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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 ...»

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The food groups are described and defined in Section 2, and Appendix 2 provides a comprehensive list of specific food items comprising each of the ten groups.

Appropriate uses of the indicator The MDD-W was developed as a proxy indicator to reflect the micronutrient adequacy of women’s diets. The main use of the MDD-W is for assessment at national and subnational levels. It is a population-level indicator based on a recall period of a single day and night, so although data are collected from individual women, the indicator cannot be used to describe diet quality for an individual woman. This is because of normal day-to-day variability in individual intakes.

Groups of WRA where a higher proportion consume food items from at least five of the ten food groups are likely to have higher micronutrient adequacy than other groups that have a lower proportion of women achieving the threshold of food items from at least five food groups. Put another way, a higher prevalence of MDD-W is a proxy for better micronutrient adequacy among WRA in the population. Groups of WRA who consume food items from five or more of the ten groups are also highly likely to consume at least one animal-source food and either pulses or nuts/seeds and food items from two or more of the fruit/vegetable food groups (Martin-Prével et al., 2015).

See, for example, the WHO Healthy Diet Fact Sheet (http://www.who.int/mediacentre/factsheets/fs394/en/), 6 which summarises several WHO and FAO reports and advises that a healthy diet contains fruits, vegetables, pulses, nuts and whole grains.

That is, women who have reached their 15th birthday but who have not yet reached their 50th birthday. This is 7 sometimes expressed as aged 15.0 to 49.9 years.

2 Minimum Dietary Diversity for Women A Guide to Measurement

Section 1 Introduction

The MDD-W can be used:

• As a proxy to describe one important dimension of women’s diet quality (micronutrient adequacy) in national and subnational assessments;

• To compare with previous assessments, so long as survey timing accounts for seasonality8.

The indicator should not be used to:

• Screen individuals for selection for interventions, nor to identify individuals at risk for poor intakes.

In the context of programmes, this indicator may be useful when the programme design, activities and impact pathway indicate a potential to increase food group diversity. Note that many agricultural and health sector projects may improve nutrition, but only some will do so by increasing food group diversity.

In many contexts, it will also be important to increase the quantity of nutrient-dense food groups that are accessible and consumed by target groups. Programme users should note that consumption of food items from five or more food groups, while useful as a population-level benchmark, does not ensure micronutrient adequacy for the population, particularly if quantities of micronutrient-dense foods consumed are too small.

Distinction between food group diversity indicators and food-based dietary guidelines Indicators and guidelines are often confused with each other. In the case of dietary diversity indicators, this may be because many countries have developed food-based dietary guidelines (FBDG) and graphics (pyramids, plates, etc.) that provide guidance to populations about consumption of diverse diets and/or of food items from specific sets of food groups9. National FBDG are developed through a structured process and are meant to shape policy and national programmes (Albert, 2007).

There is no global harmonisation of FBDG10, and the MDD-W threshold of at least five of ten food groups may not align exactly with national recommendations. The indicator should not be confused with a dietary guideline, nor should it be used as a basis to inform the development of guidelines or programmatic behaviour change communication or counselling messages.

However, although the MDD-W food groups may not align perfectly with those recommended for consumption in national FBDG, all such guidelines do advocate consumption of diverse food groups. Thus, measurement of this dimension of diet quality, with an aim to assess and advocate for improvement, is consistent with the principles behind dietary guidance given at country level. Also, in many cases, the food groups on the MDD-W questionnaire could be aggregated during analysis to reflect food groups in national FBDG and could provide information on consumption of these groups in addition to the prevalence of meeting the MDD-W threshold.

Seasonality is important because the relationship between food group diversity and micronutrient intakes and 8 adequacy can vary by season. See Appendix 1 for a discussion of seasonality and of other considerations for survey design and sampling.

9 FAO compiles national FBDG, which are available at http://www.fao.org/nutrition/nutrition-education/food-dietaryguidelines/en/.

However, development of global guidance has been recommended in the Conference Outcome Document:

10 Framework for Action of the Second International Conference on Nutrition Rome 19–21 November 2014.

(“Recommendation 13: Develop, adopt and adapt, where appropriate, international guidelines on healthy diets”, p. 3).

–  –  –

The advantage of using an indicator such as MDD-W rather than a measure tailored to an individual country’s FBDG is the ability to compare across time and location, and even in the event that national FBDG change.

Comparison with other food group diversity indicators Dietary diversity has been measured in many different ways, in both research and programmatic contexts. However, only a few simple food group diversity indicators have been promoted for wide population-level use in resource-poor settings. These include the Household Dietary Diversity Score (HDDS), the MDD and the Women’s Dietary Diversity Score (WDDS), which are compared with the MDD-W in Table 1.

The WDDS resulted from a preliminary step in the process of developing the dichotomous MDD-W.

Earlier research resulted in a suggestion of several scores that reflected micronutrient adequacy;

however, no single score was proposed for global use (Arimond et al., 2010). One of these scores, a WDDS based on nine food groups, was described by FAO (2011) and selected for use by the U.S.

Agency for International Development (USAID) Feed the Future and Food for Peace development food assistance programmes, and others. However, demand for a dichotomous indicator grew, particularly for use in policy and advocacy contexts. Another round of research with more data sets replicated and extended the earlier study and resulted in the proposal of the MDD-W, a dichotomous indicator based on a set of ten food groups (Martin-Prével et al., 2015).

