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Background We have developed a simple and globally applicable tool, the Global Diet Quality Score (GDQS), to measure diet quality. Objectives To test the utility of the GDQS, we examined the associations of the GDQS with weight change and risk of obesity in US women. Methods Health, lifestyle, and diet information were collected from women (n = 68,336) in the Nurses’ Health Study II (aged 27–44 y in 1991) through repeated questionnaires (1991–2015). The GDQS has 25 food groups (maximum = 49 points) and scoring higher points reflects a healthier diet. The association between GDQS change in 4-y intervals and concurrent weight change was computed with linear models adjusted for confounders. Results Mean ± SD weight gain across 4-y periods was 1.68 ± 6.26 kg. A >5-point improvement in GDQS was associated with −1.13 kg (95% CI: −1.19, −0.77 kg) weight gain compared with a score change of 5-point score decrease was associated with 1.13 kg (95% CI: 1.04, 1.22 kg) more weight gain in women aged 5-point increase and 1.32 (95% CI: 1.26, 1.37) for a >5-point decrease. Risk of obesity did not differ by age. Compared with other diet quality scores, the Alternate Healthy Eating Index-2010 had somewhat stronger associations than the GDQS (P

Background The global diet quality score (GDQS) is a simple, standardized metric appropriate for population-based measurement of diet quality globally. Objectives We aimed to operationalize data collection by modifying the quantity of consumption cutoffs originally developed for the GDQS food groups and to statistically evaluate the performance of the operationalized GDQS relative to the original GDQS against nutrient adequacy and noncommunicable disease (NCD)-related outcomes. Methods The GDQS application uses a 24-h open-recall to collect a full list of all foods consumed during the previous day or night, and automatically classifies them into corresponding GDQS food group. Respondents use a set of 10 cubes in a range of predetermined sizes to determine if the quantity consumed per GDQS food group was below, or equal to or above food group-specific cutoffs established in grams. Because there is only a total of 10 cubes but as many as 54 cutoffs for the GDQS food groups, the operationalized cutoffs differ slightly from the original GDQS cutoffs. Results A secondary analysis using 5 cross-sectional datasets comparing the GDQS with the original and operationalized cutoffs showed that the operationalized GDQS remained strongly correlated with nutrient adequacy and was equally sensitive to anthropometric and other clinical measures of NCD risk. In a secondary analysis of a longitudinal cohort study of Mexican teachers, there were no differences between the 2 modalities with the beta coefficients per 1 SD change in the original and operationalized GDQS scores being nearly identical for weight gain (-0.37 and -0.36, respectively, P

Background The prevalence of type 2 diabetes has increased substantially in India over the past 3 decades. Undiagnosed diabetes presents a public health challenge, especially in rural areas, where access to laboratory testing for diagnosis may not be readily available. Objectives The present work explores the use of several machine learning and statistical methods in the development of a predictive tool to screen for prediabetes using survey data from an FFQ to compute the Global Diet Quality Score (GDQS). Methods The outcome variable prediabetes status (yes/no) used throughout this study was determined based upon a fasting blood glucose measurement ≥100 mg/dL. The algorithms utilized included the generalized linear model (GLM), random forest, least absolute shrinkage and selection operator (LASSO), elastic net (EN), and generalized linear mixed model (GLMM) with family unit as a (cluster) random (intercept) effect to account for intrafamily correlation. Model performance was assessed on held-out test data, and comparisons made with respect to area under the receiver operating characteristic curve (AUC), sensitivity, and specificity. Results The GLMM, GLM, LASSO, and random forest modeling techniques each performed quite well (AUCs >0.70) and included the GDQS food groups and age, among other predictors. The fully adjusted GLMM, which included a random intercept for family unit, achieved slightly superior results (AUC of 0.72) in classifying the prediabetes outcome in these cluster-correlated data. Conclusions The models presented in the current work show promise in identifying individuals at risk of developing diabetes, although further studies are necessary to assess other potentially impactful predictors, as well as the consistency and generalizability of model performance. In addition, future studies to examine the utility of the GDQS in screening for other noncommunicable diseases are recommended.

Background Key nutrient deficits remain widespread throughout sub-Saharan Africa (SSA) whereas noncommunicable diseases (NCDs) now cause one-third of deaths. Easy-to-use metrics are needed to track contributions of diet quality to this double burden. Objectives We evaluated comparative performance of a novel food-based Global Diet Quality Score (GDQS) against other diet metrics in capturing nutrient adequacy and undernutrition in rural SSA adults. Methods We scored the GDQS, Minimum Dietary Diversity–Women (MDD-W), and Alternative Healthy Eating Index–2010 (AHEI-2010) using FFQ data from rural men and nonpregnant, nonlactating women of reproductive age (15–49 y) in 10 SSA countries. We evaluated Spearman correlations between metrics and energy-adjusted nutrient intakes, and age-adjusted associations with BMI, midupper arm circumference (MUAC), and hemoglobin in regression models. Results Correlations between the GDQS and an energy-adjusted aggregate measure of dietary protein, fiber, calcium, iron, zinc, vitamin A, folate, and vitamin B-12 adequacy were 0.34 (95% CI: 0.30, 0.38) in men and 0.37 (95% CI: 0.32, 0.41) in women. The GDQS was associated (P

