Nutrition profiles of farm households across different farming systems in Ethiopia: Unpacking the determinants and implications for nutrition-sensitive interventions

Tackling nutrition insecurity remains a critical challenge in developing countries. In the predominantly rain-fed and smallholder-based farming systems of Ethiopia, production diversity and livelihood strategies of the farm households vary across geographic areas. However, the effects of household socioeconomic characteristics, production diversity, and household incomes on nutrition profiles in distinct settings have been inadequately understood. Therefore, this study was undertaken to examine the association of farming system type, sources of income, and household wealth status with household nutrition profiles in three remote locations such as Mennisa, Welmel Tiqa, and Agam Wuha that represent root crops-based farming, maize-based semi-pastoral farming, and teff-based cereal farming systems, respectively. A combination of qualitative and quantitative data collection techniques was employed. A multistage sampling procedure was used to select a total of 265 smallholder households for the structured survey interviews. Standard statistical tests and Tobit regression analyses were performed after determining the wealth category of each household. Results revealed a diversity of income sources used by each of the farm households with average values of 9 in Mennisa, 10 in Agam Wuha, and 11 in Welmel Tiqa, with the contributions of each income source varying by household wealth category and location. As expected, expenditures on food significantly exceeded those on non-food categories for poor households and vice versa for rich wealth households. The average total food variety score (FVS) for Welmel Tiqa was twice that for Agam Wuha, confirming the need for site-specific nutrition profile assessments. Despite the observed differences in household nutrition profiles among wealth categories and locations, the apparent intakes of vitamin A, vitamin B12, vitamin D, and calcium were consistently below the population-level estimated average requirements across all locations. The number of adequately consumed nutrients by farm households was negatively associated with family size, age of household heads, livestock holdings, wealth categories, and irrigation use, and positively associated with crop production diversity, income diversity, and FVS. The negative association between irrigation use and nutrition security was likely due to the focus on producing crops with a high market value on land under irrigation, coupled with ineffective allocation of generated income for enhancing household nutritional outcomes. Therefore, programs that include irrigated agriculture investments should consider adopting a more integrated nutrition-sensitive interventions, including consideration of locally adapted nutritious crops, such as orange-flesh sweet potato, to address critical deficiency of Vitamin A, nutrition training coupled with development of recipes and cooking demonstrations, and marketing and promotion for nutritious crops.

Pollinator-dependent crops significantly contribute to diets and reduce household nutrient deficiencies in sub-Saharan Africa

Recent literature highlights the potential of animal pollinator-dependent (PD) crops in enhancing food and nutrition security, although there is a lack of detailed household-level estimates. In this study, we investigate the nutrient composition, productivity, and contribution of PD and pollinator-independent (PI) crops to household nutrition in four sub-Saharan African (SSA) countries. We also evaluate the impact of reallocating resources from PI crops to PD crops on nutrient deficiencies, utilizing nationally representative panel data from three waves and over 30,000 household-year observations. Our findings reveal that PD crops exhibit higher micronutrient content per unit, albeit with lower macronutrient content compared to PI crops. PI crops have higher yield of calories per hectare while PD crops have higher vitamin A yield per hectare. However, protein and iron yield for PD and PI crops varies across countries. PI crops predominantly contribute to macronutrients and iron, while PD crops significantly contribute to vitamin A production. Our econometric results demonstrate that increasing the cultivation of PD crops relative to PI crops reduces the prevalence of nutrient deficiencies and increases crop income without compromising macronutrients production. This suggests that greater investment in PD crop production can be an integral approach to achieving nutrition security in SSA.

Could local foods achieve recommended calcium intakes for nutritionally vulnerable populations in Uganda, Guatemala, and Bangladesh?

Globally, dietary intake of calcium is often insufficient, and it is unclear if adequacy could be achieved by promoting calcium-rich local foods. This study used linear programming and household consumption data from Uganda, Bangladesh, and Guatemala to assess whether local foods could meet calcium population reference intakes (Ca PRIs). The most promising food-based approaches to promote dietary calcium adequacy were identified for 12- to 23-month-old breastfed children, 4- to 6-year-old children, 10- to 14-year-old girls, and nonpregnant and nonbreastfeeding (NPNB) women of reproductive age living in two regions of each country. Calcium-optimized diets achieved 75-253% of the Ca PRI, depending on the population, and were <100% for 4- to 6-year-olds in one region of each country and 10- to 14-year-old girls in Sylhet, Bangladesh. The best food sources of calcium were green leafy vegetables and milk, across geographic locations, and species of small fish, nixtamalized (lime-treated) maize products, sesame seeds, and bean varieties, where consumed. Food-based recommendations (FBRs) achieving the minimum calcium threshold were identified for 12- to 23-month-olds and NPNB women across geographic locations, and for 4- to 6-year-olds and 10-to 14-year-old girls in Uganda. However, for 4- to 6-year-olds and 10- to 14-year-old girls in Bangladesh and Guatemala, calcium-adequate FBRs could not be identified, indicating a need for alternative calcium sources or increased access to and consumption of local calcium-rich foods.

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.

Using Household Consumption Data to Flag Low Nutrient Access

BACKGROUND

Information on food consumption, dietary diversity, and nutrient inadequacies are key for informing food security and nutrition programming. Household- and individual-level data together provide the most complete information, but individual dietary modules are not always feasible in humanitarian contexts due to cost and time constraints.

OBJECTIVE

This article asks to what extent it is possible to use food consumption data which is commonly collected at household level through food security and vulnerability surveys, to assess the household's access to vitamin A and iron.

METHODS

The validation analysis uses household food consumption and expenditure surveys from Guatemala, Honduras, Nepal, and Uganda and the adult male equivalent approach for calculating nutrient access.

RESULTS

The results show a positive significant correlation between the frequency of consumption and adequacy as estimated from comprehensive household food consumption modules, with correlation in the range of 0.4 to 0.7. Frequency thresholds for distinguishing between adequate and inadequate nutrient access, based on how often foods rich in the relevant nutrient are eaten during 1 week, mostly fulfill standard sensitivity and specificity criteria.

CONCLUSIONS

The article concludes that in humanitarian contexts, a frequency-based proxy for nutrient access based on household data commonly collected in emergency assessments and through monitoring systems can be used and can support this particular data gap. As a rule of thumb, a frequency threshold of 7 should be used for vitamin A and of 12 for iron.

