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DIETARY ASSESSMENT AND
        LINKS
     WITH NUTRITIONAL
     ASSESSMENT
         #6C
                     Lalita Bhattacharjee
                         Nutritionist
National Food Policy Capacity Strengthening Programme
Food and Agriculture Organization of the United Nations
                       Bangladesh
                Presented on 5 July 2011
                           at the
 Training Workshop on “Food Security Concepts, Basic Facts and
                   Measurement Issues”
OUTLINE
 Introduction
 National and household food consumption surveys
 Individual dietary assessment
 Rapid methods of dietary assessment, micronutrient
    assessment and FFQ
   Validation of dietary assessment
   Dietary diversity
   Conversion of dietary intakes to nutrients
   Conclusion
Dimensions and methods for
assessing food security and under
nutrition
  Methods         Availability   Access to   Consumption   Utilization
                    of food        food        of food          of
                                                           nutrients

 FAO Method

 Household
   income
& expenditure
   surveys

Individual food
 consumption/
intake surveys

Anthropometry


  Qualitative
  measures of
 food security
DIETARY ASSESSMENT AND
        NUTRITIONAL ASSESSMENT
 A DIETARY ASSESMENT is a comprehensive evaluation of a person's
  food intake. It is one of the established methods of nutritional
  assessment. Dietary assessment techniques range from food records
  to questionnaires and biological markers.

 NUTRITIONAL ASSESSMENT is more comprehensive and includes d
  determining nutritional status by analyzing the individual’s brief socio
  economic background, medical
  history, dietary, anthropometric, biochemical, clinical data and drug –
  nutrient interactions

 NUTRITIONAL STATUS is the measurement of the extent to which an
  individual’s physiologic need for nutrients is being met

 NUTRIENT INTAKE depends on actual food consumption which is
  influenced by factors such as economic situation, eating
  behaviour, emotional climate, cultural influences, effects of disease
  states on appetite and the ability to absorb nutrients

 NUTRIENT REQUIREMENTS are determined and influenced by
  age, sex, BMR, physiological status, activity patterns, physiologic
OPTIMAL NUTRITIONAL
STATUS




                Source: Mahan and Stump, 2000
DIETARY ASSESSMENT
PRINCIPLES
 Adequacy : a diet that provides enough energy and nutrients to
 meet the needs according to the recommended dietary allowances
 for good health

 Balance : a diet that provides enough, but not too much of each
 type of food

 Variety : a diet that includes a wide selection of foods within each
  food group

Nutrient Density : a diet that includes foods that provide the most
nutrients for the least number of calories (nutrient dense foods)

 Moderation : A diet that limits intake of foods high in sugar and fat
Methods of assessing dietary
intake

 National food supply data
 Household data
 Individual data (Food records, 24 hr dietary
  recall, FFQs, diet histories,food habit
  questionnaires, combined methods
 RAP - rapid assessment procedure ( focus
  groups to gather information on food
  behaviours, beliefs and intakes)
National and household food
          consumption

 Food consumption data collected at national, HH
    or individual levels
   Individual intake data required for assessing
    nutrient adequacy
   Food supply and HH data can provide useful
    information
   Food consumption assessment at national level
    based on FBS ( per capita availability, no
    individual variation in food intake)
   Food supply data useful
National and household level
         consumption


 Preferred source of food consumption surveys (
 provide more information than FBS)

 Provide consumption characteristics of specific
 vulnerable groups including those from urban
 /rural populations

 HIES 2010
SHARE OF FOOD GROUPS AS % OF DIETARY ENERGY
SUPPLIES
         2007                                                   78                                                       3.5         6.6        2.5 2 2 3.1 2.3

         2006                                                  78.1                                                      3.5         7.2         2.71.4 3 2.4
                                                                                                                                                      1.7

         2005                                                  78.2                                                      4.1          6.6        2.51.7 3 2.2
                                                                                                                                                      1.7

         2004                                                   80.4                                                       3.1         6.3        2 21.22.8 2.3

         2003                                                    82.2                                                           2.4         6     1.9 1.12.81.8
                                                                                                                                                     1.8
  Year




         2002                                                        82.6                                                        2.7 5.4 1.72.11 2.81.7

         2001                                                    80.8                                                          3.2         6.8     1.9 2 1 2.61.7

         2000                                                    81.6                                                          2.7         6.7     1.8 1 2.71.9
                                                                                                                                                     1.6

         1999                                                        83.1                                                        2.8 5.2 1.8 1 2.61.7
                                                                                                                                            1.8

         1998                                                   79.6                                                       3.2             8.7     1.2 1 2.61.8
                                                                                                                                                     1.9


                0%        10%           20%         30%         40%              50%          60%            70%        80%                      90%           100%


                      Cereal    Sugar         Oil   Roots & Tubers          Pulses     Fruits & Vegetables     Meat, Milk, Egg & Fish                  Other




                     Source: Adapted from FBS, FAO, 2010
Comparative Per capita food intake (g)
     HIES 1991 -92 to 2010
Per capita/d intake of major food items
(g)
Per capita dietary energy (kcal)
intake
           (HIES, 2010)
(En%) of
       cereals and rice to Bangladesh
  diet
Source/Year      Energy       Cereal (g)   Rice (g)
              intake (kcal)      En %       En %



                                452         440
HIES 2005        2238
                                70%         68%
                                442         416
HIES 2010        2318
                                66%         64%
Potential key indicators to be mapped at national
&sub-national levels by sector : FOOD AND
NUTRITION
 Food intake indicators



