Still waiting for Godot? Improving Household Consumption and Expenditures Surveys (HCES) to enable more evidence-based nutrition policies

Food Insecurity Classification in Rural Areas of Mozambique: An Integrated Analysis of Survey-Based Indicators

National food insecurity early warning systems and food policy interventions need reliable information concerning the classification of food insecurity. The aim of this paper was to produce an acute food insecurity classification in Mozambique, by: i) analyzing food insecurity indicators individually; ii) comparing it with a new integrated analysis of survey-based indicators called the "Matrix Analysis." The Matrix results show more severe classifications than the single indicators for the analyzed districts. The matrix novelty consists on a cross-tabulation of all indicators, allowing a less subjective analysis. Further research is needed on how the Matrix approach could complement national classification systems.

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.

Using household economic survey data to assess food expenditure patterns and trends in a high-income country with notable health inequities

This study aimed to identify dietary trends in Aotearoa New Zealand (NZ) and whether inequities in dietary patterns are changing. We extracted data from the Household Economic Survey (HES), which was designed to provide information on impacts of policy-making in NZ, and performed descriptive analyses on food expenditures. Overall, total household food expenditure per capita increased by 0.38% annually over this period. Low-income households spent around three quarters of what high-income households spent on food per capita. High-income households experienced a greater increase in expenditure on nuts and seeds and a greater reduction in expenditure on processed meat. There was increased expenditure over time on fruit and vegetables nuts and seeds, and healthy foods in Māori (Indigenous) households with little variations in non-Māori households. But there was little change in processed meat expenditure for Māori households and expenditure on less healthy foods also increased over time. Routinely collected HES data were useful and cost-effective for understanding trends in food expenditure patterns to inform public health interventions, in the absence of nutrition survey data. Potentially positive expenditure trends for Māori were identified, however, food expenditure inequities in processed meat and less healthy foods by ethnicity and income continue to be substantial.

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.

Using Household Expenditure Surveys for Comparable and Replicable Nutritional Analysis: Evidence from México

In this study, we explore how to use household expenditures and income surveys (HEIS) to provide replicable and comparable measures of nutrients availability at the population level. Our method formalizes the common practice in the literature and consists of three steps: identification of relevant food categories, pairing of food contents food groups in HEIS data, and calculation of the typical amount of nutrients by food group. We illustrate the usage of the method with Mexican data and provide a publicly available data set to readily convert food purchases into six nutrients: calories, proteins, vitamins A and C, iron, and zinc. We perform a descriptive analysis of the evolution of nutrients intake among Mexican households between 2008 and 2020, considering differences by income level. Our results reflect the effect of the COVID-19 pandemic on nutrient availability in Mexican households, mainly driven by a substantial reduction in the expenditure in food consumed away from home, although for most nutrients the trend was stable over most of the 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.

Household-level consumption data can be redistributed for individual-level Optifood diet modeling: analysis from four countries

A barrier to using Optifood linear programming (LP), which identifies nutrient gaps and supports population‐specific food‐based recommendation (FBR) development, is the requirement for dietary intake data. We investigated whether Household Consumption and Expenditure Surveys (HCESs) could be used instead of individual‐level 24‐h recalls (24HRs). The 24HR data from 12‐ to 23‐month‐old breastfeeding children in rural Kenya, Uganda, Guatemala, and Bangladesh were paired with HCES food consumption data from similar areas (n = 8) and time periods. HCES food intakes (g/week) were estimated using adult male equivalents, adjusted for breastfeeding. Paired HCES‐ and 24HR‐defined LP inputs and outputs were compared using percentage agreement. Mean overall percentage agreements were 42%, 63%, and 80%, for food, food subgroup, and food‐group model parameters, respectively. HCES food lists were on average 1.3 times longer than 24HR. Similar nutrient gaps (77–100% agreement), food sources of nutrients (71–100% agreement), and FBRs (80–100% agreement) were identified. The results suggest that HCES data can be used in Optifood analyses for 12‐ to 23‐month‐old children, despite recognized challenges of using it to estimate dietary intakes of young children compared with older age groups. Further analyses, however, are required for different age groups and locations to confirm expectations that it would perform equally well.