Validation of the INDDEX24 mobile app v. a pen-and-paper 24-hour dietary recall using the weighed food record as a benchmark in Burkina Faso

Effective nutrition policies require timely, accurate individual dietary consumption data; collection of such information has been hampered by cost and complexity of dietary surveys and lag in producing results. The objective of this work was to assess accuracy and cost-effectiveness of a streamlined, tablet-based dietary data collection platform for 24-hour individual dietary recalls (24HR) administered using INDDEX24 platform v. a pen-and-paper interview(PAPI) questionnaire, with weighed food record (WFR) as a benchmark. This cross-sectional comparative study included women 18-49 years old from rural Burkina Faso (n 116 INDDEX24; n 115 PAPI). A WFR was conducted; the following day, a 24HR was administered by different interviewers. Food consumption data were converted into nutrient intakes. Validity of 24HR estimates of nutrient and food group consumption was based on comparison with WFR using equivalence tests (group level) and percentages of participants within ranges of percentage error (individual level). Both modalities performed comparably estimating consumption of macro- and micronutrients, food groups and quantities (modalities' divergence from WFR not significantly different). Accuracy of both modalities was acceptable (equivalence to WFR significant at P < 0·05) at group level for macronutrients, less so for micronutrients and individual-level consumption (percentage within ±20 % for WFR, 17-45 % for macronutrients, 5-17 % for micronutrients). INDDEX24 was more cost-effective than PAPI based on superior accuracy of a composite nutrient intake measure (but not gram amount or item count) due to lower time and personnel costs. INDDEX24 for 24HR dietary surveys linked to dietary reference data shows comparable accuracy to PAPI at lower cost.

Spatial spillovers, living environment and obesity in France: Evidence from a spatial econometric framework

In 2019, obesity affected 17% of French adults. In this article, we use a unique data set that combines individual-level health and consumption data with living environment data (food, sports and health amenities). We develop a spatial econometric framework to address French health disparities in obesity prevalence across space. We find that regulations on fast food restaurant locations could be a policy instrument to counter the prevalence of obesity. We also establish the existence of spatial spillovers of sports and medical amenities on obesity. This new evidence points to the need to consider a wider context than just the immediate local environment in the fight against the obesity pandemic.

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.

Is nutritional functional diversity in the rural food and nutrition system associated with food security and nutrient adequacy? A case study of rural areas of Zahedan district, Iran

BACKGROUND

An overlooked problem in food and nutrition system analysis is assuring adequate diversity for a healthy diet. Little is known about nutrient diversity in food and nutrition systems and how it transmits to dietary diversity. Nutritional functional diversity (NFD) is a metric that describes diversity in providing nutrients from farm to market and the consumption level. The objective of this study is to determine the NFD score at different stages of the rural food and nutrition system, including household's agricultural and home production, domestic food processing, purchased food, and diet. It also aims to explore the association between NFD and nutrient adequacy, food security, and anthropometric indicators.

METHODS

A cross-sectional study was conducted on 321 households in 6 villages of Zahedan district. The NFD score was measured at three subsystems (production, processing, and consumption) of the food and nutrition system. Household food security, mean adequacy ratio (MAR), and anthropometrics of the household's head were measured to assess the association between NFD and food and nutrition indicators. Linear and bivariate statistical techniques were applied to study the associations between variables.

RESULTS

In the rural food and nutrition system, the food purchased from the city plays the main role in the households NFD score. Their contribution to total NFD was twice that of the food items purchased from the village. The NFD score of homestead production and households food processing was found to be five times less than those of food purchased from cities. The food insecure households had significantly lower NFD scores for food purchased from the city and higher NFD scores for purchased food items from the rural market and native wild vegetable consumption. A strong and positive relationship was observed between NFD of food items purchased from the city and households'MAR. No significant association was found between the NFD score of homestead production, processing, and dependent variables, i.e. food insecurity, MAR, and household head anthropometrics.

CONCLUSION

NFD score, as a relatively new metric, could help in determining diversity from farm to diet and identifying the gaps to plan appropriate interventions for improving diversity in the local food system.

Decomposition of Socioeconomic Changes in the Consumption of Micronutrients in Pakistan between 2006 and 2016

This study is conducted to decompose inequality in four important micronutrient intakes, i.e. calcium, iodine, iron, and zinc due to socioeconomic factors during 2006-2016. For this purpose, data were taken from national-level surveys, i.e. HIES-2006 and HIICS-2016. We applied a recently proposed decomposition method based on copula function to decompose between year changes in the consumption of micronutrients into structure and composition effect. The results show that average calcium and iron intakes increased by 518.54 (mg) and 0.962 (mg), respectively, while average iodine and zinc intakes decreased by 2.009 (mg) and 3.411 (mg), respectively, during the decade. Estimates of structure effect show that calcium, iodine, and iron consumption increased on average, i.e. 525.316 (mg), 14.615 (mg), and 2.15 (mg), respectively, while zinc intake decreased by 2.735 (mg). The composition effect is negative for all the four micronutrients, implying that consumption of calcium, iodine, iron, and zinc decreased as 6.7766 (mg), 16.624 (mg), 1.189 (mg), and 0.677 (mg), respectively. The main factors of this change are household income, urbanization, provinces, and household size. The policymakers need to know the importance of socioeconomic factors to improve hidden hunger in terms of micronutrient intakes.

Deforestation reduces fruit and vegetable consumption in rural Tanzania

Two billion people across the planet suffer from nutrient deficiencies. Dietary diversification is key to solving this problem, yet many food and nutrition security policies, especially in low- and middle-income countries, still focus on increasing agricultural production and access to sufficient calories as the main solution. But calories are not all equal. Here, we show how deforestation in Tanzania caused a reduction in fruit and vegetable consumption (of 14 g per person per day) and thus vitamin A adequacy of diets. Using a combination of regression and weighting analyses to generate quasi-experimental quantitative estimates of the impacts of deforestation on people’s food intake, our study establishes a causal link between deforestation and people’s dietary quality.

Strategies to improve food and nutrition security continue to promote increasing food via agricultural intensification. Little (if any) consideration is given to the role of natural landscapes such as forests in meeting nutrition goals, despite a growing body of literature that shows that having access to these landscapes can improve people’s diets, particularly in rural areas of low- and middle-income countries. In this study, we tested whether deforestation over a 5-y period (2008–2013) affected people’s dietary quality in rural Tanzania using a modeling approach that combined two-way fixed-effects regression analysis with covariate balancing generalized propensity score (CBGPS) weighting which allowed for causal inferences to be made. We found that, over the 5 y, deforestation caused a reduction in household fruit and vegetable consumption and thus vitamin A adequacy of diets. The average household member experienced a reduction in fruit and vegetable consumption of 14 g⋅d⁻¹, which represented a substantial proportion (11%) of average daily intake. Conversely, we found that forest fragmentation over the survey period led to an increase in consumption of these foods and dietary vitamin A adequacy. This study finds a causal link between deforestation and people’s dietary quality, and the results have important implications for policy makers given that forests are largely overlooked in strategies to improve nutrition, but offer potential “win–wins” in terms of meeting nutrition goals as well as conservation and environmental goals.

