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Minimum Dietary Diversity for Women

A Guide to Measurement

Minimum Dietary Diversity for Women

A Guide to Measurement

Published by

the Food and Agriculture Organization of the United Nations


USAID’s Food and Nutrition Technical Assistance III Project (FANTA), managed by FHI 360

Rome, 2016

Recommended citation: FAO and FHI 360. 2016. Minimum Dietary Diversity for Women:

A Guide for Measurement. Rome: FAO.

The designations employed and the presentation of material in this information product do not imply the expression of any opinion whatsoever on the part of the Food and Agriculture Organization of the United Nations (FAO), or of FANTA/FHI 360 concerning the legal or development status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or products of manufacturers, whether or not these have been patented, does not imply that these have been endorsed or recommended by FAO, or FHI 360 in preference to others of a similar nature that are not mentioned.

Additional funding for this publication was made possible by the generous support of the American people through the support of the Office of Health, Infectious Diseases, and Nutrition, Bureau for Global Health, U.S. Agency for International Development (USAID), under terms of Cooperative Agreement AID-OAA-A-12-00005 through the Food and Nutrition Technical Assistance III Project (FANTA), managed by FHI 360.

The views expressed in this information product are those of the author(s) and do not necessarily reflect the views or policies of FAO, FHI 360, UC Davis, USAID or the U.S. Government.

FAO encourages the use, reproduction and dissemination of material in this information product. Except where otherwise indicated, material may be copied, downloaded and printed for private study, research and teaching purposes, or for use in non-commercial products or services, provided that appropriate acknowledgement of FAO as the source and copyright holder is given and that FAO’s endorsement of users’ views, products or services is not implied in any way.

All requests for translation and adaptation rights, and for resale and other commercial use rights should be made via www.fao.org/contact-us/licence-request or addressed to copyright@fao.org.

FAO information products are available on the FAO website (www.fao.org/publications) and can be purchased through publications-sales@fao.org © FAO, 2016 ISBN 978-92-5-109153-1 (FAO) Contents Acknowledgements

Abbreviations and acronyms

Quick Start Guide

Section 1. Introduction

Section 2. Description of food groups

Section 3. Model questionnaire

Section 4. Preparing the MDD-W questionnaire

Section 5. Selection and training of enumerators

Section 6. Tabulation, presentation and interpretation


Appendix 1. Sampling and design issues specific to measurement of Minimum Dietary Diversity for Women of Reproductive Age

Appendix 2. Guidance on assigning individual foods to food groups for Minimum Dietary Diversity for Women of Reproductive Age

Appendix 3. Alternative method for collecting information on food groups consumed – the list-based method

Appendix 4. Comparing Minimum Dietary Diversity for Women of Reproductive Age and Infant and Young Child Feeding Minimum Dietary Diversity

Minimum Dietary Diversity for Women A Guide to Measurement Acknowledgements This document reflects many contributions. The writing team was led by Mary Arimond1 and Terri Ballard2, and included Megan Deitchler3, Gina Kennedy4 and Yves Martin-Prével5. The authors are very grateful to participants at a July 2014 consensus meeting and a January 2015 technical meeting who shared field experiences and provided many insights that are reflected herein. See http:// www.fantaproject.org/monitoring-and-evaluation/minimum-dietary-diversity-women-indicatormddw for the meeting report from July 2014 and for the lists of participants at both meetings.

Previous versions of this document were reviewed by Elodie Becquey, Marie-Claude Dop, Leslie Koo, Claudia Lazarte Pardo, Warren Lee, Mary Lung’aho, Judiann McNulty, Theodora Mouratidou, Mourad Moursi and Anne Swindale; the authors are very grateful for the reviewers’ many insightful comments. Pauline Allemand, Kiersten Johnson and Jef Leroy also made contributions on key points.

