Overcoming Dietary Assessment Challenges in Low-Income Countries: Technological Solutions Proposed by the International Dietary Data Expansion (INDDEX) Project

Objective assessment of shared plate eating using a wearable camera in urban and rural households in Ghana

Background

Shared plate eating (SPE), defined as two or more individuals eating directly from the same plate or bowl, is a common household food consumption practice in many Low- and Middle-Income Countries (LMICs). Examination of household engagement in SPE remains largely unexplored, highlighting a gap in research when interpreting dietary information obtained from these settings. The dearth of research into SPE can be attributed to the inherent limitations of traditional dietary assessment methods which constrain their usability in settings where SPE is common.

Objective

In this expository narrative, we describe what SPE is when it is practiced in an LMIC such as Ghana; and also compare the frequency of SPE versus individual plate eating (IPE) by different household members in rural and urban households using a wearable camera (Automatic Ingestion Monitor version 2: AIM-2).

Methods

Purposive convenience sampling was employed to recruit and enroll 30 households each from an urban and a rural community (n = 60 households) in Ghana. The AIM-2 was worn on eyeglass frames for 3 days by selected household members. The AIM-2, when worn, automatically collects images to capture food consumption in participants' environments, thus enabling passive capture of household SPE dynamics.

Results

A higher percentage of SPE occasions was observed for rural (96.7%) compared to urban (36.7%) households (p < 0.001). Common SPE dynamics included only adults sharing, adults and children sharing, only children sharing, and non-household member participation in SPE.

Conclusion

The wearable camera captured eating dynamics within households that would have likely been missed or altered by traditional dietary assessment methods. Obtaining reliable and accurate data is crucial for assessing dietary intake in settings where SPE is a norm.

Diet Quality Among Mothers and Children in India: Roles of Social and Behavior Change Communication and Nutrition-Sensitive Social Protection Programs

BACKGROUND

Limited evidence exists on determinants of maternal and child diet quality.

OBJECTIVES

This study examined the role of social and behavior change communication (SBCC) and nutrition-sensitive social protection (NSSP) programs on maternal and child diet quality.

METHODS

Data were from cross-sectional phone survey on 6627 Indian mothers that took place in late 2021. The Diet Quality Questionnaire (DQQ) was used to measure maternal and child diet quality, including minimum dietary diversity (MDD), dietary diversity scores (DDSs), noncommunicable disease (NCD)-protect and NCD-risk scores, adherence to dietary guidelines (All-5 and India-All-6), and unhealthy child feeding. Multivariate regression models were used to explore the association between diet indicators and coverage of SBCC and NSSP programs.

RESULTS

Maternal and child diet quality was suboptimal, with more mothers (57%) achieving MDD than children (23%). SBCC was positively associated with healthy food consumption in children (odds ratio [OR]: 2.14 for MDD; β: 0.60 for DDS and 0.54 for NCD-protect) and mothers (β: 0.38 for DDS and 0.43 for NCD-protect). Cash transfers were associated with healthier diets in mothers (OR: 1.45 for MDD, 1.86 for All-5, and 2.14 for India-All-6; β: 0.43 for DDS and 0.26 for NCD-protect), but less associations noted for children (β: 0.14 for NCD-protect). Receiving food was associated not only with healthier diets in mothers (OR: 1.47 for MDD; β: 0.27 for DDS and 0.33 for NCD-protect) and children (β: 0.19 for DDS and 0.15 for NCD-protect) but also with unhealthy food in children (OR: 1.34). Exposure to multiple programs showed stronger associations with diet quality.

CONCLUSIONS

SBCC has greater positive impact on child feeding than food and cash transfers, while cash has a stronger association with improved maternal diets. Food and cash are also associated with unhealthy food consumption. Our study underscores the importance of interventions that combine education, resource provision, and targeted support to promote maternal and child diet quality.

AI nutritionist: Intelligent software as the next generation pioneer of precision nutrition

With the rapid development of information technology and artificial intelligence (AI), people have acquired the abilities and are encouraged to develop intelligent tools and software, which begins to shed light on intelligent and precise food nutrition. Despite the rapid development of such software, disparities still exist in terms of methodology, contents, and implementation strategies. Hence, a set of panoramic profiles is urgently needed to elucidate their values and guide their future development. Here a comprehensive review was conducted aiming to summarize and compare the objects, contents, intelligent algorithms, and functions realized by the already released software in current research. Consequently, 177 AI nutritionists in recent years were collected and analyzed. The advantages, limitations, and trends concerning their application scenarios were analyzed. It was found that AI nutritionists have been gradually advancing the production modes and efficiency of food recognition, dietary recording/monitoring, nutritional assessment, and nutrient/recipe recommendation. Most AI nutritionists have a relatively low level of intelligence. However, new trends combining advanced AI algorithms, intelligent sensors and big data are coming with new applications in real-time and precision nutrition. AI models concerning molecular-level behaviors are becoming the new focus to drive AI nutritionists. Multi-center and multi-level studies have also gradually been realized to be necessary.

Dietary Quality and Associated Factors among Women of Reproductive Age in Six Sub-Saharan African Countries

The burden of micronutrient malnutrition is high among women of reproductive age (WRA) in sub-Saharan Africa. We examined the dietary quality and associated factors for WRA in Cameroon, Côte d'Ivoire, Kenya, Nigeria, Senegal, and Tanzania. Data were collected from women aged 15-49 years using representative Diet Quality Questionnaire surveys. The Minimum Dietary Diversity for Women (MDD-W), All-5 (key food group) consumption, noncommunicable disease risk (NCD-Risk), and Global Dietary Recommendation (GDR) indicators were assessed. Participants included N = 16,584 women [Cameroon: N = 2073; Côte d'Ivoire: N = 242; Kenya: N = 864; Adamawa State (Nigeria): N = 1283; Benue State (Nigeria): N = 1047; Nasarawa State (Nigeria): N = 1151; Senegal: N = 7232; Tanzania: N = 2692]. The MDD-W ranged from 43.0% in Tanzania to 81.4% in Côte d'Ivoire and was higher in urban, compared to rural, areas in Cameroon, Kenya, Nasarawa, Senegal, and Tanzania (p < 0.001). Increased education and wealth were positively associated with MDD-W in Kenya, Benue, Senegal, and Tanzania. Fewer than half of all women attained All-5 consumption. NCD-Risk scores ranged from 1.13 (95% CI: 1.08, 1.17) in Tanzania to 2.28 (95% CI: 2.16, 2.40) in Nasarawa, and women's GDR scores ranged from 10.47 (95% CI: 10.40, 10.54) in Cameroon to 11.45 (95% CI: 11.25, 11.64) in Côte d'Ivoire. Our findings highlight key aspects of women's diets in sub-Saharan African settings to enable greater awareness and more targeted responses to the specific areas needing the most improvement.

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

CONTEXT

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

OBJECTIVE

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

DATA SOURCES

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

DATA EXTRACTION

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

DATA ANALYSIS

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

CONCLUSION

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021253607.