Systematic review of metrics used to characterise dietary nutrient supply from household consumption and expenditure surveys

OBJECTIVE

To review existing publications using Household Consumption and Expenditure Survey (HCES) data to estimate household dietary nutrient supply to (1) describe scope of available literature, (2) identify the metrics reported and parameters used to construct these metrics, (3) summarise comparisons between estimates derived from HCES and individual dietary assessment data and (4) explore the demographic and socio-economic sub-groups used to characterise risks of nutrient inadequacy.

DESIGN

This study is a systematic review of publications identified from online databases published between 2000 to 2019 that used HCES food consumption data to estimate household dietary nutrient supply. Further publications were identified by 'snowballing' the references of included database-identified publications.

SETTING

Publications using data from low- and lower-middle income countries.

RESULTS

In total, fifty-eight publications were included. Three metrics were reported that characterised household dietary nutrient supply: apparent nutrient intake per adult-male equivalent per day (n 35), apparent nutrient intake per capita per day (n 24) and nutrient density (n 5). Nutrient intakes were generally overestimated using HCES food consumption data, with several studies finding sizeable discrepancies compared with intake estimates based on individual dietary assessment methods. Sub-group analyses predominantly focused on measuring variation in household dietary nutrient supply according to socio-economic position and geography.

CONCLUSION

HCES data are increasingly being used to assess diets across populations. More research is needed to inform the development of a framework to guide the use of and qualified interpretation of dietary assessments based on these data.

Characteristics of Distinct Dietary Patterns in Rural Bangladesh: Nutrient Adequacy and Vulnerability to Shocks

Food security in Bangladesh has improved in recent years, but the country is now facing a double burden of malnutrition while also being highly vulnerable to climate change. Little is known about how this may affect food supply to different sectors of the population. To inform this, we used a national dietary survey of 800 rural households to define dietary patterns using latent class analysis. Nutrient adequacy of dietary patterns and their potential vulnerability to climate shocks (based on diversity of calorie sources) were assessed. We fitted mixed effects logistic regression models to identify factors associated with dietary patterns. Four dietary patterns were identified: rice and low diversity; wheat and high diversity; pulses and vegetables; meat and fish. The wheat and high diversity and meat and fish patterns tended to be consumed by households with higher levels of wealth and education, while the rice and low diversity pattern was consumed by households with lower levels of wealth and education. The pulses and vegetables pattern was consumed by households of intermediate socio-economic status. While energy intake was high, fat and protein intake were suboptimal for all patterns except for the wheat and high diversity pattern. All patterns had fruit and vegetable intake below the WHO recommendation. The wheat and high diversity pattern was least vulnerable to shocks, while the rice and low diversity pattern was the most vulnerable, relying mainly on single cereal staples. The diets showed "double vulnerability" where the nutrient inadequate patterns were also those most vulnerable to shocks.

The nutritional quality of cereals varies geospatially in Ethiopia and Malawi

Micronutrient deficiencies (MNDs) remain widespread among people in sub-Saharan Africa1-5, where access to sufficient food from plant and animal sources that is rich in micronutrients (vitamins and minerals) is limited due to socioeconomic and geographical reasons4-6. Here we report the micronutrient composition (calcium, iron, selenium and zinc) of staple cereal grains for most of the cereal production areas in Ethiopia and Malawi. We show that there is geospatial variation in the composition of micronutrients that is nutritionally important at subnational scales. Soil and environmental covariates of grain micronutrient concentrations included soil pH, soil organic matter, temperature, rainfall and topography, which were specific to micronutrient and crop type. For rural households consuming locally sourced food-including many smallholder farming communities-the location of residence can be the largest influencing factor in determining the dietary intake of micronutrients from cereals. Positive relationships between the concentration of selenium in grain and biomarkers of selenium dietary status occur in both countries. Surveillance of MNDs on the basis of biomarkers of status and dietary intakes from national- and regional-scale food-composition data1-7 could be improved using subnational data on the composition of grain micronutrients. Beyond dietary diversification, interventions to alleviate MNDs, such as food fortification8,9 and biofortification to increase the micronutrient concentrations in crops10,11, should account for geographical effects that can be larger in magnitude than intervention outcomes.

Divergence and agreement on nutrient intake between the two food composition tables of Bangladesh

In Bangladesh, two food composition tables (FCTs) were published over two consecutive years, in 2012 and in 2013. When different databases are used to calculate nutrient intakes, assessment of divergence and agreements is required. This study aimed to compare the differences in nutrient intakes, to assess the similarities in nutrient intakes between the two FCTs, and to explore the factors that cause the difference in nutrient intakes, if any. A total sample of 40 households was taken from the Household Income Expenditure Survey of 2010. Adult male equivalent (AME) units were used to estimate weighted average intake. Weighted k statistics were used to assess agreements between the two FCTs. Although median intake of energy and energy-yielding nutrients (protein, fats, and carbohydrates) were found statistically significant between the two databases, the differences were not large enough to have practical significance. Excellent agreements were found in energy and carbohydrates with good for fats and fair for protein. However, statistically significant median percent differences were seen in beta carotene (441%), vitamin B6 (153%), and folate (129%), vitamin C (106%), zinc (101%), and iron (41%) intakes. For thiamin, iron, calcium, and phosphorous, more than 50% of the subjects were found in the same quintile, whereas nine out of 15 vitamins and minerals were misclassified into the opposite quintiles (≥10%). Fair agreements were found for most of the micronutrients. Variations in analytical methods and sources of nutrient information were the main contributing factors for actual differences. FCT data should be interpreted with caution, especially for micronutrients.

Household Engagement in Both Aquaculture and Horticulture Is Associated with Higher Diet Quality than Either Alone

The consumption of high-quality diverse diets is crucial for optimal growth, health, and wellbeing.

OBJECTIVE

This study assessed the diet quality of households by their type of engagement in homestead aquaculture and/or horticulture. Socio-demographic determinants of diet quality were also studied.

METHOD

Diet quality was assessed using a nutrient adequacy ratio (NAR), based on the preceding 7 days' dietary recall at the household level. Adult male equivalent units (AMEs) were used for age- and sex-specific intra-household distribution of household intakes. Mean adequacy ratios (MAR) were computed as an overall measure of diet quality, using NAR.

RESULTS

Better diet quality (mean ± SD) was associated with households engaged in both homestead aquaculture and horticulture (0.43 ± 0.23; p < 0.001) compared to only one type of agriculture (0.38 ± 0.20) or none (0.36 ± 0.20). Tukey's post-hoc test confirmed significant differences in diet quality between both and either engagement (0.05 ± 0.01, p < 0.001), both and no engagement (0.07 ± 0.01, p < 0.001), and either and no engagement households (0.02 ± 0.01, p < 0.001). Beyond farm production of nutrient-rich foods, generalized estimating equations showed that diet quality was influenced by the higher educational level and occupation of adult household members, higher daily per capita food expenditure, sex, family size and region.

CONCLUSIONS

Projects that promote and support household engagement in both homestead aquaculture and horticulture have the potential to improve the diet quality of households.

