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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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Essentially all medium-to-dark green leafy vegetables are vitamin A-rich (see Box 2 for criteria for classifying items as vitamin A-rich). Only very light leaves, such as iceberg lettuce, are not. Medium green leaves, such as Chinese cabbage, romaine and bibb lettuce, along with darker greens, are all vitamin A-rich and are included in this group. In addition to being rich in vitamin A, many green leafy vegetables are rich in folate and several other micronutrients.

Commonly consumed leaves vary widely by country and region, and include many wild and foraged species, as well as the green leaves of other food crops (e.g. cassava leaves, bean leaves, pumpkin leaves, amaranth leaves and others). See Appendix 2 for a detailed list of cultivated leafy vegetables.

In the absence of information on nutrient content, wild/foraged leaves that are medium-to-dark green can be assumed to be vitamin A-rich and placed in this group.

Box 2. Criteria for defining foods and liquids as “sources” of vitamin A

For plant foods: Foods providing at least 120 retinol equivalents (RE) per 100 g are considered “sources” of vitamin A.* This is roughly equivalent to 60 retinol activity equivalents (RAE).

Food composition tables may report vitamin A content of foods using the older RE units or the more recently adopted RAE.

For liquids (e.g. juices): Liquids providing 60 RE or 30 RAE per 100 g are considered to be sources of vitamin A.

*120 RE per 100 g corresponds to 15 percent of the Nutrient Reference Value (NRV; 800 RE) established by the Codex Alimentarius. The Codex standard for identifying a food as a “source” of any nutrient states that the food should provide any of the following: 15 percent per 100 g solid food, 7.5 percent per 100 g liquids, 5 percent per 100 kcal or 15 percent per serving. To be identified as a “high source”, the food must provide twice this amount (e.g. 30 percent or 240 RE per 100 g solid food). The NRVs are set at a level that should meet the needs of approximately 97 percent of individuals in the age/sex group with highest needs (excluding pregnant and lactating women). For the definition of “source”, see Codex Alimentarius Commission, Guidelines adopted 1997, revised 2004. For the definition of NRV, see Codex Alimentarius Commission, Guidelines adopted 1985, revised 1993 (for all Codex Standards, see http://www.codexalimentarius.org/).

15 Section 2 Description of food groups

GROUP 8 – OTHER VITAMIN A-RICH FRUITS AND VEGETABLES

This group includes both vitamin A-rich fruits and a small but diverse group of vitamin A-rich vegetables other than leafy greens. These foods may also be good sources of vitamin C and/or folate and/or other micronutrients. While “Other vitamin A-rich fruits and vegetables” constitutes one of the ten distinct food groups in the indicator, fruits are listed separately from vegetables on the questionnaire, as this may be more intuitive for enumerators.

The most common vitamin A-rich fruits are ripe mango and ripe papaya; others include red palm fruit/pulp, passion fruit, apricot and several types of melon. When eaten “green” (unripe), mango and papaya are not rich in vitamin A and if consumed “green” should be classified with “Other fruits”.

Certain varieties of ripe, deep yellow-fleshed or orange-fleshed bananas are also rich in vitamin A, but white/cream-fleshed bananas are not. Deep yellow-fleshed and orange-fleshed bananas may be classified with vitamin A-rich fruits when their high vitamin A content is known to survey planners and it is considered feasible to distinguish bananas by colour during fieldwork. Otherwise, all bananas should be classified with “Other fruits” (see below), to avoid falsely inflating the proportion of women consuming vitamin A-rich fruits and vegetables.

Other vitamin A-rich vegetables include orange-fleshed sweet potato, carrot, pumpkin and deep yellow- or orange-fleshed squash. See Appendix 2 for a list of other vitamin A-rich fruits and vegetables.

GROUP 9 – OTHER VEGETABLES This group includes vegetables not counted above as dark green leafy vegetables or as other vitamin A-rich vegetables. Diets rich in fruits and vegetables are associated with positive health outcomes.

This may be due to consumption of a range of bioactive compounds found in fruits and vegetables, including phenolics, flavonoids and fibre, and not just to their commonly recognised role as sources of micronutrients (Liu, 2013; Turati et al., 2015).

