A Simple Method of Measuring Dietary Diversity at Population Level

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2 A Simple Method of Measuring Dietary Diversity at Population Level NP Steyn, D Labadarios, JH Nel Social science that makes a difference Date:

3 Introduction Determining dietary diversity in RSA adults has not been possible to date since there are no national dietary data on adolescents or adults However a national study on food consumption in children (NFCS) in RSA showed a very monotonous type of diet with specific deficiencies including: Energy, iron, zinc, calcium, vitamins A, C, E, B6, B2, niacin and folic acid. Largely due to the majority of the population consuming large amounts of maize meal, bread and sugar with low intakes of animal protein and fruit and vegetables. It is known that a diverse diet is more likely to contain all the essential nutrients than a monotonous one, hence measuring dietary diversity is a simple way of identifying the likelihood of having an adequate diet in terms of essential micronutrients.

4 Objective of the study To measure dietary diversity in South Africans aged 16 years and older from all population groups

5 Methods A cross-sectional study representative of adults from all specified ages, provinces, geographic localities, and socio-economic strata in South Africa was used (n= 3287). Trained interviewers visited participants at their homes during the survey. Dietary data was collected by means of a face validated 24 hour recall which was not quantified. A dietary diversity score (DDS) was calculated by counting each of 9 food groups. A DDS <4 was regarded as reflecting poor dietary diversity and poor food security.

6 Individual dietary variety Use of an adapted FAO (2011) method using 9 food groups. Groups were based on outcomes of the NFCS Starchy staples (cereals, roots, tubers) Vitamin A rich fruit and vegetables Other fruit Other vegetables Legumes and nuts Fats and oils Meat/poultry/fish Milk and milk products Eggs FAO have an organ meats group and a dark green leafy group and combine other fruits and vegetables

7 Cut-off value for dietary diversity used This was based on a validation study done with data from the NFCS with assistance from FAO (Steyn NP et al, PHN 2005). A dietary diversity score ( DDS) of at least 4 (groups) was shown to be the lowest minimum requirement and provided a specificity of 70% and a sensitivity of 75% of at least at 50% MAR of the overall diet in children. Furthermore, z scores for weight and height for age of children rose above zero at a DDS of 4. No validation data available on adults

8 24 Hour recall Each participant was required to list all foods and drinks consumed on the previous day. No quantities were recorded. Each item consumed from a specific food group was counted once only. A DDS< 4 would represent poor diversity. Some studies include a minimum of 15 g per item per day.

9 Results

10 % Population in each province having a low DDS (<4 groups)

11 Social science that makes a difference % Population having a low DDS by area

12 % Population having a low DDs by SES status Social science that makes a difference

13 % population having a low DDS by ethnic group

14 Mean DDS of different SES categories Living Standard Measure Low Medium High Sample size c Mean DDS 2.93 [C] 3.84 [B] 4.72 [A] 95% CI

15 Mean DDS by geographic area Geographic area RSA Urban, formal Urban, informal Tribal Rural, All Sample size Mean DDS 95%CI 4.42 [A] [B] [C] [B]

16 Mean DDS by ethnic group Ethnicity RSA Black / African Mixed ancestry Indian/Asian White All Sample size Mean DDS 3.63 [C] 4.43 [B] 4.44 [B] 4.96 [A] % CI

17 Most commonly consumed food groups % Consumers 95%CI Cereals Vitamin A rich fruit & veg Other fruit Other vegetables Legumes & nuts Fat & oils Meat/poultry Milk & milk products Eggs

18 Odd ratios of factors associated with having a DDS<4 Factor Odds Ratio 95% CI Casual work 2.769* Buys at spaza 1.979* Lives in traditional house 2.394* Water source is river 7.060* No toilet 3.350* No electricity 2.310*

19 Odd ratios of factors associated with having a DDS<4 Factor Odds Ratio 95% CI Employed full time 0.672* Supermarket close by 0.584* Flush toilet 0.467* Electricity in house 0.389* Motor vehicle 0.326* Mobile phone 0.473*

20 Conclusions Overall the major adults consumed a diet low in variety Tribal areas & informal urban areas were worst affected Eggs, legumes and vitamin A rich fruit & vegetables were least consumed Will include organ meats and dark green leafy vegetables in future as groups