FJ consumption (including complexities surrounding categorisations). Nonetheless, using a comparable/homogenous definition, the mean intake of FJ among consumers was approximately 1 × 150 ml glass/day for adults/older adults, with lower intakes among infants (86 g/d), children (108 g/d) and teenagers (112 g/d). FJ made important contributions to intakes of vitamin C while making little contribution to energy intakes but also contributed 2-14 % of free sugars intake (which may be considered modest compared to other sources). The complexity of collating and interpreting data on FJ intake as elucidated in this review raises questions surrounding the categorisation of FJ in research and presents significant challenges for policymakers with respect to dietary guidance for FJ.

Harmonising dietary datasets for global surveillance: methods and findings from the Global Dietary Database

OBJECTIVE

The Global Dietary Database (GDD) expanded its previous methods to harmonise and publicly disseminate individual-level dietary data from nutrition surveys worldwide.

DESIGN

Analysis of cross-sectional data.

SETTING

Global.

PARTICIPANTS

General population.

METHODS

Comprehensive methods to streamline the harmonisation of primary, individual-level 24-h recall and food record data worldwide were developed. To standardise the varying food descriptions, FoodEx2 was used, a highly detailed food classification and description system developed and adapted for international use by European Food Safety Authority (EFSA). Standardised processes were developed to: identify eligible surveys; contact data owners; screen surveys for inclusion; harmonise data structure, variable definition and unit and food characterisation; perform data checks and publicly disseminate the harmonised datasets. The GDD joined forces with FAO and EFSA, given the shared goal of harmonising individual-level dietary data worldwide.

RESULTS

Of 1500 dietary surveys identified, 600 met the eligibility criteria, and 156 were prioritised and contacted; fifty-five surveys were included for harmonisation and, ultimately, fifty two were harmonised. The included surveys were primarily nationally representative (59 %); included high- (39 %), upper-middle (21 %), lower-middle (27 %) and low- (13 %) income countries; usually collected multiple recalls/ records (64 %) and largely captured both sexes, all ages and both rural and urban areas. Surveys from low- and lower-middle v. high- and upper-middle income countries reported fewer nutrients (median 17 v. 30) and rarely included nutrients relevant to diet-related chronic diseases, such as n-3 fatty acids and Na.

CONCLUSIONS

Diverse 24-h recalls/records can be harmonised to provide highly granular, standardised data, supporting nutrition programming, research and capacity development worldwide.

Performance of the Global Diet Quality Score (GDQS) App in Predicting Nutrient Adequacy and Metabolic Risk Factors among Thai Adults

BACKGROUND

The Global Diet Quality Score (GDQS) was developed for monitoring nutrient adequacy and diet-related noncommunicable disease risk in diverse populations. A software application (GDQS app) was recently developed for the standardized collection of GDQS data. The application involves a simplified 24-h dietary recall (24HR) where foods are matched to GDQS-food groups using an onboard database, portion sizes are estimated at the food group level using cubic models, and the GDQS is computed.

OBJECTIVES

The study aimed to estimate associations between GDQS scores collected using the GDQS app and nutrient adequacy and metabolic risks.

METHODS

In this cross-sectional study of 600 Thai males and nonpregnant/nonlactating females (40-60 y), we collected 2 d of GDQS app and paper-based 24HR, food-frequency questionnaires (FFQs), anthropometry, body composition, blood pressure, and biomarkers. Associations between application scores and outcomes were estimated using multiple regression, and application performance was compared with that of metrics scored using 24HR and FFQ data: GDQS, Minimum Dietary Diversity-Women, Alternative Healthy Eating Index-2010, and Global Dietary Recommendations score.

RESULTS

In covariate-adjusted models, application scores were significantly (P < 0.05) associated with higher energy-adjusted mean micronutrient adequacy computed using 24HR (range in estimated mean adequacy between score quintiles 1 and 5: 36.3%-44.5%) and FFQ (Q1-Q5: 40.6%-44.2%), and probability of protein adequacy from 24HR (Q1-Q5: 63%-72.5%). Application scores were inversely associated with BMI kg/m2 (Q1-Q5: 26.3-24.9), body fat percentage (Q1-Q5: 31.7%-29.1%), diastolic blood pressure (Q1-Q5: 84-81 mm Hg), and a locally-developed sodium intake score (Q1-Q5: 27.5-24.0 points out of 100); positively associated with high-density lipoprotein cholesterol (Q1-Q5: 49-53 mg/dL) and 24-h urinary potassium (Q1-Q5: 1385-1646 mg); and inversely associated with high midupper arm circumference (Q5/Q1 odds ratio: 0.52) and abdominal obesity (Q5/Q1 odds ratio: 0.51). Significant associations for the application outnumbered those for metrics computed using 24HR or FFQ.

CONCLUSIONS

The GDQS app effectively assesses nutrient adequacy and metabolic risk in population surveys.

A multi-country comparison of jurisdictions with and without mandatory nutrition labelling policies in restaurants: analysis of behaviours associated with menu labelling in the 2019 International Food Policy Study

OBJECTIVE

To examine differences in noticing and use of nutrition information comparing jurisdictions with and without mandatory menu labelling policies and examine differences among sociodemographic groups.

DESIGN

Cross-sectional data from the International Food Policy Study (IFPS) online survey.

SETTING

IFPS participants from Australia, Canada, Mexico, United Kingdom and USA in 2019.

PARTICIPANTS

Adults aged 18-99; n 19 393.

RESULTS

Participants in jurisdictions with mandatory policies were significantly more likely to notice and use nutrition information, order something different, eat less of their order and change restaurants compared to jurisdictions without policies. For noticed nutrition information, the differences between policy groups were greatest comparing older to younger age groups and comparing high education (difference of 10·7 %, 95 % CI 8·9, 12·6) to low education (difference of 4·1 %, 95 % CI 1·8, 6·3). For used nutrition information, differences were greatest comparing high education (difference of 4·9 %, 95 % CI 3·5, 6·4) to low education (difference of 1·8 %, 95 % CI 0·2, 3·5). Mandatory labelling was associated with an increase in ordering something different among the majority ethnicity group and a decrease among the minority ethnicity group. For changed restaurant visited, differences were greater for medium and high education compared to low education, and differences were greater for higher compared to lower income adequacy.

CONCLUSIONS

Participants living in jurisdictions with mandatory nutrition information in restaurants were more likely to report noticing and using nutrition information, as well as greater efforts to modify their consumption. However, the magnitudes of these differences were relatively small.

Individual- and supply-level macronutrient intakes are well correlated over a 50-year period (1961-2011) in 18 countries in Asia, North America, and Europe

Reliable information on dietary trends is essential. We compared individual-level dietary estimates for total energy, carbohydrate, fat, and protein intake over time with national supply data from the Global Expanded Nutrient Supply Model (186 paired estimates from 1961 to 2011, 18 countries). We hypothesized that supply data would overestimate individual measures and that the two measures would be weakly correlated. Individual- and supply-level estimates were compared using Spearman correlation coefficients and linear mixed-effect models were used to estimate the differences between measures. Overall, the correlations between individual- and supply-level measures were moderate for energy (rs = 0.34) and carbohydrate (rs = 0.39), strong for fat (rs = 0.85), and protein (rs = 0.69). Trends in total energy measured by individual-level surveys and total energy supply were positively correlated in 38.9% of countries, whereas trends in macronutrients aligned between estimates in most countries. Supply-level dietary data overestimated individual-level intakes, especially in higher income countries in Europe and in the United States. In the United States, supply-level data exceeded individual-level estimates by 26.3% to 29.9% for energy, carbohydrate, and fat, whereas protein estimates were similar between measures. In Europe, supply-level estimates overestimated individual-level intake by 19.9% for energy, 17.0% for carbohydrate, 13.7% for fat, and 7.7% for protein, whereas estimates for energy and macronutrients were similar in Asia. In Asia and lower income countries, our findings generally support the use of supply-level data in the absence of individual-level data, though this finding may be related to smaller sample size and differences in underlying national statistics that inform supply data.

