Addressing women and children’s

nutrition – measures of food intake

and nutritional status

Gina Kennedy and Jody Harris

Bioversity International and IFPRI

6 December, 2013

Health environment

Natural resources

Food market environment

Nutrition and health knowledge

Food accessFood

expenditure

Non-food

expenditure

Diet Child

nutrition

outcomes

Ho

use

ho

ld a

sset

s an

d liv

elih

oo

ds

Health status

Mother’s

nutrition

outcomes

Health care

Women’s

empowerment

National

nutrition

profile

Agricultural

income

Caring capacity

& practices

Female energy

expenditure

Food

production &

gathering

National

economic

growth

IndividualHousehold

Enabling environment

Processing

& storage

Agri

cult

ura

l P

roduct

ion

Production diversity

Household food security

Knowledge / attitudes

Target food consumption

Individual diet diversity

Target nutrient consumption

Anthropometry / biomarkers

Infant and young child

feeding

Environmental contaminants

or vectors

Food prices and

availability

Women’s Empowerment

in Ag Index

Consumption / Expenditure

Energy expenditureTime use

Commonly used individual indicatorsIndicator Relationship to Food Security Examples of Commonly used

indicators

Individual Dietary Diversity and

Frequency

Ability of the diet of the diet to meet energy

and micronutrient needs

Individual Dietary Diversity Score (IDDS)

Minimum Dietary Diversity (MDD)

% Consuming target foods

% Meeting Requirements for Nutrients

Knowledge and attitudes Provides important information on barriers

or optimizers related to dietary practices

Knowledge on nutritious foods

Attitudes toward good/bad foods for

children

Anthropometry Outcome indicators of multiple factors Stunting, Underweight Wasting

Body Mass Index

Desirable “ Do No Harm” Indicators Provides important desirable information

often related to “ do no harm”

Breastfeeding

Minimum meal Frequency

Women’s energy expenditure

Individual dietary intakes

• FOOD and DIET are THE KEY areas for ag-nutrition pathway

• Womens’ dietary diversity

• Infant and young child dietary diversity (Minimum Dietary Diversity)

• 24 hour recall/Food frequency

Quantitative dietary assessment cumbersome and difficult need for a simple proxy of intake

Objective of dietary diversityprovide tools to produce relevant and dietary intake information related to diet particularly at decentralized level

the collection of information on diet is meant to complement other indicators related to food security, health and nutritional status; thereby forming a suite of relevant indicators

Rationale for development of individual dietary diversity

INDIVIDUAL DIETARY DIVERSITY SCORES

• Sum of food groups consumed over the past 24 hours

–Women’s Dietary Diversity Score

–Minimum Dietary Diversity of children 6-23 months of age

Dietary Diversity Scores: Snapshot of Increasing Diversification

1 2 3 4 5

Method of data collection –

Women’s dietary diversity• Use open recall questionnaire form

• When open recall is finished go through food group list and mark “1” next to food groups consumed

• For any blank food group ask respondent if any food from this group was consumed the previous day. Mark “1” for yes and “0” for no

• Use tabulation sheet or computer program for WDD 9* food groups

Dietary Diversity (open)“Please describe the foods (meals and snacks) that you ate yesterday during the day and night, whether at home or outside the home. Start with the first food eaten in the morning.After the respondent tells you about the first thing they had to eat of drink, ask about what they ate or drank next. Write down all food and drinks mentioned by the respondent. When the respondent has finished, probe for meals and snacks not mentioned. If they had tea or coffee ask if there was milk or sugar added. Ask the respondent to mention the ingredients of any mixed dishes.