A Typology of Food Environments in the Pacific Region and Their Relationship to Diet Quality in Solomon Islands

Extensive literature describes the importance of food environments (FEs) as a driver of food choices and nutrition outcomes; yet existing FE frameworks do not adequately capture the diversity of FEs relevant to the Pacific Region. This limits identification of opportunities in food systems to reduce the multiple burden of malnutrition. We present a conceptual typology of FEs including six primary FEs relevant in the Pacific; wild; cultivated; kin and community; informal retail; formal retail; and food aid and services. We then apply this typology to food acquisition data from Solomon Islands 2012/13 Household Income and Expenditure Survey and analyse the relationship between FEs and diet quality. The cultivated FE accounts for 60% of the quantity of food acquired nationally, followed by wild (15%), kin and community (9%), and formal and informal retail FEs (8% each), with wide variation between urban and rural households, provinces and wealth groups. Reliance on different FEs is a significant predictor of diet quality and affirms the importance of subsistence fisheries and agriculture, and community and kinship networks. Integration of a FE typology such as the one presented here in commonly conducted household expenditure surveys offers significant opportunity to advance our understanding of food system leverage points to improve nutrition and health.

Perspective: The Importance of Water Security for Ensuring Food Security, Good Nutrition, and Well-being

Water security is a powerful concept that is still in its early days in the field of nutrition. Given the prevalence and severity of water issues and the many interconnections between water and nutrition, we argue that water security deserves attention commensurate with its importance to human nutrition and health. To this end, we first give a brief introduction to water insecurity and discuss its conceptualization in terms of availability, access, use, and stability. We then lay out the empirical grounding for its assessment. Parallels to the food-security literature are drawn throughout, both because the concepts are analogous and food security is familiar to the nutrition community. Specifically, we review the evolution of scales to measure water and food security and compare select characteristics. We then review the burgeoning evidence for the causes and consequences of water insecurity and conclude with 4 recommendations: 1) collect more water-insecurity data (i.e., on prevalence, causes, consequences, and intervention impacts); 2) collect better data on water insecurity (i.e., measure it concurrently with food security and other nutritional indicators, measure intrahousehold variation, and establish baseline indicators of both water and nutrition before interventions are implemented); 3) consider food and water issues jointly in policy and practice (e.g., establish linkages and possibilities for joint interventions, recognize the environmental footprint of nutritional guidelines, strengthen the nutrition sensitivity of water-management practices, and use experience-based scales for improving governance and regulation across food and water systems); and 4) make findings easily available so that they can be used by the media, community organizations, and other scientists for advocacy and in governance (e.g., tracking progress towards development goals and holding implementers accountable). As recognition of the importance of water security grows, we hope that so too will the prioritization of water in nutrition research, funding, and policy.

Affordability of nutritious foods for complementary feeding in Eastern and Southern Africa

Low intake of diverse complementary foods causes critical nutrient gaps in the diets of young children. Inadequate nutrient intake in the first 2 years of life can lead to poor health, educational, and economic outcomes. In this study, the extent to which food affordability is a barrier to consumption of several nutrients critical for child growth and development was examined in Ethiopia, Mozambique, South Africa, Tanzania, Uganda, and Zambia. Drawing upon data from nutrient gap assessments, household surveys, and food composition tables, current consumption levels were assessed, the cost of purchasing key nutritious foods that could fill likely nutrient gaps was calculated, and these costs were compared with current household food expenditure. Vitamin A is affordable for most households (via dark leafy greens, orange-fleshed vegetables, and liver) but only a few foods (fish, legumes, dairy, dark leafy greens, liver) are affordable sources of iron, animal-source protein, or calcium, and only in some countries. Zinc is ubiquitously unaffordable. For unaffordable nutrients, approaches to reduce prices, enhance household production, or increase household resources for nutritious foods are needed.

Affordability of nutritious foods for complementary feeding in South Asia

The high prevalence of stunting and micronutrient deficiencies among children in South Asia has lifelong health, educational, and economic consequences. For children aged 6-23 months, undernutrition is influenced by inadequate intake of complementary foods containing nutrients critical for growth and development. The affordability of nutrients lacking in young children's diets in Bangladesh, India, and Pakistan was assessed in this study. Using data from nutrient gap assessments and household surveys, household food expenditures were compared with the cost of purchasing foods that could fill nutrient gaps. In all 3 countries, there are multiple affordable sources of vitamin A (orange-fleshed vegetables, dark leafy greens, liver), vitamin B12 (liver, fish, milk), and folate (dark leafy greens, liver, legumes, okra); few affordable sources of iron and calcium (dark leafy greens); and no affordable sources of zinc. Affordability of animal-source protein varies, with several options in Pakistan (fish, chicken, eggs, beef) and India (fish, eggs, milk) but few in Bangladesh (eggs). Approaches to reduce prices, enhance household production, or increase incomes are needed to improve affordability.