This group includes legumes when the fresh/green pod is consumed (as in fresh peas, snow peas, snap peas or green beans). In general, the “Other vegetables” group follows the culinary definition of a vegetable, not the botanical definition. It includes stems, fruits and flowers of plants when generally consumed in savoury dishes and considered as vegetables in culinary systems. So, for example, cucumber, tomato and okra (all fruits in botanical terms) are included as “Other vegetables”.

However, this group excludes high-carbohydrate “starchy” roots and tubers, such as white potatoes, white yams, cassava and cocoyam, because their nutrient contributions differ, even though they are considered vegetables in some culinary definitions. Exclusion of roots and tubers is consistent with how WHO documents define which vegetables count towards the recommended consumption of fruits and vegetables15.





As with dark green leafy vegetables, commonly consumed vegetables vary widely with geography and can include foraged as well as cultivated foods.

For example, see the Healthy Diet Fact Sheet at http://www.who.int/mediacentre/factsheets/fs394/en/, accessed 15 July 1, 2015, and Agudo, 2005.

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GROUP 10 – OTHER FRUITS This group includes most fruits, excluding vitamin A-rich fruits. Health effects of diets rich in fruits and vegetables were noted above. As with “Other vegetables”, this group follows the culinary definition of fruits and so does not include tomatoes, etc., as explained above. Fruits are usually easily recognised and classified as such. Note that plantains are classified with starchy staples (Group 1, above), but sweet white bananas are classified with fruit.

As with vegetables, commonly consumed fruits vary widely with geography and can include foraged as well as cultivated fruits. A detailed list is provided in Appendix 2.

OTHER FOOD CATEGORIES

The food categories listed below do not count in the construction of the MDD-W indicator.

Insects and small protein foods – optional This category includes insects, insect larvae/grubs, insect eggs, fish roe, spiders, land and sea snails and any other small invertebrates. It does not include frogs, snakes or other reptiles and amphibians, which are included in the “Meat, poultry and fish” group.

Insects and other small protein foods are diverse and have diverse nutrient content. Considering insects alone, it is estimated that there are more than 2,000 edible species, but nutrient data are available for only about 10 percent of these (Rumpold and Schlüter, 2013). Data on quantities consumed are also scant. For those species with nutrient composition data, it appears insects are nutrient dense and could potentially provide protein, fatty acids and micronutrients. But information on bioavailability is also lacking. Given these uncertainties, insects and other small protein foods are not included in the MDD-W count (this is also in harmony with the IYCF MDD indicator). As with condiments and several other items above, it is judged better to err on the side of not including/not counting these small protein foods given the diversity in nutrient content and uncertainty about the amount usually consumed. This avoids the risk of falsely inflating the proportion of women reported to consume nutrient-dense animal-source foods.

Reasons for including this category on the questionnaire: the category includes highly nutritious foods, and there may be an interest in knowing the proportion of WRA who are consuming these foods. These foods are also being promoted to play a greater role in the future in filling nutrient gaps (FAO, 2013).

If these foods are not eaten or are considered very rare throughout the survey area, this category does not need to be included on the questionnaire.

Red palm oil – optional This category includes only red palm oil, which is usually consumed as an ingredient in mixed dishes.

Reason for including this category on the questionnaire: red palm oil is extremely high in vitamin A. In geographic areas where it is available, it may be of interest to know the proportion of WRA consuming it. Note that the oily red palm fruit is classified as a vitamin A-rich fruit. In areas where grown, either the oil or the oily fruit may be consumed, depending on the particular mixed dish.

If red palm oil is not available, not consumed or considered very rare throughout the survey area, this category does not need to be included on the questionnaire.

17 Section 2 Description of food groups

Other oils and fats – optional, but recommended This category includes all other solid and liquid oils and fats, including those of plant or animal origin. Examples are lard, suet (tallow) and butter (solid animal fats); margarine and “shortening” (hydrogenated vegetable oil); and a range of oils extracted from nuts, seeds and grains. This category also includes very high-fat dairy items, such as cream and sour cream.

