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Community and International Nutrition
Community and International Nutrition
ABSTRACT Simple indicators reflecting diet quality for young children are needed both for programs and in some
research contexts. Measures of dietary diversity are relatively simple and were shown to be associated with nutrient
adequacy and nutritional status. However, dietary diversity also tends to increase with income and wealth; thus,
the association between dietary diversity and child nutrition may be confounded by socioeconomic factors. We
used data from 11 recent Demographic and Health Surveys (DHS) to examine the association between dietary
diversity and height-for-age Z-scores (HAZ) for children 6 –23 mo old, while controlling for household wealth/
welfare and several other potentially confounding factors. Bivariate associations between dietary diversity and HAZ
were observed in 9 of the 11 countries. Dietary diversity remained significant as a main effect in 7 countries in
multivariate models, and interacted significantly with other factors (e.g., child age, breast-feeding status, urban/
rural location) in 3 of the 4 remaining countries. Thus, dietary diversity was significantly associated with HAZ, either
as a main effect or in an interaction, in all but one of the countries analyzed. These findings suggest that there is
an association between child dietary diversity and nutritional status that is independent of socioeconomic factors,
and that dietary diversity may indeed reflect diet quality. Before dietary diversity can be recommended for
widespread use as an indicator of diet quality, additional research is required to confirm and clarify relations
between various dietary diversity indicators and nutrient intake, adequacy, and density, for children with differing
dietary patterns. J. Nutr. 134: 2579 –2585, 2004.
KEY WORDS: ● Demographic and Health Surveys (DHS) ● dietary diversity ● child nutritional status
● diet quality ● socioeconomic factors
All people need a variety of foods to meet requirements for indicators are particularly attractive because they are relatively
essential nutrients, and the value of a diverse diet has long simple to measure and they are thought to reflect nutrient
been recognized. Lack of diversity is a particularly severe adequacy, i.e., individuals consuming more diverse diets are
problem among poor populations in the developing world, thought to be more likely to meet their nutrient needs. Simple
where diets are based predominantly on starchy staples and yet valid indicators are of particular importance for large
often include few or no animal products and only seasonal household surveys and for program management.
fruits and vegetables. For vulnerable infants and young chil- In developed countries, there are a number of studies link-
dren, the problem is particularly critical because they need ing dietary diversity to nutrient intake, particularly among
energy- and nutrient-dense foods to grow and develop both adults; these studies are reviewed by Kant (2). Although there
physically and mentally and to live a healthy life. For these is some indication from the literature that dietary diversity is
reasons, dietary diversity is now included as a specific recom- positively associated with a greater intake of energy and sev-
mendation in the recently updated guidance for complemen- eral other nutrients among young children in developing
tary feeding of the breast-fed child aged 6 to 23 mo (1). countries (3– 6), additional research is warranted to character-
Because of the perceived importance of dietary diversity for ize the exact nature of the relation between dietary diversity
health and nutrition, indicators of dietary diversity have be- and nutrient intake and adequacy. In young children, dietary
come increasingly popular in recent years. These types of
diversity has also been associated with improved nutritional
status (4,7–9), suggesting that diversity may indeed reflect
1
Preliminary results were reported in Proceedings of the 2nd International
higher dietary quality and greater likelihood of meeting daily
Workshop, Ouagadougou, November 23–28, 2003 [Ruel, M. T. & Arimond, M. energy and nutrient requirements.
(2004) Dietary diversity and growth: an analysis of recent demographic and However, dietary diversity was also shown to be strongly
health surveys. In: Food Based Approaches for a Healthy Nutrition in West Africa
(Brower, E. D., Traore, A. S. & Treche, S., eds.). University Press, Ouagadougou associated with household socioeconomic status (8,10), and
(in press)]. links between socioeconomic status and child nutrition and
2
Funded in part by the Food and Nutrition Technical Assistance Project health outcomes have long been established. Interpretation of
(FANTA) managed by the Academy for Educational Development for USAID.