Aquatic Foods and Nutrition in the Pacific

National rates of aquatic food consumption in Pacific Island Countries and Territories are among the highest in the world, yet the region is suffering from extensive levels of diet-related ill health. The aim of this paper is to examine the variation in consumption patterns and in nutrient composition of aquatic foods in the Pacific, to help improve understanding of their contribution to food and nutrition security. For this examination we analysed nutrient composition data and trade data from two novel region-specific databases, as well as consumption data from national and village level surveys for two Melanesian case studies, Vanuatu and Solomon Islands. Results demonstrated that consumption depends on availability and the amount and type of aquatic food consumed, and its contribution to nutrition security varies within different geographic and socio-demographic contexts. More data is needed on locally relevant species and consumption patterns, to better inform dietary guidelines and improve public health both now and into the future. Advice on aquatic food consumption must consider the nutrient composition and quantity of products consumed, as well as accessibility through local food systems, to ensure they contribute to diverse and healthy diets.

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.

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.

Assessing food security using household consumption expenditure surveys (HCES): a scoping literature review

OBJECTIVE

To meet some of the UN's seventeen Sustainable Development Goals by 2030, there is a need for more effective policy to reduce food insecurity in low-income and lower-middle-income countries (LMIC). Measuring progress towards these goals requires reliable indicators of food security in these countries. Routinely conducted household consumption and expenditure surveys (HCES) provide potentially valuable and nationally representative data sets for this purpose. The present study aimed to assess methods used to determine national food security status using proxy measures from HCES data in LMIC globally.

DESIGN

A scoping literature review was conducted using electronic databases. Of the 929 abstracts identified, a total of twenty articles were reviewed against strict inclusion and exclusion criteria and included for further analysis.

RESULTS

Fourteen LMIC globally were represented in the twenty articles. The simplest metric used to indicate food insecurity compared household food expenditure against a level of expenditure considered to be below the poverty line. Data on acquisition of food was commonly converted to available energy for the household using local food composition tables and expressed as a proportion of household total energy requirements. Dietary diversity was also assessed in some studies as well as experience of food insecurity.

CONCLUSIONS

The review demonstrated that routinely collected HCES data sets provide a useful resource for the measurement of household food security in often resource-limited LMIC. Standardisation of methods used to assess food security is needed to allow for more useful comparisons between countries, as well as to assess temporal trends.

Does ownership of improved dairy cow breeds improve child nutrition? A pathway analysis for Uganda

The promotion of livestock production is widely believed to support enhanced diet quality and child nutrition, but the empirical evidence for this causal linkage remains narrow and ambiguous. This study examines whether adoption of improved dairy cow breeds is linked to farm-level outcomes that translate into household-level benefits including improved child nutrition outcomes in Uganda. Using nationwide data from Uganda’s National Panel Survey, propensity score matching is used to create an unbiased counterfactual, based on observed characteristics, to assess the net impacts of improved dairy cow adoption. All estimates were tested for robustness and sensitivity to variations in observable and unobservable confounders. Results based on the matched samples showed that households adopting improved dairy cows significantly increased milk yield—by over 200% on average. This resulted in higher milk sales and milk intakes, demonstrating the potential of this agricultural technology to both integrate households into modern value chains and increase households’ access to animal source foods. Use of improved dairy cows increased household food expenditures by about 16%. Although undernutrition was widely prevalent in the study sample and in matched households, the adoption of improved dairy cows was associated with lower child stunting in adopter household. In scale terms, results also showed that holding larger farms tends to support adoption, but that this also stimulates the household’s ability to achieve gains from adoption, which can translate into enhanced nutrition.

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.

Comparison of a Household Consumption and Expenditures Survey with Nationally Representative Food Frequency Questionnaire and 24-hour Dietary Recall Data for Assessing Consumption of Fortifiable Foods by Women and Young Children in Cameroon

BACKGROUND

Household Consumption and Expenditures Surveys (HCES) are potential sources of data on dietary patterns for planning fortification programs, but they rarely have been compared with individual-level dietary assessment methods.

OBJECTIVE

To compare apparent consumption of fortifiable foods estimated from the Third Cameroon Household Survey (ECAM3) with the results of a national dietary survey using food frequency questionnaire (FFQ) and 24-hour recall (24HR) methods among women aged 15 to 49 years and children aged 12 to 59 months.