 Average energy intake             Percentage of energy from fat

 Average food intake of major      Percentage of protein from
  food groups                        animal source

 Daily per caput protein intake    Percentage of protein from
                                     vegetable source
 Percentage of energy from
  protein                           Dietary Energy Supply

 Daily per caput carbohydrate      Percentage of undernourished
  intake                             population

 Percentage of energy from
  carbohydrates
 Daily per caput fat intake
Assessment of individual intakes
  Dietary records

 Record all foods and beverages consumed over a specific
  time period ( 3-4 d)

 Amount consumed determined by weighing with a scale or
  measuring volume using standard cups and spoons

 Specific/special foods may be recorded (fat, vitamin A, iron
  rich)

 Total energy intake will require all foods to be recorded.
Assessment of individual
   intakes
24 hour recall :
 Recall all the foods and beverages consumed the
  previous day or 24 hours prior to the interview
 Interviewers should be knowledgeable about foods
  available in the market
 Regional and ethnic preparations and methods
 Interview conducted face –to-face, structured w/o probing
  questions
 Estimates of portion size are made using standardized
  cups and spoons
 Record of food amounts converted into nutrient intakes
  using food composition tables
Assessment of individual
intakes
Food frequency questionnaire (FFQ)
 Report usual frequency of consumption of each
  food item from a list of food items in reference
    to a specified period (past wk/mo/yr)
 Face to face interview, telephone or by self
    administration
 Describes dietary patterns or food habits not
   nutrient intake
 Semi quantified tools can obtain information on
    portion size using household measures
Estimating average intake of
 nutrients
 Specification of portion size – standardized
    portions (Willet )
   Description of portion size – small, medium, large
    (Block)
   Information on frequency and serving size allows
    for estimating nutrient intakes
   Food list should contain foods that contribute to
    majority of the nutrients/specific in the diet
   % adequacy of food groups
   % adequacy of RDA for energy and nutrients
   Used in epidemiological research to study diet
Assessment of individual
 intakes
Diet history
• Collection of information on frequency of intake of
  various
• foods and usual meal pattern
• Entails detailed listing of foods and beverages
   consumed at each eating session
• 3 d - diet record as an independent check on food
  intake
• Methods of preparation
Rapid methods for community
  dietary
            assessment
 Dietary assessment of         development of culture -
  HHs with children under 5s     specific relevant food usage
                                 list
 Rapid assessment survey
  (focus group interviews,      Linking food intake data with
                                 weighing /measuring of
  selected target group
                                 children & mother
  interviews IYCF practices,
                                Derive mother’s BMI from
 Social customs and food        standard tables
  beliefs, behaviours &
  intakes
 Key informants –
  community leaders, local
  shop owners or health
  personnel
 Small clusters of women
  5-6 women sufficient for
  FGD
Strengths and limitations of dietary assessment
methods
Method          Strengths                                 Limitations

Food record     Does not rely on memory; open ended       High participation burden; requires
                                                          literacy; may alter intake behaviour (
                                                          ?? community use )
24 hr recall    Immediate recall period, easy to obtain   Relies on memory; requires skilled
                information; since interviewers           interviewer; does not reflect the
                administer tool & records the             usual dietary intake
                responses, literacy is not a              ( need for food list, std menu
                problem, respondent burden minimal;       types; need for community based
                does not alter intake behaviour; wide     training ) memory; requires complex
FFQs            Inexpensive ; preferred for nutrients
                range of use                              Relies on
                with high day-to-day variability; does    calculations to estimate frequencies;
                not alter intake behaviour; lower         requires literacy, doe not quantify
                respondent burden; epidemiological        intake ( need for exhaustive food
                research to study diet-disease            list; need for manual tally type
                relationships                             calculations)
Food habit      Rapid &low cost; does not alter intake    may rely on memory; may require
questionnaire   behaviour                                 trained interviewer ( need for food
                                                          list; std menu types; community
                                                          based training)
                                                          Relies on memory; may require
Diet history    No literacy needed;                       trained interviewer ( need for food
                                                          list & community based training
Selecting appropriate methods for
      community dietary assessment
 RAP –low cost, primary method for collecting
    dietary data (locally available /commonly
    consumed foods, dietary habits, behaviour)
   Household surveys – provide data on foods
    consumed by HH not individuals
   Point to which foods are major contributors to
    nutrients of particular concern ( identify
    vulnerability/at risk of dietary deficiency - e.g no
    fresh vegetables/fruits, lack of DGLV/YOV–lack of
    vitamin C & A in diet; inadequate presence of
    dietary enhancers for iron absorption??)
   Food record and 24 hr recall methods of choice
    for estimating mean intakes
   Combine with quantitative dietary intake methods
    to obtain individual nutrient intakes
Simplified assessment for specific
   nutrients
 FFQ
 Simple, short questionnaires
 Assessing intakes of specific nutrients to study diet –
  disease relationships
 Questionnaires should focus on assessing intakes of
  specific nutrients (e.g calcium and osteoporosis, anti
  oxidants and CD –cancer, heart disease, V&F and
  certain cancers, specific micronutrients and
  VAD, anemia; iodized salt, sea foods and fortified foods
  and IDD)
 Questionnaires need to be tested in diverse populations
  to assess validity
 VS, HKI Simplified FFQ
Validation of dietary
methods
 Need to establish validity and reliability
 Validity - how well it measures what it purports to
    measure (accuracy)
   Reliability – how well it agrees on retesting under
    the same conditions (consistency)
   Assessment of reliability is feasible , validity
    poses a problem
   Gold standard established – dietary record/direct
    observation of subject’s consumption
   Reference for validation
Relative validation
 Unlike other methods, 24 hr recall is more susceptive to
    direct validation
   Since time covered is short and limited, direct observation
    and measurements of intake are possible and also
    practical
   Studies that compared 24 hr recall with observation
    and weighed duplicate meals have found that that the
    2 methods yield similar results
   Dietary intake varies from day to day, single recall may not
    be representative
   Many studies confirm that variations within
    individuals, mean intake of group was not found to be
    significantly different from day to day
   Inter individual variability is less marked than intra
    individual variation
Errors in dietary surveys
 RANDOM (reduced reliability)
 Generate larger total variances
 Reduce the statistical power to detect association between
  intake and a disease
 Accentuate the estimates of possible associations

