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.
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).
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.
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.
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.
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.
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
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
Lalita 6c dietary assessment
DIETARY ASSESSMENT AND LINKS WITH NUTRITIONAL ASSESSMENT #6C Lalita Bhattacharjee NutritionistNational Food Policy Capacity Strengthening ProgrammeFood 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 forassessing food security and undernutrition Methods Availability Access to Consumption Utilization of food food of food of nutrients FAO Method Household income& expenditure surveysIndividual food consumption/intake surveysAnthropometry Qualitative measures of food security
DIETARY ASSESSMENT AND NUTRITIONAL ASSESSMENT A DIETARY ASSESMENT is a comprehensive evaluation of a persons 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 NUTRITIONALSTATUS Source: Mahan and Stump, 2000
DIETARY ASSESSMENTPRINCIPLES 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 groupNutrient Density : a diet that includes foods that provide the mostnutrients 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 dietaryintake 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
Per capita dietary energy (kcal)intake (HIES, 2010)
(En%) of cereals and rice to Bangladesh dietSource/Year Energy Cereal (g) Rice (g) intake (kcal) En % En % 452 440HIES 2005 2238 70% 68% 442 416HIES 2010 2318 66% 64%
Potential key indicators to be mapped at national&sub-national levels by sector : FOOD ANDNUTRITION 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 intakes24 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 individualintakesFood 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 intakesDiet 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 assessmentmethodsMethod Strengths LimitationsFood 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 complexFFQs 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 requirequestionnaire behaviour trained interviewer ( need for food list; std menu types; community based training) Relies on memory; may requireDiet 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 dietarymethods 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 methodMethods relying on simple recall or ability to provide reliable estimatesof 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 historyerror records food weight and FFQs recordsFCT /recipe + + + +booksFood coding + + + +Wrong weight _ + + +of foodsReporting error _ _ + +Variation of + + + _diet with timeWrong _ _ _ +frequencyModified ± ± _ _eating patternResponse bias ± ± ± ±Sampling bias + + + Ferro –Luzzi in FAO, 2002 Source: Anna +
Illustration of associationbetween dietary adequacy andanthropometryPrevalence % % Totalof UW inadequate adequate% <-2SDs 20 10 30% > -2SDs 0 70 70Total 20 80 100Source : Mason, 2002 in “Measurement and Assessment of Food Deprivation and Undernutrition”, FAO
Dietary diversity (DD) : when to measure Objective TimingAssessment of the In rural, agriculture In non agriculture basedtypical diet of based communities communitiesHH/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 tomeasure Objective TimingAssessment of the food security During the period of greatest foodsituation in rural, agriculture-based shortage, such as immediately priorcommunities to the harvest or immediately after emergencies or natural disasters This may also serve as a baseline for monitoring change for investigating seasonalityAssessment of the food security At the moment of concern to identifysituation in non-agricultural a possible food security problemcommunities May also serve as a baseline for monitoring changes due to an interventionMonitoring of food security/nutrition Repeated measures to assessprogrammes or agricultural impact of the intervention on theinterventions such as crop and quality of the diet, conducted at thelivelihood diversification same time of year as the baseline (to avoid interference due to
Dietary diversity : Key stepsActivities prior to data collection Translation and adaptation steps Review Key informant and community meetings Refining the food lists and translations Use of local namesTechnical issues Minimum quantities Individual food items that can be classified into more than one food group Mixed dishesTrainingInstructions for administering the questionnaireHousehold levelAnalyzing dietary diversity dataDietary diversity scores
DIETARY DIVERSITY SCORES : Aggregation of food groups to create HDDS and WDDS HDDS WDDSQuestion no. Food Group Question no. Food Group1. Cereals 1,2 Starchy staples2. White tubers and 4 Dark green leafy roots vegetables3,4,5 Vegetables 3,6 and red palm oil Other vitamin A rich as applicable fruits and vegetables6,7 Fruits 5,7 Other fruits and vegetables8,9 Meat 8 Organ meat10 Egg 9,11 Meat and fish11 Fish and other sea 10 Egg food12 Legumes, nuts and 12 Legumes, nuts and seeds seeds13 Milk and milk products 13 Milk and milk products14 Oils and fats15 Sweets16 Spices, condiments and beverages
Food groups consumed by ≥ 50 % HHby diversity tertilesLowest dietary Medium dietary High dietary diversitydiversity (≤ 3 food diversity (≥ 6 food groups)groups ) ( 4 and 5 food groups)Cereals Cereals CerealsGreen leafy vegetables Green leafy vegetables Green leafy vegetablesVitamin 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
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)
Estimating energy requirements Sedentary work : 30 -35kcal/kg/BW Moderately active : 40kcal/kg/BW Very physically active : 50kcal/kg/BWSuppose a person’s ideal BW is 60 kg 40 x 60 = 2400 kcal = energy requirementCalculation of approximate energy requirement BMR : 1 x24x 60 = 1440 kcal Physical activity = 800 kcal SDA = 250 kcal Energy requirement = 2490 kcal
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