Development of this document was funded by the U.S. Agency for International Development (USAID) through the Food and Nutrition Technical Assistance III Project (FANTA), the Food and Agriculture Organization of the United Nations (FAO) and the World Food Center at the University of California, Davis. Finally, the authors are very grateful to members of the Women’s Dietary Diversity Project (WDDP), a long-running collaboration whose members, in addition to the fivemember writing team, include Pauline Allemand, Elodie Becquey, Alicia Carriquiry, Melissa Daniels, Marie-Claude Dop, Elaine Ferguson, Nadia Fanou-Fogny, Maria Joseph-King, Warren Lee, Mourad Moursi, Marie Ruel, Liv Elin Torheim and Doris Wiesmann. WDDP members have shared thoughts and experiences for many years and these too are reflected within. However, the writing team is responsible for the content and any errors.

Program in International and Community Nutrition, University of California, Davis 1 Food and Agriculture Organization of the United Nations 2 FANTA/FHI 360 3 Bioversity International 4 Nutripass Research Unit, Institut de Recherche pour le Développement 5 i Minimum Dietary Diversity for Women A Guide to Measurement Abbreviations and acronyms CAPI Computer-Assisted Personal Interviewing FAO Food and Agriculture Organization of the United Nations FBDG Food-based dietary guidelines FCS Food Consumption Score HDDS Household Dietary Diversity Score IYCF Infant and young child feeding MDD Minimum Dietary Diversity MDD-W Minimum Dietary Diversity for Women of Reproductive Age MSG Monosodium glutamate NRV Nutrient Reference Value RE Retinol equivalents RAE Retinol activity equivalents UHT Ultra-high temperature USAID U.S. Agency for International Development WDDS Women’s Dietary Diversity Score WFP World Food Programme WHO World Health Organization WRA Women of reproductive age


Measuring women’s dietary diversity – Quick Start Guide This Quick Start Guide provides hyperlinks to guidance on specific questions and tasks and also a cautionary list of common errors (see box below).

All users should read the Quick Start Guide for an overview of available guidance and common pitfalls.

We encourage users with no prior experience with simple food group diversity indicators to consider reading the full manual. Experienced users may find this page useful for quickly finding answers to specific questions. Please also see the Frequently Asked Questions.

• Why measure Minimum Dietary Diversity for Women of Reproductive Age (MDD-W)?

• Indicator definition • Appropriate uses of the MDD-W indicator • Comparison with other food group diversity indicators (see also Appendix 4) • How to collect data – introducing the guided open recall • Survey sampling and design issues for food group recalls • Brief descriptions of the ten MDD-W food groups • Detailed food lists for the food groups • “Problem foods” that are difficult to classify • Model questionnaires to be adapted: open recall and list based method • Translating and adapting the questionnaire • Choosing and training enumerators • Example of instructions for enumerators • Tabulating the MDD-W indicator • Recommendations for presenting MDD-W results


Improper uses of MDD-W • Do not use to assess diet quality of individual women.

• Do not use as a basis for developing dietary guidance; use standard best practices from the World Health Organization (WHO) and the Food and Agriculture Organization of the United Nations (FAO).

• Do not use to develop behaviour change messages; use standard best practices, for example, toolkits found from Alive & Thrive, The CHANGE Project, The C-Change Project, and K4Health.

Inadequate or incorrect preparation of questionnaires • If you cannot afford to adapt a model questionnaire to your context, reconsider collecting data for this indicator. Model questionnaires for open recalls and list-based methods are available. Guidance on adaptation is available.

• Do not drop or combine required food groups (rows) that are included on the model questionnaire.

Incorrect comparisons with other MDD-W surveys • Do not compare survey results from different seasons or agro-ecological zones without considering seasonal and harvest patterns. See guidance in Appendix 1.