In addition to the simple food group indicators in Table 1, a variety of more complex indicators and indices have been used in specific countries or contexts. For example, the World Food Programme (WFP) uses a more complex food group diversity indicator (the Food Consumption Score [FCS]) in the context of food security analyses. The FCS is a weighted household-level food group score that also incorporates frequency of consumption over 7 days (WFP, 2008).

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a HDDS = Household Dietary Diversity Score; see http://www.fantaproject.org/monitoring-and-evaluation/householddietary-diversity-score and Food and Agriculture Organization of the United Nations (FAO) (2011).

b IYCF MDD = Minimum Dietary Diversity indicator, as an indicator of infant and young child feeding practices; see http:// www.who.int/maternal_child_adolescent/documents/9789241596664/en/.

c WDDS = Women’s Dietary Diversity Score; see FAO (2011).

d MDD-W = Minimum Dietary Diversity for Women of Reproductive Age e During analytic work comparing candidate indicators to micronutrient adequacy for women, the 7-group IYCF MDD and dichotomous indicators based on the 9 groups in the WDDS were explored but did not perform as well as the 10-group MDD-W (Martin-Prével et al., 2015).

5 Section 1 Introduction

Methodological approaches to measurement of food group diversity While food group diversity indicators can be derived from detailed quantitative dietary intake surveys, this guide is intended for users who are not in a position to conduct such surveys. When relatively simple data collection approaches are required, as in a number of large-scale and multimodule surveys, food group diversity indicators can be measured using two main methods: open recall and list-based.


In a qualitative open 24-hour recall (henceforth, “open recall”), the enumerator asks a series of standard probing questions to help the respondent recall all foods and beverages consumed the previous day and night and also probes for main ingredients in mixed dishes. Specifically, the recall period covers from when the respondent awoke the previous day, through the day and night for a 24-hour period.

The recall is “open” because the enumerator does not read predefined foods/groups to the respondent. Each food or beverage that the respondent mentions can be circled, underlined or ticked on a predefined list. Foods not already included on the predefined list can be either classified by the enumerator into an existing predefined food group or recorded in a separate place on the questionnaire and coded later into one of the predefined food groups.

This method is recommended and is detailed in Section 3 (model questionnaire).

LIST-BASED METHOD In the list-based method, the enumerator does read a list of foods and beverages to the respondent. The enumerator informs respondents that they should respond “yes” for each food or beverage consumed during the specified recall period of the previous day and night. The enumerator continues by reading a list of foods organized in groups, giving multiple examples for each food group.

There is anecdotal evidence that data collected with this method are less complete. An example questionnaire and more details are given in Appendix 3.


There are advantages and disadvantages to each method; these are detailed in Table 2. This guide describes and recommends the open recall because it may lead to more accurate and complete recall of all foods and beverages consumed.

Of key concern are the linked issues of respondent burden and the time needed (and thus cost) to implement the recall. There is no universal answer regarding which method is quicker, because it depends on the simplicity or complexity of the woman’s diet, on the length of the food group list11 and on the number of examples needed for each food group on a list-based questionnaire. When diets are simple, the open recall is likely to be the quicker of the two.

See Section 2 for an explanation of required and optional food and beverages categories (rows) for the MDD-W 11 questionnaire.

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As noted in Section 1, MDD-W is a dichotomous indicator of whether or not women 15–49 years of age have consumed at least five out of ten defined food groups the previous day or night. This

section provides a description of each of the ten MDD-W food groups:

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The food groups that make up the MDD-W are mutually exclusive – that is, no food or ingredient is placed in more than one food group. Note that on the model questionnaire (see Section 3), three of the ten groups are further subdivided. This is for ease of recording and to make the questionnaire more intuitive for enumerators. For example, the food group “Meat, poultry and fish” is recorded on three rows (subgroups) on the questionnaire.

In addition, this section provides descriptions of six optional and two required categories12 (pages 17–19) that appear on the model questionnaire (Section 3) but that are not part of the indicator calculation.

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The required categories are:

• Condiments and seasonings • Other beverages and foods The rationale for including both the optional and required categories is stated in the descriptions below. Some of these categories are of interest in the context of the nutrition transition while other categories are included primarily to provide a place for enumerators to mark each food and to avoid falsely classifying items into one of the ten MDD-W groups. The “Condiments and seasonings” category contains diverse foods and ingredients and is designed to avoid allowing foods consumed in very small quantities to “count” in the MDD-W indicator. See Box 1 on page 13 for further discussion of “how much is enough to count?” and of the “Condiments and seasonings” category.

These are referred to as “categories” rather than “groups” to avoid confusion with the MDD-W food groups.

12 However, these, too, consist of lists of food or beverage items.

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In addition to the descriptions in this section, detailed lists of foods belonging in each MDD-W food group, as well as in the other categories, are provided in Appendix 2. Appendix 2 also includes a table listing specific foods and ingredients that are difficult to classify.

A discussion of mixed dishes is provided at the end of this section.

Fortified foods and products The MDD-W reflects healthy diversity in unfortified foods and is neither designed nor adequate for assessing coverage or impact of fortification or biofortification programmes. Separate questions on consumption of fortified foods and/or biofortified foods may be added to the questionnaire.

These will be context-specific and are not described in this guide. Such questions could also assess coverage of specialised products, such as blended fortified foods (corn-soy blend, wheat-soy blend, etc.) or ready-to-use foods.

Guidance is available elsewhere on monitoring and evaluation of fortification programmes (e.g.

WHO/FAO, 2006). Whether or not optional questions are developed and added to the model questionnaire, for the purposes of MDD-W, fortified and biofortified foods should be classified in their food group “home” (e.g. fortified wheat flour should be classified as a grain).

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