Dietary intake and associated risk factors among pregnant women in Mbeya, Tanzania

Poor dietary intake among pregnant women has serious detrimental consequences for pregnancy and offspring both in developed and developing countries. This study aimed to assess dietary intake and associated risk factors among pregnant women. A cross-sectional study was conducted in Mbeya, Tanzania with a sample size of 420 pregnant women attending antenatal clinics to assess the factors associated with dietary intake. Dietary intake was assessed using a piloted questionnaire of the Prime Diet Quality Score. A tested standard questionnaire was also used to collect factors that are associated with dietary intake among pregnant women. The strengths of the associations between the dependent and independent variables were tested using the Pearson chi-square tests and the multivariate log-binomial regression method was performed to calculate the adjusted risk ratios (ARR) and 95% confidence interval (CI). The study revealed that out of 420 pregnant women who participated in this study only 12.6% and 29.3% consumed at least four servings of fruits and vegetables per week respectively. Poor dietary intakes were less likely among cohabiting pregnant women [Adjusted RR 0.22 (95% CI 0.09-0.50)] and; those who reported taking Fansidar tablets during the pregnancy [Adjusted RR 0.55 (95% CI 0.31-0.96)]. Further, we found that poor dietary intakes were more likely among pregnant women who were classified as overweight and obesity by the MUAC above 33cm [Adjusted RR 3.49 (95% CI 1.10-11.06)]. The study results affirm that cohabitation and obesity affect dietary intakes among pregnant women differently compared to married women in rural settings of Tanzania. Further research is needed to investigate the social aspects that link dietary intake outcomes for developing a tailored gestational intervention to improve maternal and birth outcomes in sub-Saharan African countries.

Assessing the performance of national sentinel food lists at subnational levels in six countries

OBJECTIVE

To assess how well national sentinel lists of the most frequently consumed foods in each food group capture data at subnational levels to measure minimum diet diversity (MDD).

DESIGN

We analysed data from seven surveys with 24-h open dietary recalls to evaluate: (1) the percentage of reported foods that were included in each sentinel food list; (2) whether these lists captured consumption of some food groups better than others and (3) differences between estimates of dietary diversity calculated from all food items mentioned in the open 24-h recall v. only food items included in the sentinel lists.

SETTING

Seven subnational areas: Bangladesh (2), Benin, Colombia, Kenya, Malawi and Nepal.

PARTICIPANTS

8094 women 15-49 years; 4588 children 6-23 months.

RESULTS

National sentinel food lists captured most foods reportedly consumed by women (84 %) and children (86 %). Food groups with the highest variability were 'other fruits' and 'other vegetables.' MDD calculated from the sentinel list was, on average, 6·5 (women) and 4·1 (children) percentage points lower than when calculated from open 24-h recalls, with a statistically significant difference in most subnational areas.

CONCLUSION

National sentinel food lists can provide reliable data at subnational levels for most food groups, with some variability by country and sub-region. Assessing the accuracy of national sentinel food lists, especially for fruits and vegetables, before using them at the subnational level could avoid potentially underestimating dietary diversity and provide more accurate local information for programmes, policy and research.

Evaluation of Acceptability, Functionality, and Validity of a Passive Image-Based Dietary Intake Assessment Method in Adults and Children of Ghanaian and Kenyan Origin Living in London, UK

BACKGROUND

Accurate estimation of dietary intake is challenging. However, whilst some progress has been made in high-income countries, low- and middle-income countries (LMICs) remain behind, contributing to critical nutritional data gaps. This study aimed to validate an objective, passive image-based dietary intake assessment method against weighed food records in London, UK, for onward deployment to LMICs.

METHODS

Wearable camera devices were used to capture food intake on eating occasions in 18 adults and 17 children of Ghanaian and Kenyan origin living in London. Participants were provided pre-weighed meals of Ghanaian and Kenyan cuisine and camera devices to automatically capture images of the eating occasions. Food images were assessed for portion size, energy, nutrient intake, and the relative validity of the method compared to the weighed food records.

RESULTS

The Pearson and Intraclass correlation coefficients of estimates of intakes of food, energy, and 19 nutrients ranged from 0.60 to 0.95 and 0.67 to 0.90, respectively. Bland-Altman analysis showed good agreement between the image-based method and the weighed food record. Under-estimation of dietary intake by the image-based method ranged from 4 to 23%.

CONCLUSIONS

Passive food image capture and analysis provides an objective assessment of dietary intake comparable to weighed food records.

Adapting a US dietary analysis software and nutrient database for use in Brazil

In many countries, assessing food and nutrient intake for research and surveillance purposes is difficult due to the lack of comprehensive, country-specific food and nutrient databases and/or a dietary analysis software program. In this case study, we describe the approach used to adapt a United States (US) dietary analysis software and nutrient database (Nutrition Data System for Research [NDSR]) for use in analyzing 24-hour dietary recalls collected for the Brazil Kids Nutrition and Health Study (KNHS). A team of experts that included individuals knowledgeable about Brazil and US eating traditions was assembled to devise solutions for between-country differences in eating habits, food supply, food nomenclature, and language. Solutions devised relied on several key resources, including the Brazilian Food Composition Table (TBCA) and a list of 200 foods commonly consumed in Brazil. These solutions included creating data entry rules that specified how each reported food should be entered into NDSR, creation of User Recipes for foods lacking a close nutritionally matching food in the NDSR database, and adjustment for food fortification differences as part of the analysis of study data. This case study illustrates that NDSR can be adapted for use outside of the United States through a structured process.

Diet Quality Index and Food Choice Motives in Vietnam: The Roles of Sensory Appeal, Mood, Convenience, and Familiarity

Food choices that shape human diets and health are influenced by various socio-economic factors. Vietnam struggles to meet many nutrition targets where links between food choice and diet have not been widely explored. This study assesses the food choice motives, based on a 28-item food choice questionnaire (FCQ), and the diet quality of 603 adults in three sites (urban, peri-urban, and rural) in northern Vietnam. We assess diet quality using the Diet Quality Index-Vietnam (DQI-V) which consists of variety, adequacy, moderation, and balance components. Using factor analysis, we grouped FCQ items into five factors: health focus, sensory appeal, mood ethics, convenience, and familiarity. The structural equation modeling indicates that food choice motives significantly impact the DQI-V and its components but in different directions. The results show that sensory appeal has a positive association with the overall DQI-V score, while having a negative impact on the variety component. Findings present a potential trade-off issue for interventions and policies related to food products. Nutrition knowledge is positively associated with all elements of diet quality across all three study sites. Vietnamese agrobiodiversity could be better utilized to increase dietary diversity. Differentiated policies are necessary to address the poor dietary diversity and adequacy in northern Vietnam.

A generic theory of change-based framework with core indicators for monitoring the effectiveness of large-scale food fortification programs in low- and middle-income countries

Large-scale food fortification (LSFF) programs are widely implemented in low- and middle-income countries (LMIC) to alleviate micronutrient deficiencies. However, these programs may not achieve the desired impact due to poor design or bottlenecks in program implementation. Monitoring and evaluation (M&E) frameworks and a set of agreed indicators can help to benchmark progress and to strengthen the evidence-base of effectiveness in a standardized way. We aimed to formulate recommendations towards core indicators for evaluating the effectiveness of LSFF programs with their associated metrics, methods, and tools (IMMT). For this, we used a multi-method iterative approach, including a mapping review of the literature, semi-structured interviews with international experts, compilation of a generic Theory of Change (ToC) framework for LSFF program delivery, and selection of IMMT for M&E of LSFF programs at key stages along the ToC delivery framework. Lastly, we conducted exploratory, qualitative interviews with key informants in Nigeria to explore experiences and perceptions related to the implementation of LSFF programs in Nigeria's context, and their opinion towards the proposed set of core IMMT. The literature search resulted in 14 published and 15 grey literature documents, from which we extracted a total of 41 indicators. Based on the available literature and interviews with international experts, we mapped a ToC delivery framework and selected nine core indicators at the output, outcome and impact level for M&E of the effectiveness of LSFF programs. Key informants in Nigeria revealed that the main bottlenecks for implementation of the proposed IMMT are related to the lack of technical capacity, equipment, laboratory infrastructure, and financial resources. In conclusion, we propose a set of nine core indicators for enabling comprehensive M&E of the effectiveness of LSFF programs in LMIC. This proposed set of core indicators can be used for further evaluation, harmonization and integration in national and international protocols for M&E of LSFF programs.