   SYSTEMATIC (bias)
   Represent greater hazards than random errors
   Alter results
   Very little can be done to correct for their effect

 Structure of errors differs according to type of survey
   method
Methods relying on simple recall or ability to provide reliable
   estimates
of usual eating habits tend to be more prone to systematic errors
   while
SOURCES OF ERROR IN DIETARY
   ASSESSMENT
       METHODS (INDIVIDUAL INTAKES)
Source of        Weighed food   Estimated     24 hr recall     Dietary history
error            records        food weight                    and FFQs
                                records
FCT /recipe          +          +             +                +
books
Food coding      +              +             +                +

Wrong weight     _              +             +                +
of foods
Reporting error _               _             +                +

Variation of     +              +             +                _
diet with time
Wrong            _              _             _                +
frequency
Modified         ±              ±             _                _
eating pattern
Response bias    ±              ±             ±                ±

Sampling bias    +              +             +                Ferro –Luzzi in FAO, 2002
                                                  Source: Anna +
Illustration of association
between dietary adequacy and
anthropometry

Prevalence %          %                                                Total
of UW      inadequate adequate

% <-2SDs                       20                     10                  30

% > -2SDs                         0                    70                 70

Total                          20                      80               100


Source : Mason, 2002 in “Measurement and Assessment of Food Deprivation and Undernutrition”, FAO
Dietary diversity (DD) : when to
  measure
      Objective                                           Timing
Assessment of the   In rural, agriculture       In non agriculture based
typical diet of     based communities           communities
HH/individuals
                    When food supplies are      Anytime of the year (if
                     still adequate (maybe      seasonality is not an issue)
                    up to 4-5 mo after the
                    main harvest)
                    Looking at DD at
                    different points in the
                    agricultural cycle is one
                    way of investigating
                    seasonality of food
                    security
                    In many areas there are
                    important seasonal
                    differences in dietary
                    patterns.
                    For a more complete
                    assessment of usual
                    diet, DD should be
Dietary diversity (DD) : when to
measure
               Objective                                        Timing
Assessment of the food security         During the period of greatest food
situation in rural, agriculture-based   shortage, such as immediately prior
communities                             to the harvest or immediately after
                                        emergencies or natural disasters
                                        This may also serve as a baseline
                                        for monitoring change for
                                        investigating seasonality
Assessment of the food security         At the moment of concern to identify
situation in non-agricultural           a possible food security problem
communities                              May also serve as a baseline for
                                        monitoring changes due to an
                                        intervention
Monitoring of food security/nutrition   Repeated measures to assess
programmes or agricultural              impact of the intervention on the
interventions such as crop and          quality of the diet, conducted at the
livelihood diversification              same time of year as the baseline
                                        (to avoid interference due to
Dietary diversity : Key steps
Activities prior to data collection
 Translation and adaptation steps
 Review
 Key informant and community meetings
 Refining the food lists and translations
 Use of local names
Technical issues
 Minimum quantities
 Individual food items that can be classified into more than one
  food group
 Mixed dishes
Training
Instructions for administering the questionnaire
Household level
Analyzing dietary diversity data
Dietary diversity scores
DIETARY DIVERSITY SCORES : Aggregation of food groups to create HDDS and
 WDDS
                  HDDS                                               WDDS

Question no.         Food Group               Question no.            Food Group

1.                   Cereals                  1,2                     Starchy staples

2.                   White tubers and         4                       Dark green leafy
                     roots                                            vegetables
3,4,5                Vegetables               3,6 and red palm oil    Other vitamin A rich
                                              as applicable           fruits and vegetables
6,7                  Fruits                   5,7                     Other fruits and
                                                                      vegetables
8,9                  Meat                     8                       Organ meat

10                   Egg                      9,11                    Meat and fish

11                   Fish and other sea       10                      Egg
                     food
12                   Legumes, nuts and        12                      Legumes, nuts and
                     seeds                                            seeds
13                   Milk and milk products   13                      Milk and milk products

14                   Oils and fats

15                   Sweets

16                   Spices, condiments
                     and beverages
Food groups consumed by ≥ 50 % HH
by
          diversity tertiles
Lowest dietary           Medium dietary         High dietary diversity
diversity (≤ 3 food      diversity              (≥ 6 food groups)
groups )                 ( 4 and 5 food groups)
Cereals                  Cereals                  Cereals
Green leafy vegetables   Green leafy vegetables   Green leafy vegetables
Vitamin A rich fruit     Oil                      Vitamin A rich fruit
                                                  Oil
                                                  Other vegetables
                                                  Fish
                                                  Legumes, nuts and
                                                  seeds