Diet Quality and Urbanization in Mozambique

Robust income growth combined with the highest urban population growth in the world is driving rapid changes in the food system of sub-Saharan Africa. Demand is increasing for higher quality as well as more processed foods. Countries are increasingly experiencing a double burden of over and under nutrition as the overweight and obesity epidemic spreads. In this context, we seek to understand the key drivers and likely evolution of diet quality in Mozambique, in both its positive and negative dimensions, while specifically examining the role of farm ownership among increasingly urban populations. We use national household expenditure survey data and a set of ordinary least square and analysis of variance regressions to observe patterns of current diet quality across city size categories, household income, household education, and other demographic variables. We then anticipate the likely directions of change in diet quality over these same dimensions based on expected income growth and expenditure elasticities developed for several alternative nutrients. We find that growing incomes and the consumption of processed foods are associated with a worsening of negative factors in the diet. Furthermore, urbanization, controlling for income, is associated more strongly with a worsening of negative factors than with an improvement in positive factors in the diet. The effect on diet quality of farm ownership, however, is positive and significant, primarily driven by these households purchasing fewer unhealthy foods. African cities need to consider what mix of policies will counteract the negative effects of continued urbanization and rising incomes on diets.

Household coverage of vitamin A fortification of edible oil in Bangladesh

Mandatory fortification of edible oil (soybean and palm) with vitamin A was decreed in Bangladesh in 2013. Yet, there is a dearth of data on the availability and consumption of vitamin A fortifiable oil at household level across population sub-groups. To fill this gap, our study used a nationally representative survey in Bangladesh to assess the purchase of fortifiable edible oil among households and project potential vitamin A intake across population sub-groups. Data is presented by strata, age range and poverty-the factors that potentially influence oil coverage. Across 1,512 households, purchase of commercially produced fortifiable edible oil was high (87.5%). Urban households were more likely to purchase fortifiable oil (94.0%) than households in rural low performing (79.7%) and rural other strata (88.1%) (p value: 0.01). Households in poverty were less likely to purchase fortifiable oil (82.1%) than households not in poverty (91.4%) (p <0.001). Projected estimates suggested that vitamin A fortified edible oil would at least partially meet daily vitamin A estimated average requirement (EAR) for the majority of the population. However, certain population sub-groups may still have vitamin A intake below the EAR and alternative strategies may be applied to address the vitamin A needs of these vulnerable sub-groups. This study concludes that a high percentage of Bangladeshi population across different sub-groups have access to fortifiable edible oil and further provides evidence to support mandatory edible oil fortification with vitamin A in Bangladesh.

Dietary Patterns and Determinants of Changing Diets in Bangladesh from 1985 to 2010

BACKGROUND

The government of Bangladesh has implemented multiple policies since 1971 to provide the population with more diverse and nutritious diets.

OBJECTIVE

The aim of this study was to examine the drivers of dietary change over time and the roles agriculture and economic development have played.

METHODS

We used principal component analysis to derive dietary patterns from 7 cross-sectional rounds of the Bangladesh Household [Income and] Expenditure Survey. We then used linear probability models to estimate associations of adherence to dietary patterns with socio-economic characteristics of households, and with agricultural production on the household and regional level. For dietary patterns that increased or decreased over time, Blinder-Oaxaca decomposition was used to assess factors associated with these changes.

RESULTS

Seven dietary patterns were identified: modern, traditional, festival, winter, summer, monotonous, and spices. All diets were present in all survey rounds. In 1985, over 40% of households had diets not associated with any identified pattern, which declined to 12% by 2010. The proportion of the population in households adhering to the modern, winter, summer, and monotonous diets increased over time, whereas the proportion adhering to the traditional diet decreased. Although many factors were associated with adherence to dietary patterns in the pooled sample, changes in observed factors only explained a limited proportion of change over time due to variation in coefficients between periods. Increased real per capita expenditure was the largest driver of elevated adherence to dietary patterns over time, whereas changes in the agricultural system increased adherence to less diverse dietary patterns.

CONCLUSIONS

These findings highlight the need for both diversified agricultural production and a continued reduction in poverty in order to drive dietary improvement. This study lays the groundwork for further analysis of the impact of changing diets on health and nutrition.

Getting the food list 'right': an approach for the development of nutrition-relevant food lists for household consumption and expenditure surveys

OBJECTIVE

The present paper aimed to demonstrate how 24 h dietary recall data can be used to generate a nutrition-relevant food list for household consumption and expenditure surveys (HCES) using contribution analysis and stepwise regression.

DESIGN

The analysis used data from the 2011/12 Bangladesh Integrated Household Survey (BIHS), which is nationally representative of rural Bangladesh. A total of 325 primary sampling units (PSU=village) were surveyed through a two-stage stratified sampling approach. The household food consumption module used for the analysis consisted of a 24 h open dietary recall in which the female member in charge of preparing and serving food was asked about foods and quantities consumed by the whole household.

SETTING

Rural Bangladesh.ParticipantsA total of 6500 households.

RESULTS

The original 24 h open dietary recall data in the BIHS were comprised of 288 individual foods that were grouped into ninety-four similar food groups. Contribution analysis and stepwise regression were based on nutrients of public health interest in Bangladesh (energy, protein, fat, Fe, Zn, vitamin A). These steps revealed that a list of fifty-nine food items captures approximately 90 % of the total intake and up to 90 % of the between-person variation for the key nutrients based on the diets of the population.

CONCLUSIONS

The study illustrates how 24 h open dietary recall data can be used to generate a country-specific nutrition-relevant food list that could be integrated into an HCES consumption module to enable more accurate and comprehensive household-level food and nutrient analyses.

Potential Dietary Contributions From Rice and Wheat Flour Fortification in the Solomon Islands: Results From the 2012-2013 Household Income and Expenditure Survey

BACKGROUND

Solomon Islands (SI) mandated wheat flour fortification in 2010. Rice is a key staple food in SI, and its fortification may provide an opportunity to deliver additional micronutrients to the population.

OBJECTIVE

To determine whether fortified rice (proposed) and fortified wheat flour potentially benefit women of reproductive age (WRA).

METHODS

We analyzed data from the 2012-2013 Household Income and Expenditure Survey to quantify food purchases, which served as a proxy for food consumption. We accounted for varied household composition by using adult male equivalent (AME) adjustments.

RESULTS

Among 4478 households, 95.6% purchased rice and 86.6% purchased at least 1 food containing fortified wheat flour in the previous 14 days. Median apparent intake of rice among WRA was 205 g/d/AME. If fortified according to proposed standards, this apparent intake could result in the consumption of 12.3 mg iron/d, fulfilling 44% of the estimated average requirement (EAR), and 226 µg folic acid/d, satisfying 57% of World Health Organization's recommended intake of 400 µg/d. Overall, apparent rice consumption could fulfill 113%, 114%, and 131% of the EAR for WRA for zinc, thiamin, and niacin, respectively. Fortified wheat flour was consumed in much lower quantities, with an estimated apparent median intake of 22 g/d/AME among WRA and 78 g/d/AME among women in urban populations.