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

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

The DQQ is a Valid Tool to Collect Population-Level Food Group Consumption Data: A Study Among Women in Ethiopia, Vietnam, and Solomon Islands

BACKGROUND

The Diet Quality Questionnaire (DQQ) is a rapid dietary assessment tool designed to enable feasible measuring and monitoring of diet quality at population level in the general public.

OBJECTIVES

To evaluate validity of the DQQ for collecting population-level food group consumption data required for calculating diet quality indicators by comparing them with a multipass 24-h dietary recall (24hR) as the reference.

METHODS

Cross-sectional data were collected among female participants aged 15-49 y in Ethiopia (n = 488), 18-49 y in Vietnam (n = 200), and 19-69 y in Solomon Islands (n = 65) to compare DQQ and 24hR data in proportional differences in food group consumption prevalence, percentage of participants achieving Minimum Dietary Diversity for Women (MDD-W), percent agreement, percentage misreporting food group consumption, and diet quality scores of Food Group Diversity Score (FGDS), noncommunicable disease (NCD)-Protect, NCD-Risk, and the Global Dietary Recommendation (GDR) score using a nonparametric analysis.

RESULTS

The mean (standard deviation) percentage point difference between DQQ and 24hR in population prevalence of food group consumption was 0.6 (0.7), 2.4 (2.0), and 2.5 (2.7) in Ethiopia, Vietnam, and Solomon Islands, respectively. Percent agreement of food group consumption data ranged from 88.6% (10.1) in Solomon Islands to 96.3% (4.9) in Ethiopia. There was no significant difference between DQQ and 24hR in population prevalence of achieving MDD-W except for Ethiopia (DQQ 6.1 percentage points higher, P < 0.01). Median (25th-75th percentiles) scores of FGDS, NCD-Protect, NCD-Risk, and GDR score were comparable between the tools.

CONCLUSIONS

The DQQ is a suitable tool for collecting population-level food group consumption data for estimating diet quality with food group-based indicators such as the MDD-W, FGDS, NCD-Protect, NCD-Risk, and GDR score.

Dietary patterns derived using principal component analysis and associations with sociodemographic characteristics and overweight and obesity: A cross-sectional analysis of Iranian adults

Introduction

This study examined the cross-sectional association between household dietary patterns and sociodemographic characteristics and BMI in a nationally representative sample of Iranian adults.

Methods

Data on 6,833 households (n = 17,824 adults) from the National Comprehensive Study on Household Food Consumption Pattern and Nutritional Status 2001-2003 were used. Principal component analysis (PCA) was used to extract dietary patterns from three household 24-h dietary recalls. Linear regression analyses were used to examine associations between dietary patterns and sociodemographic characteristics and BMI.

Results

Three dietary patterns were identified: the first was characterized by high citrus fruit intake, the second by high hydrogenated fats intake and the third by high non-leafy vegetables intake. The first and third patterns were associated with household heads with higher education and living in urban areas, while the second was associated with household heads with lower education and living in rural areas. All dietary patterns were positively associated with BMI. The strongest association was found with the first dietary pattern (β: 0.49, 95% CI: 0.43, 0.55).

Discussion

While all three dietary patterns were positively associated with BMI, the sociodemographic characteristics of Iranian adults who consumed them differed. These findings inform the design of population-level dietary interventions to address rising obesity rates in Iran.

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.

Relative validity of a mobile AI-technology-assisted dietary assessment in adolescent females in Vietnam

BACKGROUND

There is a gap in data on dietary intake of adolescents in low- and middle-income countries (LMICs). Traditional methods for dietary assessment are resource intensive and lack accuracy with regard to portion-size estimation. Technology-assisted dietary assessment tools have been proposed but few have been validated for feasibility of use in LMICs.

OBJECTIVES

We assessed the relative validity of FRANI (Food Recognition Assistance and Nudging Insights), a mobile artificial intelligence (AI) application for dietary assessment in adolescent females (n = 36) aged 12-18 y in Vietnam, against a weighed records (WR) standard and compared FRANI performance with a multi-pass 24-h recall (24HR).

METHODS

Dietary intake was assessed using 3 methods: FRANI, WR, and 24HRs undertaken on 3 nonconsecutive days. Equivalence of nutrient intakes was tested using mixed-effects models adjusting for repeated measures, using 10%, 15%, and 20% bounds. The concordance correlation coefficient (CCC) was used to assess the agreement between methods. Sources of errors were identified for memory and portion-size estimation bias.

RESULTS

Equivalence between the FRANI app and WR was determined at the 10% bound for energy, protein, and fat and 4 nutrients (iron, riboflavin, vitamin B-6, and zinc), and at 15% and 20% bounds for carbohydrate, calcium, vitamin C, thiamin, niacin, and folate. Similar results were observed for differences between 24HRs and WR with a 20% equivalent bound for all nutrients except for vitamin A. The CCCs between FRANI and WR (0.60, 0.81) were slightly lower between 24HRs and WR (0.70, 0.89) for energy and most nutrients. Memory error (food omissions or intrusions) was ∼21%, with no clear pattern apparent on portion-size estimation bias for foods.

CONCLUSIONS

AI-assisted dietary assessment and 24HRs accurately estimate nutrient intake in adolescent females when compared with WR. Errors could be reduced with further improvements in AI-assisted food recognition and portion estimation.

COVID-19 market disruptions and food security: Evidence from households in rural Liberia and Malawi

We use data collected from panel phone surveys to document the changes in food security of households in rural Liberia and Malawi during the market disruptions associated with the COVID-19 lockdowns in 2020. We use two distinct empirical approaches in our analysis: (a) an event study around the date of the lockdowns (March to July 2020), and (b) a difference-in-differences analysis comparing the lockdown period in 2020 to the same months in 2021, in order to attempt to control for seasonality. In both countries, market activity was severely disrupted and we observe declines in expenditures. However, we find no evidence of declines in food security.

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.

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.