3
To whom correspondence should be addressed. associations between dietary diversity and nutritional status is
E-mail: [email protected]. therefore complicated by the fact that both are strongly linked
2579
to household socioeconomic factors. Families with greater measurements or had unacceptably extreme values. The proportion of
incomes and resources tend to have more diverse diets, but children with missing or extreme anthropometric values ranged from
they are also likely to have better access to health care, and 2% in Nepal to 20% in Zimbabwe; these children were excluded from
better environmental conditions. Clearly, children in wealth- bivariate and multivariate analyses.
ier households are better off and grow better for a number of
reasons, but improved nutrient adequacy may be one impor- Variable creation
tant way in which household wealth and resources translate Dietary diversity. The dietary diversity indicator used in the
into better outcomes for children. Thus, a key question is analysis was created using data from the 7-d recall of foods/food
whether dietary diversity is independently associated with groups available in the MEASURE DHS⫹ surveys.6 Our general
better child nutritional status because it accurately reflects approach was to develop a score that included a point for each of the
nutrient adequacy, or whether the association is found primar- major nutritionally important types of food the child may have eaten,
ily because dietary diversity is a particularly good proxy for while providing some balance between plant foods and animal-source
household socioeconomic status. foods. Therefore, for the purpose of our analysis, foods/food groups
The present study addresses this question using data from were regrouped and summed into a 7-point dietary diversity score, as
follows:7 1) starchy staples (foods made from grain, roots, or tubers);
recent Demographic and Health Surveys (DHS)4 from 11
2) legumes; 3) dairy (milk other than breast milk, cheese, or yogurt);
countries. Our focus is on infants and young children 6 –23 mo 4) meat, poultry, fish, or eggs; 5) vitamin A-rich fruits and vegetables
of age, during the vulnerable period of transition from breast- (pumpkin; red or yellow yams or squash; carrots or red sweet potatoes;
feeding to the family diet. The overall goal of the research was green leafy vegetables; fruits such as mango, papaya, or other local
to determine whether an association between child dietary vitamin A-rich fruits); 6) other fruits and vegetables (or fruit juices);
diversity and nutritional status among 6- to 23-mo-old chil- and 7) foods made with oil, fat, or butter. Foods/food groups that the
dren was found across countries and regions with varying child had consumed on ⱖ3 d in the previous week received a score of
dietary patterns, and whether this association remained once “1” and those that the child had consumed ⬍3 times in the past week
socioeconomic factors were controlled for by multivariate were scored “0.”8 The choice of “ⱖ3 d” was arbitrary but was meant
analyses. Answers to these questions are key to understanding to capture foods eaten regularly.
Terciles of dietary diversity were used to classify children into low,
the nature of the links between dietary diversity and child average, and high diversity. The terciles were derived separately for
outcomes, and to fostering progress in developing simple in- each country, and were made age-specific within the following age
dicators of dietary quality. ranges: 6 – 8 mo, 9 –11 mo, 12–17 mo, and 18 –23 mo. The rationale
for using age-specific terciles is that diversity increases rapidly with
SUBJECTS AND METHODS age; by using age-specific terciles, children were ranked as having low,
average, or high diversity compared with other children in their age
Data range. For example, in Malawi, the high diversity tercile included
Data from recent DHS surveys from 11 countries were used. The infants 6 – 8 mo who ate 2 or more food groups, those 9 –11 mo who
DHS are a series of standardized, nationally representative surveys ate 3 or more, and those 12–23 mo who ate 4 or more. Country-
that have been implemented in ⬃70 countries since 1984. The specific terciles were used because there are currently no international
selection criteria for the countries included in the analyses were the guidelines or recommendations on which to base cutoffs for “low” or
following: 1) Data set was available in mid-2002 and used the general “high” diversity. Tercile cutoffs were lowest in Mali and Ethiopia, and
format of the most recent “MEASURE DHS⫹” questionnaire; 2) The highest in the LAC region across all age groups.
country was from the African, South or Southeast Asian, or the Latin Maternal and child nutritional status. Height-for-age Z-scores
America/Caribbean (LAC) region; 3) At least 6 of 7 broad food (HAZ) were used as an indicator of nutritional status, and maternal
groups needed to create the diversity indicator (see description be- height and BMI were used for maternal nutritional status; extreme
low) were represented in the questionnaire. Eleven data sets met values were excluded (11).