Background The double burdens of under- and overnutrition are changing the health of individuals and the economic and disease burdens in China. Poor diet plays an important role; however, a valid and easily operationalized metric that could capture the full range of characteristics of the diet that are relevant to both under- and overnutrition is lacking in China. Objectives We aimed to examine the application of the Global Diet Quality Score (GDQS) to evaluate nutrient inadequacy and metabolic syndrome in different demographic groups of Chinese adults. Methods A total of 35,146 individuals (men 14,978, women 20,168) aged >18 y from the 2010–2012 China National Nutrition and Health Survey were included. We scored the GDQS using average intakes of 25 food groups from 3 d of 24-h dietary recalls. Double burden was defined as coexisting metabolic syndrome and nutrient inadequacy. Results Diet quality assessed by GDQS was significantly higher in urban than in rural residents (20.8 compared with 18.7), and increased with both educational level and household income (P-trends < 0.0001). A higher GDQS score was inversely associated with metabolic syndrome and nutrient inadequacy, or both (P-trends < 0.0001): multivariate adjusted ORs comparing extreme quintiles of GDQS were 0.79 (95% CI: 0.69, 0.91) for metabolic syndrome, 0.17 (95% CI: 0.14, 0.20) for nutrient inadequacy, and 0.59 (95% CI: 0.50, 0.69) for the double burden. These associations were consistent across different household income levels (P-interaction = 0.26), suggestively stronger in younger (

Background Evidence on concurrent changes in overall diet quality and weight and waist circumference in women of reproductive age from low- and middle-income countries is limited. Objectives We examined the associations of changes in the Global Diet Quality Score (GDQS) and each GDQS food group with concurrent weight and waist circumference change in Mexican women. Methods We followed prospectively 8967 nonpregnant nonlactating women aged 25–49 y in the Mexican Teachers’ Cohort between 2006 and 2008. We assessed diet using an FFQ of the previous year and anthropometric measures were self-reported. Regression models were used to examine 2-y changes in the GDQS and each food group (servings/d) with weight and waist circumference changes within the same period, adjusting for demographic and lifestyle factors. Results Compared with those with little change in the GDQS (−2 to 2 points), women with the largest increase in the GDQS (>5 points) had less weight (β: −0.81 kg/2 y; 95% CI: −1.11, −0.51 kg/2 y) and waist circumference gain (β: −1.05 cm/2 y; 95% CI: −1.62, −0.48 cm/2 y); likewise, women with the largest decrease in the GDQS (

Background We have developed a diet quality metric intended for global use. To assess its utility in high-income settings, an evaluation of its ability to predict chronic disease is needed. Objectives We aimed to prospectively examine the ability of the Global Diet Quality Score (GDQS) to predict the risk of type 2 diabetes in the United States, examine potential differences of association by age, and compare the GDQS with other diet quality scores. Methods Health, lifestyle, and diet information was collected from women (n = 88,520) in the Nurses’ Health Study II aged 27–44 y at baseline through repeated questionnaires between 1991 and 2017. The overall GDQS consists of 25 food groups. Points are awarded for higher intake of healthy groups and lower intake of unhealthy groups (maximum of 49 points). Multivariable HRs were computed for confirmed type 2 diabetes using proportional hazards models. We also compared the GDQS with the Minimum Diet Diversity score for Women (MDD-W) and the Alternate Healthy Eating Index-2010 (AHEI-2010). Results We ascertained 6305 incident cases of type 2 diabetes during follow-up. We observed a lower risk of diabetes with higher GDQS; the multivariable HR comparing extreme quintiles of the GDQS was 0.83 (95% CI: 0.76, 0.91; P-trend

Background Poor diet quality is a major driver of both classical malnutrition and noncommunicable disease (NCD) and was responsible for 22% of adult deaths in 2017. Most countries face dual burdens of undernutrition and NCDs, yet no simple global standard metric exists for monitoring diet quality in populations and population subgroups. Objectives We aimed to develop an easy-to-use metric for nutrient adequacy and diet related NCD risk in diverse settings. Methods Using cross-sectional and cohort data from nonpregnant, nonlactating women of reproductive age in 10 African countries as well as China, India, Mexico, and the United States, we undertook secondary analyses to develop novel metrics of diet quality and to evaluate associations between metrics and nutrient intakes and adequacy, anthropometry, biomarkers, type 2 diabetes, and iteratively modified metric design to improve performance and to compare novel metric performance to that of existing metrics. Results We developed the Global Diet Quality Score (GDQS), a food-based metric incorporating a more comprehensive list of food groups than most existing diet metrics, and a simple means of scoring consumed amounts. In secondary analyses, the GDQS performed comparably with the Minimum Dietary Diversity - Women indicator in predicting an energy-adjusted aggregate measure of dietary protein, fiber, calcium, iron, zinc, vitamin A, folate, and vitamin B12 adequacy and with anthropometric and biochemical indicators of undernutrition (including underweight, anemia, and serum folate deficiency), and the GDQS also performed comparably or better than the Alternative Healthy Eating Index - 2010 in capturing NCD-related outcomes (including metabolic syndrome, change in weight and waist circumference, and incident type 2 diabetes). Conclusions The simplicity of the GDQS and its ability to capture both nutrient adequacy and diet-related NCD risk render it a promising candidate for global monitoring platforms. Research is warranted to validate methods to operationalize GDQS assessment in population surveys, including a novel application–based 24-h recall system developed as part of this project.