Socio-cognitive barriers to healthy eating among mothers: A segmentation analysis in Argentina, France, and Denmark

The prevalence of childhood obesity has increased at an alarming rate despite several actions to reverse this trend. It is important to focus on tackling the constraints for healthy food provisioning. We focus on identifying segments of mothers in relation to factors acting as barriers to healthy eating. Five hundred mothers in each country (Argentina, France and Denmark) completed an online survey. In each of the three countries, four segments are identified, varying mostly on working and socio-economic status, self-efficacy and attitudes to health experts. Segments of mothers who are skeptical to nutrition advice from health professionals were identified. Another important finding is that staying-at-home mothers might face more barriers to healthy eating than mothers who work outside the home. We provide suggestions for targeted interventions addressing healthy eating behaviors among mothers with different profiles.

Qualitative Review of National Nutrition Surveillance Systems in the Eastern Mediterranean Region

The World Food Conference in 1974 emphasized the significance of establishing global nutrition surveillance to monitor and address nutritional challenges effectively. However, many countries, especially in the EMRO region, continue to encounter substantial difficulties in regularly generating disaggregated data on nutrition. The current study aimed to review the existing nutrition surveillance systems in the region and to identify their strengths and weaknesses, as well as the challenges they face in functioning optimally.

METHODS

This study focused on the functional nutrition surveillance systems in eight Arab countries; namely Kuwait, Morocco, Oman, Palestine, Saudi Arabia, Sudan, Syria, and Yemen. The study's analysis involved utilizing primary data collected from both published and unpublished reports. Additionally, a structured checklist was employed to gather information from all countries involved in the study. Furthermore, interviews were conducted with the EMRO offices to gain deeper insights into the challenges, if any, that these nutrition surveillance systems face in functioning optimally.

RESULTS

All countries use health facilities as a basic source of data for their nutrition surveillance, some countries triangulate their nutrition surveillance reports with data from other sources of information such as community or school surveys. Identified nutrition surveillance approaches are closely split between those who operate in stable settings and use routine health information systems (Morocco, Saudi Arabia, Oman, and Kuwait) and other countries that operate in fragile settings; for example, Yemen, Syria, Palestine, and Sudan struggle to provide early warning reports for rapid nutritional responses.

CONCLUSIONS

Nutrition surveillance systems that utilize existing health information systems are the most sustained in the EMRO region. However, by integrating data from multiple sources, such as health facilities, surveys, and population censuses, countries can provide a holistic view of the nutritional situation, enhance their response to any emergency, and can leverage the infrastructure and resources already in place for health data collection and reporting. Collaboration between countries in the region through sharing experiences and success stories is important in order to reach a standardized system that can be implemented in different settings.

Energy and macronutrient intakes in Jordan: a population study

Jordan has never conducted a nutrition survey to determine nutrient and energy intakes. The current study aimed to describe the energy and macronutrient consumed by the Jordanian population. A cross-sectional food consumption study was conducted, including a sample of Jordanians using two non-consecutive 24-h dietary recalls (24-h DR) between October 2021 and March 2022. A total of 2145 males and females aged 8 to 85 years old living in households were studied. The average of two 24-h DRs for each individual was converted into energy and nutrient intakes. After measuring weight, height, and waist circumference, the body mass index (BMI) and waist-to-height ratio (WHtR) were calculated. The percentage of under-reporters was higher in women than men (58.2% vs. 45.9%). Adults and older adult women had the highest prevalence of obesity (29.6%), while adults and older adult men had the highest prevalence of overweight (41.4%). There is a significant increase in energy intake in children, boys, and all adults, compared to the recommended calories. The mean energy percentage (E %) of total fat was 38%, exceeding the upper limit of the Acceptable Macronutrient Distribution Range (AMDR). At the same time, the mean daily dietary fiber intake fell below the recommended levels (ranging from 13.5 g in children to 19.5 g in older adults). The study population consumes more fat and less fiber than the recommended levels. Actions must be taken across all age groups to correct the deviation of energy and macronutrient intakes from the recommended dietary allowances.

Current perspectives on global sugar consumption: definitions, recommendations, population intakes, challenges and future direction

Currently, there is considerable emphasis on the relationship between dietary sugar consumption and various health outcomes, with some countries and regions implementing national sugar reduction campaigns. This has resulted in significant efforts to quantify dietary sugar intakes, to agree on terms to describe dietary sugars and to establish associated recommendations. However, this information is infrequently collated on a global basis and in a regularised manner. The present review provides context regarding sugar definitions and recommendations. It provides a global review of the available data regarding dietary sugar intake, considering forms such as total, free and added sugars. A comprehensive breakdown of intakes is provided by age group, country and sugar form. This analysis shows that free sugar intakes as a percentage of total energy (%E) are the highest for children and adolescents (12-14%E) and the lowest for older adults (8%E). This trend across lifecycle stages has also been observed for added sugars. The available data also suggest that, while some reductions in sugar intake are observed in a few individual studies, overall intakes of free/added sugars remain above recommendations. However, any wider conclusions are hampered by a lack of detailed high-quality data on sugar intake, especially in developing countries. Furthermore, there is a need for harmonisation of terms describing sugars (ideally driven by public health objectives) and for collaborative efforts to ensure that the most up-to-date food composition data are used to underpin recommendations and any estimates of intake or modelling scenarios.

Changes in energy, macronutrient, and food consumption in 47 countries over the last 70 years (1950-2019): a systematic review and meta-analysis

OBJECTIVES

We aimed to systematically examine trends in dietary energy, macronutrient, and food consumption in different geographic regions.

METHODS

We searched Medline, Embase, CINAHL, and organizations for studies and reports using individual-level dietary assessments from 1950 to 2019 (PROSPERO CRD42022302843) and quantified changes using multivariable linear mixed-effects models.

RESULTS

We identified 109 articles and reports from 47 countries, including Europe and Australasia (47% of studies), Asia (30%), Latin America (13%), the Middle East (6%), and North America (4%). In Southeast and East Asia, carbohydrate intake decreased, whereas fat consumption increased; the opposite pattern occurred in North America; and fat decreased while carbohydrate intake remained stable in Europe and Australasia. Consumption of carbohydrate and fat were stable in South Asia, Latin America, and the Middle East, but data were limited in these regions. A greater increase in national gross domestic product over time was associated with decreased carbohydrate and increased fat and protein intake. Dietary saturated fatty acid intake decreased in Northern and Eastern Europe and was stable in other regions. Changes in food varied by region; East and Southeast Asia increased meat, fish, dairy, egg, fruit, and vegetable consumption and decreased intake of grains, roots and tubers, legumes, whereas North America decreased dairy and red meat but increased eggs, nuts, poultry, and vegetable oil intake. Intakes of fruits, nuts, legumes, and roots and tubers were below recommendations in most regions.

CONCLUSIONS

Our findings indicate regional variations in dietary trends and identify countries that would benefit from nutritional policies aimed at decreasing lower-quality carbohydrate foods and increasing consumption of fruits, vegetables, nuts, legumes, and dairy.

Soft Drink Intake in Europe—A Review of Data from Nationally Representative Food Consumption Surveys

Public health interest in reducing the intake of sugar-sweetened soft drinks has resulted in various guidelines and initiatives related to their consumption, together with an increase in availability and sales of low and no-sugars versions. The aim of this review was to gain insight regarding individual-level amounts and types of soft drinks consumed across the lifecycle as reported in nationally representative surveys in Europe. The review highlighted significant gaps and challenges regarding the availability of recent country-specific soft drink consumption data including heterogeneity in categorisations used in reporting soft drinks. Nonetheless, crude estimates of mean intake (across countries) indicated that total soft drinks and soft drinks with sugars was highest in adolescents and lowest in infants/toddlers and older adults. For infants/toddlers, crude mean intakes of soft drinks with reduced/no sugars were higher than soft drinks with sugars. The review also found that consumption of total soft drinks is decreasing with a shift to consumption of soft drinks with reduced/no sugars in replacement of sugars-containing soft drinks. This review provides valuable insight into what data are currently available on soft drink consumption in Europe with heterogeneity in categorisations, terminology, and definitions of soft drinks observed.