these criteria: Benin (2001), Cambodia (2000), Colombia (2000), Proxies for household wealth and welfare. A variety of ap-
Ethiopia (2000), Haiti (2000), Malawi (2000), Mali (2001), Nepal proaches have been used to characterize household wealth, welfare,
(2001), Peru (2000), Rwanda (2000), and Zimbabwe (1999).5 and socioeconomic status, including measurement of income and
All of the DHS that follow a standard protocol were given blanket expenditures and approaches incorporating information about house-
approval by the ORC Macro Institutional Review Board. Every hold assets and access to services (12). Recently, authors analyzing
survey that deviated substantially from the standard protocol was DHS and other similar surveys developed indices using information
reviewed and approved separately. Each survey also received approval on household assets, water and sanitation, and services (13,14). We
from an in-country ethical review board, if such an organization used a similar approach, with factor analysis as a data reduction tool,
existed (personal communication, Altrena Mukuria, ORC Macro, to combine a large number of household-level variables into several
International). factors, with the objective of constructing a proxy for household
wealth and welfare. Categories of variables included in the factor
analysis (when available) were as follows: ownership of household
Samples assets (radios, telephones, television, refrigerator), productive assets
After excluding children for whom age information was missing, (agricultural implements, land, sewing machines, bicycles, boats),
we randomly selected 1 child ⬍ 2 y of age in each household. The animals; main source of drinking water; type of sanitation facility;
proportion of children with missing values for age ranged from 0% in main material of the floor and of the roof; and crowding (number of
3 countries (Ethiopia, Colombia, and Peru) to 8% in Zimbabwe. household members per sleeping room).
Sample sizes for children aged 6 –23 mo ranged from 958 in Zimbabwe Factor analysis was done separately for each country; some cate-
to 3662 in Peru. A number of children were missing anthropometric gories of variables were not available in all countries. Variables were
entered into the factor analysis either as summed scores or as ordered
variables with increasing scores reflecting increasing quality. For
4
Abbreviations used: DHS, Demographic and Health Surveys [The DHS
program is funded by the U.S. Agency for International Development (USAID) and
6
administered by ORC Macro. ORC Macro provides technical assistance to part- In Haiti, the 24-h food group recall was used to construct the dietary
ner institutions in each country.]; HAZ, height-for-age Z-score(s); LAC, Latin diversity variable, because the Haitian questionnaire did not include a 7-d recall.
7
America/Caribbean; VIF, variance inflation factor; WHZ, weight-for height Z- Ten of the 11 countries included all 7 food groups. In Zimbabwe, the food
score(s). group list did not include foods made with fats and oils.
5 8
At the time data were accessed, data from Ethiopia, Haiti, Mali, Nepal, and In Haiti, children received a score of “1” if they had the food yesterday, and
Peru were indicated to be “preliminary data” on ORC Macro website. “0” if not.
example, household assets, productive assets, and animals were each nal [height, BMI, education and number of prenatal care visits (a
summed, with items scored “1” if present, “0” if not. Water source, proxy for access to health care)], and household level (wealth/welfare
sanitation facilities, and floor and roof materials were scored from factors 1 and 2, urban/rural location, and number of children ⬍ 5 y
lowest to highest quality. old). Least-square means (adjusted for continuous variables in the
The factors were derived separately for urban and rural areas, model) were computed to assess the difference in HAZ by dietary
because the assets and household characteristics that differentiate diversity terciles. Multicollinearity was assessed in the models using
better off from worse off households in urban and rural areas are likely the variance inflation factor (VIF) (15); only age and age squared
to differ. After initial exploration, all models were restricted to 2 showed evidence of multicollinearity (VIF ⬎ 10). Removing age
factors that, taken together, explained from 47 to 68% of the shared squared from the models did not change results for dietary diversity;
variability in urban areas, and from 33 to 62% of the shared variabil- thus, age squared was retained in the models for theoretical reasons.