METHODS

We estimated coverage and frequency of consumption in the previous week (ECAM3 and FFQ) and coverage and amount consumed on the previous day (ECAM3 and 24HR) of refined vegetable oil, wheat flour, sugar, and bouillon cubes.

RESULTS

Coverage in the past week as measured by the ECAM3 and FFQ, respectively, was 64% vs. 54% for oil, 60% vs. 92% for flour, 69% vs. 78% for sugar, and 85% vs. 96% for bouillon cubes. The different methods identified similar patterns of coverage among subgroups for oil, but patterns for other foods were variable. Frequency of consumption and previous-day coverage were lower with the ECAM3 than with the FFQ and 24HR, likely reflecting infrequent acquisition relative to intake. For women, the mean amounts consumed on the previous day (among consumers) were 43 vs. 29 g of oil, 71 vs. 83 g of flour, 42 vs. 32 g of sugar, and 5.0 vs. 2.4 g of bouillon cubes (ECAM and 24HR, respectively).

CONCLUSIONS

HCES provide useful information on patterns of food access but inadequate information on individual consumption amounts to estimate appropriate food fortification levels.

A cross-sectional analysis of the cost and affordability of achieving recommended intakes of non-starchy fruits and vegetables in the capital of Vanuatu

Background

The low-income Pacific Island nation of Vanuatu is experiencing a double burden of diet-related disease whereby micronutrient deficiencies and underweight occur at the same time as obesity related non-communicable diseases. Increasing intakes of nutrient dense, energy dilute foods such as fruits and vegetables will be important to address this issue. However, reduced access to agricultural land in urban areas provides limited opportunities for traditional subsistence fruit and vegetable production. Set in Port Vila, Vanuatu’s capital and main urban centre, this study aimed to determine the cost and affordability of meeting international recommendations to consume at least 400 g of non-starchy fruits and vegetables (NSFV) per person per day, and assess the adequacy of households’ NSFV expenditure.

Methods

NSFV prices from the 2010 Vanuatu Consumer Price Index (n = 56) were used to determine the minimum monthly cost of purchasing 400 g of local NSFV per person, after accounting for wastage. The 2010 Vanuatu Household Income and Expenditure Survey (n = 578 households) was analysed to determine the proportion of households’ total and food budget required to purchase 400 g of local NSFV for all household members. Household NSFV costs were also compared against actual household expenditure on these items. Consumption of own-produce and gifts received were included within estimates of food expenditure.

Results

The minimum cost of purchasing the recommended amount of local NSFV was 1,486.24 vatu ($16.60 US) per person per month. This level of expenditure would require an average of 9.6% (SD 6.4%) of households’ total budget and 26.3% (SD 25.8%) of their food budget. The poorest households would need to allocate 40.9% (SD 34.3%) of their total food budget to NSFV to purchase recommended amounts of these foods. Twenty-one percent of households recorded sufficient NSFV expenditure while 23.4% recorded less than 10% of the expenditure required to meet the NSFV recommendations.

Conclusions

Achieving recommended intakes of local NSFV in Port Vila is largely unaffordable, and expenditure on these foods was inadequate for most households in Port Vila in 2010. Addressing fruit and vegetable affordability will be an important consideration in prevention of non-communicable diseases in the Pacific region.

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.

Trade as a structural driver of dietary risk factors for noncommunicable diseases in the Pacific: an analysis of household income and expenditure survey data

Background

Noncommunicable diseases are a health and development challenge. Pacific Island countries are heavily affected by NCDs, with diabetes and obesity rates among the highest in the world. Trade is one of multiple structural drivers of NCDs in the Pacific, but country-level data linking trade, diets and NCD risk factors are scarce. We attempted to illustrate these links in five countries. The study had three objectives: generate cross-country profiles of food consumption and expenditure patterns; highlight the main ‘unhealthy’ food imports in each country to inform targeted policymaking; and demonstrate the potential of HCES data to analyze links between trade, diets and NCD risk factors, such as obesity.

Methods

We used two types of data: obesity rates as reported by WHO and aggregated household-level food expenditure and consumption from Household Income and Expenditure Survey reports. We classified foods in HIES data into four categories: imported/local, ‘unhealthy’/’healthy’, nontraditional/traditional, processed/unprocessed. We generated cross-country profiles and cross-country regressions to examine the relationships between imported foods and unhealthy foods, and between imported foods and obesity.