           Source: FAO, 2010
Measures and use of DD
 Dietary diversity as a measure of HH access and
    food consumption can be triangulated with other
    food related information
   Gives a holistic picture of food and nutrition
    security status across a broader area
   DD being used increasingly to provide indicators
    of HH access and individual dietary quality
   Contextual use : Baseline and impact
    assessment , national surveys, surveillance
    systems, M&E of programmes and policies
   Phase classification for identifying emergencies
Lalita 6c dietary assessment
Easy way to count your calories
(Measures providing 100 kcal
   Cereals : 30 g ( 1/5 cup)          Egg : 60 g ( 1 medium size)
   Bread : 40 g ( 2 slices)           Chicken : 90 g ( 3 small
   Pulses : 30 (2 Tbsp)                  pieces)
   Leafy vegetables (sak): 250 g        Mutton: 85 g
    ( 2 small bunches)                   Fish (lean) 100 g
   Other vegetables : 400 g (4          Fish (fatty) 60 g
    cups)                                Shrimp : 30 g
   Potato : 100 ( 1 cup)                Prawn : 100 g
   Nuts/oilseeds : 20 g (handful)       Sugar : 25 g ( 5 tsp)
   Fruit : 150 g/ 1-2 fruits            Spices : 40 g ( 6 tsp)
   Milk/Curd :150 ml ( 1 cup)           Oil/ghee : 10 g (2 tsp)
   Butter milk (ghol) : 670 ml ( 4      Butter : 15 g (1 Tbsp)
    cups)
   Channa/paneer/cheese : 30 g
    (1 pkt)
Energy expenditure of selected
    activities - kcal expended/minute
 Activity     Kcal/min/   45kg   55kg   65kg
                 kg
  Sitting      0.021      0.9    1.2    1.4
  quietly
  Walking      0.080      3.6    4.4    5.2
normal pace
  Writing,     0.029      1.3    1.6    1.9
  sitting
Vacuuming      0.048      2.2    2.6    3.1
 cleaning/
 mopping
  Ironing      0.064      2.9    3.5    4.2
 Running       0.135      6.1    7.4    8.8
  11.5
 min/mile
Cycling 5.5    0.064      2.9    3.5    4.2
   mph
Estimating energy requirements
 Sedentary work : 30 -35kcal/kg/BW
 Moderately active : 40kcal/kg/BW
 Very physically active : 50kcal/kg/BW


Suppose a person’s ideal BW is 60 kg
 40 x 60 = 2400 kcal = energy requirement
Calculation of approximate energy requirement
 BMR : 1 x24x 60 = 1440 kcal
 Physical activity = 800 kcal
 SDA = 250 kcal
 Energy requirement =      2490 kcal
Normogram for determining BMI
Conclusions
 Need to use core indicators linked to food security &
    nutrition outcomes;
   Identify food and nutrition vulnerability through information
    on food consumption patterns
   Need to obtain information on intra household distribution
    of food for accurate assessment of individual intakes;
   Differential nutritional status associated with differences in
    morbidity or illness or other factors within HHs provides
    valuable information on food distribution
   Knowledge of HH food allocation patterns and underlying
    reasons for food / diet related behaviour, so that
    effectiveness of nutrition interventions can be improved.
Conclusions
 Choice of method : Information needed, resources
    available
   Food/nutrients of primary interest, group/vs individual
    data, absolute /vs relative intake , population
    characteristics
   Include statistical expertise while designing survey and
    questions
   Can provide qualitative data on dietary intake of HH
   Can be combined with other methods to obtain individual
    quantitative data
   When absolute vs relative estimates are required, food
    record, 24 dietary recall are methods of choice
   For day –to-day variability – FFQ useful
   DD – dietary patterns/habits/semi qualitative can be
    quantified
   Dietary assessment is essential to identify populations at
    risk

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Topic 18 multiple regression
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Topic17 regression spss
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Lalita 6c dietary assessment