CONCLUSIONS

The potential benefit of fortified wheat flour in SI is likely limited to urban populations. Apparent consumption of fortified rice in SI could contribute considerably to daily intake of iron, B vitamins including folic acid, and zinc among WRA.

Comparison between household food purchase and individual food consumption in Brazil

Objective

The present study aimed to compare Household Budget Survey (HBS) data on food purchasing and individual food consumption, collected in the same nationwide survey.

Design

Food purchase information for each household was collected by a seven-day collective acquisition diary, applied to 55 970 households. Food consumption information was obtained from household members over 10 years old by the application of two non-consecutive food records in a sub-sample of the HBS. Cooking and correction factors were applied when necessary, and all food items reported were grouped into twelve main food groups. Food purchase and consumption data were presented as absolute weight (g/person per d) and as relative contribution to energy intake (%) for the overall study population, which was stratified according to household income.

Setting

Brazil.

Participants

National estimates of food consumption and purchase for Brazil.

Results

The greatest differences between purchase and consumption data (purchase minus consumption) were observed for meat (−168 g), beans/legumes (−48 g), roots/tubers (−36 g) and fruits (−31 g). When expressed in terms of energy contribution, the highest differences were found for cereals (13 %) and oils and fats (11 %). Differences between purchase and consumption data were generally lower in the highest compared with the lowest household income quintile; and were lower for most main food groups when considering only foods reported as being eaten at home.

Conclusions

With few exceptions, food purchase expressed as relative energy contribution, as opposed to absolute weight, can provide a good picture of actual consumption in the Brazilian population.

Assessing dietary intakes from household budget surveys: A national analysis in Bangladesh

BACKGROUND

Accurate national information on dietary intakes, including heterogeneity among individuals, is critical to inform health implications and policy priorities. In low- and middle-income countries, household expenditure surveys constitute the major source of food data, but with uncertain validity for individual-level intakes.

OBJECTIVE

To investigate how individualized dietary consumption estimated from household survey data compared with individual-level 24-hr dietary recalls (24hR); and to assess potential heterogeneity by method for individualizing household intakes, dietary indicator, and individual characteristics (age, sex, education, religion, household income).

METHODS

We evaluated data from the 2011-2012 Bangladesh Household Integrated Survey (BIHS), which included household-level consumption data (5,503 households) and individual-level dietary data based on 24hR from these households (22,173 participants). Household and 24hR estimates were standardized and harmonized for 33 dietary indicators, including 9 food groups, total energy, 8 macronutrients, and 15 micronutrients. Individual consumption was estimated from household data using two approaches, the Adult Male Equivalent (AME) and per capita (PC) approach. For each dietary indicator, differences in household vs. individual mean estimates were evaluated overall and by strata of individual characteristics, using Spearman's correlations and univariate and multivariate linear regression models.

RESULTS

Individualized household estimates overestimated individual intakes from 24hR for all dietary factors using either estimation method (P<0.001 for each), except for starchy vegetables (AME: P = 0.15; PC: P = 0.85). For foods, overestimation ranged from 4% for seafood to about 240% for fruits, and for nutrients from 11% for carbohydrates and poly-unsaturated fats to 55% for vitamin C, with similar overestimation for the AME and the PC method. By strata, overestimation was modestly higher in men vs. women, in children (0-10y) vs. adolescents (11-19y) and adults (20-44y, ≥45y), among adults of higher (≥6y) vs. lower (<6y) education, in Muslims vs. other religions (Christians, Hindus), and for the lowest vs. all other income groups. This overestimation was notably higher in young children (0-5y) vs. all other age groups and in the lowest vs. all other income groups. Underestimation was rarely observed, for example for milk intake (-56%) in young children (0-5y). The PC approach did not capture heterogeneity in validity of estimation of different dietary factors by age, mainly in children (0-5y, 6-10y). Spearman's correlations between individualized household estimates and 24hR data were higher for the AME (0.30-0.70) than PC (0.20-0.50) approach. Findings were similar with and without multivariate regression, with proportions of variance (R2) in 24hR intakes explained by the AME being generally greater than PC estimates, yet still low to modest.

CONCLUSIONS

In this national survey, established methods for estimating individual level intakes from household surveys produce overestimation of intakes of nearly all dietary indicators, with significant variation depending on the dietary factor and modest variation depending on individual characteristics. These findings suggest a need for new methods to estimate individual-level consumption from household survey estimates.

Household food group expenditure patterns are associated with child anthropometry at ages 5, 8 and 12 years in Ethiopia, India, Peru and Vietnam

Population-level analysis of dietary influences on nutritional status is challenging in part due to limitations in dietary intake data. Household expenditure surveys, covering recent household expenditures and including key food groups, are routinely conducted in low- and middle-income countries. These data may help identify patterns of food expenditure that relate to child growth.

OBJECTIVES

We investigated the relationship between household food expenditures and child growth using factor analysis.

METHODS

We used data on 6993 children from Ethiopia, India, Peru and Vietnam at ages 5, 8 and 12y from the Young Lives cohort. We compared associations between household food expenditures and child growth (height-for-age z scores, HAZ; body mass index-for-age z scores, BMI-Z) using total household food expenditures and the "household food group expenditure index" (HFGEI) extracted from household expenditures with factor analysis on the seven food groups in the child dietary diversity scale, controlling for total food expenditures, child dietary diversity, data collection round, rural/urban residence and child sex. We used the HFGEI to capture households' allocations of their finances across food groups in the context of local food pricing, availability and pReferences RESULTS: The HFGEI was associated with significant increases in child HAZ in Ethiopia (0.07), India (0.14), and Vietnam (0.07) after adjusting for all control variables. Total food expenditures remained significantly associated with increases in BMI-Z for India (0.15), Peru (0.11) and Vietnam (0.06) after adjusting for study round, HFGEI, dietary diversity, rural residence, and whether the child was female. Dietary diversity was inversely associated with BMI-Z in India and Peru. Mean dietary diversity increased from age 5y to 8y and decreased from age 8y to 12y in all countries.

CONCLUSION

Household food expenditure data provide insights into household food purchasing patterns that significantly predict HAZ and BMI-Z. Including food expenditure patterns data in analyses may yield important information about child nutritional status and linear growth.

Estimates of average energy requirements in Bangladesh: Adult Male Equivalent values for use in analyzing household consumption and expenditure surveys

This dataset contains Adult Male Equivalent (AME) values for use in Bangladesh. These were constructed using prescriptive nutritional constructs adapted to the actual growth and weight pattern seen in Bangladesh. This dataset provides a common base to facilitate for future work with household consumption and expenditure data in Bangladesh while updating the average energy requirements for infants and young children for the WHO 2006 growth standards and 2007 growth reference curves.