Individual-level quantitative dietary data can provide suitably disaggregated information to identify the needs of all population sub-groups, which can in turn inform agricultural, nutrition, food safety, and environmental policies and programs. The purpose of this discussion paper is to provide an overview of dietary surveys conducted in low- and middle-income countries (LMICs) from 1980 to 2019, analyzing their key characteristics to understand the trends in dietary data collection across time. The present study analyzes the information gathered by the Food and Agriculture Organization of the United Nations/World Health Organization Global Individual Food consumption data Tool (FAO/WHO GIFT). FAO/WHO GIFT is a growing repository of individual-level dietary data and contains information about dietary surveys from around the world, collected through published survey results, literature reviews, and direct contact with data owners. The analysis indicates an important increase in the number of dietary surveys conducted in LMICs in the past four decades and a notable increase in the number of national dietary surveys. It is hoped that this trend continues, together with associated efforts to validate and standardize the dietary methods used. The regular implementation of dietary surveys in LMICs is key to support evidence-based policies for improved nutrition.

Background In India, there is a need to monitor population-level trends in changes in diet quality in relation to both undernutrition and noncommunicable diseases. Objectives We conducted a study to validate a novel diet quality score in southern India. Methods We included data from 3041 nonpregnant women of reproductive age (15–49 years) from 2 studies in India. Diet was assessed using a validated food frequency questionnaire (FFQ). The Global Diet Quality Score (GDQS) was calculated from 25 food groups (16 healthy; 9 unhealthy), with points for each group based on the frequency and quantity of items consumed in each group. We used Spearman correlations to examine correlations between the GDQS and several nutrient intakes of concern. We examined associations between the GDQS [overall, healthy (GDQS+), and unhealthy (GDQS−) submetrics] and overall nutrient adequacy, micro- and macronutrients, body mass index (BMI), midupper arm circumference, hemoglobin, blood pressure, high density lipoprotein (HDL), and total cholesterol (TC). Results The mean GDQS was 23 points (SD, 3.6; maximum, 46.5). In energy-adjusted models, positive associations were found between the overall GDQS and GDQS+ and intakes of calcium, fiber, folate, iron, monounsaturated fatty acid (MUFA), protein, polyunsaturated fatty acid (PUFA), saturated fatty acid (SFA), total fat, and zinc (ρ = 0.12–0.39; P

Background The Global Diet Quality Score (GDQS) is intended as a simple global diet quality metric feasible in low- and middle-income countries facing the double burden of malnutrition. Objective The aim of this study was to evaluate the performance of the GDQS with markers of nutrient adequacy and chronic disease in nonpregnant nonlactating (NPNL) Mexican women of reproductive age and to compare it with the Alternate Healthy Eating Index-2010 (AHEI-2010) and the Minimum Dietary Diversity for Women (MDD-W). Methods We included NPNL women aged 15 to 49 y from the Mexican National Health and Nutrition Surveys (2012 and 2016) with 24-h recall (n = 2542) or a FFQ (n = 4975) (separate samples). We evaluated the correlation of the GDQS with the energy-adjusted intake of several nutrients and evaluated its association with health parameters using covariate-adjusted linear regression models. Results The GDQS was positively correlated with the intake of calcium, folate, iron, vitamin A, vitamin B-12, zinc, fiber, protein, and total fat (rho = 0.09 to 0.38, P < 0.05) and was inversely correlated with the intake of added sugar (rho = −0.37 and −0.38, P < 0.05) using both instruments, and with total fat, SFA, and MUFA only with 24-h recall data (rho = −0.06 to −0.16, P < 0.05). The GDQS was inversely associated with serum ferritin, BMI, waist circumference, and serum total and LDL cholesterol using FFQ data (P