Dietary Diversity Predicts the Adequacy of Micronutrient Intake in 6- to 23-Month-Old Children Regardless of the Season in Rural Southern Benin

BACKGROUND

The Infants and Young Children Dietary Diversity Score (IYC-DDS-7) has been validated to assess dietary quality in children. However, its applicability to predict the adequacy of micronutrient intake remains a challenge in all contexts.

DESIGN AND METHODS

A 24-hour dietary recall assessment was conducted on a sample of 628 children aged 6 to 23 months in the plenty season (PS) as well as in the lean season (LS). The IYC-DDS-7 was calculated based on 7 food groups, whereas the mean micronutrient density adequacy (MMDA) for 11 micronutrients. The β regression models were used to assess the relationship between IYC-DDS and MMDA and differences in nutrient intake between the 2 seasons. A receiver-operating characteristic curve analysis was also performed to determine IYC-DDS-7 cutoff levels that maximized sensitivity and specificity in assessing dietary quality and predicting MMDA below- or above-selected cutoff levels.

RESULTS

Participating children's MMDA was 56.9% ± 12.8% versus 61.9% ± 8.6% and IYC-DDS-7 was 3.43 ± 1.5 versus 3.77 ± 1.0 in the PS and LS. The IYC-DDS-7 had a positive correlation with MMDA, irrespective of the season. For a 1-unit increase in IYC-DDS-7, MMDA increased by a mean of 10.7% (CI, 8.3%-13.1%; P < .001). The minimum threshold of the 4 food groups corresponded to a sensitivity of 76% and 61% and a specificity of 75% and 70% for the prediction of inadequate diet in the PS and LS, respectively.

CONCLUSIONS

The IYC-DDS-7 predicted MMDA, regardless of seasons for infants and young children. The IYC-DDS-7 cutoff of 4 groups performed well in classifying children with low-diet quality.

The cost and cost efficiency of conducting a 24-h dietary recall using INDDEX24, a mobile dietary assessment platform, compared with pen-and-paper interview in Viet Nam and Burkina Faso

The INDDEX24 Dietary Assessment Platform (INDDEX24) was developed to facilitate the collection of 24-h dietary recall (24HR) data. Alongside validation studies in Viet Nam and Burkina Faso in 2019-2020, we conducted activity-based costing studies to estimate the cost of conducting a 24HR among women of reproductive age using INDDEX24 compared with the pen-and-paper interview (PAPI) approach. We also modelled alternative scenarios in which: (1) 25-75 % of dietary reference data were borrowed from the INDDEX24 Global Food Matters Database (FMDB); (2) all study personnel were locally based and (3) national-scale surveys. In the primary analysis, in Viet Nam, the 24HR cost US $111 004 ($755/respondent, n 147) using INDDEX24 and $120 483 ($820/respondent, n 147) using PAPI. In Burkina Faso, the 24HR cost $78 105 ($539/respondent, n 145) using INDDEX24 and $79 465 ($544/respondent, n 146) using PAPI. In modelled scenarios, borrowing dietary reference data from the FMDB decreased the cost of INDDEX24 by 17-34 % (Viet Nam) and 5-15 % (Burkina Faso). With all locally based personnel, INDDEX24 cost more than PAPI ($498 v. $448 per respondent in Viet Nam and $456 v. $410 in Burkina Faso). However, at national scales (n 4376, Viet Nam; n 6500, Burkina Faso) using all locally based personnel, INDDEX24 was more cost-efficient ($109 v. $137 per respondent in Viet Nam and $123 v. $148 in Burkina Faso). In two countries and under most circumstances, INDDEX24 was less expensive than PAPI. Higher INDDEX24 survey preparation costs (including purchasing equipment) were more than offset by higher PAPI data entry, cleaning and processing costs. INDDEX24 may facilitate cost-efficient dietary data collection.

Food composition databases in the era of Big Data: Vegetable oils as a case study

Understanding the population's dietary patterns and their impacts on health requires many different sources of information. The development of reliable food composition databases is a key step in this pursuit. With them, nutrition and health care professionals can provide better public health advice and guide society toward achieving a better and healthier life. Unfortunately, these databases are full of caveats. Focusing on the specific case of vegetable oils, we analyzed the possible obsolescence of the information and the differences or inconsistencies among databases. We show that in many cases, the information is limited, incompletely documented, old or unreliable. More importantly, despite the many efforts carried out in the last decades, there is still much work to be done. As such, institutions should develop long-standing programs that can ensure the quality of the information on what we eat in the long term. In the face of climate change and complex societal challenges in an interconnected world, the full diversity of the food system needs to be recognized and more efforts should be put toward achieving a data-driven food system.

Nationally representative estimates of the cost of adequate diets, nutrient level drivers, and policy options for households in rural Malawi

A growing literature uses least-cost diets to evaluate how effectively a food system supports access to nutritious foods. We identify the cost of meeting nutrient requirements for whole households in rural Malawi from and the nutrient-level drivers thereof. From 2013 to 2017, we can identify a household least-cost diet only 60% of the time with an average cost of $2.32/person/day (2011 US$ PPP). We illustrate that larger households have more diverse nutrient needs and face a higher cost for 1000 calories of a sufficiently nutrient dense diet. Shadow price analysis shows riboflavin to be the costliest nutrient in the market. We use policy scenarios to understand what drives the infeasibility and high cost. Simulating the impact of selenium soil biofortification of maize results in a feasible diet 94% of the time at half the cost ($1.22/person/day on average) and eliminates the shadow price of copper. This is explained by insufficient selenium from sources low in copper such that under baseline conditions it is impossible to get enough selenium without too much copper. Even when feasible, to avoid copper, more higher cost foods enter the diet than would be otherwise needed to meet remaining nutrient requirements. Other value chain scenarios to increase the availability and lower the cost of nutrient-dense foods did not meaningfully change the diet cost results. Of direct relevance to Malawi, this study demonstrates more broadly how least-cost diet methods can be used to assess barriers to accessing an adequate diet and the potential impacts of policy options.

Development and Validation of the Vietnamese Children’s Short Dietary Questionnaire to Evaluate Food Groups Intakes and Dietary Practices among 9–11-Year-Olds Children in Urban Vietnam

This study aims to develop and assess the reproducibility and validity of the Vietnamese Children’s Short Dietary Questionnaire (VCSDQ) in evaluating food groups intakes and dietary practices among school-aged children 9–11 years old in urban Vietnam. A 26-item questionnaire covering frequency intakes of five core food groups, five non-core food groups, five dietary practices over a week, and daily intakes of fruits, vegetables, and water was developed. Children (n = 144) from four primary schools in four areas of Ho Chi Minh City, Vietnam completed the VCSDQ twice, as well as three consecutive 24 h recalls over a week. Intra-class correlation, Spearman correlation, weighted kappa, cross-classification, and Bland–Altman plots were used to evaluate the reproducibility and validity. The direct validity of food groups from VCSDQ against the 24 h recalls was examined using Wilcoxon-test for trend. The VCSDQ had good reproducibility in 12 out of 15 group items; the ICC ranged from 0.33 (grains) to 0.84 (eating while watching screens). This VCSDQ had low relative validity, two items (instant noodles, eating while watching screens) had a moderate to good agreement (k = 0.43, k = 0.84). There was good direct validity in three core-food groups (fruits, vegetables, dairy) and three non-core food groups (sweetened beverages, instant noodles, processed meat). In addition, the VCSDQ can also be used to classify daily intakes of fruits and vegetables from low to high.