Assessing the Diets of Young Children and Adolescents in India: Challenges and Opportunities

Sustainably addressing the crisis of undernutrition for children and adolescents in underserved and resource-limited communities will require, among other investments, interventions aimed at optimizing the diets of these vulnerable populations. However, to date, there are substantial global gaps in the collection of dietary data in children and adolescents. This review article summarizes the challenges and opportunities in assessing diet among children and adolescents in India. National surveys in India identify the scale of the triple burden of malnutrition (undernutrition, micronutrient deficiencies and overnutrition) in children and adolescents and assess key nutrition and food security indicators for making informed policy decisions. However, national surveys do not collect data on diet, instead relying on anthropometry, biomarkers of micronutrient deficiencies, and summary measures of diet, such as the WHO infant and young child feeding summary indicators. Sub-national surveys and the scientific literature thus fill important gaps in describing the nutrient intakes of children and adolescents in India; however large gaps remain. Future research can be improved by investments in infrastructure to streamline the assessment of diet in India. The current challenges confronting the collection and analysis of high-quality dietary data occur in both the data collection and data analysis phases. Common methods for assessing diets in low-resource settings-such as 24 h recalls and food frequency questionnaires are particularly challenging to implement well in young children and adolescents due to motivation and memory issues in young respondents. Additionally, there are challenges with parental recall including children having multiple caretakers and meals outside the home. Furthermore, analysis of dietary data is hindered by the lack of affordable, accessible software for dietary data analysis relevant to the diversity in Indian diets. New technologies can address some of the challenges in dietary data collection and analysis, but to date, there are no platforms designed for population-level dietary assessment in India. Public and private sector investment in dietary assessment, as well as collaboration of researchers and the creation of open-source platforms for the sharing of data inputs (local food lists, recipe databases, etc.) will be essential to build infrastructure to better understand the diets of children and adolescents in India and improve dietary interventions in these target groups.

Review of dietary assessment studies conducted among Khmer populations living in Cambodia

Background

Despite economic growth, Cambodia continues to have high rates of malnutrition, anaemia and nutrition‐related deficiencies. Government policies promote nutrition strategies, although dietary intake data is limited. A detailed synthesis of existing intake data is needed to inform nutrition policy and practice change. This review aims to characterise and assess quality of dietary assessment methods and outcomes from individual‐level ‘whole diet’ studies of Khmer people living in Cambodia.

Methods

Searches were conducted using PRISMA‐ScR guidelines. Included papers reported dietary intake at an individual level for ‘whole diet’. Studies using secondary data or lacking dietary assessment details were excluded. Extracted data included dietary assessment features, nutrient/food group intakes and database.

Results

Nineteen publications (15 studies) were included, with nine carried out among children under 5 years and six among women. Eleven studies reported intake by food groups and four by nutrients, prominently energy, protein, vitamin A, iron, calcium and zinc. Inconsistent intakes, food groupings and reporting of study characteristics limited data synthesis. All but one study used 24‐h recalls. Trained local fieldworkers used traditional interview‐administered data collection and varied portion estimation tools. Food composition databases for analysis were not tailored to the Cambodian diet. Overall quality was rated as ‘good’.

Conclusions

We recommend the development of a best‐practice protocol for conducting dietary assessment, a Cambodia‐specific food composition database and a competent trained workforce of nutrition professionals, with global support of expertise and funding for future dietary assessment studies conducted in Cambodia.

Fifteen studies with highly variable intake data included in the review.

The food composition databases used were not specific to Cambodian diet.

Minimum reporting standards and best practice protocols recommended, including in‐country nutrition training.

Lack of whole population dietary intake data indicates the need for a national survey.

Applying Zinc Nutrient Reference Values as Proposed by Different Authorities Results in Large Differences in the Estimated Prevalence of Inadequate Zinc Intake by Young Children and Women and in Cameroon

Nutrient reference values (NRVs) for zinc set by several expert groups differ widely and may affect the predicted prevalence of inadequate zinc intake. We examined this possibility using NRVs published by four different authorities and nationally representative dietary intake data collected among children aged 12–59 months and women in Cameroon. Usual zinc intake was estimated from 24 h recall data using the National Cancer Institute method. Prevalences of total zinc intake below the dietary requirement and of “absorbable zinc intake” below the physiological requirement were estimated using NRVs published by the World Health Organization (WHO), US Institute of Medicine (IOM), International Zinc Nutrition Consultative Group (IZiNCG), and European Food Safety Authority (EFSA). The prevalence of inadequate zinc intake ranged from 10% (IZiNCG—physiological requirement, 95% CI 7–13%) to 81% (EFSA—physiological requirement, 95% CI 78–84%) among children and 9% (WHO—physiological requirement, 95% CI 8–11.0%) to 94% (IOM—physiological requirement, 95% CI 92–95%) among women These differences in the prevalence of inadequate intake translated into sizeable differences in the predicted benefit and cost-effectiveness of zinc fortification programs. Depending on the NRVs applied, assessments differ regarding the need for and design of zinc fortification programs. Efforts are needed to harmonize NRVs for zinc.

Sensitivity of Food-Based Recommendations Developed Using Linear Programming to Model Input Data in Young Kenyan Children

Food-based recommendations (FBR) developed using linear programming generally use dietary intake and energy and nutrient requirement data. It is still unknown to what extent the availability and selection of these data affect the developed FBR and identified problem nutrients. We used 24 h dietary recalls of 62 Kenyan children (4-6 years of age) to analyse the sensitivity of the FBR and problem nutrients to (1) dietary intake data, (2) selection criteria applied to these data and (3) energy and nutrient requirement data, using linear programming (Optifood©), by comparing a reference scenario with eight alternative scenarios. Replacing reported by estimated consumption frequencies increased the recommended frequencies in the FBR for most food groups while folate was no longer identified as a problem nutrient. Using the 10-90th instead of the 5-95th percentile of distribution to define minimum and maximum frequencies/week decreased the recommended frequencies in the FBR and doubled the number of problem nutrients. Other alternative scenarios negligibly affected the FBR and identified problem nutrients. Our study shows the importance of consumption frequencies for developing FBR and identifying problem nutrients by linear programming. We recommend that reported consumption frequencies and the 5-95th percentiles of distribution of reported frequencies be used to define the minimum and maximum frequencies.

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

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

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

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

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

Scoping review of nutrition intervention and dietary assessment studies in Khmer populations living in Cambodia

BACKGROUND

This scoping review aims to describe the body of nutrition intervention and dietary assessment research undertaken with Khmer populations in Cambodia, as well as summarise the nutrition knowledge base and highlight priority areas for future research.

METHODS

Five databases and the grey literature were searched, following PRISMA-ScR guidelines. Studies involving dietary assessment or nutrition interventions published after 1992 were identified using specific search terms and extracted to a customised data extraction table for categorisation and analysis. Study participants were Khmer people of any age and gender, living in rural or urban Cambodia.

RESULTS

Of the 100 included studies, 58 were dietary assessment only studies, 24 were nutrition interventions only, and 18 studies involved both assessment of intake and an intervention. Sixty-eight percent of study populations were mothers and young children, of which 52 studies focused on children aged under 5 years. Nineteen interventions involved supplementation and six trialled fortification of rice or fish sauce. Anaemia was the most common nutrition condition studied (n = 17), followed by malnutrition (n = 15) and malnutrition risk factors (n = 11). General nutrition status was explored in 25 studies, and individual micronutrients that were studied included iron (n = 27), zinc (n = 6), vitamin A (n = 4) and thiamine (n = 3).

CONCLUSIONS

Diet-related research in Khmer populations in Cambodia has predominantly focused on dietary assessment or evaluation of interventions aimed at reducing malnutrition and resolving micronutrient deficiencies. Areas identified as emerging needs included non-communicable diseases, the ageing population and non-iron deficiency anaemia.

Developing an online food composition database for an Indigenous population in south-western Uganda

OBJECTIVE

To develop an online food composition database of locally consumed foods among an Indigenous population in south-western Uganda.