ity in rural areas. In most cases, retaining 2 factors was equivalent to Two-way interactions between dietary diversity and several factors
retaining all factors with initial eigenvalues ⬎ 1. Scores for the 2 were also tested in the multivariate analyses because we hypothesized
factors were used as continuous variables in the models. that the association between diversity and child nutritional status
might vary depending on certain child, maternal, or household char-
Analytical methods acteristics, i.e., we tested the two-way interactions between dietary
diversity and the following plausible factors: child age, whether child
Sample weights were used for all analyses, and statistical testing was still breast-fed, mother’s education, urban/rural location, and
was performed in Stata (version 7) (15). Stata allows specification of wealth/welfare factors. Main effects and interactions were considered
the sample design (stratification and clustering) of the surveys. significant at P-values ⬍ 0.05. For categorical variables, statistical
Descriptive analyses are presented first, to provide general infor- significance was assessed with joint tests of main effects.
mation on the characteristics of the study populations. They are
followed by results of the bivariate analyses of the association be- RESULTS
tween children’s dietary diversity terciles and mean HAZ. The sig-
nificance of differences between means was tested using an adjusted Characteristics of survey households, mothers,
Wald test for joint hypothesis testing. Associations were considered and children
significant at P-values ⬍ 0.05.
Multivariate ordinary least-squares methods were then used to test Key descriptive statistics for the survey households, mothers
whether associations between dietary diversity and HAZ remained and children highlight some of the major differences between
significant after controlling for several potentially confounding fac- countries (Table 1). In most countries, more than two-thirds
tors at the child (age, age squared, sex, breast-feeding status), mater- of the households lived in rural areas; in Colombia and Peru,
TABLE 1
Selected household, maternal, and child characteristics, by country
Characteristic Benin Ethiopia Malawi Mali Rwanda Zimbabwe Cambodia Nepal Colombia Haiti Peru
Households, n 1312 2697 3228 1136 2110 958 2049 1809 1346 1758 3662
Rural 67 90 86 71 84 67 87 93 31 67 44
Female-headed 13 12 19 22 17 32 18 12 21 37 13
Piped water 40 13 22 27 35 43 3 34 83 51 66
No sanitary facility 71 86 20 19 3 29 85 77 12 46 30
Electricity 19 7 4 12 7 34 12 18 93 32 60
Maternal
Height,1 cm 158.1 157.2 155.7 161.6 158.0 159.4 152.5 150.3 154.5 158.1 150.2
BMI,1 kg/m2 21.9 20.0 21.9 21.8 22.4 22.9 20.4 20.1 24.4 22.3 24.8
⬍18.5, % 11 26 6 9 6 5 20 24 3 10 1
⬎25.0, % 13 3 10 13 15 20 4 3 38 19 42
Education
None, % 71 81 32 81 33 6 32 73 3 7 38
TABLE 2
Dietary diversity for children aged 6 –23 mo (food groups eaten ⱖ3 d in the last week), by country
Mean diversity score % with low diversity % with middle diversity % with high diversity
(range 0–7) 0–2 food groups 3–4 food groups 5–7 food groups
Africa
Benin 3.2 38 31 33
Ethiopia 2.2 61 33 6
Malawi 2.4 57 37 6
Mali 1.7 70 21 8
Rwanda 2.9 42 43 16
Zimbabwe1 3.1 38 44 18
Asia
Cambodia 2.8 44 40 15
Nepal 2.8 43 45 12
Latin America/Caribbean
Colombia 4.8 11 25 65
Haiti (24-h)2 (3.8) (19) (47) (34)
Peru 4.5 13 29 58
1 The mean diversity score for Zimbabwe is on a scale of 0 – 6 because one food group was missing from the questionnaire.
2 The scores for Haiti are based on a 24-h recall, because the 7-d recall was not available.
the proportion was much lower. In general, Colombia and Mean dietary diversity was lowest in Mali, followed by
Peru had more favorable household characteristics, whereas Ethiopia and Malawi (Table 2). Note that in Mali and Ethi-
Ethiopia consistently ranked low. opia, the low mean reflects a large proportion of children who
Mean maternal height was lowest in the Asian countries received none of the food groups (Table 1); in Malawi, very
and in Peru and highest in Haiti, Benin, Mali, and Zimbabwe. few children ate none of the groups in the previous week, yet
The proportion of women with low BMI (⬍18.5) ranged from diversity was very low. Mean dietary diversity was observed to
1 to 11% in most countries, but was markedly higher in be highest in Peru and Colombia.