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.

The Nordic Nutrition Recommendations 2022 - food consumption and nutrient intake in the adult population of the Nordic and Baltic countries

Background

Knowledge about the nutrient intakes and food consumption in the Nordic and Baltic countries is important for the formulation of dietary reference values (DRVs) and food-based dietary guidelines (FBDGs), as part of the Nordic Nutrition Recommendations 2022 project (NNR2022).

Objective

To describe nutrient intake and food consumption at a broad level in the adult population of each Nordic and Baltic country. This paper also provides guidance on where to find more information on the nutrient intake and food consumption reported from each country.

Design

Information about the dietary surveys as well as the daily mean intakes was retrieved from the national dietary surveys in each of the Nordic and Baltic countries. Tabulation of the population intakes divided by sex for macronutrients, 20 micronutrients, and for the following broader food groups, Beverages, Cereals, Potatoes, Vegetables, Fruits and berries, Fish and seafood, Meat and meat products, Milk and dairy products, Cheese, Eggs, Fats and oils, and Sweets and sweet bakery products, was done.

Results and Discussion

The Nordic and Baltic countries share not only similarities but also differences in food consumption patterns, which is reflected in differences in average food consumption and nutrient intakes between the countries. This may be related to the dietary assessment method, prevalence of misreporting, and participation rates in the different dietary surveys. Other factors that may play a role are differences in the calculation procedures in the food composition databases and the definition of food groups.

Conclusion

The nutrient intake and, especially, food consumption differ between the Nordic and Baltic countries because of differences in food patterns and factors related to the dietary surveying, food grouping, and calculation procedures in each country. To facilitate future comparisons between countries, it would be of interest to harmonize food groupings and the age groups reported on.

The Conceptual Framework for the International Food Policy Study: Evaluating the Population-Level Impact of Food Policy

An unhealthy diet is among the leading global causes of death and disability. Globally, a range of policies are being implemented to support healthy food choices at a population level, including novel polices in the areas of food marketing, nutrition labeling, and taxation of less healthy foods. There is a need to evaluate and inform the implementation of these policies, including their impacts on marginalized population subgroups. The International Food Policy Study (IFPS) consists of repeated cross-sectional surveys conducted in 5 high- and upper-middle-income countries: Australia, Canada, Mexico, the United Kingdom, and the United States. In each country, approximately 4000 adults and 1200 children and youth (aged 10-17) were recruited from a global commercial panel to complete an online survey using consistent measures and methodologies across countries. The first annual IFPS surveys were conducted in 2017 with adults; annual surveys for young people aged 10-17 were launched in 2019 in the same countries, as well as in Chile. The design of the IFPS surveys creates a framework for evaluating "natural experiments" in food policies, including comparisons over time within countries implementing the policy and comparisons with countries in which the policy was not implemented. IFPS surveys have 3 primary areas of focus: 1) knowledge, attitudes, and beliefs associated with specific policies; 2) diet-related behaviors; and 3) dietary intake, including 24-hour dietary recalls for adults in 4 of the 5 countries. Surveys also assess food insecurity, income adequacy, sex and gender, race/ethnicity, and a range of other measures to assess trends among priority subgroups. Overall, the IFPS project has the potential to address important gaps in national monitoring surveys for dietary patterns, and to evaluate the impacts of novel food policies implemented in any of the 5 countries over the study period.

Update on Analytical Methods and Research Gaps in the Use of Household Consumption and Expenditure Survey Data to Inform the Design of Food-Fortification Programs

The lack of nationally representative, individual-level dietary intake data has led researchers to increasingly turn to household-level data on food acquisitions and/or consumption to inform the design of food-fortification programs in low- and middle-income countries (LMICs). These nationally representative, household-level data come from household consumption and expenditure surveys (HCESs), which are collected regularly in many LMICs and are often made publicly available. Our objectives were to examine the utility of HCES data to inform the design of food-fortification programs and to identify best-practice methods for analyzing HCES data for this purpose. To this end, we summarized information needed to design fortification programs and assessed the extent to which HCES data can provide corresponding indicators. We concluded that HCES data are well suited to guide the selection of appropriate food vehicles, but because individual-level estimates of apparent nutrient intakes rely on assumptions about the intrahousehold distribution of food, more caution is advised when using HCES data to select the target micronutrient content of fortified foods. We also developed a checklist to guide analysts through the use of HCES data and, where possible, identified research-based, best-practice analytical methods for analyzing HCES data, including selecting the number of days of recall data to include in the analysis and converting reported units to standard units. More research is needed on how best to deal with composite foods, foods consumed away from home, and extreme values, as well as the best methods for assessing the adequacy of apparent intakes. Ultimately, we recommend sensitivity analyses around key model parameters, and the continual triangulation of HCES-based results with other national and subnational data on food availability, dietary intake, and nutritional status when designing food-fortification programs.

A Cross-Sectional Assessment of Dietary Patterns and Their Relationship to Hypertension and Obesity in Indonesia

Background

There is a marked increase in the intake of foods associated with higher risks for hypertension and obesity in Indonesia. However, studies assessing the relationship between dietary patterns and health outcomes are few.

Objective

The purpose of this study was to characterize dietary patterns and investigate their relationship with hypertension and obesity in Indonesia.

Methods

Exploratory factor analysis was used to derive dietary patterns from a brief food scanner filled by 31,160 respondents aged 15 y and older in the Indonesian Family Life Survey wave 5 (IFLS 5). Age- and gender-specific quintiles of consumption were created for each pattern and the association between quintiles of each dietary pattern and the odds for hypertension and obesity were assessed using multivariate logistic regression analyses.

Results

Two dietary patterns were identified: a modern dietary pattern characterized by fast foods, soft drinks, sweet snacks, and salty snacks and a traditional pattern characterized by fish, vegetables, and fruits. Younger age and being male were significantly correlated with higher consumption of the modern pattern (P < 0.0001 and P = 0.03, respectively). Analyses showed no association between hypertension and the modern pattern. However, the traditional pattern revealed lower odds for hypertension among those in the highest quintile compared with the lowest quintile (OR: 0.84; 95% CI: 0.74, 0.95; P-trend < 0.05). Individuals in the highest quintile of each dietary pattern had higher odds of obesity compared with those in the lowest quintile (modern pattern-OR: 1.31; 95% CI: 1.15, 1.49; P-trend < 0.00; traditional pattern-OR: 1.25; 95% CI: 1.10, 1.42; P-trend < 0.01).

Conclusions

More studies using gold-standard measures of dietary intake are needed to better understand the relationship between the modern dietary pattern and hypertension in Indonesia. Also, both modern and traditional dietary patterns in Indonesia may be energy dense, leading to higher risk for obesity.

Accuracy and cost-effectiveness of the INDDEX24 Dietary Assessment Platform in Viet Nam

Technology-enabled approaches to conducting 24-h dietary recalls (24HR) may reduce dietary assessment bottlenecks in low-resource settings. However, few studies have assessed their performance relative to conventional pen-and-paper interview (PAPI) approaches and none have validated performance against a benchmark (e.g. weighed food record (WFR)) in a low- and middle-income country (LMIC). This study assessed relative accuracy and cost-effectiveness of INDDEX24, a technology-enabled approach to conducting 24HR, compared with a PAPI approach and against an observer WFR. Women aged 18-49 years from northern Viet Nam (n 234) were randomly assigned to be interviewed using INDDEX24 or PAPI 24HR following a WFR. The two one-sided t test approach assessed the equivalence of each recall modality to the benchmark. Difference-in-differences analysis compared the recall-benchmark results across modalities. Cost per percentage point of accuracy for INDDEX24 and PAPI was derived from accuracy results and the cost to conduct the 24HR. The PAPI and INDDEX24 24HR were statistically equivalent to the WFR for all nutrients except vitamin A. INDDEX24 diverged significantly less than PAPI from the WFR for Fe (0·9 v. -1·3 mg) and PAPI diverged less for protein (-3·7 v. 7·9 g). At the individual level, 26 % of PAPI and 32 % of INDDEX24 respondents had energy intakes within +/- 10 % of the WFR. INDDEX24 cost $111 004 and the PAPI cost $120 483 (USD 2019), making INDDEX24 more cost-effective across most indicators. INDDEX24 was an accurate and cost-effective method for assessing dietary intake in the study context and represents a preferred alternative to PAPI 24HR in Viet Nam and other LMIC.