Food Group DDS record “1” yes “0” no

1 Starchy Staples

2 Dark green leafy vegetables

3 Other vitamin A rich vegetables and fruits

4 Other fruits and vegetables

5 Organ meat

6 Eggs

7 Meat and Fish and other seafood

8 Legumes, nuts and seeds

9 Milk and milk products

Sum above for WDDS

Oils and fats

Sweets, candy , sugar

Spices, condiments

Alcoholic beverages

Calculation of WDDS

• Sum the total number of food groups out of nine consumed during the 24 hour recall period

• Score range 0-9

• Calculate average WDDS

• Analyze frequency of food group consumption

• CAN MODIFY TOOL FOR TARGET FOODS

Guidelines Available

• English

• French

• Spanish

http://www.fao.org/docrep/014/i1983e/i1983e00.pdf

Minimum Dietary Diversity (MDD)

• The indicator is meant to reflect the quality of the complementary food diet of infants and young children 6-23 months of age

Data collection for MDD

• A standardized questionnaire can be downloaded from WHO (IYCF) indicators

• Data collected on children 6-23 months of age

• Could be disaggregated by boys/girls

• Breastfeeding status and child age also need to be collected for correct calculation of the indicator

Calculating MDD

Strengths of DD measures

• Simple to administer

• Quick to analyze

• Have undergone robust validation as proxy indicators for micronutrient adequacy of the diet

DD measures recently recommended

Masset, Haddad Cornelius & Isaza-Castro, 2012

Review of effectiveness of agriculture interventions that aim to improve nutritional status of children“Indices of diversity of the diet should be used to assess the effect on production and dietary composition”

Headey and Ecker, 2012

“dietary diversity indicators have substantial scope to add more value to food security measurement, especially if they can be refined and improved, rendered more comparable across populations and measured more frequently over time”

• Agriculture, Fishery, Forestry programmes▫ Crop diversification/integration

▫ Promotion of indigenous plant and animal foods

• Food security and nutrition programmes▫ Sustainable livelihood support and diversification

▫ Programmes in HIV affected areas

▫ Food-based nutrition programmes

▫ Nutrition education

• Cross-cutting issues▫ Gender

▫ HIV/AIDS

▫ Right to Food

Dietary diversity tools are useful in programmes and initiatives where a primary or secondary objective is to

improve the diet of the beneficiary population

The cost will be marginal !

Quantitative food intake

(target nutrient consumption and

women’s energy intakes)

• Quantitative 24 hour recalls can be used to assess intakes of energy, protein, fat and micronutrients

▫ Requires high level skills in training, supervision of data collection and analysis

▫ Special equipment (weighing scales, recipes, food composition tables)

Additional Infant and young child

indicators• These and fall under “ Do no harm” principle

• Minimum meal frequency

• Breastfeeding

• SEE WHO GUIDELINES

Additional indicators for IYCF

Anthropometry in children and adults

Children

• STUNTING: height-for-age < -2 standard deviations of the WHO Child Growth Standards Median (chronic malnutrition)

• WASTHING: weight-for-height < -2 standard deviations of the WHO Child Growth Standards Median (acute malnutrition)

• UNDERWEIGHT: weight-for-age < -2 standard deviations of the WHO Child Growth Standards Median (global malnutrition)

Adults

Body Mass Index (BMI)

• Requires specialized training of enumerators

• Special equipment, height board/ weighing scales

Anthropometric data can be obtained from:

- WHO GLOBAL DATABASE

- http://www.who.int/nutgrowthdb/en/

- National nutrition surveys

- Nutritional monitoring/surveillance

- (e.g. IFAD, WFP monitoring systems)

- Demographpic and Health and (DHS) and Multiple Indicator Cluster (MICS) surveys

Biochemical indicators

• To assess if the program actually changed micronutrient status of the population a biochemical marker such as serum retinol or hemoglobin can be used

▫ REQUIRES BLOOD SAMPLE AND ADDITIONAL LEVELS OF ETHICAL CLEARANCE

EXAMPLES OF KAP INDICATORS

Short to medium term indicators

Example

Example

Example

Percent of mothers who can identify three local foods rich in vitamin A

Percent of mothers who think eggs are a good source of food for children

KnowledgeAttitudesPractices

Percent of children 6-23 months fed an iron-rich food source the previous day

Food Insecurity Scales and Seasonality

• Household Food Insecurity Access Scale (HFIAS)