Background Nutritionally inadequate diets in Ethiopia contribute to a persisting national burden of adult undernutrition, while the prevalence of noncommunicable diseases (NCDs) is rising. Objectives To evaluate performance of a novel Global Diet Quality Score (GDQS) in capturing diet quality outcomes among Ethiopian adults. Methods We scored the GDQS and a suite of comparison metrics in secondary analyses of FFQ and 24-hour recall (24HR) data from a population-based cross-sectional survey of nonpregnant, nonlactating women of reproductive age and men (15–49 years) in Addis Ababa and 5 predominately rural regions. We evaluated Spearman correlations between metrics and energy-adjusted nutrient adequacy, and associations between metrics and anthropometric/biomarker outcomes in covariate-adjusted regression models. Results In the FFQ analysis, correlations between the GDQS and an energy-adjusted aggregate measure of dietary protein, fiber, calcium, iron, zinc, vitamin A, folate, and vitamin B12 adequacy were 0.32 in men and 0.26 in women. GDQS scores were inversely associated with folate deficiency in men and women (GDQS Quintile 5 compared with Quintile 1 OR in women, 0.50; 95% CI: 0.31–0.79); inversely associated with underweight (OR, 0.63; 95% CI: 0.44–0.90), low midupper arm circumference (OR, 0.61; 95% CI: 0.45–0.84), and anemia (OR, 0.59; 95% CI: 0.38–0.91) in women; and positively associated with hypertension in men (OR: 1.77, 95% CI: 1.12–2.80). For comparison, the Minimum Dietary Diversity–Women (MDD-W) was associated more positively (P

Objective:To determine if a global mid-upper arm circumference (MUAC) cut-off can be established to classify underweight in adults (men and non-pregnant women).Design:We conducted an individual participant data meta-analysis (IPDMA) to explore the sensitivity (SENS) and specificity (SPEC) of various MUAC cut-offs for identifying underweight among adults (defined as BMI < 18·5 kg/m2). Measures of diagnostic accuracy were determined every 0·5 cm across MUAC values from 19·0 to 26·5 cm. A bivariate random effects model was used to jointly estimate SENS and SPEC while accounting for heterogeneity between studies. Various subgroup analyses were performed.Setting:Twenty datasets from Africa, South Asia, Southeast Asia, North America and South America were included.Participants:All eligible participants from the original datasets were included.Results:The total sample size was 13 835. Mean age was 32·6 years and 65 % of participants were female. Mean MUAC was 25·7 cm, and 28 % of all participants had low BMI (2). The area under the receiver operating characteristic curve for the pooled dataset was 0·91 (range across studies 0·61–0·98). Results showed that MUAC cut-offs in the range of ≤23·5 to ≤25·0 cm could serve as an appropriate screening indicator for underweight.Conclusions:MUAC is highly discriminatory in its ability to distinguish adults with BMI above and below 18·5 kg/m2. This IPDMA is the first step towards determining a global MUAC cut-off for adults. Validation studies are needed to determine whether the proposed MUAC cut-off of 24 cm is associated with poor functional outcomes.

OBJECTIVES: We aimed to develop and evaluate an easily-tabulated metric that is sensitive to diet quality in diverse settings. In this analysis, we examined associations between a novel food-based metric – the Global Diet Quality Score (GDQS) - and diet quality using data from rural Africa. METHODS: The GDQS gives points for higher intake of 16 healthy food groups and lower intake of 9 unhealthy groups, based on 3 intake ranges for each group. We scored the GDQS using food frequency questionnaire (FFQ) data from 1613 men and 1710 nonpregnant nonlactating women ages 15–49 (median: 30) in 12 rural African villages participating in the Millennium Villages Project in 2006 to 2009. We evaluated associations between the GDQS and nutrient intakes calculated from the same FFQ, body mass index (BMI), mid-upper arm circumference (MUAC), hemoglobin, and an overall nutrient adequacy score ranging from 0 to 7 (1 point given for each of 7 nutrients meeting average requirements). Associations were also derived for GDQS submetrics (GDQS+ and GDQS−) computed using only healthy or unhealthy food groups, respectively, and simplified versions of the GDQS and submetrics (scored using 2 intake ranges for each food group). RESULTS: Moderate rank correlations were observed between the GDQS+ and energy-adjusted intakes of fiber (women: 0.43, men: 0.33), folate (0.40, 0.30), vitamin A (0.40, 0.34), and zinc (0.38, 0.30), exceeding correlations with the Minimum Dietary Diversity Score for Women (p for difference between metrics 0.05): women and men in the highest GDQS+ quintile had an OR of anemia of 0.25 (95% CI 0.09, 0.68) and 0.16 (95% CI 0.04, 0.46), respectively, relative to those in the lowest. Metrics were not associated with BMI or MUAC in adjusted analyses. CONCLUSIONS: The GDQS and submetrics were associated with nutrient intakes, hemoglobin, and reduced anemia in rural African adults. FUNDING SOURCES: Intake - Center for Dietary Assessment at FHI Solutions.

Moderate acute malnutrition (MAM) affects 11% of children −2. The median duration of feeding was 2 wk, with a maximum of 12 wk. The hypothesis tested was that children treated with either RUSF would be more likely to remain well-nourished than those treated with CSB++. The primary outcome, remaining well-nourished, was defined as mid-upper arm circumference ≥12.5 cm or WHZ ≥−2 for the entire duration of follow-up. During the 12-mo follow-up period, only 1230 (63%) children remained well-nourished, 334 (17%) relapsed to MAM, 190 (10%) developed severe acute malnutrition, 74 (4%) died, and 139 (7%) were lost to follow-up. Children who were treated with soy/whey RUSF were more likely to remain well-nourished (67%) than those treated with CSB++ (62%) or soy RUSF (59%) (P = 0.01). A seasonal pattern of food insecurity and adverse clinical outcomes was observed. This study demonstrates that children successfully treated for MAM with soy/whey RUSF are more likely to remain well-nourished; however, all children successfully treated for MAM remain vulnerable.