DESIGN

Using a community-based approach and collaboration with local nutritionists, we collected a list of foods for inclusion in the database through focus group discussions, an individual dietary survey and markets and shops assessment. The food database was then created using seven steps: identification of foods for inclusion in the database; initial data cleaning and removal of duplicate items; linkage of foods to existing generic food composition tables; mapping and calculation of the nutrient content of recipes and foods; allocating portion sizes and accompanying foods; quality checks with local and international nutritionists; and translation into relevant local languages.

SETTING

Kanungu District, south-western Uganda.

PARTICIPANTS

Seventy-four participants, 36 Indigenous Batwa and 38 Bakiga, were randomly selected and interviewed to inform the development of a food list prior the construction of the food database.

RESULTS

We developed an online food database for south-western Uganda including 148 commonly consumed foods complete with values for 120 micronutrients and macronutrients. This was for use with the online dietary assessment tool myfood24. Of the locally reported foods included, 56 % (n 82 items) of the items were already available in the myfood24 database, while 25 % (n 37 items) were found in existing Ugandan and Tanzanian food databases, 18 % (n 27 items) came from generated recipes and 1 % (n 2 items) from food packaging labels.

CONCLUSION

Locally relevant food databases are sparse for African Indigenous communities. Here, we created a tool that can be used for assessing food intake and for tracking undernutrition among the communities living in Kanungu District. This will help to develop locally relevant food and nutrition policies.

Portion size estimation in dietary assessment: a systematic review of existing tools, their strengths and limitations

CONTEXT

Overestimation or underestimation of portion size leads to measurement error during dietary assessment.

OBJECTIVE

To identify portion size estimation elements (PSEEs) and evaluate their relative efficacy in relation to dietary assessment, and assess the quality of studies validating PSEEs.

DATA SELECTION AND EXTRACTION

Electronic databases, internet sites, and cross-references of published records were searched, generating 16 801 initial records, from which 334 records were reviewed and 542 PSEEs were identified, comprising 5% 1-dimensional tools (eg, food guides), 46% 2-dimensional tools (eg, photographic atlases), and 49% 3-dimensional tools (eg, household utensils). Out of 334 studies, 21 validated a PSEE (compared PSEE to actual food amounts) and 13 compared PSEEs with other PSEEs.

CONCLUSION

Quality assessment showed that only a few validation studies were of high quality. According to the findings of validation and comparison studies, food image-based PSEEs were more accurate than food models and household utensils. Key factors to consider when selecting a PSEE include efficiency of the PSEE and its applicability to targeted settings and populations.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A comparison of diet quality indices in a nationally representative cross-sectional study of Iranian households

BACKGROUND

Iranian diet quality has been evaluated using indices that have not been created based on Iranian dietary guidelines. This study aimed to examine the applicability of two diet quality indices by examining their associations with nutrient adequacy, nutrient intakes and sociodemographics.

METHODS

Dietary data were collected using three 24-h dietary recalls from Iranian households. Nutrient adequacy was assessed using World Health Organization/Food and Agriculture Organization 2002 (WHO/FAO) cut points. Household diet quality was calculated using the Healthy Eating Index (HEI) and Diet Quality Index-International (DQI-I). Sociodemographics of the household members were assessed. Regression analyses were used to examine associations between diet quality and nutrient adequacy, and between sociodemographics and diet quality.

RESULTS

A total of 6935 households were included in the analysis. Higher household diet quality was associated with adequate intake of calcium (HEI: OR 1.11, 95% CI: 1.10, 1.13; DQI-I: OR 1.14, 95% CI: 1.13, 1.16), vitamin C (HEI: OR 1.19, 95% CI: 1.17, 1.20; DQI-I: OR 1.12, 95% CI: 1.11, 1.12) and protein (HEI: OR 1.01, 95% CI: 1.00, 1.02; DQI-I: OR 1.09, 95% CI: 1.08, 1.09). Higher household diet quality was associated with household heads who were older (> 56 years old) (HEI: β 2.06, 95% CI: 1.63, 2.50; DQI-I β 2.90, 95% CI: 2.34, 3.45), higher educated (college/university completed) (HEI: β 4.54, 95% CI: 4.02, 5.06; DQI-I: β 2.11, 95% CI: 1.45, 2.77) and living in urban areas (HEI: β 2.85, 95% CI: 2.54, 3.16; DQI-I: β 0.72, 95% CI: 0.32, 1.12).

CONCLUSIONS

Based on associations with nutrient adequacy and sociodemographics, the applicability of two diet quality indices for assessing the diet quality of Iranian households was demonstrated. Results also indicated DQI-I may be more applicable than HEI for evaluating Iranian nutrient adequacy. Findings have implications for the design and assessment of diet quality in Iranian populations. Future research should examine the link between these diet quality indices and health outcomes.

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

Women of reproductive age (WRA) need adequate nutrient intakes to sustain a healthy pregnancy, support fetal growth, and breastfeed after childbirth. However, data on women's dietary intake in low‐ and middle‐income countries (LMICs) are limited, and assessment of differences between dietary intakes of pregnant or lactating women compared with that of nonpregnant, nonlactating (NPNL) women is untested. Using single, multiple‐pass 24‐h dietary recall data from a sample of WRA residing in rural Bangladesh, we examined women's dietary intakes for energy, protein, calcium, iron, vitamin A, and dietary diversity for three groups: NPNL (n = 2,903), pregnant (n = 197), and lactating women (n = 944). We used equivalence testing to examine similarity in adjusted intakes for pregnant versus NPNL women and lactating versus NPNL women with a predetermined equivalence threshold based on recommendations specific for each reproductive stage. On average, both pregnant and lactating women had insufficient intakes for all dietary measures. Although statistically significant differences were observed between pregnant and NPNL women for energy intake and dietary diversity and between lactating and NPNL women for energy and protein intake, the magnitudes of these differences were too small to reject equivalence. Statistical similarity was also evident in all micronutrients and dietary diversity for both two‐group comparisons. Understanding statistical differences and similarities between dietary measures of women in distinct reproductive stages has important implications for the relevance, appropriateness, and evaluation of maternal diet‐enhancing interventions in LMICs, especially during pregnancy and lactation, when demand for macronutrients and micronutrients is elevated.

The Use of Tablet-Based Multiple-Pass 24-Hour Dietary Recall Application (MP24Diet) to Collect Dietary Intake of Children under Two Years Old in the Prospective Cohort Study in Indonesia

Dietary intake data are crucial for developing or evaluating nutrition interventions to improve the nutritional status of populations. The collection of accurate and reliable dietary data in developing countries, however, remains challenging. The emergence of new technologies, which facilitate electronic data capture, might address some of these challenges. This paper aims to describe an application developed to collect a multiple-pass 24-h dietary recall, using electronic data capture, and compare the results to those estimated using a paper-based method. In this study, a tablet-based application was developed, in the CommCare platform, to evaluate the effectiveness, for improving dietary adequacy, of a package of behavior change interventions to reduce stunting and anemia among 6-23-month-old children in East Java, Indonesia (Baduta project). Dietary intakes of energy and nutrients were estimated using electronic data capture in the cohort study of the Baduta project (n = 680). We compared these results with those estimated using paper-based data capture in the project's end-line cross-sectional study (n = 2740). We found a higher percentage of children classified as acceptable energy reporters (reported energy intake within the 95% CI of Total Energy Expenditure) with the electronic data capture compared with paper-based data capture (i.e., 60.8%, 72.4% and 80.7% for 6-8-, 9-11- and 12-23-month-old children, respectively, vs. 40.9%, 56.9%, and 54.3%, respectively). The estimated mean energy and nutrient intakes were not significantly different between these dietary data capture methods. These results suggest dietary data collection, using a tablet-based application, is feasible and can improve the quality of dietary data collected in developing countries.