Results

Expenditure on imported foods was considerable in all countries but varied across countries, with highest values in Kiribati (53%) and Tonga (52%) and lowest values in Solomon Islands and Vanuatu (30%). Rice and sugar accounted for significant amounts of imported foods in terms of expenditure and calories, ranking among the top 3 foods in most countries. We found significant or near-significant associations in expenditure and caloric intake between ‘unhealthy’ and imported foods as well as between imported foods and obesity, though inferences based on these associations should be made carefully due to data constraints.

Conclusions

While additional research is needed, this study supports previous findings on trade as a structural driver of NCD risk and identifies the top imported foods that could serve as policy targets. Moreover, this analysis is proof-of-concept that the methodology is a cost-effective way for countries to use existing data to generate policy-relevant evidence on links between trade and NCDs. We believe that the methodology is replicable to other countries globally. A user-friendly Excel tool is available upon request to assist such analyses.

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.

Maize flour fortification in Africa: markets, feasibility, coverage, and costs

The economic feasibility of maize flour and maize meal fortification in Kenya, Uganda, and Zambia is assessed using information about the maize milling industry, households' purchases and consumption levels of maize flour, and the incremental cost and estimated price impacts of fortification. Premix costs comprise the overwhelming share of incremental fortification costs and vary by 50% in Kenya and by more than 100% across the three countries. The estimated incremental cost of maize flour fortification per metric ton varies from $3.19 in Zambia to $4.41 in Uganda. Assuming all incremental costs are passed onto the consumer, fortification in Zambia would result in at most a 0.9% increase in the price of maize flour, and would increase annual outlays of the average maize flour-consuming household by 0.2%. The increases for Kenyans and Ugandans would be even less. Although the coverage of maize flour fortification is not likely to be as high as some advocates have predicted, fortification is economically feasible, and would reduce deficiencies of multiple micronutrients, which are significant public health problems in each of these countries.

What are we assessing when we measure food security? A compendium and review of current metrics

The appropriate measurement of food security is critical for targeting food and economic aid; supporting early famine warning and global monitoring systems; evaluating nutrition, health, and development programs; and informing government policy across many sectors. This important work is complicated by the multiple approaches and tools for assessing food security. In response, we have prepared a compendium and review of food security assessment tools in which we review issues of terminology, measurement, and validation. We begin by describing the evolving definition of food security and use this discussion to frame a review of the current landscape of measurement tools available for assessing food security. We critically assess the purpose/s of these tools, the domains of food security assessed by each, the conceptualizations of food security that underpin each metric, as well as the approaches that have been used to validate these metrics. Specifically, we describe measurement tools that 1) provide national-level estimates of food security, 2) inform global monitoring and early warning systems, 3) assess household food access and acquisition, and 4) measure food consumption and utilization. After describing a number of outstanding measurement challenges that might be addressed in future research, we conclude by offering suggestions to guide the selection of appropriate food security metrics.

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.

Methods of Using Household Consumption and Expenditures Survey (HCES) Data to Estimate the Potential Nutritional Impact of Fortified Staple Foods

Background

Micronutrient malnutrition, caused largely by inadequate dietary intake, is a global public health problem that adversely affects health, child growth and development, work capacity, and quality of life. Mass fortification of widely consumed edible products has the potential to increase micronutrient intakes and thus alleviate some nutritional deficiencies. Although individual-level data about food consumption patterns are ideal for informing the design of food fortification programs, they are often unavailable. Household Consumption and Expenditures Surveys (HCES) are nationally representative cross-sectional surveys conducted over a 12-month period every 2 to 5 years, primarily to characterize household expenditures.

Objective

We describe how expenditure data from HCES can serve as a proxy for household food consumption and thus aid in choosing which foods to fortify and in determining how much of a micronutrient to add to that food.

Methods

We describe methods of using HCES data to characterize apparent food consumption patterns among different strata within a population.

Results

There are several limitations of using HCES data to describe apparent food consumption. HCES do not directly capture information about true food intake, but rather describe food expenditures. We assume that purchased foods are not shared with guests, wasted, fed to animals, gifted, or stockpiled for later use. We also assume that foods are allocated within each household based on energy needs.

Conclusions

Despite the limitations of using HCES data to estimate apparent food consumption, the dearth of individual-level data about food intake renders HCES data useful in designing food fortification programs.

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