OBJECTIVE: To estimate the global burden of malnutrition and highlight data on child feeding practices and coverage of key nutrition interventions. METHODS: Linear mixed-effects modeling was used to estimate prevalence rates and numbers of underweight and stunted children according to United Nations region from 1990 to 2010 by using surveys from 147 countries. Indicators of infant and young child feeding practices and intervention coverage were calculated from Demographic and Health Survey data from 46 developing countries between 2002 and 2008. RESULTS: In 2010, globally, an estimated 27% (171 million) of children younger than 5 years were stunted and 16% (104 million) were underweight. Africa and Asia have more severe burdens of undernutrition, but the problem persists in some Latin American countries. Few children in the developing world benefit from optimal breastfeeding and complementary feeding practices. Fewer than half of infants were put to the breast within 1 hour of birth, and 36% of infants younger than 6 months were exclusively breastfed. Fewer than one-third of 6- to 23-month-old children met the minimum criteria for dietary diversity, and only ∼50% received the minimum number of meals. Although effective health-sector–based interventions for tackling childhood undernutrition are known, intervention-coverage data are available for only a small proportion of them and reveal mostly low coverage. CONCLUSIONS: Undernutrition continues to be high and progress toward reaching Millennium Development Goal 1 has been slow. Previously unrecognized extremely poor breastfeeding and complementary feeding practices and lack of comprehensive data on intervention coverage require urgent action to improve child nutrition.

Regular semi-annual distribution of high-dose (200,000 IU) vitamin A capsules (VACs) to children 1 - 5 years of age (previously identified as underweight), in Leyte Province, the Philippines, was compared to providing extra VACs to give three-monthly dosing, and to vitamin A-fortified cooking oil (VAFO) promotion (with continued VACs every 6 months). Serum retinol (SR) was measured at baseline and after 12 or 18 months (for VAFO). No sustained increase in SR was determined from the three-month VAC dosing regimen, and the prevalence of vitamin A deficiency (VAD) as assessed by SR (< 20 mcg / dL) remained around 30 % (in line with national survey estimates over the previous 15 years). The major difference found was that 18 months of VAFO (of which 9 months had sustained promotion) was associated with reducing the prevalence of VAD to < 10 %. The effective fortification and lack of effect of semi-annual VAC results are in line with previous studies; testing with dosing of VAC every three months is a new intervention. The results imply that promotion of fortified oil would reduce VAD in these conditions; whether it can replace or needs to be added to semi-annual VAC dosing remains to be determined. A phased changeover to reliance on fortified commodities (including oil) with careful monitoring of VAD trends is indicated.

Women of reproductive age living in resource-poor settings are at high risk of inadequate micronutrient intakes when diets lack diversity and are dominated by staple foods. Yet comparative information on diet quality is scarce and quantitative data on nutrient intakes is expensive and difficult to gather. We assessed the potential of simple indicators of dietary diversity, such as could be generated from large household surveys, to serve as proxy indicators of micronutrient adequacy for population-level assessment. We used 5 existing data sets (from Burkina Faso, Mali, Mozambique, Bangladesh, and the Philippines) with repeat 24-h recalls to construct 8 candidate food group diversity indicators (FGI) and to calculate the mean probability of adequacy (MPA) for 11 micronutrients. FGI varied in food group disaggregation and in minimum consumption required for a food group to count. There were large gaps between intakes and requirements across a range of micronutrients in each site. All 8 FGI were correlated with MPA in all sites; regression analysis confirmed that associations remained when controlling for energy intake. Assessment of dichotomous indicators through receiver-operating characteristic analysis showed moderate predictive strength for the best choice indicators, which varied by site. Simple FGI hold promise as proxy indicators of micronutrient adequacy. J. Nutr. 140: 2059S-2069S, 2010.