• In pre-post designs, do not change the questionnaire and then compare between baseline and endline.

ivvSection 1. Introduction

Background Women of reproductive age (WRA)1 are often nutritionally vulnerable because of the physiological demands of pregnancy and lactation. Requirements for most nutrients are higher for pregnant and lactating women than for adult men (National Research Council, 2006; World Health Organization [WHO]/Food and Agriculture Organization of the United Nations [FAO], 2004). Outside of pregnancy and lactation, other than for iron, requirements for WRA may be similar to or lower than those of adult men, but because women may be smaller and eat less (fewer calories), they require a more nutrient-dense diet (Torheim and Arimond, 2013)2. Insufficient nutrient intakes before and during pregnancy and lactation can affect both women and their infants. Yet in many resourcepoor environments, diet quality for WRA is very poor, and there are gaps between intakes and requirements for a range of micronutrients (Arimond et al., 2010; Lee et al. 2013).

These vulnerabilities and gaps in diet quality have been recognised for a long time. However, despite decades of appeals to improve women’s diet quality and nutrition, there has been little programmatic action. Historically, one major impediment has been a lack of effective platforms and programmes reaching adolescent girls and WRA outside of prenatal care. A lack of indicators to allow for assessment, advocacy and accountability has been another constraint.

The Minimum Dietary Diversity for WRA (MDD-W)3 indicator defined and described in this document

is a food group diversity indicator that has been shown to reflect one key dimension of diet quality:

micronutrient adequacy, summarised across 11 micronutrients (Martin-Prével et al., 2015)4. The indicator constitutes an important step towards filling the need for indicators for use in national and subnational assessments. Such indicators must be relatively simple to collect and suitable for large surveys5.

Promotion of diverse diets is one of several approaches to improving micronutrient nutrition for WRA; additional diet quality indicators would be needed in settings where other strategies, including fortification, biofortification and/or supplementation, are used. Furthermore, diet quality is multidimensional. In addition to micronutrient adequacy, high-quality diets are characterised by balance in intake of protein, carbohydrates and fat (Institute of Medicine, 2005) and moderation in consumption of certain foods – those low in nutrient density and those associated with increased risks for chronic disease (George et al., 2014). In the context of rapid nutrition transitions in many For the purposes of this document and indicator, WRA are defined as those 15–49 years of age.

1 “Nutrient density” refers to the ratio of nutrients (such as vitamins and minerals) to the energy content of foods.

2 Additional background on the indicator is available at: http://www.fantaproject.org/monitoring-and-evaluation/ 3 minimum-dietary-diversity-women-indicator-mddw.

The 11 micronutrients were vitamin A, thiamine, riboflavin, niacin, vitamin B6, folate, vitamin B12, vitamin C, 4 calcium, iron and zinc. See Arimond et al., 2010, and Martin-Prével et al., 2015, for the rationale for selection of micronutrients and for methods and results of a multistage research process assessing and comparing candidate indicators. See http://www.fantaproject.org/monitoring-and-evaluation/minimum-dietary-diversity-womenindicator-mddw for a description of a 2014 consensus meeting where stakeholders reviewed results and finalised indicator selection.

Many other indicators of diet quality can be generated from more detailed dietary surveys (e.g. those employing 5 repeat quantitative 24-hour recalls or weighed food records), but at present detailed quantitative surveys are not feasible and affordable for repeated implementation in most low-income countries.

1 Minimum Dietary Diversity for Women A Guide to Measurement

Section 1 Introduction

low- and middle-income countries, additional simple and feasible indicators are needed to reflect these dimensions of balance and moderation.

It is beyond the scope of this guide to describe or operationalise a full set of indicators for diet quality or nutrition for WRA. But consumption of food items from diverse food groups is universally recommended, whether or not other strategies for improving nutrition are in place6, and similarly, an indicator of food group diversity is relevant globally.

Indicator definition The MDD-W is so named to harmonise with a similar Minimum Dietary Diversity (MDD) indicator for infants and young children (WHO, 2008) (see p. 4 for a comparison of several food group diversity indicators currently in use).

MDD-W is a dichotomous indicator of whether or not women 15–49 years of age7 have consumed at least five out of ten defined food groups the previous day or night. The proportion of women 15–49 years of age who reach this minimum in a population can be used as a proxy indicator for higher micronutrient adequacy, one important dimension of diet quality.

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