  • 1. DIETARY ASSESSMENT AND LINKS WITH NUTRITIONAL ASSESSMENT #6C Lalita Bhattacharjee Nutritionist National Food Policy Capacity Strengthening Programme Food and Agriculture Organization of the United Nations Bangladesh Presented on 5 July 2011 at the Training Workshop on “Food Security Concepts, Basic Facts and Measurement Issues”
  • 2. OUTLINE  Introduction  National and household food consumption surveys  Individual dietary assessment  Rapid methods of dietary assessment, micronutrient assessment and FFQ  Validation of dietary assessment  Dietary diversity  Conversion of dietary intakes to nutrients  Conclusion
  • 3. Dimensions and methods for assessing food security and under nutrition Methods Availability Access to Consumption Utilization of food food of food of nutrients FAO Method Household income & expenditure surveys Individual food consumption/ intake surveys Anthropometry Qualitative measures of food security
  • 4. DIETARY ASSESSMENT AND NUTRITIONAL ASSESSMENT  A DIETARY ASSESMENT is a comprehensive evaluation of a person's food intake. It is one of the established methods of nutritional assessment. Dietary assessment techniques range from food records to questionnaires and biological markers.  NUTRITIONAL ASSESSMENT is more comprehensive and includes d determining nutritional status by analyzing the individual’s brief socio economic background, medical history, dietary, anthropometric, biochemical, clinical data and drug – nutrient interactions  NUTRITIONAL STATUS is the measurement of the extent to which an individual’s physiologic need for nutrients is being met  NUTRIENT INTAKE depends on actual food consumption which is influenced by factors such as economic situation, eating behaviour, emotional climate, cultural influences, effects of disease states on appetite and the ability to absorb nutrients  NUTRIENT REQUIREMENTS are determined and influenced by age, sex, BMR, physiological status, activity patterns, physiologic
  • 5. OPTIMAL NUTRITIONAL STATUS Source: Mahan and Stump, 2000
  • 6. DIETARY ASSESSMENT PRINCIPLES Adequacy : a diet that provides enough energy and nutrients to meet the needs according to the recommended dietary allowances for good health Balance : a diet that provides enough, but not too much of each type of food Variety : a diet that includes a wide selection of foods within each food group Nutrient Density : a diet that includes foods that provide the most nutrients for the least number of calories (nutrient dense foods) Moderation : A diet that limits intake of foods high in sugar and fat
  • 7. Methods of assessing dietary intake  National food supply data  Household data  Individual data (Food records, 24 hr dietary recall, FFQs, diet histories,food habit questionnaires, combined methods  RAP - rapid assessment procedure ( focus groups to gather information on food behaviours, beliefs and intakes)
  • 8. National and household food consumption  Food consumption data collected at national, HH or individual levels  Individual intake data required for assessing nutrient adequacy  Food supply and HH data can provide useful information  Food consumption assessment at national level based on FBS ( per capita availability, no individual variation in food intake)  Food supply data useful
  • 9. National and household level consumption  Preferred source of food consumption surveys ( provide more information than FBS)  Provide consumption characteristics of specific vulnerable groups including those from urban /rural populations  HIES 2010
  • 10. SHARE OF FOOD GROUPS AS % OF DIETARY ENERGY SUPPLIES 2007 78 3.5 6.6 2.5 2 2 3.1 2.3 2006 78.1 3.5 7.2 2.71.4 3 2.4 1.7 2005 78.2 4.1 6.6 2.51.7 3 2.2 1.7 2004 80.4 3.1 6.3 2 21.22.8 2.3 2003 82.2 2.4 6 1.9 1.12.81.8 1.8 Year 2002 82.6 2.7 5.4 1.72.11 2.81.7 2001 80.8 3.2 6.8 1.9 2 1 2.61.7 2000 81.6 2.7 6.7 1.8 1 2.71.9 1.6 1999 83.1 2.8 5.2 1.8 1 2.61.7 1.8 1998 79.6 3.2 8.7 1.2 1 2.61.8 1.9 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Cereal Sugar Oil Roots & Tubers Pulses Fruits & Vegetables Meat, Milk, Egg & Fish Other Source: Adapted from FBS, FAO, 2010
  • 11. Comparative Per capita food intake (g) HIES 1991 -92 to 2010
  • 12. Per capita/d intake of major food items (g)
  • 13. Per capita dietary energy (kcal) intake (HIES, 2010)
  • 14. (En%) of cereals and rice to Bangladesh diet Source/Year Energy Cereal (g) Rice (g) intake (kcal) En % En % 452 440 HIES 2005 2238 70% 68% 442 416 HIES 2010 2318 66% 64%
  • 15. Potential key indicators to be mapped at national &sub-national levels by sector : FOOD AND NUTRITION  Food intake indicators  Average energy intake  Percentage of energy from fat  Average food intake of major  Percentage of protein from food groups animal source  Daily per caput protein intake  Percentage of protein from vegetable source  Percentage of energy from protein  Dietary Energy Supply  Daily per caput carbohydrate  Percentage of undernourished intake population  Percentage of energy from carbohydrates  Daily per caput fat intake
  • 16. Assessment of individual intakes Dietary records  Record all foods and beverages consumed over a specific time period ( 3-4 d)  Amount consumed determined by weighing with a scale or measuring volume using standard cups and spoons  Specific/special foods may be recorded (fat, vitamin A, iron rich)  Total energy intake will require all foods to be recorded.
  • 17. Assessment of individual intakes 24 hour recall :  Recall all the foods and beverages consumed the previous day or 24 hours prior to the interview  Interviewers should be knowledgeable about foods available in the market  Regional and ethnic preparations and methods  Interview conducted face –to-face, structured w/o probing questions  Estimates of portion size are made using standardized cups and spoons  Record of food amounts converted into nutrient intakes using food composition tables
  • 18. Assessment of individual intakes Food frequency questionnaire (FFQ)  Report usual frequency of consumption of each food item from a list of food items in reference to a specified period (past wk/mo/yr)  Face to face interview, telephone or by self administration  Describes dietary patterns or food habits not nutrient intake  Semi quantified tools can obtain information on portion size using household measures