Gender and Age Differences in Meal Structures, Food Away from Home, Chrono-Nutrition, and Nutrition Intakes among Adults and Children in Tanzania Using a Newly Developed Tablet-Based 24-Hour Recall Tool

Background

In many regions of the world, little is known about meal structures, meal patterns, and nutrient intake because the collection of quantitative dietary intake is expensive and labor-intensive.

Objectives

We describe the development and field feasibility of a tablet-based Tanzania 24-h recall tool (TZ-24hr-DR) and dietary intakes collected from adults and children in rural and urban settings.

Methods

Using the Tanzanian food-composition table, the TZ-24hr-DR tool was developed on an Android platform using the Open Data Kit. The module provides food lists, meal lists, ingredient lists, quantity and amount consumed, breastfeeding frequency, and a recipe feature. Similar to the USDA Automated Multiple Pass Method, this TZ-24hr-DR contains review features such as time in-between meals, a summary of meals, and portion sizes.

Results

Dietary intake using TZ-24hr-DR was collected among 1) 845 children 0-18 mo of age enrolled in the Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS) trial (ClinicalTrials.gov identifier: NCT03759821) in Mara, Tanzania, and 2) 312 adult families from the Diet, Environment, and Choices of positive living (DECIDE) observational study in peri-urban Dar es Salaam. Interviewers were trained on paper-based methods with food models and tablet-based collection. Conversion to nutrient intake was readily linked and accessible, enabling rapid review and analysis. Overall, 2158 and 8197 dietary meal records were collected from the DECIDE study and EFFECTS trial, respectively. Among adults, 63% of men and 92% of women reported eating at home, and there were differences in protein, fat, and zinc. Food consumed outside the home typically occurs for the first 2 meals. Children's intake of nutrients increased with age; however, median micronutrient intakes for calcium, iron, zinc, and vitamin A remained below recommended nutrient intakes.

Conclusions

The TZ-24hr-DR is a field- and user-friendly tool that can collect large samples of dietary intakes. Further validation is needed. The tool is available freely for research purposes and can be further adapted to other contexts in East Africa.

Implementation of Harmonized Food Consumption Data Collection in the Balkan Region According to the EFSA EU Menu Methodology Standards

Initiatives in the Capacity Development in Nutrition Research in the Balkan region in the last decade have been toward the creation of contemporary, harmonized Research Infrastructure (RI) compliant with European standards. This study describes the process of creation and implementation of the European Food Safety Authority (EFSA) EU Menu methodology in the Balkan region during the EFSA support projects for food consumption data collection in four countries (Serbia, Montenegro, Bosnia and Herzegovina, and North Macedonia). This process entailed the application and improvement of an innovative tool, the DIET ASSESS and PLAN (DAP), a platform for standardized food consumption data collection and dietary intake assessment. DAP comprises computerized food consumption, anthropometric measurements, and physical activity questionnaires, validated food picture book, and FoodEx2 exposure hierarchy with sets of facet descriptors of the interest. It hosts the Balkan food platform with a Serbian food composition database (FCDB) and Regional FCDB, compliant with European Food Information Resource (EuroFIR™) standards. The implementation of the DAP platform in national dietary surveys conducted with the support of the EFSA EU Menu project in Balkan countries enabled harmonized food consumption data compilation and reporting. Application of the methodology entailed the development of study protocol and extensive education and training of study personnel. The entire data collection process was managed by internal and external survey coordinators. A pilot study was conducted to test the entire data collection and control process and was afterward used to make necessary improvements and adjustments to meet EU Menu requirements. Data collected are internationally comparable with food consumption data in other European countries within the framework of the EU Menu program. The existence of such data in the Balkan region will catalyze research activities in emerging topics, such as identification of dietary patterns, the establishment of national nutrient reference values and food-based dietary guidelines (not only in Serbia, but in the whole Balkan region), dietary exposure assessments, the endorsement and evaluation of new food legislations, the environmental and other effects of diet on the food system. The developed and implemented methodology underpins evidence-based policy-making processes lacking in the field of public health nutrition in the region.

Changes in food habits amongst Norwegian adolescents in 2016 and 2019 according to gender and socioeconomic status

Background

Monitoring dietary habits is important in order to identify risk groups and as a basis for targeted public health initiatives.

Objective

To study trends in consumption of selected foods and beverages from 2016 to 2019 amongst Norwegian adolescents according to gender and parental education.

Design

Repeated cross-sectional study amongst 25,996 adolescents, aged 14–17 years old. Consumption of selected food and beverages was measured by an online food frequency questionnaire and general linear models were applied to estimate changes in dietary habits.

Results

Between 2016 and 2019, we observed a reduced frequency of consumption of vegetables (from 4.7 to 4.4 times/week), fruit and berries (from 4.4 to 4.2 times/week), whole-grain bread (from 5.1 to 4.2 times/week), and fish (from 2.3 to 1.6 times/week). During this time period, we also observed a reduced frequency of consumption of salty snacks (from 2.1 to 1.9 times/week), sweets (from 2.3 to 2.0 times/week), sugar-sweetened beverages (from 2.8 to 2.6 times/week), and artificially sweetened beverages (from 2.2 to 1.5 times/week). In girls, there was a decrease in the reported frequency of consumption of fruit and berries (−4%, vs. no change in boys). The decrease in consumption frequency of whole-grain bread was larger in girls than in boys (−19% vs. −14%). Further, a 17% decrease in consumption of sweets was observed amongst adolescents with no or only one parent having college/university education compared to a 13% decrease in adolescents whose both parents had college/university education.

Conclusion

Our results showed a decrease in frequency of consumption of selected healthy and unhealthy food and beverages amongst adolescents between 2016 and 2019. The gender gap in consumption of fruit and berries and whole-grain bread seemed to decrease during this time period, and the socio-economic gap in consumption of sweets seemed to disappear.

Comparing estimated cost-effectiveness of micronutrient intervention programs using primary and secondary data: evidence from Cameroon

Designing a cost-effective portfolio of micronutrient intervention programs is complex and generally undertaken with limited data. We developed the MINIMOD-Secondary Data (MINIMOD-SD) tool, which uses household consumption and expenditure survey data and other secondary data to estimate apparent nutrient intakes and model the effectiveness and cost-effectiveness of micronutrient intervention programs. We present the SD tool methodology and results in the context of Cameroon, with a particular focus on vitamin A (VA) for children and folate for women of reproductive age (WRA). We compared the MINIMOD-SD tool estimates with those of the full MINIMOD tool, which uses 24-h dietary recall data. The SD tool consistently underestimated folate intake among women (median (IQR): 230 (143,352) versus 303 (244,367) μg dietary folate equivalents (DFEs)/day) and especially VA among children (141 (64,279) versus 227 (102,369)). Qualitatively, however, the two tools were generally consistent in predicted subnational patterns of micronutrient adequacy and identification of effective and cost-effective (cost per child/WRA moving from inadequate to adequate intake) interventions. Secondary data and the MINIMOD-SD tool can provide policymakers with information to qualitatively assess deficiency risks and identify cost-effective interventions. However, accurately quantifying individual-level deficiency or dietary inadequacy and intervention effectiveness and cost-effectiveness will likely require individual-level dietary data and biomarker measurements.