Comparison of food consumption in Indian adults between national and sub-national dietary data sources

Accurate data on dietary intake are important for public health, nutrition and agricultural policy. The National Sample Survey is widely used by policymakers in India to estimate nutritional outcomes in the country, but has not been compared with other dietary data sources. To assess relative differences across available Indian dietary data sources, we compare intake of food groups across six national and sub-national surveys between 2004 and 2012, representing various dietary intake estimation methodologies, including Household Consumption Expenditure Surveys (HCES), FFQ, food balance sheets (FBS), and 24-h recall (24HR) surveys. We matched data for relevant years, regions and economic groups, for ages 16-59. One set of national HCES and the 24HR showed a decline in food intake in India between 2004-2005 and 2011-2012, whereas another HCES and FBS showed an increase. Differences in intake were smallest between the two HCES (1 % relative difference). Relative to these, FFQ and FBS had higher intake (13 and 35 %), and the 24HR lower intake (-9 %). Cereal consumption had high agreement across comparisons (average 5 % difference), whereas fruit and nuts, eggs, meat and fish and sugar had the least (120, 119, 56 and 50 % average differences, respectively). Spearman's coefficients showed high correlation of ranked food group intake across surveys. The underlying methods of the compared data highlight possible sources of under- or over-estimation, and influence their relevance for addressing various research questions and programmatic needs.

Validation of a Dish-Based Semiquantitative Food Questionnaire in Rural Bangladesh

A locally validated tool was needed to evaluate long-term dietary intake in rural Bangladesh. We assessed the validity of a 42-item dish-based semi-quantitative food frequency questionnaire (FFQ) using two 3-day food diaries (FDs). We selected a random subset of 47 families (190 participants) from a longitudinal arsenic biomonitoring study in Bangladesh to administer the FFQ. Two 3-day FDs were completed by the female head of the households and we used an adult male equivalent method to estimate the FD for the other participants. Food and nutrient intakes measured by FFQ and FD were compared using Pearson's and Spearman's correlation, paired t-test, percent difference, cross-classification, weighted Kappa, and Bland-Altman analysis. Results showed good validity for total energy intake (paired t-test, p < 0.05; percent difference <10%), with no presence of proportional bias (Bland-Altman correlation, p > 0.05). After energy-adjustment and de-attenuation for within-person variation, macronutrient intakes had excellent correlations ranging from 0.55 to 0.70. Validity for micronutrients was mixed. High intraclass correlation coefficients (ICCs) were found for most nutrients between the two seasons, except vitamin A. This dish-based FFQ provided adequate validity to assess and rank long-term dietary intake in rural Bangladesh for most food groups and nutrients, and should be useful for studying dietary-disease relationships.

Estimating nutrient fortification levels in condiments and seasonings for public health programs: considerations and adaptations

Condiments and seasonings have been considered as potential vehicles for fortification in place of, or in addition to, fortifiable staple foods. Methodologies for establishing fortification programs focus primarily on use of staple foods, which are consumed in larger portions than condiments and seasonings. Some fortification models assume self-limiting consumption relative to the maximum energy consumed by target populations. However, this assumption may prove incorrect for estimating fortification concentrations of condiments and seasonings because they may only provide negligible energy. Although flavor or color may limit consumption, these limits would vary across each condiment or seasoning vehicle. In addition, the small volume of condiments and seasonings consumed relative to staple foods can lead to proportionally larger potential errors than with staple foods when measuring usual dietary intakes for establishing safe and effective fortification concentrations. This paper reviews available methods for setting fortification levels, whether or how available methods or conceptual frameworks could be adapted to condiments and seasonings, and gaps in knowledge for appropriately using condiments and seasonings as vehicles for fortification in public health.

Iron Absorption from an Intrinsically Labeled Lentil Meal Is Low but Upregulated in Women with Poor Iron Status

BACKGROUND

Low iron absorption from important staple foods may contribute to iron deficiency in developing countries. To date, few studies have examined the iron bioavailability of pulse crops as commonly prepared and consumed by humans.

OBJECTIVE

The objectives were to characterize the iron absorption from a test meal of intrinsically labeled (57)Fe lentils prepared as dal, to compare the bioavailability of iron from (57)Fe in dal with that observed for a reference dose of (58)Fe as ferrous sulfate, and to assess associations between iron absorption and iron status indicators.

METHODS

This crossover study included 19 nonpregnant women (n = 6 anemic; hemoglobin: <12.0 g/dL) who consumed 2 test meals on consecutive days in a counter-balanced order, ferrous sulfate (7 mg FeSO4 plus 1 mg (58)Fe) and 330 g dal (lentils enriched to 85.1% with (57)Fe, 8 mg native (57)Fe). Iron absorption was determined by analyzing blood samples taken 14 d after dosing with the use of magnetic sector thermal ionization mass spectrometry.

RESULTS

We found that the mean iron absorption from the dal was 2.20% ± 3.40% and was significantly lower than the 23.6% ± 13.2% observed from the same iron load given as ferrous sulfate (P < 0.001). Absorption of non-heme iron from dal and from ferrous sulfate was inversely associated with serum ferritin (SF; r = -0.50, P = 0.05 and r = -0.81, P < 0.001, respectively) and serum hepcidin (r = -0.45, P = 0.05 and r = -0.60, P = 0.007, respectively). Anemic women absorbed more iron from either source (1.20% from dal, P = 0.10; 18.3% from ferrous sulfate, P = 0.001) compared with women who were iron replete.

CONCLUSIONS

Iron absorption from the dal was low overall but upregulated in anemic women. Both SF and hepcidin were inversely associated with iron absorption from both a supplemental and a food-based non-heme iron source in nonanemic and anemic women.

Assessing Alternative Industrial Fortification Portfolios: A Bangladesh Case Study

Background

Approximately 1.2 million disability-adjusted life years (DALYs) are lost annually in Bangladesh due to deficiencies of vitamin A, iron, and zinc.

Objective

To provide evidence on the coverage, costs, and cost-effectiveness of alternative fortification interventions to inform nutrition policy-making in Bangladesh.

Methods

Combining the 2005 Bangladesh Household Income and Expenditure Survey with a Bangladesh food composition table, apparent intakes of energy, vitamin A, iron, and zinc, and the coverage and apparent consumption levels of fortifiable vegetable oil and wheat flour are estimated. Assuming that fortification levels are those established in official regulations, the costs and cost-effectiveness of the two vehicles are assessed independently and as a two-vehicle portfolio.