  • 19. Estimating average intake of nutrients  Specification of portion size – standardized portions (Willet )  Description of portion size – small, medium, large (Block)  Information on frequency and serving size allows for estimating nutrient intakes  Food list should contain foods that contribute to majority of the nutrients/specific in the diet  % adequacy of food groups  % adequacy of RDA for energy and nutrients  Used in epidemiological research to study diet
  • 20. Assessment of individual intakes Diet history • Collection of information on frequency of intake of various • foods and usual meal pattern • Entails detailed listing of foods and beverages consumed at each eating session • 3 d - diet record as an independent check on food intake • Methods of preparation
  • 21. Rapid methods for community dietary assessment  Dietary assessment of  development of culture - HHs with children under 5s specific relevant food usage list  Rapid assessment survey (focus group interviews,  Linking food intake data with weighing /measuring of selected target group children & mother interviews IYCF practices,  Derive mother’s BMI from  Social customs and food standard tables beliefs, behaviours & intakes  Key informants – community leaders, local shop owners or health personnel  Small clusters of women 5-6 women sufficient for FGD
  • 22. Strengths and limitations of dietary assessment methods Method Strengths Limitations Food record Does not rely on memory; open ended High participation burden; requires literacy; may alter intake behaviour ( ?? community use ) 24 hr recall Immediate recall period, easy to obtain Relies on memory; requires skilled information; since interviewers interviewer; does not reflect the administer tool & records the usual dietary intake responses, literacy is not a ( need for food list, std menu problem, respondent burden minimal; types; need for community based does not alter intake behaviour; wide training ) memory; requires complex FFQs Inexpensive ; preferred for nutrients range of use Relies on with high day-to-day variability; does calculations to estimate frequencies; not alter intake behaviour; lower requires literacy, doe not quantify respondent burden; epidemiological intake ( need for exhaustive food research to study diet-disease list; need for manual tally type relationships calculations) Food habit Rapid &low cost; does not alter intake may rely on memory; may require questionnaire behaviour trained interviewer ( need for food list; std menu types; community based training) Relies on memory; may require Diet history No literacy needed; trained interviewer ( need for food list & community based training
  • 23. Selecting appropriate methods for community dietary assessment  RAP –low cost, primary method for collecting dietary data (locally available /commonly consumed foods, dietary habits, behaviour)  Household surveys – provide data on foods consumed by HH not individuals  Point to which foods are major contributors to nutrients of particular concern ( identify vulnerability/at risk of dietary deficiency - e.g no fresh vegetables/fruits, lack of DGLV/YOV–lack of vitamin C & A in diet; inadequate presence of dietary enhancers for iron absorption??)  Food record and 24 hr recall methods of choice for estimating mean intakes  Combine with quantitative dietary intake methods to obtain individual nutrient intakes
  • 24. Simplified assessment for specific nutrients  FFQ  Simple, short questionnaires  Assessing intakes of specific nutrients to study diet – disease relationships  Questionnaires should focus on assessing intakes of specific nutrients (e.g calcium and osteoporosis, anti oxidants and CD –cancer, heart disease, V&F and certain cancers, specific micronutrients and VAD, anemia; iodized salt, sea foods and fortified foods and IDD)  Questionnaires need to be tested in diverse populations to assess validity  VS, HKI Simplified FFQ
  • 25. Validation of dietary methods  Need to establish validity and reliability  Validity - how well it measures what it purports to measure (accuracy)  Reliability – how well it agrees on retesting under the same conditions (consistency)  Assessment of reliability is feasible , validity poses a problem  Gold standard established – dietary record/direct observation of subject’s consumption  Reference for validation
  • 26. Relative validation  Unlike other methods, 24 hr recall is more susceptive to direct validation  Since time covered is short and limited, direct observation and measurements of intake are possible and also practical  Studies that compared 24 hr recall with observation and weighed duplicate meals have found that that the 2 methods yield similar results  Dietary intake varies from day to day, single recall may not be representative  Many studies confirm that variations within individuals, mean intake of group was not found to be significantly different from day to day  Inter individual variability is less marked than intra individual variation
  • 27. Errors in dietary surveys  RANDOM (reduced reliability)  Generate larger total variances  Reduce the statistical power to detect association between intake and a disease  Accentuate the estimates of possible associations  SYSTEMATIC (bias)  Represent greater hazards than random errors  Alter results  Very little can be done to correct for their effect  Structure of errors differs according to type of survey method Methods relying on simple recall or ability to provide reliable estimates of usual eating habits tend to be more prone to systematic errors while
  • 28. SOURCES OF ERROR IN DIETARY ASSESSMENT METHODS (INDIVIDUAL INTAKES) Source of Weighed food Estimated 24 hr recall Dietary history error records food weight and FFQs records FCT /recipe + + + + books Food coding + + + + Wrong weight _ + + + of foods Reporting error _ _ + + Variation of + + + _ diet with time Wrong _ _ _ + frequency Modified ± ± _ _ eating pattern Response bias ± ± ± ± Sampling bias + + + Ferro –Luzzi in FAO, 2002 Source: Anna +
  • 29. Illustration of association between dietary adequacy and anthropometry Prevalence % % Total of UW inadequate adequate % <-2SDs 20 10 30 % > -2SDs 0 70 70 Total 20 80 100 Source : Mason, 2002 in “Measurement and Assessment of Food Deprivation and Undernutrition”, FAO