A systematic review of the validity of dietary assessment methods in children when compared with the method of doubly labelled water

Assessing energy intake (EI) in children and adolescents is essential for monitoring population nutrition trends and interpreting clinical outcomes. The aim of this review was to examine the validity of dietary assessment methods for estimating EI in children and adolescents when compared with total energy expenditure (TEE) measured using doubly labelled water (DLW). Six online databases were searched to identify articles published in English. Studies were included if they were conducted in participants aged ≤18 years, if they estimated EI via a dietary assessment method, and if they compared this estimate to TEE measured using the DLW method. The search strategy identified 345 articles, of which 13 articles (12 studies) (n = 306 children) met the selection criteria. Five studies were carried out in children aged 5-11 years with dietary intake of children reported by parents/caregivers. The most common dietary assessment methods used were food frequency questionnaires (n = 5) and weighed food records (n = 4). All methods were found to have some level of misreporting. Child characteristics including weight status, age, and sex were not found to consistently influence the accuracy of reported EI. Five studies employing technology-assisted approaches for assessing dietary intake in children were identified and reported mixed findings. Validity studies using DLW remain sparse in the literature. Studies including participants less than 5 years or older than 11 years, and from diverse ethnicities and socioeconomic backgrounds are warranted to explore other demographic differences that may affect the accuracy of dietary assessment methods. While reported in few studies, technology-assisted methods were found to perform equally well in estimating intakes when compared to DLW and other traditional forms of dietary assessment.

Current Understanding of Innate Immune Cell Dysfunction in Childhood Undernutrition

Undernutrition affects millions of children in low- and middle-income countries (LMIC) and underlies almost half of all deaths among children under 5 years old. The growth deficits that characterize childhood undernutrition (stunting and wasting) result from simultaneous underlying defects in multiple physiological processes, and current treatment regimens do not completely normalize these pathways. Most deaths among undernourished children are due to infections, indicating that their anti-pathogen immune responses are impaired. Defects in the body's first-line-of-defense against pathogens, the innate immune system, is a plausible yet understudied pathway that could contribute to this increased infection risk. In this review, we discuss the evidence for innate immune cell dysfunction from cohort studies of childhood undernutrition in LMIC, highlighting knowledge gaps in almost all innate immune cell types. We supplement these gaps with insights from relevant experimental models and make recommendations for how human and animal studies could be improved. A better understanding of innate immune function could inform future tractable immune-targeted interventions for childhood undernutrition to reduce mortality and improve long-term health, growth and development.

Dietary Assessment of Shared Plate Eating: A Missing Link

Shared plate eating is a defining feature of the way food is consumed in some countries and cultures. Food may be portioned to another serving vessel or directly consumed into the mouth from a centralised dish rather than served individually onto a discrete plate for each person. Shared plate eating is common in some low- and lower-middle income countries (LLMIC). The aim of this narrative review was to synthesise research that has reported on the assessment of dietary intake from shared plate eating, investigate specific aspects such as individual portion size or consumption from shared plates and use of technology in order to guide future development work in this area. Variations of shared plate eating that were identified in this review included foods consumed directly from a central dish or shared plate food, served onto additional plates shared by two or more people. In some settings, a hierarchical sharing structure was reported whereby different family members eat in turn from the shared plate. A range of dietary assessment methods have been used in studies assessing shared plate eating with the most common being 24-h recalls. The tools reported as being used to assist in the quantification of food intake from shared plate eating included food photographs, portion size images, line drawings, and the carrying capacity of bread, which is often used rather than utensils. Overall few studies were identified that have assessed and reported on methods to assess shared plate eating, highlighting the identified gap in an area of research that is important in improving understanding of, and redressing dietary inadequacies in LLMIC.

Dietary assessment toolkits: an overview

OBJECTIVE

A wide variety of methods are available to assess dietary intake, each one with different strengths and weaknesses. Researchers face multiple challenges when diet and nutrition need to be accurately assessed, particularly in the selection of the most appropriate dietary assessment method for their study. The goal of the current collaborative work is to present a collection of available resources for dietary assessment implementation.Design/Setting/ParticipantsAs a follow-up to the 9th International Conference on Diet and Physical Activity Methods held in 2015, developers of dietary assessment toolkits agreed to collaborate in the preparation of the present paper, which provides an overview of each toolkit. The toolkits presented include: the Diet, Anthropometry and Physical Activity Measurement Toolkit (DAPA; UK); the National Cancer Institute's (NCI) Dietary Assessment Primer (USA); the Nutritools website (UK); the Australasian Child and Adolescent Obesity Research Network (ACAORN) method selector (Australia); and the Danone Dietary Assessment Toolkit (DanoneDAT; France). An at-a-glance summary of features and comparison of the toolkits is provided.

RESULTS

The present review contains general background on dietary assessment, along with a summary of each of the included toolkits, a feature comparison table and direct links to each toolkit, all of which are freely available online.

CONCLUSIONS

This overview of dietary assessment toolkits provides comprehensive information to aid users in the selection and implementation of the most appropriate dietary assessment method, or combination of methods, with the goal of collecting the highest-quality dietary data possible.

FAO/WHO GIFT (Global Individual Food consumption data Tool): a global repository for harmonised individual quantitative food consumption studies

Knowing who eats what, understanding the various eating habits of different population groups, according to the geographical area, is critical to develop evidence-based policies for nutrition and food safety. The FAO/WHO Global Individual Food consumption data Tool (FAO/WHO GIFT) is a novel open-access online platform, hosted by FAO and supported by WHO, providing access to harmonised individual quantitative food consumption (IQFC) data, especially in low- and middle-income countries (LMIC). FAO/WHO GIFT is a growing repository, which will serve as the global FAO/WHO hub to disseminate IQFC microdata. Currently five datasets from LMIC are available for dissemination, and an additional fifty datasets will be made available by 2022. To facilitate the use of these data by policy makers, ready-to-use food-based indicators are provided for an overview of key data according to population segments and food groups. FAO/WHO GIFT also provides an inventory of existing IQFC data worldwide, which currently contains detailed information on 188 surveys conducted in seventy-two countries. In order for end-users to be able to aggregate the available data, all datasets are harmonised with the European Food Safety Authority's food classification and description system FoodEx2 (modified for global use). This harmonisation is aimed at enhancing the consistency and reliability of nutrient intake and dietary exposure assessments. FAO/WHO GIFT is developed in synergy with other global initiatives aimed at increasing the quality, availability and use of IQFC data in LMIC to enable evidence-based decision-making and policy development for better nutrition and food safety.

Validity of Dietary Assessment Methods When Compared to the Method of Doubly Labeled Water: A Systematic Review in Adults

Accuracy in quantifying energy intake (EI) using common dietary assessment methods is crucial for interpreting the relationship between diet and chronic disease. The aim of this systematic review was to evaluate the validity of dietary assessment methods used to estimate the EI of adults in comparison to total energy expenditure (TEE) measured by doubly labeled water (DLW). Articles in English across nine electronic databases, published between 1973 and February 2019 were retrieved. Studies were included if participants were adults (≥18 years) and used the DLW technique to measure TEE compared to self-reported EI. A total of 59 studies were included, with a total of 6,298 free living adults and a mean of 107 participants per study. The majority of studies including 16 studies that included a technology based method reported significant (P < 0.05) under-reporting of EI when compared to TEE, with few over-reporting EI. Misreporting was more frequent among females compared to males within recall based dietary assessment methods. The degree of under-reporting was highly variable within studies using the same method, with 24 h recalls having less variation and degree of under-reporting compared to other methods.