The conventional method for assessing the prevalence of Global Acute Malnutrition (GAM) in emergency settings is the 30 x 30 cluster-survey. This study describes alternative approaches: three Lot Quality Assurance Sampling (LQAS) designs to assess GAM. The LQAS designs were field-tested and their results compared with those from a 30 x 30 cluster-survey.Computer simulations confirmed that small clusters instead of a simple random sample could be used for LQAS assessments of GAM. Three LQAS designs were developed (33 x 6, 67 x 3, Sequential design) to assess GAM thresholds of 10, 15 and 20%. The designs were field-tested simultaneously with a 30 x 30 cluster-survey in Siraro, Ethiopia during June 2003. Using a nested study design, anthropometric, morbidity and vaccination data were collected on all children 6-59 months in sampled households. Hypothesis tests about GAM thresholds were conducted for each LQAS design. Point estimates were obtained for the 30 x 30 cluster-survey and the 33 x 6 and 67 x 3 LQAS designs.Hypothesis tests showed GAM as10% for the 33 x 6 design and GAM asor =10% for the 67 x 3 and Sequential designs. Point estimates for the 33 x 6 and 67 x 3 designs were similar to those of the 30 x 30 cluster-survey for GAM (6.7%, CI = 3.2-10.2%; 8.2%, CI = 4.3-12.1%, 7.4%, CI = 4.8-9.9%) and all other indicators. The CIs for the LQAS designs were only slightly wider than the CIs for the 30 x 30 cluster-survey; yet the LQAS designs required substantially less time to administer.The LQAS designs provide statistically appropriate alternatives to the more time-consuming 30 x 30 cluster-survey. However, additional field-testing is needed using independent samples rather than a nested study design.

Objectives Maternal infections are associated with intra-uterine growth restriction and preterm birth. Dental infections are common in low-income settings but their contribution to adverse pregnancy outcomes is unknown. We studied the epidemiology of dental periapical infections among pregnant women and their association to fetal growth restriction and the duration of pregnancy in a rural sub-Saharan African population. Methods This was a cross-sectional study on the association between maternal dental periapical infections and birth outcomes in Malawi Africa. We assessed oral health clinically and radiologically among recently delivered women with known duration of pregnancy and measured birth weight length and head-circumference of their infants. Results Of 1024 analyzed participants 23.5% had periapical infections. Mean duration of pregnancy was 39.4 weeks birth weight 2979 g and length 49.7 cm. Women with periapical infection had mean (95% CI) pregnancy duration 0.4 (0.1-0.8) week shorter and delivered infants with 79 g (13-145) lower birth weight and 0.5cm (0.2-0.9) shorter neonatal length than women without periapical infection. The incidence of preterm birth was 10.0% among women with periapical infection and 7.3% among those without (adjusted difference 3.5% 95% CI -1.1%- 8.1%). Corresponding prevalences for stunting were 20.9% and 14.2% (adjusted difference 9.0% 95% CI 2.7% - 15.2%). The population-attributable risk fraction attributable to periapical infection was 9.7% for preterm birth and 12.8% for stunting. Conclusions Periapical infection was associated with shorter pregnancy duration and intra-uterine growth restriction in the study area; interventions addressing this risk factor may improve birth outcomes in low-income settings.

Combined data on micronutrient deficiencies (and underweight prevalences) were previously assembled for the Micronutrient Report in 2001 published by the Micronutrient Initiative and the International Development Research Centre. To update these data and understand recent trends we carried out a global survey of national micronutrient programs and survey results from 2001 to 2003 mainly through e-mail contact with governmental United Nations and nongovernmental offices in some 100 developing countries (referred to below as the "country survey"). The published literature and unpublished material were searched by various means including through on-line databases and web searching. The results described here were first used for the publication on "Vitamin and Mineral Deficiency" issued by Micronutrient Initiative and UNICEF in 2004 for which an early draft of the present results was provided. This document now presents the results on prevalences at the national regional and global (all developing countries) levels with further detail. Here the methods are recorded and the estimates are provided in tables figures and annexes. The information from countries responding to the questionnaire in the country survey (49 replied with new data) are available on file and certain of these have been transferred to the Web. (excerpt)

The following are summaries of country case studies that were presented at a workshop on "Successful Micronutrient Programs" held at the International Union of Nutritional Sciences Vienna August 2001. In the past decade Bangladesh has made substantial improvement in food production. However people still suffer from imbalance in nutrient intake characterized by protein and micronutrient deficiencies. From 1991 to 1999 among children under five years of age the prevalence of stunting decreased from 71% to 55% and the prevalence of underweight decreased from 72% to 61%. Women had in 1991-1999 an average pregnancy weight gain of less than 6 kg. Over half of the adult population was undernourished during this time with 10% suffering from severe malnutrition. (excerpt)

Micronutrient-deficiency control programs have been greatly extended at the national level in the last 10 to 15 years. However, rigorous evaluations of these are scarce, so that conclusions on impact are tentative and based mainly on indirect evidence. The coverage of vitamin A capsule distribution programs has exceeded 70% in most study countries. In countries implementing national iodized salt programs, the coverage reaches 60% to 90% of households with adequately iodized salt. Of the three micronutrients, coverage of iron tablet supplementation is the least well documented due to inadequate program monitoring systems and population survey data. Supplementation of preschool children 6 to 59 months of age with vitamin A capsules has plausibly contributed to the reduction in clinical vitamin A deficiency and its near-elimination in many countries. The impact of vitamin A capsule supplementation on children's biochemical vitamin A status (serum retinol) in national programs may be less. National data on salt iodization show a consistent relation to reduced prevalence of iodine-deficiency disorder symptoms (goiter); the rates of cretinism and other results of iodine deficiency are almost certainly falling too. The evaluation of the impact of salt iodization programs on biochemical iodine status is limited by a lack of data. Although trials have demonstrated the efficacy of iron supplementation in reducing the prevalence of anemia, the interpretation of national-level data is not so clear. Given the substantial financial and technical commitment required to implement national micronutrient-deficiency control programs, it is vital that investment enable the evaluation of the impact of these programs. It is becoming increasingly important to collect data on subclinical deficiency (e.g., biochemical data) to assess program impact.