  • 30. Dietary diversity (DD) : when to measure Objective Timing Assessment of the In rural, agriculture In non agriculture based typical diet of based communities communities HH/individuals When food supplies are Anytime of the year (if still adequate (maybe seasonality is not an issue) up to 4-5 mo after the main harvest) Looking at DD at different points in the agricultural cycle is one way of investigating seasonality of food security In many areas there are important seasonal differences in dietary patterns. For a more complete assessment of usual diet, DD should be
  • 31. Dietary diversity (DD) : when to measure Objective Timing Assessment of the food security During the period of greatest food situation in rural, agriculture-based shortage, such as immediately prior communities to the harvest or immediately after emergencies or natural disasters This may also serve as a baseline for monitoring change for investigating seasonality Assessment of the food security At the moment of concern to identify situation in non-agricultural a possible food security problem communities  May also serve as a baseline for monitoring changes due to an intervention Monitoring of food security/nutrition Repeated measures to assess programmes or agricultural impact of the intervention on the interventions such as crop and quality of the diet, conducted at the livelihood diversification same time of year as the baseline (to avoid interference due to
  • 32. Dietary diversity : Key steps Activities prior to data collection  Translation and adaptation steps  Review  Key informant and community meetings  Refining the food lists and translations  Use of local names Technical issues  Minimum quantities  Individual food items that can be classified into more than one food group  Mixed dishes Training Instructions for administering the questionnaire Household level Analyzing dietary diversity data Dietary diversity scores
  • 33. DIETARY DIVERSITY SCORES : Aggregation of food groups to create HDDS and WDDS HDDS WDDS Question no. Food Group Question no. Food Group 1. Cereals 1,2 Starchy staples 2. White tubers and 4 Dark green leafy roots vegetables 3,4,5 Vegetables 3,6 and red palm oil Other vitamin A rich as applicable fruits and vegetables 6,7 Fruits 5,7 Other fruits and vegetables 8,9 Meat 8 Organ meat 10 Egg 9,11 Meat and fish 11 Fish and other sea 10 Egg food 12 Legumes, nuts and 12 Legumes, nuts and seeds seeds 13 Milk and milk products 13 Milk and milk products 14 Oils and fats 15 Sweets 16 Spices, condiments and beverages
  • 34. Food groups consumed by ≥ 50 % HH by diversity tertiles Lowest dietary Medium dietary High dietary diversity diversity (≤ 3 food diversity (≥ 6 food groups) groups ) ( 4 and 5 food groups) Cereals Cereals Cereals Green leafy vegetables Green leafy vegetables Green leafy vegetables Vitamin A rich fruit Oil Vitamin A rich fruit Oil Other vegetables Fish Legumes, nuts and seeds Source: FAO, 2010
  • 35. Measures and use of DD  Dietary diversity as a measure of HH access and food consumption can be triangulated with other food related information  Gives a holistic picture of food and nutrition security status across a broader area  DD being used increasingly to provide indicators of HH access and individual dietary quality  Contextual use : Baseline and impact assessment , national surveys, surveillance systems, M&E of programmes and policies  Phase classification for identifying emergencies
  • 37. Easy way to count your calories (Measures providing 100 kcal  Cereals : 30 g ( 1/5 cup)  Egg : 60 g ( 1 medium size)  Bread : 40 g ( 2 slices)  Chicken : 90 g ( 3 small  Pulses : 30 (2 Tbsp) pieces)  Leafy vegetables (sak): 250 g  Mutton: 85 g ( 2 small bunches)  Fish (lean) 100 g  Other vegetables : 400 g (4  Fish (fatty) 60 g cups)  Shrimp : 30 g  Potato : 100 ( 1 cup)  Prawn : 100 g  Nuts/oilseeds : 20 g (handful)  Sugar : 25 g ( 5 tsp)  Fruit : 150 g/ 1-2 fruits  Spices : 40 g ( 6 tsp)  Milk/Curd :150 ml ( 1 cup)  Oil/ghee : 10 g (2 tsp)  Butter milk (ghol) : 670 ml ( 4  Butter : 15 g (1 Tbsp) cups)  Channa/paneer/cheese : 30 g (1 pkt)
  • 38. Energy expenditure of selected activities - kcal expended/minute Activity Kcal/min/ 45kg 55kg 65kg kg Sitting 0.021 0.9 1.2 1.4 quietly Walking 0.080 3.6 4.4 5.2 normal pace Writing, 0.029 1.3 1.6 1.9 sitting Vacuuming 0.048 2.2 2.6 3.1 cleaning/ mopping Ironing 0.064 2.9 3.5 4.2 Running 0.135 6.1 7.4 8.8 11.5 min/mile Cycling 5.5 0.064 2.9 3.5 4.2 mph
  • 39. Estimating energy requirements  Sedentary work : 30 -35kcal/kg/BW  Moderately active : 40kcal/kg/BW  Very physically active : 50kcal/kg/BW Suppose a person’s ideal BW is 60 kg  40 x 60 = 2400 kcal = energy requirement Calculation of approximate energy requirement  BMR : 1 x24x 60 = 1440 kcal  Physical activity = 800 kcal  SDA = 250 kcal  Energy requirement = 2490 kcal
  • 41. Conclusions  Need to use core indicators linked to food security & nutrition outcomes;  Identify food and nutrition vulnerability through information on food consumption patterns  Need to obtain information on intra household distribution of food for accurate assessment of individual intakes;  Differential nutritional status associated with differences in morbidity or illness or other factors within HHs provides valuable information on food distribution  Knowledge of HH food allocation patterns and underlying reasons for food / diet related behaviour, so that effectiveness of nutrition interventions can be improved.
  • 42. Conclusions  Choice of method : Information needed, resources available  Food/nutrients of primary interest, group/vs individual data, absolute /vs relative intake , population characteristics  Include statistical expertise while designing survey and questions  Can provide qualitative data on dietary intake of HH  Can be combined with other methods to obtain individual quantitative data  When absolute vs relative estimates are required, food record, 24 dietary recall are methods of choice  For day –to-day variability – FFQ useful  DD – dietary patterns/habits/semi qualitative can be quantified  Dietary assessment is essential to identify populations at risk

