«Minimum Dietary Diversity for Women A Guide to Measurement Minimum Dietary Diversity for Women A Guide to Measurement Published by the Food and ...»
Selection of the ten food groups for MDD-W Dietary diversity indicators group foods together when they are considered nutritionally similar and/or play the same role in the diet (Ruel, 2003). While developing the MDD-W, many different candidate indicators, with different numbers of food groups and different food group definitions, were considered. The indicator based on the ten groups described here had a stronger relationship to micronutrient adequacy than other candidate indicators with different groupings (Martin-Prével et al., 2015).
Food group descriptions Note that the food groups described here generally follow culinary, rather than botanical, definitions and classifications for such items as fruits, vegetables and seeds. For example, tomatoes and peppers are classified as vegetables rather than fruits, and the “Nuts and seeds” group includes only certain types of seeds that are typically described as such in one or many cuisines (e.g. sesame seeds or pumpkin/squash seeds).
GROUP 1 – GRAINS, WHITE ROOTS AND TUBERS, AND PLANTAINS
Common examples from this group include all types of breads and flatbreads, stiff porridges of maize, sorghum, millet or cassava (manioc), pasta, potatoes, white-fleshed sweet potatoes, white yams, yucca and plantains.
Phytates are considered “anti-nutrients” because they bind with certain minerals and prevent absorption.
GROUP 2 – PULSES (BEANS, PEAS AND LENTILS) This group includes members of the plant family Fabaceae (alternate name Leguminoseae), such as beans, peas and lentils. The seeds are harvested at maturity and dried and used as food or processed into a variety of food products. This group does not include the same plants harvested green or immature and eaten fresh in the pod – these are included in the “Other vegetables” group.
It also does not include groundnut (peanut) because while groundnut is in the Fabaceae family, both its high fat content and most common culinary uses are different from other legumes and similar to those of tree nuts. The pulses group does include mature seeds (beans) and processed products, such as tofu, tempeh and other soy products. The group is high in protein and B vitamins, although the protein is not “complete” and certain amino acids must be supplied by other foods.
Pulses represent a very important protein source in plant-based diets and among populations where animal-source foods are largely unaffordable. Fat content of pulses is generally low, with the exception of soybean. Pulses contain varying amounts of anti-nutrients that inhibit absorption of certain nutrients.
Common examples from this group include common bean (black, kidney, pinto), broad bean (fava, field bean), chickpea (garbanzo), pigeon pea, cowpea, lentil and soybean/soybean products or other legume products.
GROUP 3 – NUTS AND SEEDS14 This group comprises mostly tree nuts but also includes groundnut (peanut) and may include certain seeds when consumed in substantial quantities. While seeds are usually recorded in the “Condiments and seasonings” category (below), they are included in the nuts/seeds category if they are a substantial ingredient in local mixed dishes or if they are eaten as a substantial snack or side dish. This group also includes nut and seed “butters”, such as pounded groundnut/peanut butter, cashew butter or sesame butter (tahini), when consumed in substantial amounts and not merely added to flavour mixed dishes. See “Condiments and seasonings” (below) and Box 1 for more detailed discussion of when to include particular nuts and seeds in this food group. Note that oils extracted from nuts and seeds are not included in this group.
Nuts and certain seeds are rich in unsaturated fatty acids, vegetable protein, fibre, minerals, tocopherols, phytosterols and phenolic compounds. They may have unique health benefits (Alasalvar and Bolling, 2015; Del Gobbo et al., 2015; Ros, 2015). With the exception of chestnuts, they generally have a very high fat content.
Common tropical tree nuts include cashew, macadamia and Brazil nut; common nuts grown in more temperate zones include almond, chestnut, hazelnut, pecan, pistachio and walnut. Peanut/ groundnut cultivars are grown in a wide range of climates. Commonly consumed seeds include sesame, sunflower, pumpkin/squash/gourd and pine nut (see Appendix 2).
“Seeds” in the botanical sense includes a very broad range of items, including grains and pulses. However, in 14 culinary systems, there is usually a limited number of other seeds, typically high in fat content and consumed as snacks or side dishes, in pastes or to season mixed dishes. For purposes of this grouping, “seeds” excludes grains and pulses. The group also excludes seeds when they are added in small amount to flavour dishes (see Box 1). Examples of seeds that may be eaten in larger amounts include squash/melon/gourd seeds used as a main ingredient in West African stews and sesame seed paste (tahini) in some dishes in Middle Eastern cuisines.
11 Section 2 Description of food groups
GROUP 4 – DAIRY Dairy foods are easily understood as a group and are important sources of high-quality protein, potassium and calcium, as well as vitamin B12 (available only from animal-source foods) and other micronutrients. This group includes almost all liquid and solid dairy products from cows, goats, buffalo, sheep or camels. Tinned, powdered or ultra-high temperature (UHT) milk, soft and hard cheeses and yoghurt and kefir are also included.
However, butter, cream and sour cream, ice cream, sweetened condensed milk and processed/ packaged “yoghurt drinks” are excluded. Butter, cream and sour cream are classified with fats and oils because of their high fat content and most typical culinary uses. Ice cream and sweetened condensed milk are classified with sweets. Commercially processed/packaged “yoghurt drinks” are classified with sweet drinks, because these are usually high in sugar and low in dairy content. While high-quality ice cream and yoghurt drinks can contain substantial amounts of dairy and associated nutrients, cheaper and poorer-quality products do not, and the classification is aimed to avoid false inflation of the proportion of women consuming nutritious dairy products.