Excess micronutrient intake: defining toxic effects and upper limits in vulnerable populations

Excessive micronutrient intake causes a variety of adverse health effects, depending on dose and duration. The risk of excess intake carries significant implications for micronutrient delivery interventions, particularly when such programs are overlapping. To minimize risk and provide public health guidance, several countries and the Food and Agriculture Organization of the United Nations/World Health Organization have set upper intake levels (ULs) for various life-stage populations using the risk assessment framework. However, there is a lack of international consensus on the actual ULs due to variability in application of this framework and a scarcity of evidence from which to draw upon, especially for children. Often ULs for children are established through a downward weight-based extrapolation from adult ULs, which is not always appropriate. The published ULs of nine organizations are compared, recent population nutrient intake evidence is presented, and the toxic effects of key minerals and vitamins are reviewed. Finally, the evidence for toxicity and setting of ULs for each nutrient is discussed including a comment on our degree of confidence in the strength of existing individual ULs. Challenges with risk assessment and opportunities for strengthening the definition of ULs are discussed.

How well do different dietary and nutrition assessment tools match? Insights from rural Kenya

OBJECTIVE

Various indicators and assessment tools exist to measure diets and nutrition. Most studies eventually rely on one approach. Relatively little is known about how closely results match when different tools are used in the same context. The present study compares and correlates different indicators for the same households and individuals to better understand which indicators can be used as proxies for others.

DESIGN

A survey of households and individuals was carried out in Kenya in 2015. Seven-day food consumption and 24 h dietary recalls were administered at household and individual level, respectively. Individual height and weight measures were taken. Different indicators of food access (energy consumption, household dietary diversity scores), dietary quality (individual dietary diversity scores, micronutrient intakes) and nutrition (anthropometric indicators) were calculated and correlated to evaluate associations.

SETTING

Rural farm households in western Kenya.ParticipantsData collected from 809 households and 1556 individuals living in these households (782 female adults, 479 male adults, 295 children aged 6-59 months).

RESULTS

All measures of food access and dietary quality were positively correlated at individual level. Household-level and individual-level dietary indicators were also positively correlated. Correlations between dietary indicators and anthropometric measures were small and mostly statistically insignificant.

CONCLUSIONS

Dietary indicators from 7d food consumption recalls at the household level can be used as proxies of individual dietary quality of children and male and female adults. Individual dietary diversity scores are good proxies of micronutrient intakes. However, neither household-level nor individual-level dietary indicators are good proxies of individual nutritional status in this setting.

Dietary Assessment with a Wearable Camera among Children: Feasibility and Intercoder Reliability

BACKGROUND

The eButton, a multisensor device worn on the chest, uses a camera to passively capture images of everything in front of the child throughout the day. These images can be analyzed to provide a passive method of dietary intake assessment.

OBJECTIVE

This study assessed the eButton's feasibility and intercoder reliability for dietary intake assessment.

DESIGN

Children were recruited in the summer and fall of 2015, in Houston, TX, to wear the eButton to take 2 full days of dietary images, and the child-parent dyad participated in a following-day interview to verify what dietitians recorded from the images.

PARTICIPANTS/SETTING

Thirty 9- to 13-year-old children participated during days convenient to them.

MAIN OUTCOME MEASURES

Two dietitians independently manually reviewed the images to identify eating events, foods in those events, and portion sizes.

STATISTICAL ANALYSES PERFORMED

Descriptive statistics of agreements and disagreements were calculated between dietitians and with children; t tests and Bland-Altman plots of differences in total kilocalories were calculated between dietitians and between initial dietitian estimates and those finalized after the verification interviews.

RESULTS

The dietitians agreed on the identity of 60.5% of the 1,026 foods but disagreed on 28.6% of the foods and on the names for 10.8% of the foods. After the verification interviews, the dietitians agreed with the child-parent dyads on the identity of 77.0% of the 921 foods; the child-parent dyad identified 12.4% of the day's foods when images were not available or not clear; the child-parent dyad clarified that 5.4% of the foods identified were not consumed by the child; and the child-parent dyad clarified the identity of 5.2% of the foods. A software-based approach (three-dimensional wire mesh) could be used to estimate portion size on 24% of the foods, and professional judgment was required for 67.8%. Mean caloric intakes per day were not statistically significantly different between dietitians but were different between dietitians and child-parent dyads in total and on day 2.

CONCLUSIONS

An early test of intercoder reliability of an all-day image method of dietary intake assessment obtained intercoder agreement between the two dietitians processing these images of intraclass correlation coefficient=0.67. A following-day verification interview with the child and parent was necessary to ensure completeness of estimates. Several feasibility problems occurred, which may be remedied with additional participant and dietitian training and further technological development.

Low potassium and high sodium intakes: a double health threat to Cape Verdeans

BACKGROUND

Cape Verde presents a high rate of cardiovascular diseases. Low potassium and high sodium intakes are related to cardiovascular diseases. However, studies regarding these two micronutrients continue to be rare in African urban settings. This work aims to estimate potassium and sodium intakes and to analyse the self-reported salt intake by gender and by type of urban area in the city of Praia - the capital of Cape Verde.

METHODS

In the first stage (n = 1912), an intra-urban study was designed in two types of urban areas (formal and informal), using a sampling strategy based on random selection of geographical coordinates, in order to apply a questionnaire. In a second stage, a 24-h dietary recall and anthropometric measurements were performed by local nutritionists. Potassium and sodium intakes were estimated for 599 participants (149 men and 450 women). Non-parametric methods (including quantile regression) were used in the statistical analysis.

RESULTS

In informal areas, a higher percentage of women reported having hypertension (31.0%) compared to formal areas (19.7%). Based on 24-h dietary recall, median potassium intake for men was 2924.2 mg/day and for women and 2562.6 mg/day. Almost 70.0% of men and 80.0% of women ingested less than the recommended 3510 mg/day of potassium. In informal areas, men and women presented high medians of sodium intakes compared to formal areas (men: 4131.2 vs 3014.6 mg/day and women: 3243.4 vs 2522.4 mg/day). On the other hand, the percentage of participants exceeding 2000 mg/day for sodium was high (≥70.8%), even for participants that self-reported low-salt intake. Quantile regression models revealed effects of the type of urban area and gender in the potassium and sodium intakes, at least, in some quartiles, accounting for age, academic qualifications, and professional situation.

CONCLUSIONS

A low potassium intake and a high sodium intake were found in Praia. Thus, efficient health education campaigns and health promotion are needed and should be tailored considering gender and urban areas.