Ethiopia and in both Asian countries. At the other end of the Similar patterns were observed when examining the per-
spectrum, the highest rates of overweight and obesity (BMI centages of children with low, average, or high dietary diver-
ⱖ 25) were in the 2 Latin American countries. sity in each country, using fixed cutoff points to define these 3
Maternal education and literacy varied widely among coun- categories. A very high percentage of children from Mali,
tries. In 4 countries, more than two thirds of the women Ethiopia, and Malawi scored in the lowest diversity group
reported that they had never attended school (Benin, Ethio- (having consumed only 0 –2 food groups on 3 or more days in
pia, Mali and Nepal), whereas this was reported by approxi- the previous week), whereas more than half of the children in
mately one third of the mothers in another set of 4 countries the 2 Latin American countries (Colombia and Peru) scored
(Malawi, Rwanda, Cambodia, and Haiti). In the remaining in the highest diversity group (having consumed 5–7 food
countries (Zimbabwe, Colombia, and Peru) the proportion of groups on 3⫹ d in the previous week). Mean dietary diversity
women who had no schooling was ⬍10% and in these same was consistently higher in urban than in rural areas in every
countries, ⬎50% of the women reported having at least some country studied (not shown); this is consistent with findings
secondary education. from previous analyses of other DHS data sets (16,17).
Among children aged 6 –23 mo, the prevalence of stunting
(HAZ less than ⫺2 SD) was highest in Ethiopia and Malawi, Associations between dietary diversity and height-for-age
and was notably lower in all 3 countries in the LAC region.
The prevalence of wasting (WHZ less than ⫺2 SD) was Bivariate associations. Significant associations between
highest in Ethiopia, the West African countries (Benin and HAZ and dietary diversity terciles were found in bivariate
Mali), and in both Asian countries (Cambodia and Nepal), analyses in 9 of the 11 countries, but not in Benin or Cam-
and very low in the 2 Latin American countries. bodia. Differences between extreme terciles in the 9 countries
ranged from 0.26 in Haiti to 0.56 in Peru. The differences were
Feeding practices generally in the expected direction, but in some cases were not
consistent in direction. For example, in Malawi and Mali,
Feeding practices for children aged 6 –23 mo also differed by children in the middle diversity tercile had the lowest mean
country (Table 1). Breast-feeding was maintained through y 2 HAZ.
of life for most children in these countries. Over 85% of the Multivariate analyses. Associations between dietary di-
children were still breast-fed in 5 of the 6 African countries, versity and HAZ were significant as a main effect in 7 of the
and in Nepal. Rates were lowest in Colombia and Haiti. Low countries studied: 4 in Africa (Ethiopia, Mali, Rwanda, and
frequency of feeding appeared to be a problem in most coun- Zimbabwe), the 2 Asian countries (Cambodia and Nepal) and
tries, and particularly in Mali, Rwanda, and Haiti. In these 3 Colombia (Table 3).9 In these countries, the size of the
countries, the mean frequency of feeding was ⬍2 on the day adjusted Z-score differences between low and high diversity
before the survey. Late introduction of solids/semisolids was a
problem in a number of countries, and is particularly extreme
in Ethiopia and Mali, where more than half of the 6- to 9
In 2 countries (Mali and Rwanda), P-values for individual contrasts between
8-mo-old children received none of the food groups in the high and low diversity tended to be significant (P ⫽ 0.06 and 0.07, respectively),
previous week. but the joint test for significance of all contrasts was significant, P ⬍ 0.05.