Development of an Unified Food Composition Database for the European Project "Stance4Health"

The European Commission funded project Stance4Health (S4H) aims to develop a complete personalised nutrition service. In order to succeed, sources of information on nutritional composition and other characteristics of foods need to be as comprehensive as possible. Food composition tables or databases (FCT/FCDB) are the most commonly used tools for this purpose. The aim of this study is to describe the harmonisation efforts carried out to obtain the Stance4Health FCDB. A total of 10 FCT/FCDB were selected from different countries and organizations. Data were classified using FoodEx2 and INFOODS tagnames to harmonise the information. Hazard analysis and critical control points analysis was applied as the quality control method. Data were processed by spreadsheets and MySQL. S4H’s FCDB is composed of 880 elements, including nutrients and bioactive compounds. A total of 2648 unified foods were used to complete the missing values of the national FCDB used. Recipes and dishes were estimated following EuroFIR standards via linked tables. S4H’s FCDB will be part of the smartphone app developed in the framework of the Stance4Health European project, which will be used in different personalized nutrition intervention studies. S4H FCDB has great perspectives, being one of the most complete in terms of number of harmonized foods, nutrients and bioactive compounds included.

Raw versus cooked food matching: Nutrient intake using the 2015/16 Kenya Integrated Household Budget Survey

•

Dietary energy assessment does not require matching foods in cooked form.

•

Macronutrient dietary assessment does not require matching foods in cooked form.

•

Vitamin and mineral dietary assessment requires matching foods in cooked form.

In many countries, statistics from household consumption and expenditure surveys are increasingly being used to inform policies and programs. In household surveys, foods are typically reported as they are acquired (the majority are raw). However, the micronutrient content of some foods diminishes during processing and cooking. Using food consumption data from the 2015/16 Kenya Integrated Household Budget Survey, this study analyzes whether mean consumption estimates of dietary energy, macronutrients, and eight micronutrients are equivalent (applying a two-side paired equivalence test) when matching foods: (1) considering the nutrient content in raw foods (as reported in the survey), and (2) considering the nutrient content in foods as typically consumed, thus applying yield and retention factors as needed. Both food matching approaches rendered statistically equivalent mean consumption estimates, at national and county levels, for dietary energy, protein, fats, available carbohydrates, total fiber, calcium and zinc. Non-equivalent means were found for iron, vitamins A, B1, B2, B12, and C. The higher differences between the means were, in percentage change, for vitamin C (47 %), B1 (34 %) and B12 (26 %).

The Supply of Calories, Proteins, and Fats in Low-Income Countries: A Four-Decade Retrospective Study

Over the past decades, both the quantity and quality of food supply for millions of people have improved substantially in the course of economic growth across the developing world. However, the number of undernourished people has resumed growth in the 2010s amid food supply disruptions, economic slowdowns, and protectionist restrictions to agricultural trade. Having been common to most nations, these challenges to the food security status of the population still vary depending on the level of economic development and national income of individual countries. In order to explore the long-run determinants of food supply transformations, this study employs five-stage multiple regression analysis to identify the strengths and directions of effects of agricultural production parameters, income level, price indices, food trade, and currency exchange on supply of calories, proteins, and fats across 11 groups of agricultural products in 1980-2018. To address the diversity of effects across developing nations, the study includes 99 countries of Asia, Europe, Latin America, the Middle East, and Africa categorized as low-income, lower-middle-income, and upper-middle-income economies. It is found that in low-income countries, food supply parameters are more strongly affected by production factors compared to economic and trade variables. The effect of economic factors on the food supply of higher-value food products, such as meat and dairy products, fruit, and vegetables, increases with the rise in the level of income, but it stays marginal for staples in all three groups of countries. The influence of trade factors on food supply is stronger compared to production and economic parameters in import-dependent economies irrelevant of the gross national income per capita. The approach presented in this paper contributes to the research on how food supply patterns and their determinants evolve in the course of economic transformations in low-income countries.

The complexity of producing and interpreting dietary vitamin A statistics

•

38 of 90 food composition tables reviewed report total vitamin A values poorly.

•

Only 9 tables provide total vitamin A values expressed in both RE and RAE.

•

25 tables provide enough information to calculate total vitamin A in RE and RAE.

•

Consensus on the conversion of pro-vitamin A carotenoids to retinol is needed.

•

Vitamin A adequacy ratios vary with the unit of intake and source of requirements.

Producing, reporting, and interpreting vitamin A statistics present multiple challenges largely attributable to the systems of equivalence used to convert pro-vitamin A carotenoids into retinol equivalents, and to the criteria used by institutions to set recommendations. This study describes the information on total vitamin A, retinol and provitamin A carotenoids available in 90 food composition tables/databases (FCTs/FCDBs). It also evaluates the effect of the definition of vitamin A intake (Retinol Equivalents [RE] or Retinol Activity Equivalents [RAE]) and the source of requirements on the potential contribution of dietary intake to the population’s requirements. We found that 43 percent of the FCTs/FCDBs reviewed, many of them from high-income countries, do not provide total vitamin A or sufficient information for computing it, or present inconsistencies between the metadata and the published values; 9 percent publish total vitamin A in RE and RAE; and 28 percent provide information on retinol and provitamin A carotenoids that enables calculating total vitamin A in both definitions.

Vitamin A adequacy ratios are lowest when the consumption unit is RAE and the source of requirements is the US Health and Medicine Division. When the consumption definition is RE, adequacy ratios are higher using FAO/WHO than EFSA requirements. It is imperative to reach consensus on the system of conversion of provitamin A carotenoids into retinol equivalents.

Data-Driven Dietary Patterns, Nutrient Intake and Body Weight Status in a Cross-Section of Singaporean Children Aged 6-12 Years

Pattern analysis of children’s diet may provide insights into chronic disease risk in adolescence and adulthood. This study aimed to assess dietary patterns of young Singaporean children using cluster analysis. An existing dataset included 15,820 items consumed by 561 participants (aged 6–12 years) over 2 days of dietary recall. Thirty-seven food groups were defined and expressed as a percentage contribution of total energy. Dietary patterns were identified using k-means cluster analysis. Three clusters were identified, “Western”, “Convenience” and “Local/hawker”, none of which were defined by more prudent dietary choices. The “Convenience” cluster group had the lowest total energy intake (mean 85.8 ± SD 25.3% of Average Requirement for Energy) compared to the other groups (95.4 ± 25.9% for “Western” and 93.4 ± 25.3% for “Local/hawker”, p < 0.001) but also had the lowest calcium intake (66.3 ± 34.7% of Recommended Dietary Allowance), similar to intake in the “Local/hawker” group (69.5 ± 38.9%) but less than the “Western” group (82.8 ± 36.1%, p < 0.001). These findings highlight the need for longitudinal analysis of dietary habit in younger Singaporeans in order to better define public health messaging targeted at reducing risk of major noncommunicable disease.

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.

Global Dietary Database 2017: data availability and gaps on 54 major foods, beverages and nutrients among 5.6 million children and adults from 1220 surveys worldwide

BACKGROUND

We aimed to systematically identify, standardise and disseminate individual-level dietary intake surveys from up to 207 countries for 54 foods, beverages and nutrients, including subnational intakes by age, sex, education and urban/rural residence, from 1980 to 2015.

METHODS

Between 2008-2011 and 2014-2020, the Global Dietary Database (GDD) project systematically searched for surveys assessing individual-level intake worldwide. We prioritised nationally or subnationally representative surveys using 24-hour recalls, Food-Frequency Questionnaires or short standardised questionnaires. Data were retrieved from websites or corresponding members as individual-level food group microdata or aggregate stratum-level data. Standardisation included quality assessment; data cleaning; categorising of foods and nutrients and their units; aggregation by demographic strata and energy adjustment.