Results

Vegetable oil has a coverage rate of 76% and is estimated to reduce the prevalence of inadequate vitamin A intake from 83% to 64%. The coverage of wheat flour is high (65%), but the small quantities consumed result in small reductions in the prevalence of inadequate intakes: 1.5 percentage points for iron, less than 1 for zinc, and 2 for vitamin A, while reducing average Estimated Average Requirement (EAR) gaps by 8%, 9%, and 15%, respectively. The most cost-effective 10-micronutrient wheat flour formulation costs US$1.91 million annually, saving 129,212 DALYs at a unit cost of US$14.75. Fortifying vegetable oil would cost US$1.27 million annually, saving 406,877 DALYs at an average cost of US$3.25. Sensitivity analyses explore various permutations of the wheat flour formulation. Divisional variations in coverage, cost, and impact are examined.

Conclusions

Vegetable oil fortification is the most cost-effective of the three portfolios analyzed, but all three are very cost-effective options for Bangladesh.

Food crop production, nutrient availability, and nutrient intakes in Bangladesh: exploring the agriculture-nutrition nexus with the 2010 Household Income and Expenditure Survey

BACKGROUND

Systematic collection of national agricultural data has been neglected in many low- and middle-income countries for the past 20 years. Commonly conducted nationally representative household surveys collect substantial quantities of highly underutilized food crop production data.

OBJECTIVE

To demonstrate the potential usefulness of commonly available household survey databases for analyzing the agriculture-nutrition nexus.

METHODS

Using household data from the 2010 Bangladesh Household Income and Expenditure Survey, the role and significance of crop selection, area planted, yield, nutrient production, and the disposition of 34 food crops in affecting the adequacy of farming households' nutrient availability and nutrient intake status are explored. The adequacy of each farming household's available energy, vitamin A, calcium, iron, and zinc and households' apparent intakes and intake adequacies are estimated. Each household's total apparent nutrient intake adequacies are estimated, taking into account the amount of each crop that households consume from their own production, together with food purchased or obtained from other sources.

RESULTS

Even though rice contains relatively small amounts of micronutrients, has relatively low nutrient density, and is a relatively poor source of nutrients compared with what other crops can produce on a given tract of land, because so much rice is produced in Bangladesh, it is the source of 90% of the total available energy, 85% of the zinc, 67% of the calcium, and 55% of the iron produced by the agricultural sector. The domination of agriculture and diet by rice is a major constraint to improving nutrition in Bangladesh. Simple examples of how minor changes in the five most common cropping patterns could improve farming households' nutritional status are provided.

CONCLUSIONS

Household surveys' agricultural modules can provide a useful tool for better understanding national nutrient production realities and possibilities.

Differences in Relative Iron Bioavailability in Traditional Bangladeshi Meal Plans

Background

Iron deficiency is the most common nutrient deficiency worldwide. Large intakes of micronutrient-poor staple crops, coupled with low intakes of highly bioavailable dietary iron, are a major cause of this deficiency.

Objective

To examine the concentration and relative bioavailability of iron in several models ( n = 23) of traditional Bangladeshi meals (rice, lentils/dal, vegetable, and fish), as well as the effect of removal of the lentil seed coat on the nutritional quality of iron.

Methods

The relative bioavailability of iron was assessed by the in vitro/Caco-2 cell culture method, iron concentration by an inductively coupled argon-plasma emission spectrometer (ICAP-ES), and phytic acid concentration by colorimetric assay. The recipes contained 75% to 85% rice, 0% to 15% dal (containing whole or dehulled lentils), 0% to 15% vegetable curry, and 0% to 8% fish.

Results

While the iron concentrations of recipes containing dehulled dal were significantly lower than those of recipes containing whole dal ( p = .005), seed coat removal doubled relative iron bioavailability and increased phytic acid concentration ( p < .001). The addition of fish to the meals had no significant effect on relative iron bioavailability. Iron concentration and relative iron bioavailability were correlated in the recipes containing dehulled dal ( r = 0.48, p = .03), but not whole dal ( r = −0.047, p = .84).

Conclusions

The total amount of iron absorbed from traditional Bangladeshi meals is dependent upon iron concentration, and dehulling lentils removes inhibitory factors increasing iron uptake but also increases the density of phytic acid in the lentil sample. Thus, along with breeding for high iron concentration and bioavailability (i.e., biofortification), seed coat removal plus measures to lower phytic acid concentrations may be an important strategy to improve the bioavailability of iron in lentils and other pulse crops.

Estimating the impact of vitamin A-fortified vegetable oil in Bangladesh in the absence of dietary assessment data

Objective

Vitamin A deficiency is a serious health problem in Bangladesh. The 2011–12 Bangladesh Micronutrient Survey found 76·8 % of children of pre-school age were vitamin A deficient. In the absence of nationally representative, individual dietary assessment data, we use an alternative – household income and expenditure survey data – to estimate the potential impact of the introduction of vitamin A-fortified vegetable oil in Bangladesh.

Design

Items in the household income and expenditure survey were matched to food composition tables to estimate households’ usual vitamin A intakes. Then, assuming (i) the intra-household distribution of food is in direct proportion to household members’ share of the household’s total adult male consumption equivalents, (ii) all vegetable oil that is made from other-than mustard seed and that is purchased is fortifiable and (iii) oil fortification standards are implemented, we modelled the additional vitamin A intake due to the new fortification initiative.

Setting

Nationwide in Bangladesh.

Subjects

A weighted sample of 12240 households comprised of 55580 individuals.

Results

Ninety-nine per cent of the Bangladesh population consumes vegetable oil. The quantities consumed are sufficiently large and, varying little by socio-economic status, are able to provide an important, large-scale impact. At full implementation, vegetable oil fortification will reduce the number of persons with inadequate vitamin A intake from 115 million to 86 million and decrease the prevalence of inadequate vitamin A intake from 80 % to 60 %.

Conclusions

Vegetable oil is an ideal fortification vehicle in Bangladesh. Its fortification with vitamin A is an important public health intervention.

Policy Implications of Using a Household Consumption and Expenditures Survey versus an Observed-Weighed Food Record Survey to Design a Food Fortification Program

Background

Observed-Weighed Food Record Surveys (OWFR) are regarded as the most precise dietary assessment methodology, despite their recognized shortcomings, which include limited availability, high cost, small samples with uncertain external validity that rarely include all household members, Hawthorne effects, and using only 1 or 2 days to identify “usual intake.” Although Household Consumption and Expenditures Surveys (HCES) also have significant limitations, they are increasingly being used to inform nutrition policy.

Objective

To investigate differences in fortification simulations based on OWFR and HCES from Bangladesh.

Methods

The pre- and postfortification nutrient intake levels from the two surveys were compared.

Results

The total population-based rank orderings of oil, wheat flour, and sugar coverage were identical for the two surveys. OWFR found differences in women's and children's coverage rates and average quantities consumed for all three foods that were not detected by HCES. Guided by the Food Fortification Formulator, we found that these differences did not result in differences in recommended fortification levels. Differences were found, however, in estimated impacts: although both surveys found that oil would be effective in reducing the prevalence of inadequate vitamin A intake among both subpopulations, only OWFR also found that sugar and wheat flour fortification would significantly reduce inadequate vitamin A intake among children.

