Background: Dietary diversity is a key element of diet quality but diets of women of reproductive age (WRA; 15-49 y) in resource-poor settings are often deficient in a range of micronutrients. Previous work demonstrated relationships between simple food group diversity indicators (FGI) and micronutrient adequacy among WRA. For operational and advocacy purposes, however, there is strong demand for a dichotomous indicator reflecting an acceptable level of dietary diversity.
Objective: To develop a dichotomous indicator of dietary diversity among WRA. 
Methods: We performed a secondary analysis of 9 data sets containing quantitative dietary data from WRA in resource-poor settings (N total = 4,166). From the raw dietary data we calculated an individual "mean probability of adequacy" (MPA) across 11 micronutrients. Several candidate FGI were constructed. Indicator performance in predicting MPA > 0.60 was assessed within each data set using receiver-operating characteristics (ROC) analysis and sensitivity/specificity analysis at various FGI cut-offs. The analysis was performed separately for non-pregnant and non-lactating (NPNL) and for lactating women. 
Results: We identified 2 "best candidate" dichotomous indicators based on 9- or 10-point food group scores (FGI-9 and FGI-10) with a cut-off of 5 food groups or more. Both were significantly correlated to MPA in each site (P < 0.001). Areas under the curve (AUC) were moderate, ranging from 0.62 to 0.82 among NPNL women and from 0.56 to 0.90 among lactating women. Comparisons of results slightly favored FGI-10 for all women. 
Conclusions: When resource-intensive dietary methods are not feasible, a simple dichotomous indicator based on a cut-off of >5 of 10 defined food groups reflects "Minimum dietary diversity for women of reproductive age" (MDD-W). According to the conclusions of a consensus meeting of experts, this indicator is well suited for population-level assessment, advocacy, and maybe also for tracking of change in dietary diversity across time.

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Development of a Dichotomous Indicator for Population-Level Assessment of Dietary Diversity in Women of Reproductive Age

Food insecurity is a global public health challenge. Household food insecurity is the leading risk factor of malnutrition, claiming approximately 300,000 deaths each year. Whether directly or indirectly, due to inadequate food consumption and poor diet quality, it is also accountable for over half of all deaths among children in Sub-Saharan Africa. It is estimated that the prevalence of food-insecure individuals in the area will reach 17 million by the year 2021. Inadequate nutrition may result in low immunity, impaired physical and mental development and reduced productivity among children under five years and throughout the life course. This review article attempts to discuss the various household food insecurity determinants and their association with child malnutrition in a Sub-Saharan Africa context. The purposes of this article are to inform governments, policymakers and service providers regarding the importance of household food security and its determinants on child malnutrition, and to plan strategies to improve the household food security status in Sub-Saharan Africa. Current Research in Nutrition and Food Science www.foodandnutritionjournal.org ISSN: 2347-467X, Vol. 07, No. (3) 2019, Pg. 610-623 CONTACT Wuyeh Drammeh wuyehdrammeh1@yahoo.com Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia. © 2019 The Author(s). Published by Enviro Research Publishers. This is an Open Access article licensed under a Creative Commons license: Attribution 4.0 International (CC-BY). Doi: http://dx.doi.org/10.12944/CRNFSJ.7.3.02 Article History Received: 23 September 2019 Accepted: 17 December 2019

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Determinants of Household Food Insecurity and Its Association with Child Malnutrition in Sub-Saharan Africa: A Review of the Literature

Women's empowerment is associated with improved child nutrition, and both underpin the achievement of multiple Sustainable Development Goals (SDGs). We examined pathways by which women's empowerment influences child nutritional status. We pooled nationally representative data from Demographic and Health Surveys (2011–2016) collected from married women with children aged 6–24 months in Ethiopia, Kenya, Rwanda, Tanzania, and Uganda (n = 13,780). We operationalized child nutritional status using anemia, height-for-age z-score (HAZ), and weight-for-age z-score (WHZ). We operationalized women's empowerment using a validated measure comprised of three latent domains: social/human assets (“assets”), intrinsic agency (attitudes about intimate partner violence), and instrumental agency (influence in household decision making). We used structural equation models with latent constructs to estimate hypothesized pathways from women's empowerment to child nutritional status with further mediation by maternal body mass index (BMI) and stratification by wealth. Women's empowerment domains were directly and positively associated with maternal BMI (estimate±SE: assets, 0.17 ± 0.03; intrinsic agency, 0.23 ± 0.03; instrumental agency, 0.03 ± 0.01). Maternal BMI was directly and positively associated with child HAZ (0.08 ± 0.04) and child WHZ (0.35 ± 0.03). Assets were indirectly associated with child HAZ and WHZ through intrinsic agency and maternal BMI. In the lowest wealth category, the direct effects from women's empowerment to child nutritional status were significant (assets and instrumental agency were associated with anemia; intrinsic agency associated with HAZ). In the highest wealth category, direct effects from women's empowerment on child nutritional status were significant (intrinsic and instrumental agency associated with WHZ). Improving women's empowerment, especially intrinsic agency, in East Africa could improve child nutrition directly and via improved maternal nutrition. These findings suggest that efforts to realize SDG 5 may have spillover effects on other SDGs. However, strategies to improve nutrition through empowerment approaches may need to also address household resource constraints.