GROUP 5 – MEAT, POULTRY AND FISH This group is sometimes referred to as “flesh foods”. All meats, organ meats, poultry and other birds and fresh and dried fish and seafood/shellfish are included. Wild birds and mammals (“bush meat”), snakes, frogs and other reptiles and amphibians are also included. On the questionnaire, these appear as three subgroups: organ meat, meat and poultry, and fish/seafood. All flesh foods are important sources of high-quality protein and bioavailable micronutrients, notably iron, zinc and vitamin B12 (the last is available only from animal-source foods).
There is increasing interest in and concern regarding consumption of red meat and processed meats (see, for example, Bouvard et al., 2015, and http://www.who.int/features/qa/cancer-red-meat/en/).
In some settings, consumption of animal-source foods is very low, while in others it is consumed in excess of needs.
For the purposes of the MDD-W indicator, all flesh foods, including red meat and processed meat, are included in this group. However, in settings where there are public health concerns about excessive consumption and/or where processed meats are widely consumed, an additional row could be added to the questionnaire to disaggregate and capture descriptive information about specific types of meat of concern, i.e. to separate red meat and/or processed meat from other items.
For global comparability, however, these items should still “count” in MDD-W in the same way as poultry or fish.
GROUP 6 – EGGS This group includes eggs from any type of bird (domesticated poultry and wild birds) but not fish roe, which are classified with small protein foods (see “Insects and other small protein foods”, p. 17). Like other animal-source foods, eggs are a good source of protein, vitamin B12 and a range of bioavailable micronutrients.
Box 1. The issue of quantity – how much is enough to “count” towards food group diversity?
Ideally, women of reproductive age (WRA) would consume adequate amounts of diverse foods, such as fruits, vegetables, legumes, nuts and animal-source foods. But what is “adequate”? Various national food-based dietary guidelines provide recommendations on serving sizes and number of servings to consume from various food groups. However, there is no global harmonisation of what constitutes a serving size or on recommended numbers of servings per day for the various food groups.
Furthermore, Minimum Dietary Diversity for Women of Reproductive Age (MDD-W) was developed exactly for situations where collection of quantitative dietary information is not feasible, that is, where it is not feasible to ask about the number and size of servings consumed.
So, how much is needed for a food group to “count” in the MDD-W? And how can this be determined without asking about quantities?
Several studies suggest that even if it is not possible to assess servings or an “adequate” amount, it is worthwhile to try to exclude very small quantities (Arimond et al., 2010; Gewa et al., 2014; Martin-Prével et al., 2015). The relationship between food group diversity and micronutrient adequacy is stronger when very small amounts of a food group are not allowed to “count”. Several studies have used a cutoff of ≥15 g (for many foods that is about one tablespoon). So for the purposes of defining “large-enough” quantities, consider if, when consumed, the food is usually consumed by WRA in quantities ≥15 g.
Experience with large dietary diversity surveys has shown that it is both feasible and best to define foods and ingredients that do and do not count for constructing the MDD-W indicator during questionnaire adaptation – that is, before enumerator training and data collection begin. Foods usually consumed in trivial quantities are placed in the “Condiments and seasonings” category. Enumerators should know the principle of not counting small quantities but should not be making decisions during data collection about whether or not a quantity is sufficient to count.
When surveys will be repeated in the same geographic area across time, it is essential to maintain the same definitions of foods that do and do not count across survey rounds. It is also useful to aim for consistency among various users in the same geographic area and to follow the same principles and process across different countries or geographic areas.
To promote consistency, this manual therefore provides a principle, suggestions for the adaptation process (Section 4) and examples (Appendix 2).
• Principle: When necessary, err on the side of not falsely inflating food group diversity.
This is particularly important when foods or ingredients are expensive and the poorest and most vulnerable women are those most likely to consume trivial amounts.
• Process: Engage nutrition experts in questionnaire adaptation. When this is not feasible, follow the classification decisions in this manual (Appendix 2) for classifying items into the “Condiments and seasonings” category.
Box 1. continued Condiments and seasonings Condiments and seasonings are food ingredients that are either usually or often used in small quantities in the “family pot” or in foods prepared outside the home. Often these food items are added to provide flavour. Common examples include all fresh or dried herbs, spices, chili peppers, garlic, ginger root, fish powder, bean paste, fermented bean paste, tomato paste, seeds added for flavouring, bouillon cubes and similar flavour cubes, soy sauce, fish sauce and pepper sauce (see also Appendix 2). Some of these are very nutritious but the amount consumed by individuals consuming the dish is most often very small.
Furthermore, in cases where these ingredients are expensive, the quantities added in poorer households may be smaller than in better-off households.
In the MDD-W method described in this manual, these items are placed in the “Condiments and seasonings” category and do not count in the ten food groups that comprise MDD-W (see Section 6 on tabulation of the indicator). This reflects a judgement that the risk of falsely inflating food group diversity is more serious than the risk of excluding these items and underestimating diversity for the relatively small number of instances where consumption of these items might be more substantial.
During survey adaptation (Section 4), survey designers can decide if there are culturally specific exceptions to this – for example, if there are situations where seeds or seed pastes are usually eaten in large quantities. In some settings, there may be additional context- and cuisine-specific items that are usually used in trivial amounts and should be excluded from the count by placing them in the “Condiments and seasonings” category (e.g. small amounts of nuts, legumes or grated vegetables if usually used to top dishes). These items can also be added to the “Condiments and seasonings” category at the discretion of nutrition experts involved in survey adaptation.
These types of decisions should be taken only in consultation with experts; when this is not possible, follow the classification decisions suggested in this manual.
14 Section 2 Description of food groups