RESULTS

We standardised and incorporated 1220 surveys into the final GDD 2017 database, together represented 188 countries and 99.0% of the world's population in 2015. 72.1% were nationally, 17.0% subnationally, and 10.9% community-level representative. 41.2% used Food-Frequency Questionnaires; 23.4%, 24-hour recalls; 15.8%, Demographic Health Survey questionnaires; 13.1%, biomarkers and 6.4%, household surveys. 73.9% of surveys included data on children; 52.2%, by urban and rural residence; and 30.2%, by education. Most surveys were in high-income countries, followed by sub-Saharan Africa and Asia. Most commonly ascertained foods were fruits (N=803 surveys), non-starchy vegetables (N=787) and sugar-sweetened beverages (N=440); and nutrients, sodium (N=343), energy (N=256), calcium (N=224) and fibre (N=200). Least available data were on iodine, vitamin A, plant protein, selenium, added sugar and animal protein.

CONCLUSIONS

This systematic search, retrieval and standardised effort provides the most comprehensive empirical evidence on dietary intakes across and within countries worldwide.

Probabilistic Risk Analysis to Assess Dietary Exposure to Aluminum in the Taiwanese Population

Aluminum (Al) exposure at human dietary levels raises health concerns, yet little is known about the Al exposure from the Taiwanese diet. The amount of aluminum (Al)-containing food consumption in the Taiwanese total diet is increasing, which contributes to the total diet consumption., which raises the health concerns. In this study, we aim to assess estimated weekly intake (EWI) and the percentage of provisional tolerable weekly intake (%PTWI) of the dietary exposure to Al in different age-sex groups. We also applied probabilistic risk analyses to quantify the parameters' uncertainty by focusing on the distribution function for the Al concentration in food, consumption rate, and body weight in specific age groups. Results indicated that the EWIs declined with increasing age after 6-years old (7-12 > 13-15 > 16-18 > 19-64 > 65+). Results indicated that the EWIs gradually declined after 6-year of age. The EWIs of Al-rich food in cake + waffle, kelp, snacks, and bread contributed 20%, 17%, 17%, and 11%, respectively, to the total EWIs, corresponding with the much higher consumption rates for these four foods. The 75th percentile of EWIs for the children aged 34-6 years had a %PTWI valued at over 100%, indicating a potential risk of Al intake via dietary exposure. Our findings show that there is a concern about the consumption of Al-rich foods for children in Taiwan.

The importance of food systems and the environment for nutrition

Global and local food system transformation is necessary in order to ensure the delivery of healthy, safe, and nutritious foods in both sustainable and equitable ways. Food systems are complex entities that affect diets, human health, and a range of other outcomes including economic growth, natural resource and environmental resiliency, and sociocultural factors. However, food systems contribute to and are vulnerable to ongoing climate and environmental changes that threaten their sustainability. Although there has been increased focus on this topic in recent years, many gaps in our knowledge persist on the relation between environmental factors, food systems, and nutritional outcomes. In this article, we summarize this emerging field and describe what innovative nutrition research is needed in order to bring about food policy changes in the era of climate disruption and environmental degradation.

Relative validity of a brief dietary survey to assess food intake and adherence to national dietary guidelines among Sri Lankan adults

BACKGROUND

Suboptimal diet is the leading cause of global morbidity and mortality. Addressing this problem requires context-specific solutions informed by context-specific data collected by context-specific tools. This study aimed to assess the relative validity of a newly developed brief dietary survey to estimate food intake and adherence to the Food Based Dietary Guidelines for Sri Lankans.

METHODS

Between December 2018 and February 2019, we interviewed 94 Sri Lankan adults living in Colombo (Western Province), Kalutara (Western Province), and Trincomalee (Eastern Province). We assessed the relative validity of the Sri Lankan Brief Dietary Survey (SLBDS) with Wilcoxon rank-sum tests, Spearman's Rho correlation coefficients, Bland-Altman plots, and Cohen's kappa tests using a 24-h Dietary Recall (24DR) as reference.

RESULTS

Ninety-four adults (40.7 years ±12.6; 66% female) completed both surveys during the same interview. With the exception of 'Fish, pulses, meat and eggs' food group median intake, which was underestimated by the SLBDS compared to the 24DR, there was no strong evidence of difference between median intakes reported by the two methods. Correlation coefficients were highest for 'Milk and dairy products' (0.84) at the food group level and for 'dosa', 'hoppers', 'milk rice', and 'dried fish' (1.00) among individual food and beverages. Visual exploration of Bland-Altman plots showed acceptable agreement between the SLBDS and 24DR, with the SLBDS tending to overestimate consumption as the number of servings of 'Rice, bread, other cereals and yams' and 'Vegetables' consumed increased and slightly underestimate consumption as the number of servings of 'Fish, pulses, meat and eggs', 'Milk and dairy products', and 'Nuts' increased. Kappa values ranged from from 0.59 (95% CI: 0.32-0.86) for 'Vegetables' to 0.81 (95% CI: 0.66-0.96) for 'Fruit' indicating a moderate to strong level of agreement.

CONCLUSIONS

Having been developed for and relatively validated with the study population in question, our study shows that the SLBDS can be used as a fit for purpose research tool. Additional research is needed to assess SLBDS test-retest reliability and to validate further the reporting of salt, oil, and coconut intake.

Is the world converging to a 'Western diet'?

OBJECTIVE

To test the nutrition transition hypothesis of global dietary convergence to a 'Western diet'.

DESIGN

Consumer-waste-adjusted FAO Food Balance Sheets are used to construct for each country a Western Diet Similarity Index (WSI), expressed as a ratio of calories from animal-sourced foods, oils, fats and sweeteners to total per capita calories. β-Convergence and associated speed are estimated by growth regressions using 1992-2013 panel data. Speed of convergence, a non-linear function of income per capita, globalisation and urbanisation, determines the steady-state or long-term global WSI. The long-term global WSI is compared with the WSI of the group of countries with the highest population-weighted average WSI. The group, determined by K-means cluster analysis, consists of sixteen Western countries.

SETTING

Worldwide.

PARTICIPANTS

Not applicable.

RESULTS

Strong evidence of global dietary convergence at a speed driven by income per capita, globalisation and urbanisation with a long-term WSI of 38 %. When compared with the WSI of Western countries (68 %), the hypothesis of global dietary convergence to a Western diet is rejected.

CONCLUSIONS

The nutrition transition is acting in two opposing directions. Some countries experienced positive and others negative WSI growth, slowing down the transition to a Western diet in the long run. Policies to further slowdown the transition by some countries to unhealthier dietary patterns are as important as policies to further speed up the transition by other countries to healthier ones.

EAT-Lancet diet score requires minimum intake values to predict higher micronutrient adequacy of diets in rural women of reproductive age from five low- and middle-income countries

The EAT-Lancet Commission promulgated a universal reference diet. Subsequently, researchers constructed an EAT-Lancet diet score (0-14 points), with minimum intake values for various dietary components set at 0 g/d, and reported inverse associations with risks of major health outcomes in a high-income population. We assessed associations between EAT-Lancet diet scores, without or with lower bound values, and the mean probability of micronutrient adequacy (MPA) among nutrition-insecure women of reproductive age (WRA) from low- and middle-income countries (LMIC). We analysed single 24-h diet recall data (n 1950) from studies in rural DRC, Ecuador, Kenya, Sri Lanka and Vietnam. Associations between EAT-Lancet diet scores and MPA were assessed by fitting linear mixed-effects models. Mean EAT-Lancet diet scores were 8·8 (SD 1·3) and 1·9 (SD 1·1) without or with minimum intake values, respectively. Pooled MPA was 0·58 (SD 0·22) and energy intake was 10·5 (SD 4·6) MJ/d. A one-point increase in the EAT-Lancet diet score, without minimum intake values, was associated with a 2·6 (SD 0·7) percentage points decrease in MPA (P < 0·001). In contrast, the EAT-Lancet diet score, with minimum intake values, was associated with a 2·4 (SD 1·3) percentage points increase in MPA (P = 0·07). Further analysis indicated positive associations between EAT-Lancet diet scores and MPA adjusted for energy intake (P < 0·05). Our findings indicate that the EAT-Lancet diet score requires minimum intake values for nutrient-dense dietary components to avoid positively scoring non-consumption of food groups and subsequently predicting lower MPA of diets, when applied to rural WRA in LMIC.