• Household Hunger Scale (HHS)

• Coping Strategies Index (CSI) and Reduced CSI

• Others (ECLSA and FIES)

• Months of Inadequate HH food provisioning

Additional indicators of interest

• Child morbidity (see DHS for example questions)

• Water and sanitation sources

• Socio-economic indicators

▫ Some form of wealth index

• Level of education (men and women)

• Literacy (men and women)

Aquaculture - Nutrition Linkages

Bangladesh: Case Study

Shakuntala Haraksingh Thilsted

Senior Nutrition Scientist

Bangladesh has made great strides in

aquaculture in the past 25 years

Focus on:

• Production and productivity

• Large fish

• Men in aquaculture

• Household income

Nutrition sensitive household pond aquaculture

Production Technology:

• Polyculture of Carps (large fish) and Nutrient-rich Small Fish, carried out by both men and women

Focus on:

• Partial Frequent Harvesting of Small Amounts of Small Fish

• Household Consumption, especially in Women and Young Children

• Sale of Carps for Household Income

• Additional Diversification strategies

Small FishIrreplaceable Animal-source

Food

Rich Source of Multiple Nutrients

Animal Protein

Essential Fats

Essential Micronutrients:

Minerals and Vitamins

Common Food eaten with Rice

Adds Flavour and Taste to the Meal

Improves Diet Diversity

Enhances Mineral Bioavailability from

Foods in the Meal

Cooked with Vegetables, Oil and Spices,

further Improving Diet Diversity, Adding

Nutrients and Growth-promoting

Substances

Processed (dried), Stored - Prolonging

Duration of Consumption, Reaching

Non-fish Producing Areas

Promotion of Orange Fleshed Sweet Potato

(OFSP)

• Suitable for small areas -

homestead gardens and dykes

• Requires minimal labour,

fertilizer and pesticides; grows

well in marginal soils

• Leaves and roots are

consumed

• Valuable in times of food

scarcity and natural disasters

• Vines are easily preserved by

households for planting in

subsequent season

M/E Indicators

• Increased production

• Increase Consumption of Target Food (Small fish) – Quantity, Frequency

and by Target Groups (Women and young children)

• Men and women in decision-making and work load sharing in production

• Women’s work load

• Intra-household food allocation

• Men’s purchase of foods (Knowledge and Practices)

Zero Sum Game? Gender and Work Load

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Husband Wife Mother-in-law

Is it embarrassing for a man to help with household work?

Strongly Disagree

Disagree

Agree

Strongly Agree

Helen Keller International (HKI) 2012

CRP / Indicator

Pro

du

ctio

n

div

ers

ity

HH

Fo

od

se

cu

rity

Wo

men

’s

emp

ow

erm

ent

Kn

ow

led

ge

/

att

itu

des

Ta

rge

t fo

od

co

nsu

mp

tio

n

IDD

S

Targ

et nutr

ient

co

nsu

mp

tio

n

Anth

ropom

etr

y /

bio

ma

rke

rs

‘Do n

o h

arm

’

Oth

er

1.1 Dryland Systems * * * *

1.2 Humidtropics * * * *

1.3 AAS * *

3.2 Maize *

3.3 GRiSP

3.4 RTB * *

3.5 Grain Legumes *

3.6 Dryland Cereals * *

3.7 L&F * *

4 A4NH \ * *

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How to choose indicators…?

• Which pathway(s) is your program trying to address?

• Which of the boxes along that pathway (or any

intermediate steps not adequately captured there) can

you feasibly measure?(As many as possible!)

• What (preferably validated) tools and metrics exist to

measure each of these?

• In what way will each of these need to be adapted to your

particular context (without losing the validity of the tool)?

• How does the totality of your indicators build a picture of

how your agriculture program is affecting food and

diets/nutrition?

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