http://www.a4nh.cgiar.org/

1. Metrics for impact on diet quality in
agricultural projects:
Strengths and limitations of indicators of
dietary diversity
Mary Arimond
IFPRI, June 6, 2013
Program in International and Community Nutrition
University of California, Davis

2. Outline
• When is it appropriate to measure diet
quality? - questions for project planners
• Measuring diet quality – why dietary diversity?
• How to operationalize & measure it
• Strengths & limitations of dietary diversity
indicators; some misconceptions & pitfalls

3. Questions for project planners
• Is improving overall diet quality an explicit project
objective? Do you expect diets to diversify, and if so
why/how?
• Within diet quality, is the main concern intakes of
micronutrients? Or other dimensions of diet quality
(e.g. obesigenic diets)?
• Is the objective more narrow - increase intake of
single/few targeted foods?
• Whose diet quality – entire household or target
individual(s)?

4. Seed grants

5. Measuring diet quality –
Why dietary diversity?
• Dietary diversity (DD) is one important dimension of
diet quality (also balance, moderation, etc.)
• Consistently associated with micronutrient density
of the diet (infants), and micronutrient adequacy
(women), in multi-site studies
• Relatively simple to measure, & relevant across
various cultural dietary patterns
• Other multidimensional indices of diet quality can take much work to
adapt and validate across settings (e.g. U.S. Healthy Eating Index)

6. Why measure dietary diversity(2)?
• All food-based national dietary guidelines
include this dimension
• Also included in WHO guidelines for feeding
infants and young children, and operationalized
in WHO indicator for global use

7. Dietary diversity and nutrient density
(Working Group on IYC Feeding Indicators 2006)
Breastfed infants 6-8 mo, MMDA by # food groups yesterday
MMDA
“MMDA” is a measure of the adequacy of nutrient density, relative to
needs, and averaged across 9 “problem nutrients”

8. IYCF DD indicator for 6-23 mo
Percent with 4 or more food groups – WHO, 2008
Ethiopia
Niger
Burkina Faso
Mali
DRC
Mozambique
Kenya
Ghana
Bangladesh
India
Cambodia
Indonesia
Haiti
Colombia
Bolivia
Peru

9. Dietary diversity & micronutrient adequacy
(Arimond et al., Women’s Dietary Diversity Project, J Nutr. 2010)
“MPA” is probability of adequacy averages across 11 micronutrients

10. Associations between DD & other outcomes
• DD is associated with height-for-age (cross-sectional studies)
(Arimond & Ruel 2004; Sawadogo et al 2006; Moursi et al. 2009; Marriot et
al 2012; Menon et al 2013)
• But few longitudinal studies; one failed to show association
between DD and subsequent infant growth (length/height)
(Bork et al, 2012)
• In one study, DD was associated with vitamin A status in
women in Kenya, even after adjustment for vitamin A intake
(Fujita et al 2012)
• In one study, DD was protective/ associated with CD4 counts,
anemia, and mortality HIV+ adults (Rawat et al 2013)
• DD within fruit and vegetable groups has been associated with
reductions in chronic disease risk (many studies)

11. Operationalizing dietary diversity –whose?
• Household-level indicators – validated against
HH-level calorie (energy) availability and NOT as
an indicator of diet quality, and not for specific
vulnerable individuals
• Concept of mother as sentinel has been
proposed, but intake of nutrient-dense food
groups differs between mothers and infants
(Nguyen et al. 2013)

12. Operationalizing individual
dietary diversity
• DD has been defined & operationalized many ways
– Number of individual foods vs. number of food groups
(with different levels of aggregation)
– Varying recall periods (yesterday & last wk most common)
– Minimum quantity limits
– Free recall vs. list-based recall
– Indicators can be dichotomous (“% with low diversity”) or
quasi-continuous scores
– Guidance available (next slide) but…
– Trade-offs between one-size fits all vs. project-specific
indicators

13. WHO IYCF indicators
for global use
FAO guidelines, HH &
individual DD (adult)

14. Limitations of DD indicators
• Measurement error and day-to-day variability in
diets mean the indicators are “noisy” at individual
level
• Relatively simple, but survey instruments need to
be adapted locally (food lists and strategy for
excluding trivial amounts)
• Information on responsiveness is still limited as
the indicators are new
• Up to now, no consensus on a dichotomous
indicator for adult women (work in progress)

15. Limited information on
responsiveness
• Up to now, few studies documenting
responsiveness to interventions, shocks
• Study of 2008 food price shock in Burkina Faso
showed impact on DD (next slide)
• Inclusion of indicators at baseline and post-
intervention in Feed the Future projects will
yield more insights in coming years (18
countries, large geographic areas)

16. Response to spike in food prices*
Ouagadougou
4.9
5.1
5.3
5.5
5.7
5.9
2007 2008
Nb of food
groups
Decrease in dietary diversity
Mean DDS
(Adjusted)
P<0.0001
Food groups that
showed the largest
percent decrease
were nutrient-dense:
Dairy, meat, poultry, fr
uits, vitamin A-rich
vegetables, nuts &
seeds
*(Martin-Prevel et al, presented FENS Madrid 2011)

17. Misconceptions & pitfalls
• DD indicators are not a proxy for nutritional
status, they are a proxy for diet quality
• Household-level indicators are not sufficient to
assess diet quality of vulnerable groups
(infants, women); some household-level indicators
include non-nutritive foods/drinks
• Use for population/group-level description, never for
screening/targeting individuals
• For repeat uses in same population, and for
comparisons between populations, attend to
seasonality

18. Dietary diversity indicators are…
• …robust & useful population-level proxies of
micronutrient density/adequacy – an important
dimension of diet quality
• ….associated with growth & health outcomes, but not
a proxy for these
When choosing or designing indicators consider:
What makes sense based on intervention design
Comparability across sites, when this is relevant
Audiences for results, communication needs

19. Thank you!
World Health Organization Indicators for Assessing Infant and
Young Child Feeding Practices: Part II Measurement
http://whqlibdoc.who.int/publications/2010/9789241599290_eng.pdf
Food and Agriculture Organization Guidelines for Measuring
Household and Individual Dietary Diversity
http://www.fao.org/docrep/014/i1983e/i1983e00.pdf
marimond@ucdavis.edu