Note that it is usually not feasible to capture information on the quality and type of fats and oils consumed in the context of simple food group recall surveys. In many contexts, labelling is insufficient and/or oils are locally produced, unlabelled or repackaged into unlabelled containers or sachets. Respondents often will not know the type of oil consumed.

Reasons for including this category on the questionnaire: to estimate the proportion of women consuming any fats/oils, particularly in very high poverty areas where fat consumption is considered too low, and to give enumerators some place to mark when these are mentioned as ingredients in mixed dishes.

Savoury and fried snacks – optional This category includes different foods in different settings, but in many settings crisps, chips, puffs and other low-cost and nutrient-poor snack foods are increasingly common. This category also includes other, more-substantial fried snacks, such as doughnuts/fried dough, samosas and other deep fried snacks and “street food” snacks. These foods may include very small amounts of meat or vegetables but are mainly fat and simple carbohydrate and may often be high in sodium as well.

Note that other fried foods – for example, fried potatoes and fried plantains – which may be consumed as meals or snacks are classified with roots and tubers because in some settings potatoes or plantains are staple foods, and classifying them with snacks might mean there would be no staple food in the count. This could result in a false “deflation” of food group diversity. Depending on their role in local diets, survey objectives and the likelihood of this false deflation, survey designers could choose to classify fried potatoes, fried plantains and similar in the “Savoury and fried snacks” category.

Reasons for including this category on questionnaires: to begin to provide descriptive information on the proportion of WRA consuming snacks that are generally nutrient-poor and energy-dense, and also to provide a place to mark these foods.

Sweets – optional This category includes sweet foods, such as candy, chocolates, cakes, sweet biscuits/cookies, sweet pastries and ice cream.

Reasons for including this category on the questionnaire are the same as for savoury and fried snacks.

Sugar-sweetened beverages – optional This category includes all sweetened fruit juices and “juice drinks”, soft drinks/fizzy drinks, chocolate drinks (including those made with powders), sweet tea or coffee with sugar. It also includes fortified sweet drinks, malt drinks and “energy drinks”, which are popular in some places.

Reasons for including this category on the questionnaire are the same as for savoury snacks and sweets. In addition, sugar-sweetened beverages have been associated with health risk factors in a number of studies and meta-analyses (Malik et al., 2013; Xi et al., 2015), and there is increasing interest in documenting prevalence of consumption.

18 Section 2 Description of food groups

Condiments and seasonings – REQUIRED This category includes all minor ingredients in mixed dishes, which primarily provide flavour and would be consumed in very small amounts in any individual serving of the dish. It includes items added at any stage of cooking or when serving food (e.g. garnishes sprinkled on top of a dish to add flavour or visual appeal). This category includes fresh or dried herbs, spices, chili peppers, ginger root, garlic, fish powder, bean paste, fermented bean paste, tomato paste and seeds added for flavour or to garnish mixed dishes. It also includes bouillon cubes, “Maggi cubes” and similar items, soy sauce, fish sauce and pepper sauce. It includes sugar when sugar is added as a flavouring to mixed dishes or side dishes.

Note that many of these items that are added to flavour dishes may be nutritious and could be promoted as nutrient-rich additions to the family meal. But the amounts consumed are typically small and do not contribute substantially to micronutrient adequacy. Several studies have shown that exclusion of foods eaten in very small quantities strengthens the association between food group diversity and micronutrient adequacy (Arimond et al. 2010; Gewa et al., 2014; Martin-Prével et al., 2015). Therefore, these items are placed in the “Condiments and seasonings” category to avoid a false inflation of women’s dietary diversity. See Box 1 for further discussion of exclusion of small quantities.

The reason for including this category on the questionnaire is primarily to give a place for enumerators to mark these foods to avoid falsely classifying elsewhere. See Section 5 for a discussion of training enumerators regarding this food category and see Appendix 2 for more examples.

Other beverages and foods – REQUIRED This category includes beverages, such as unsweetened tea, unsweetened coffee, clear broth, herbal infusions and alcohol, and miscellaneous foods, such as pickles and olives.



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