Women's empowerment and child nutrition: The role of intrinsic agency

Women’s empowerment, food security and nutrition of pastoral communities in Tanzania

There is limited knowledge about dietary quality among the adult population in low- and middle income countries (LMICs). This study aims to describe dietary quality among the adult Saharawi refugee population and to investigate whether dietary quality is associated with socioeconomic status. In 2014, a cross-sectional survey was carried out in the Saharawi refugee camps, Algeria. A three-staged cluster sampling was performed and 180 women and 175 men, aged 18–82 years, were randomly selected. The dietary intake was assessed by 24-h dietary recall and dietary diversity score (DDS) was calculated. Socioeconomic status was assessed using the WAMI index (sanitation, assets, education and income). The mean DDS among the total sample was 3.8 ± 1.4 and 2/3 of participant were at risk of low dietary adequacy. The main food groups consumed were starchy staple foods, flesh foods, and dairy. Vitamin A-rich dark green leafy vegetables, nuts and seeds and eggs were the food groups least consumed. The multiple regression model showed a positive association between DDS and the WAMI index (P < 0.001) and a negative association between DDS and age (p = 0.01). Low DDS was associated with low socioeconomic status. Programmes to improve the dietary quality among the Saharawi refugees should be implemented.

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Dietary diversity is related to socioeconomic status among adult Saharawi refugees living in Algeria

Low-quality monotonous diet is a major problem confronting resource-constrained settings across the world. Starchy staple foods dominate the diets in these settings. This places the population, especially women of reproductive age, at a risk of micronutrients deficiencies. This study seeks to examine the association between women’s decision-making autonomy and women’s achievement of higher dietary diversity (DD) and determine the socio-demographic factors that can independently predict women’s attainment of higher DD. The study used data from the 2008 Ghana Demographic and Health Survey. The participants comprised of 2262 women aged 15–49 years and who have complete dietary data. The DD score was derived from a 24-h recall of intake of foods from nine groups. The score was dichotomized into lower DD (DD ≤4) and higher (DD ≥5). Logistic regression was used to assess the association between women decision-making autonomy (final say on how to spend money, making household purchases, own health care, opinions on wife-beating, and sexual intercourse with husband) and the achievement of higher DD. The logistic regression models were adjusted for covariates at the individual and household levels. The analysis showed that women participation in decision-making regarding household purchases was significantly associated with higher DD, after adjusting for individual and household level covariates. The odds of achieving higher DD were higher among women who had a say in deciding household purchases, compared to women who did not have a say (OR = 1.74, 95 % CI = 1.24, 2.42). Women who had more than primary education were 1.6 times more likely to achieve higher DD, compared to those with no education (95 % CI = 1.12, 2.20). Compared to women who lived in polygamous households, those who lived in monogamous households had higher odds of achieving higher DD (OR = 1.42, 95 % CI = 1.04, 1.93). Net other covariates, women who have a say in making household purchases are more likely to achieve higher DD compare to those who do not have a say. This may indicate autonomy to buy nutritious foods, suggesting that improving women decision-making autonomy could have a positive impact on women dietary intake.

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Women's participation in household decision-making and higher dietary diversity: findings from nationally representative data from Ghana.

Introduction: Unhealthy food environments drive the increase of diet-related non-communicable diseases (NCDs). 

Objective: We aimed to examine healthy food environment policies in Kenya and identify priorities for future action. 

Methods: Using the Healthy Food Environment Policy Index (Food-EPI) we collected evidence on the extent of government action to create healthy food environments across 13 policy and infrastructure support domains and 43 related good practice indicators between 2017 and 2018. A panel of 15 national experts rated the extent of government action on each indicator compared to the policy development cycle and international best practice respectively. Based on gaps found, actions to improve food environments in Kenya were identified and prioritized. 

Results: In the policy development cycle, 16/43 (37%) of good practice policy indicators were judged to be in ‘implementation’ phase, including: food composition targets, packaged foods’ ingredient lists/nutrient declarations; systems regulating health claims; restrictions on marketing breast milk substitutes; and school nutrition policies. Infrastructure support actions in ‘implementation’ phase included: food-based dietary guidelines; strong political support to reduce NCDs; comprehensive NCD action plan; transparency in developing food policies; and surveys monitoring nutritional status. Half (22/43) of the indicators were judged to be ‘in development’. Compared to international best practice, the Kenyan Government was judged to be performing relatively well (‘medium’ implementation) in one policy (restrictions on marketing breast milk substitutes) and three infrastructure support areas (political leadership; comprehensive implementation plan; and ensuring all food policies are sensitive to nutrition). Implementation for 36 (83.7 %) indicators were rated as ‘low’ or ‘very little’. Taking into account importance and feasibility, seven actions within the areas of leadership, food composition, labelling, promotion, prices and health-in-all-policies were prioritized. 

Conclusion: This baseline assessment is important in creating awareness to address gaps in food environment policy. Regular monitoring using Food-EPI may contribute to addressing the burden of diet-related NCDs in Kenya.

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Benchmarking food environment policies for the prevention of diet-related non-communicable diseases in Kenya: National expert panel's assessment and priority recommendations.

Elizabeth Kimani

Papers

Women's participation in household decision-making and higher dietary diversity: findings from nationally representative data from Ghana.

Benchmarking food environment policies for the prevention of diet-related non-communicable diseases in Kenya: National expert panel's assessment and priority recommendations.