Conclusions

Despite the less precise measure of food consumption from HCES, the two surveys provide similar guidance for designing a fortification program. The external validity of these findings is limited. With relatively minor modifications, the precision of HCES in dietary assessment and the use of HCES in fortification programming could be strengthened.

Relative costs of 24-hour recall and Household Consumption and Expenditures Surveys for nutrition analysis

BACKGROUND

The technical and resource demands of the most precise dietary assessment methods, 24-hour recall and observed-weighed food records, have proven impractical for most low- and middle-income countries, leaving nutrition policymakers with a woefully inadequate evidence base and compromising nutrition program effectiveness.

OBJECTIVE

To better understand the relative costs of informing food and nutrition policy-making using two different data sources: 24-hour recall survey data and Household Consumption and Expenditures Survey (HCES) data.

METHODS

A comparative analysis of the costs of designing, implementing, and analyzing a 24-hour recall survey and the cost of secondary analysis of HCES data.

RESULTS

The cost of conducting a 24-hour recall survey with a sample of the size typical of HCES would be roughly 75 times higher than the cost of analyzing the HCES data.

CONCLUSIONS

Although the 24-hour recall method is undoubtedly more precise, it has become self-evident that the practical choice for most countries is not between these two surveys, but between having data from less precise, but much more readily available and affordable HCES or having no nationally representative data. In the light of growing concerns about inappropriate fortification policies developed without data, there is an urgent need to begin working to strengthen HCES to provide more precise food and nutrition data. The best way forward is not likely to rest with one data source or another, but with the development of an eclectic approach that exploits the strengths and weaknesses of alternative surveys and uses them to complement one another.

Monitoring and benchmarking population diet quality globally: a step-wise approach

INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support) aims to monitor and benchmark the healthiness of food environments globally. In order to assess the impact of food environments on population diets, it is necessary to monitor population diet quality between countries and over time. This paper reviews existing data sources suitable for monitoring population diet quality, and assesses their strengths and limitations. A step-wise framework is then proposed for monitoring population diet quality. Food balance sheets (FBaS), household budget and expenditure surveys (HBES) and food intake surveys are all suitable methods for assessing population diet quality. In the proposed 'minimal' approach, national trends of food and energy availability can be explored using FBaS. In the 'expanded' and 'optimal' approaches, the dietary share of ultra-processed products is measured as an indicator of energy-dense, nutrient-poor diets using HBES and food intake surveys, respectively. In addition, it is proposed that pre-defined diet quality indices are used to score diets, and some of those have been designed for application within all three monitoring approaches. However, in order to enhance the value of global efforts to monitor diet quality, data collection methods and diet quality indicators need further development work.

Household Consumption and Expenditures Surveys (HCES): a primer for food and nutrition analysts in low- and middle-income countries

BACKGROUND

The dearth of 24-hour recall and observed-weighed food record data--what most nutritionists regard as the gold standard source of food consumption data-has long been an obstacle to evidence-based food and nutrition policy. There have been a steadily growing number of studies using household food acquisition and consumption data from a variety of multipurpose, nationally representative household surveys as a proxy measure to overcome this fundamental information gap.

OBJECTIVE

To describe the key characteristics of these increasingly available Household Consumption and Expenditures Surveys (HCES) in order to help familiarize food and nutrition analysts with the strengths and shortcomings of these data and thus encourage their use in low- and middle-income countries; and to identify common shortcomings that can be readily addressed in the near term in a country-by-country approach, as new HCES are fielded, thereby beginning a process of improving the potential of these surveys as sources of useful data for better understanding food- and nutrition-related issues.

METHODS

Common characteristics of key food and nutrition information that is available in HCES and some basic common steps in processing HCES data for food and nutrition analyses are described.

RESULTS

The common characteristics of these surveys are documented, and their usefulness in addressing major food and nutrition issues, as well as their shortcomings, is demonstrated.

CONCLUSIONS

Despite their limitations, the use of HCES data constitutes a generally unexploited opportunity to address the food consumption information gap by using survey data that most countries are already routinely collecting.

Measurement of food consumption to inform food fortification and other nutrition programs: an introduction to methods and their application

BACKGROUND

Information on dietary intake is essential for the assessment, planning, monitoring, and evaluation of nutritional interventions. A number of methods are available, each with unique strengths and weaknesses. Dietary intake records, 24-hour recalls, and Food Frequency Questionnaires (FFQs) determine food consumption and nutrient intakes of populations based on individual assessment; few countries have such data at national or regional levels. Food and Agriculture Organization (FAO) Food Balance Sheets (FBS) and food industry data, available in most countries, permit calculations of per capita food consumption but do not provide data on individual consumption. Household Consumption and Expenditures Surveys (HCES) are available for most countries and provide data that can be used to calculate consumption of fortification vehicles and to estimate additional intakes of micronutrients delivered through them to specific population groups.

OBJECTIVE

To introduce the reader to the set of papers included in this Supplement reviewing methods and experience with HCES to inform nutrition, and specifically food fortification programs.

METHODS

The Monitoring, Assessment, and Data (MAD) working group and colleagues critically reviewed experiences in estimating dietary intakes,focusing on the use of secondary analysis of HCES.

RESULTS

HCES predict coverage of the population that consumes a fortification vehicle and consumed amounts of fortification vehicles. HCES allow comparisons of different population strata and may also approximate micronutrient adequacy, based on nutrient density, at the household level.

CONCLUSIONS

HCES are useful to inform food fortification and other nutrition programs for planning interventions, but further work is necessary. Currently, combined use of traditional dietary surveys is needed for assessment and for program monitoring and evaluation.

Should Household Consumption and Expenditures Surveys (HCES) be Used for Nutritional Assessment and Planning?

Background

Household Consumption and Expenditures Surveys (HCES) are routinely conducted in several countries on nationally representative samples, often on a regular basis. The HCES have been considered as a potential alternative to more expensive surveys of individuals' food intakes for use in nutritional assessment and in planning programs such as food fortification. HCES gather information on household food availability (purchased, produced, or received as gifts) and use over a given period of time, often the past week or month.

Objective

To discuss the potential usefulness of HCES consumption data for nutritional assessment and planning for populations of households and individuals within the households.

Conclusions

There are several limitations to the HCES, most notably the difficulty of estimating the intrahousehold allocation of foods and therefore of quantifying the actual food intake of individual household members. Another concern is the lack of information on the variability of consumption over time, making it difficult to estimate the distribution of usual consumption, and thus the prevalence of nutrient inadequacies or excesses. Other potential limitations might be addressed by improvements to the HCES questionnaires, such as including information on foods that are available but not consumed and those that are consumed outside the home. Research is needed to better understand both the strengths and the weaknesses of the HCES data when used to assess and plan intakes at the household and individual levels