Dietary Intakes, Patterns, and Determinants of Children Under 5 Years from Marginalized Communities in Odisha: A Cross-sectional Study

Pre-school age (3–5 years) children are vulnerable to malnutrition due to poor dietary intake, dietary habits, and socio-economic conditions. Children from marginalized families are more vulnerable than non-marginalized families due to limited access to health- and nutrition-related services, besides other socio-economic factors. This study was done to assess the dietary intakes, patterns, and determinants of pre-school age (3–5 years) children from marginalized populations in two districts of Odisha. We used three different questionnaires, namely general demographic information, single 24-h recall dietary survey, and food frequency questionnaire, to collect data. Dietary patterns were obtained using principal component analysis, and the recommended dietary allowance (RDA) method was applied to estimate the prevalence of inadequate intake. A general linear model of regression was used to investigate the relationship of dietary patterns scores with independent variables. A total of 86 boys (57.3%) and 64 girls (42.7%) were recruited for the study. The majority (more than two-third) of the children had <70% of RDA of iron, vitamin C, and zinc. The three dietary components that best described the dietary patterns among children in the study were vegetarian, non-vegetarian, and mixed patterns. They explained 54.9% of the variability. The ‘vegetarian’ dietary pattern was inversely associated with children whose mothers were illiterate (p = 0.005), who lived in families having per capita family monthly income less than INR 786 (10.3 US$) (p = 0.007), and who were first born (p = 0.04). The dietary patterns may help interventionists in designing programs aimed at preventing malnutrition and chronic diseases among children in marginalized communities.

Using nutritional survey data to inform the design of sugar-sweetened beverage taxes in low-resource contexts: a cross-sectional analysis based on data from an adult Caribbean population

OBJECTIVE

Sugar-sweetened beverage (SSB) taxes have been implemented widely. We aimed to use a pre-existing nutritional survey data to inform SSB tax design by assessing: (1) baseline consumption of SSBs and SSB-derived free sugars, (2) the percentage of SSB-derived free sugars that would be covered by a tax and (3) the extent to which a tax would differentiate between high-sugar SSBs and low-sugar SSBs. We evaluated these three considerations using pre-existing nutritional survey data in a developing economy setting.

METHODS

We used data from a nationally representative cross-sectional survey in Barbados (2012-2013, prior to SSB tax implementation). Data were available on 334 adults (25-64 years) who completed two non-consecutive 24-hour dietary recalls. We estimated the prevalence of SSB consumption and its contribution to total energy intake, overall and stratified by taxable status. We assessed the percentage of SSB-derived free sugars subject to the tax and identified the consumption-weighted sugar concentration of SSBs, stratified by taxable status.

FINDINGS

Accounting for sampling probability, 88.8% of adults (95% CI 85.1 to 92.5) reported SSB consumption, with a geometric mean of 2.4 servings/day (±2 SD, 0.6, 9.2) among SSB consumers. Sixty percent (95% CI 54.6 to 65.4) of SSB-derived free sugars would be subject to the tax. The tax did not clearly differentiate between high-sugar beverages and low-sugar beverages.

CONCLUSION

Given high SSB consumption, targeting SSBs was a sensible strategy in this setting. A substantial percentage of free sugars from SSBs were not covered by the tax, reducing possible health benefits. The considerations proposed here may help policymakers to design more effective SSB taxes.

Dietary Variation among Children Meeting and Not Meeting Minimum Dietary Diversity: An Empirical Investigation of Food Group Consumption Patterns among 73,036 Children in India

BACKGROUND

Minimum Dietary Diversity (MDD) is a widely used indicator of adequate dietary micronutrient density for children 6-23 mo old. MDD food-group data remain underutilized, despite their potential for further informing nutrition programs and policies.

OBJECTIVES

We aimed to describe the diets of children meeting MDD and not meeting MDD in India using food group data, nationally and subnationally.

METHODS

Food group data for children 6-23 mo old (n = 73,036) from the 2015-16 National Family Health Survey in India were analyzed. Per WHO standards, children consuming ≥5 of the following food groups in the past day or night met MDD: breast milk; grains, roots, or tubers; legumes or nuts; dairy; flesh foods; eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables. Children not meeting MDD consumed <5 food groups. We analyzed the number and types of foods consumed by children meeting MDD and not meeting MDD at the national and subnational geographic levels.

RESULTS

Nationally, children not meeting MDD most often consumed breast milk (84.5%), grains, roots, and tubers (62.0%), and/or dairy (42.9%). Children meeting MDD most often consumed grains, roots, and tubers (97.6%), vitamin A-rich fruits and vegetables (93.8%), breast milk (84.1%), dairy (82.1%), other fruits and vegetables (79.5%), and/or eggs (56.5%). For children not meeting MDD, district-level dairy consumption varied the most (6.4%-79.9%), whereas flesh foods consumption varied the least (0.0%-43.8%). For children meeting MDD, district-level egg consumption varied the most (0.0%-100.0%), whereas grains, roots, and tubers consumption varied the least (66.8%-100.0%).

CONCLUSIONS

Children not meeting MDD had low fruit, vegetable, and protein-rich food consumption. Many children meeting MDD also had low protein-rich food consumption. Examining the number and types of foods consumed highlights priorities for children experiencing the greatest dietary deprivation, providing valuable complementary information to MDD.

Fortified Foods Are Major Contributors to Apparent Intakes of Vitamin A and Iodine, but Not Iron, in Diets of Women of Reproductive Age in 4 African Countries

BACKGROUND

Food fortification is implemented to increase intakes of specific nutrients in the diet, but contributions of fortified foods to nutrient intakes are rarely quantified.

OBJECTIVES

We quantified iron, vitamin A, and iodine intakes from fortified staple foods and condiments among women of reproductive age (WRA).

METHODS

In subnational (Nigeria, South Africa) and national (Tanzania, Uganda) cross-sectional, clustered household surveys, we assessed fortifiable food consumption. We estimated daily nutrient intakes from fortified foods among WRA by multiplying the daily apparent fortifiable food consumption (by adult male equivalent method) by a fortification content for the food. Two fortification contents were used: measured, based on the median amount quantified from individual food samples collected from households; and potential, based on the targeted amount in national fortification standards. Results for both approaches are reported as percentages of the estimated average requirement (EAR) and recommended nutrient intake (RNI).

RESULTS

Fortified foods made modest contributions to measured iron intakes (0%-13% RNI); potential intakes if standards are met were generally higher (0%-65% RNI). Fortified foods contributed substantially to measured vitamin A and iodine intakes (20%-125% and 88%-253% EAR, respectively); potential intakes were higher (53%-655% and 115%-377% EAR, respectively) and would exceed the tolerable upper intake level among 18%-56% of WRA for vitamin A in Nigeria and 1%-8% of WRA for iodine in Nigeria, Tanzania, and Uganda.

CONCLUSIONS

Fortified foods are major contributors to apparent intakes of vitamin A and iodine, but not iron, among WRA. Contributions to vitamin A and iodine are observed despite fortification standards not consistently being met and, if constraints to meeting standards are addressed, there is risk of excessive intakes in some countries. For all programs assessed, nutrient intakes from all dietary sources and fortification standards should be reviewed to inform adjustments where needed to avoid risk of low or excessive intakes.