Micronutrient malnutrition is one of the most widespread yet largely neglected nutrition challenges faced by women living in the developing world today. An estimated 19 million pregnant women are vitamin A deficient due to poor diets (1), and 500 million women of childbearing age (;40%) are anemic (1, 2). The burden of these and other micronutrient deficiencies, such as zinc, iodine, and vitamin B-12, is particularly high in South Asia and sub-Saharan Africa (3). The consequences of micronutrient deficiencies among women are profound and far reaching; they affect not only the health and survival of women but also have long-term, irreversible effects on their offspring. Poor maternal nutrition and health can also jeopardize the ability of women to care for their children, engage in incomegenerating activities, and protect household food security. One of the most important factors responsible for maternal micronutrient deficiency, along with disease burden, is poor diets lacking diversity. Diets of the poor are largely based on cereal or tuber staples and often lack vegetables, fruits, and animal source foods, which are rich in bioavailable micronutrients. Even in households where micronutrient-rich foods are available, inequities in intra-household distribution may prevent women from having access to a high-quality diet (4). Accurate information on women’s diets and micronutrient intakes, however, is extremely scant due primarily to the challenge and cost of collecting and analyzing dietary data. Dietary intake data are timeand resource-intensive to collect and require careful processing and sophisticated analytic methods. The result is that most large data collection efforts, especially those carried out at the national level, have not included dietary intake data. Without data on women’s dietary, and more specifically micronutrient, intake, however, progress in designing, targeting, and evaluating effective programs to improve women’s micronutrient nutrition will continue to be hampered. The Women’s Dietary Diversity Project (WDDP) was designed in 2005 specifically to respond to the need for generating simple yet valid indicators of women’s dietary quality. This collaborative research initiative used existing dietary intake data from 5 resource-poor settings to document women’s diet quality, defined as micronutrient adequacy, and to test whether food group diversity indicators (FGI) could be a useful tool in large-scale nationally representative surveys to predict women’s dietary quality. This journal supplement begins with a review of the literature on women’s micronutrient intakes in Africa, Asia, and Latin America. This is followed by a presentation of empirical research findings from the WDDP initiative. These include results from analyses of 5 datasets on women’s dietary patterns and nutrient intakes from vastly different settings, including both urban/periurban (Burkina Faso, Mali, Philippines) and rural (Bangladesh, Mozambique) areas. The analyses also document the relationship between simple indicators of dietary diversity and the micronutrient adequacy of women’s diets in these settings. Collectively, the results highlight the nature and extent of the gap between women’s micronutrient requirements and their dietary intakes in the 5 areas represented. They also confirm the potential usefulness of simple dietary diversity indicators as a proxy for women’s poor diet quality in these environments. The results are particularly useful for helping focus attention on the critical problem of poor diet quality among women of reproductive age in resource-poor environments. The systematic literature review by Torheim et al. (5) shows a consistent pattern of generally low micronutrient intakes among women in Africa, Asia, and Latin America, regardless of the 1 Published in a supplement to The Journal of Nutrition. Findings of research carried out under the USAID funded Food and Nutrition Technical Assistance Project’s (FANTA) Women’s Dietary Diversity Project (WDDP). The supplement coordinators for this supplement wereMegan Deitchler, AED, andMarie T. Ruel, International Food Policy Research Institute. Supplement Coordinator disclosures: Megan Deitchler is an employee of AED. Marie T. Ruel declares no conflict of interest. The supplement is the responsibility of the Guest Editor to whom the Editor of The Journal of Nutrition has delegated supervision of both technical conformity to the published regulations of The Journal of Nutrition and general oversight of the scientific merit of each article. The Guest Editor for this supplement was Jennifer Nettleton. Guest Editor disclosure: no conflicts of interest. This publication is made possible by the generous support of the American people through the support of the Office of Health, Infectious Disease, and Nutrition, Bureau for Global Health, United States Agency for International Development (USAID), under terms of Cooperative Agreement No. GHN-A00-08-00001-00, through the Food and Nutritional Technical Assistance II Project (FANTA-2), managed by AED. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID or the United States Government. Publication costs for this supplement were defrayed in part by the payment of page charges. This publication must therefore be hereby marked "advertisement" in accordance with 18 USC section 1734 solely to indicate this fact. The opinions expressed in this publication are those of the authors and are not attributable to the sponsors or the publisher, Editor, or Editorial Board of The Journal of Nutrition. 2 Author disclosures: M. T. Ruel and M. Arimond, no conflicts of interest. M. Deitchler is an employee of AED. * To whom correspondence should be addressed. E-mail: m.ruel@cgiar.org. 6 Abbreviations used: FGI, food group diversity indicator; MPA, mean probability of adequacy; NPNL, nonpregnant, nonlactating; WDDP, Women’s Dietary Diversity Project. 7 The Women’s Dietary Diversity Project (WDDP) is a collaboration among researchers from the International Food Policy Research Institute, AED, Fafo Institute for Applied International Studies, FAO, Institute of Research for Development, Iowa State University, London School of Hygiene and Tropical Medicine, University of North Carolina at Chapel Hill, and Wageningen University.