Notas do Editor

  1. Inter
  2. The above table provides a graphical presentation of the per capita food intake in g with rural-urban break up from HIES 1991 -92 to HIES 2010. The trend in food consumption (intake) pattern over the past 30 years the total per capita food consumption (intake) in Bangladesh has increased steadily; an increase of 5.51% is noted in the last 5 yrs at the national level. Increase in food intake over the years could attributed to increases in food production, coupled with an improvement of socio-economic status of the people. While the intake in urban households has been higher than rural, the current per capita intake shows a higher level among rural than urban populations.
  3. Consumption of food items is highly dependent on availability of food, price levels, food habits and ultimately purchasing behaviour. That the consumption of rice shows a relative decline in relation to an increase in total food intake is indicative of diversification of diets in Bangladesh, though at a slow pace. A decrease from 461 g/d in 2005 to 442 g cereals in 2010 is noted. A decrease of 2.1% is noted where Cer En % now contributes to 66% dietary energy compared to a previous contribution of 68%. Consumption of rice has decreased to 416g in 2010 from 440 g in 2005 which amounts to a decrease of 5.37% of rice En in the diet. Intake of animal foods rich in protein and micronutrients has increased to 109 g/capita/d in 2010 from 95 g in 2005. This amounts to an increase of nearly 15 % over the period. Similarly the intake of vegetables and fruits has increased to 211 g from 190 g per capita/d which amounts to an increase of 11% over the period. Pulses which are an important source of protein has remained almost the remain and continues to be much below the requirement. The production of pulses has been steadily declining due to the land being competed for production of other crops. The import of pulses has also not increased. Consumption of edible oil has increased by 25% (almost ¼) which could be a source of concern if an increasing trend in consumption is continued. On the whole, diversification of diets merits attention and needs to be accelerated given its role in sustaining diets and enhancing delivery on nutrition outcomes. by increasing intakes ofnon-cereal foods, particularly meat, egg, potato, fruits and vegetables (Figure 3).
  4. The overall energy intake per capita/d significantly increased to 2318kal in 2010 from 2238 kcal in 2005 ( recording an increase of 3.56%) a finding markedly different from the previous surveys. While the increase is noted in both rural and urban areas, it has increased more in the rural areas ( 2344 kcal in 2010 from 2253 kcal in 2005) with an increase of 91 kcal/d (4.06%) during this period. In the urban areas, it ahs increased to 2244kcal in 2010 from 2194 kcal in 2005 reflecting an increase of 51 kcal/d (2.31 %) during this period. Significant increase of per capita/d energy intake might be attributed to changing food habits, increase in income and subsequent purchasing power and availability of convenience foods on the shelf (small shops and markets in both urban and rural areas). The higher level of energy intake in the rural areas compared to the urban area could also be attributed to the higher energy requirements of the rural population given their occupation in heavy work related to agricultural labour and farm activities and rehabilitation work following the natural disasters, etc. Carrying out heavy work and physical activities demands higher calorie needs and food intake.
  5. Assessment of dietary intakes at individual levels provides most useful information on the nutritional adequacy of diets. Need to record all foods and problem of omission is lessened and foods are described more fully. Requires motivated and literate respondents, which can limit its use in developing countries; recording foods as they are eaten can also affect both the type of food chosen and quantities consumed. This is a weakness, when the aim is to measure the usual dietary intake. However, when the aim is to enhance awareness of the dietary behaviour change as in some intervention studies, this effect can be seen as a strength. This method is taken to represent the “gold” standard and is used as a reference for validation of other methods.
  6. The validity of dietary recall has been studied by comparing reported intake with those recorded or weighed by trained observers. In general, group mean nutrient estimates from 24 hr recall were similar to observed intakes, although respondents with lower observed intake tended to over report and those with higher intakes tended to under report their past intakes. For some nutrients like VA with considerable variation in nutrient intake, there may be serious errors if one day recall is used to describe individual intakes. If groups are the focus of interest, the problem would be less.
  7. Some of these errors are shared by all methods; for example the quality of the FCT on which rests the precision for the estimation of energy and nutrient intake. Other errors are specific to one or another of the methods. A larger number of errors are associated with FFQ, dietary history method while the weighed food record appears to be least affected.
  8. The relationship between anthropometric and dietary energy inadequacy is not symmetric as ill health can cause growth failure in the presence of adequate food access. Food intake often will be reduced owing to poor appetite in sickness even in the presence of adequate food supply; however in a stable situation, people will not be of adequate body size with inadequate food energy even if health is good. The implications are illustrated in the table. Treating this association by placing individuals in categories depends crucially on the cut offs and implies that the cut off of – 2 z score for W/A used in the illustration is related to energy intake below requirement ( i.e hunger). In this case the cut off may be approximately correct. Crucially in a steady situation there should be no one in inadequate energy – adequate weight category (note bottom left cell is equal to 0). It is not possible to maintain an adequate weight with inadequate energy. This may help relate the indicators to each other to some extent, referring again to the table. DES indicators should go in the same direction as anthropometric indicators. Need for combination of methods support individual dietary intake surveys, including qualitative methods from HIES surveys and other HH surveys such as DHS and UNICEF – MICS surveys
  9. Weight to height ratio is a simple and widely accepted method which estimates total body mass rather than fat mass. It correlates well with amount of body fat. BMI is BW in kg divided by the square of height in meters BMI of 25 -30 is an indication of being overweight and BMI above 30 indicates obesity