Healthy ageing: the natural consequences of good nutrition-a conference report

Many countries are witnessing a marked increase in longevity and with this increased lifespan and the desire for healthy ageing, many, however, suffer from the opposite including mental and physical deterioration, lost productivity and quality of life, and increased medical costs. While adequate nutrition is fundamental for good health, it remains unclear what impact various dietary interventions may have on prolonging good quality of life. Studies which span age, geography and income all suggest that access to quality foods, host immunity and response to inflammation/infections, impaired senses (i.e., sight, taste, smell) or mobility are all factors which can limit intake or increase the body's need for specific micronutrients. New clinical studies of healthy ageing are needed and quantitative biomarkers are an essential component, particularly tools which can measure improvements in physiological integrity throughout life, thought to be a primary contributor to a long and productive life (a healthy "lifespan"). A framework for progress has recently been proposed in a WHO report which takes a broad, person-centered focus on healthy ageing, emphasizing the need to better understand an individual's intrinsic capacity, their functional abilities at various life stages, and the impact by mental, and physical health, and the environments they inhabit.

Comparison of Methods for Estimating Dietary Food and Nutrient Intakes and Intake Densities from Household Consumption and Expenditure Data in Mongolia

Household consumption and expenditure surveys are frequently conducted around the world and they usually include data on household food consumption, but their applicability to nutrition research is limited by their collection at the household level. Using data from Mongolia, this study evaluated four approaches for estimating diet from household surveys: direct inference from per-capita household consumption; disaggregation of household consumption using a statistical method and the "adult male equivalent" method, and direct prediction of dietary intake. Per-capita household consumption overestimated dietary energy in single- and multi-person households by factors of 2.63 and 1.89, respectively. Performance of disaggregation methods was variable across two household surveys analyzed, while the statistical method exhibited less bias in estimating intake densities (per 100 kcal) of most dietary components in both of the surveys. Increasingly complex prediction models explained 54% to 72% of in-sample variation in dietary energy, with consistent benefits incurred by inclusion of basic dietary measurements. In conclusion, in Mongolia and elsewhere, differences in how household and dietary measurements are recorded make their comparison challenging. Validity of disaggregation methods depends on household survey characteristics and the dietary components that are considered. Relatively precise prediction models of dietary intake can be achieved by integrating basic dietary assessment into household surveys.

Global Dietary Surveillance: Data Gaps and Challenges

BACKGROUND

Detailed information on global individual-level consumption patterns is imperative for informed policy making. However, such data are dispersed and incomplete.

OBJECTIVE

To review and discuss the methodologies, observed data availability, challenges, and opportunities pertaining to global dietary surveillance.

METHODS

This investigation provides an extensive review of global dietary assessment methodologies and challenges, including at the survey level, the dietary collection and assessment level, and the dietary data processing and analysis level. The focus is on nationally representative individual-level data, and additional types of dietary data, such as dietary biomarkers, household assessment, and food availability, are reviewed as alternatives. Practical guidance is provided to inform key decisions when designing dietary surveys and collecting, analyzing, and using dietary data. This article further identifies and describes existing global and regional dietary initiatives/data sets.

RESULTS

Harmonized and standardized primary individual-level dietary data collection, processing, and analysis worldwide are currently not available. Evaluation and decision-making should be based on best available data, that is, secondary nonharmonized yet to the extent possible, standardized individual-level dietary data. Existing initiatives differ substantially in methodologies, including survey design/representativeness, coverage, diet assessment, and dietary metric standardization and processing. Data gaps have been identified that were more profound for certain countries, certain dietary indicators across countries, population subgroups, representativeness, or time periods.

CONCLUSIONS

Optimizing worldwide dietary habits to improve population health requires systematically identified and evaluated data on a continuing basis. Leveraging existing available dietary data and efforts is an indispensable prerequisite for informed priority setting targeting the intersections between diet and disease.

Associations of childhood, maternal and household dietary patterns with childhood stunting in Ethiopia: proposing an alternative and plausible dietary analysis method to dietary diversity scores

BACKGROUND

Identifying dietary patterns that consider the overall eating habits, rather than focusing on individual foods or simple counts of consumed foods, better helps to understand the combined effects of dietary components. Therefore, this study aimed to use dietary patterns, as an alternative method to dietary diversity scores (DDSs), and investigate their associations with childhood stunting in Ethiopia.

METHODS

Mothers and their children aged under 5 years (n = 3788) were recruited using a two-stage random cluster sampling technique in two regions of Ethiopia. Socio-demographic, dietary and anthropometric data were collected. Dietary intake was assessed using standardized dietary diversity tools. Household, maternal and child DDSs were calculated and dietary patterns were identified by tetrachoric (factor) analysis. Multilevel linear and Poisson regression analyses were applied to assess the association of DDSs and dietary patterns with height-for-age z score (HAZ) and stunting, respectively.

RESULTS

The overall prevalence of stunting among children under-five was 38.5% (n = 1459). We identified three dietary patterns each, for households ("fish, meat and miscellaneous", "egg, meat, poultry and legume" and "dairy, vegetable and fruit"), mothers ("plant-based", "egg, meat, poultry and legume" and "dairy, vegetable and fruit" and children ("grain based", "egg, meat, poultry and legume" and "dairy, vegetable and fruit"). Children in the third tertile of the household "dairy, vegetable and fruit" pattern had a 0.16 (β = 0.16; 95% CI: 0.02, 0.30) increase in HAZ compared to those in the first tertile. A 0.22 (β = 0.22; 95% CI: 0.06, 0.39) and 0.19 (β = 0.19; 0.04, 0.33) increase in HAZ was found for those in the third tertiles of "dairy, vegetable and fruit" patterns of children 24-59 months and 6-59 months, respectively. Those children in the second (β = -0.17; 95% CI: -0.31, -0.04) and third (β = -0.16; 95% CI: -0.30, -0.02) tertiles of maternal "egg, meat, poultry and legume" pattern had a significantly lower HAZ compared to those in the first tertile. No significant associations between the household and child "egg, meat, poultry and legume" dietary patterns with HAZ and stunting were found. Statistically non-significant associations were found between household, maternal and child DDSs, and HAZ and stunting.

CONCLUSION

A higher adherence to a "dairy, vegetable and fruit" dietary pattern is associated with increased HAZ and reduced risk of stunting. Dietary pattern analysis methods, using routinely collected dietary data, can be an alternative approach to DDSs in low resource settings, to measure dietary quality and in determining associations of overall dietary intake with stunting.

Scaling up Dietary Data for Decision-Making in Low-Income Countries: New Technological Frontiers

Dietary surveys in low-income countries (LICs) are hindered by low investment in the necessary research infrastructure, including a lack of basic technology for data collection, links to food composition information, and data processing. The result has been a dearth of dietary data in many LICs because of the high cost and time burden associated with dietary surveys, which are typically carried out by interviewers using pencil and paper. This study reviewed innovative dietary assessment technologies and gauged their suitability to improve the quality and time required to collect dietary data in LICs. Predefined search terms were used to identify technologies from peer-reviewed and gray literature. A total of 78 technologies were identified and grouped into 6 categories: 1) computer- and tablet-based, 2) mobile-based, 3) camera-enabled, 4) scale-based, 5) wearable, and 6) handheld spectrometers. For each technology, information was extracted on a number of overarching factors, including the primary purpose, mode of administration, and data processing capabilities. Each technology was then assessed against predetermined criteria, including requirements for respondent literacy, battery life, requirements for connectivity, ability to measure macro- and micronutrients, and overall appropriateness for use in LICs. Few technologies reviewed met all the criteria, exhibiting both practical constraints and a lack of demonstrated feasibility for use in LICs, particularly for large-scale, population-based surveys. To increase collection of dietary data in LICs, development of a contextually adaptable, interviewer-administered dietary assessment platform is recommended. Additional investments in the research infrastructure are equally important to ensure time and cost savings for the user.