SummaryTraditional lot quality assurance sampling (LQAS) methods require simple random sampling to guarantee valid results. However, cluster sampling has been proposed to reduce the number of random starting points. This study uses simulations to examine the classification error of two such designs, a 67×3 (67 clusters of three observations) and a 33×6 (33 clusters of six observations) sampling scheme to assess the prevalence of global acute malnutrition (GAM). Further, we explore the use of a 67×3 sequential sampling scheme for LQAS classification of GAM prevalence. Results indicate that, for independent clusters with moderate intracluster correlation for the GAM outcome, the three sampling designs maintain approximate validity for LQAS analysis. Sequential sampling can substantially reduce the average sample size that is required for data collection. The presence of intercluster correlation can impact dramatically the classification error that is associated with LQAS analysis.

National programs for vitamin A supplementation and iodization of the salt supply were launched and sustained with high (but not universal) coverage in most of the countries studied. Iron programs (requiring daily or weekly supplementation, in contrast to vitamin A), which were distributed mainly through antenatal care, had lower coverage and acceptance. Constraints to supplementation were supply, awareness of health staff and communities, and (for vitamin A) insecurity with phasing out of the national immunization days, which have been a major vehicle for distribution. Administration to women postpartum becomes even more important and needs greater coverage. Iodized salt programs have expanded well, with good interagency collaboration and local management, supported by legislation (which may need strengthening); constraints remain in terms of too many salt producers, inadequate quality, import issues, and prices. More integrated, multifaceted programs are needed, with priority to developing and implementing fortification—especially in finding effective ways to ironfortify rice. Data are lacking, with fewer surveys once programs start, constraining monitoring and program control and adaptation. Nonetheless, interventions appear to have gone to scale remarkably successfully.

Internationally recognized research findings on the potential health benefits of preventing micronutrient deficiencies—especially reduced child mortality from vitamin A deficiency and prevention of in utero developmental damage and mental retardation from iodine deficiency—have contributed to raising the awareness of deficiencies and the commitment of many governments to their reduction or near-elimination. The procedures undertaken to decide on large-scale programs followed conventional patterns in the 12 countries included in this study (11 Asian countries plus South Africa). Thus, a sequence of national surveys, institutional arrangements through intersectoral technical committees, legislation, incorporation of programs into national plans, and resource mobilization, including external assistance, was similar for all three micronutrients. Vitamin A supplementation twice yearly to children, then to women postpartum, has reached the national level. Iodized salt is universally adopted at the national level in most countries, with a need for continuing efforts to reach underserved populations and to implement legislation and quality control. Iron programs, usually aiming at daily supplementation during pregnancy, have been pursued, but with less intensity. However, it is clear that these procedures have succeeded in creating a rapid expansion of large-scale deficiency-control programs, which while evolving are generally being maintained.

The conventional method to collect data on the health, nutrition, and food security status of a population affected by an emergency is a 30 × 30 cluster survey. This sampling method can be time and resource intensive and, accordingly, may not be the most appropriate one when data are needed rapidly for decision making. In this study, we compare the precision, time and cost of the 30 × 30 cluster survey with two alternative sampling designs: a 33 × 6 cluster design (33 clusters, 6 observations per cluster) and a 67 × 3 cluster design (67 clusters, 3 observations per cluster). Data for each sampling design were collected concurrently in West Darfur, Sudan in September-October 2005 in an emergency setting. Results of the study show the 30 × 30 design to provide more precise results (i.e. narrower 95% confidence intervals) than the 33 × 6 and 67 × 3 design for most child-level indicators. Exceptions are indicators of immunization and vitamin A capsule supplementation coverage which show a high intra-cluster correlation. Although the 33 × 6 and 67 × 3 designs provide wider confidence intervals than the 30 × 30 design for child anthropometric indicators, the 33 × 6 and 67 × 3 designs provide the opportunity to conduct a LQAS hypothesis test to detect whether or not a critical threshold of global acute malnutrition prevalence has been exceeded, whereas the 30 × 30 design does not. For the household-level indicators tested in this study, the 67 × 3 design provides the most precise results. However, our results show that neither the 33 × 6 nor the 67 × 3 design are appropriate for assessing indicators of mortality. In this field application, data collection for the 33 × 6 and 67 × 3 designs required substantially less time and cost than that required for the 30 × 30 design. The findings of this study suggest the 33 × 6 and 67 × 3 designs can provide useful time- and resource-saving alternatives to the 30 × 30 method of data collection in emergency settings.