TABLE 3
Summary of regression results with dietary diversity terciles as one determinant of HAZ:
coefficients and significant main effects, by country1
Benin Ethiopia Malawi Mali Rwanda Zimbabwe Cambodia Nepal Colombia Haiti Peru
Child age ⫺0.25* ⫺0.24* ⫺0.24* ⫺0.19* ⫺0.28* ⫺0.19* ⫺0.06 ⫺0.22* ⫺0.11* ⫺0.10* ⫺0.16*
Child age squared 0.00* 0.01* 0.00* 0.00 0.01* 0.00 0.00 0.00* 0.00 0.00 0.00*
Gender2 ⫺0.10 ⫺0.26* ⫺0.17* ⫺0.10 ⫺0.14* ⫺0.11 ⫺0.07 ⫺0.01 ⫺0.18* ⫺0.26* ⫺0.03
Maternal height 0.05* 0.04* 0.04* 0.03* 0.04* 0.03* 0.05* 0.05* 0.06* 0.05* 0.05*
Maternal BMI 0.01 0.01 0.02 0.05* 0.02 0.03 0.00 0.04* 0.02* 0.05* 0.00
Maternal education
Primary vs. none ⫺0.03 0.18 0.01* 0.14 0.12 0.12 0.15 0.17* ⫺0.09 ⫺0.09 0.11*
Secondary vs. none ⫺0.03 0.37 0.39* 0.12 0.15 ⫺0.16 0.45 0.24* ⫺0.07 0.04 0.24*
Prenatal care visits
1–3 vs. none ⫺0.21 ⫺0.03 0.15 0.14 ⫺0.03 0.38 ⫺0.12 0.10 0.02 0.30* 0.12
4⫹ vs. none ⫺0.12 0.10 0.21 0.00 0.13 0.50 0.27 0.15 0.14 0.21* 0.09
Urban or rural3 ⫺0.13 ⫺0.10 ⫺0.36* ⫺0.36* ⫺0.47* 0.06 0.43* ⫺0.38* ⫺0.10 ⫺0.17 ⫺0.55*
Wealth/welfare factors
1st factor 0.03 0.05 0.12* 0.07 0.11* ⫺0.01 0.01 0.14* 0.08* 0.10* 0.14*
2nd factor 0.06 0.01 0.10* 0.04 0.03 0.14* ⫺0.11 ⫺0.09* 0.04 0.02 0.03
Still breast-fed4 ⫺0.20 ⫺0.60* ⫺0.35* ⫺0.01 0.00 ⫺0.11 ⫺0.28 0.09 ⫺0.06 ⫺0.00 ⫺0.03
Number of children
⬍5 y old ⫺0.10* ⫺0.14* ⫺0.02 ⫺0.07 ⫺0.05 ⫺0.15 ⫺0.23* ⫺0.06 ⫺0.17* ⫺0.18* ⫺0.16*
Dietary diversity tercile
Middle vs. low ⫺0.06 0.19* 0.08 ⫺0.11* ⫺0.08* 0.47* 0.23* 0.07* 0.06* 0.08 0.03
High vs. low 0.01 0.35* 0.06 0.23* 0.17* 0.68* 0.37* 0.23* 0.19* 0.10 0.09
R2 0.24 0.19 0.19 0.28 0.20 0.15 0.17 0.24 0.26 0.23 0.29
F 26.62 20.29 33.22 14.58 29.20 6.09 7.56 25.98 23.79 27.02 40.98
n 1072 2372 2651 849 1802 617 771 1632 1179 1574 2874
1* Significant main effect, P ⬍ 0.05. For continuous variables and dichotomous variables, each coefficient with an asterisk was significant. For
categorical variables—maternal education, number of prenatal care visits, and dietary diversity terciles— coefficients are shown to be significant if
joint tests of contrasts were significant.
2 A “⫺” indicates a negative coefficient for boys compared with girls.
3 A “⫺” indicates a negative coefficient for rural areas compared with urban areas.
4 A “⫺” indicates a negative coefficient for continued breast-feeding compared with no breast-feeding.
groups ranged from 0.24 in Colombia, to 0.59 in Zimbabwe iate analysis. Only Benin had no association between dietary
(Fig. 1). The bivariate associations between dietary diversity diversity and HAZ (no main effect and no interaction with
and HAZ in Malawi, Haiti, and Peru were no longer signifi- other factors).
cant as main effects in multivariate analyses that controlled for The most frequently observed interactions were between
child, maternal, and household factors. In contrast, a signifi- dietary diversity and the age of the child, and between diver-
cant association was observed in Cambodia in the multivari- sity and current breast-feeding status (still breast-fed or not).
ate, but not in the bivariate results. In 2 of the 3 countries in which dietary diversity interacted
In examining two-way interactions (Table 4), dietary di- with the child’s breast-feeding status [Cambodia (Fig. 2) and
versity interacted with selected characteristics in a number of Nepal], the findings showed that dietary diversity was more
countries, including 3 of the 4 countries in which the main strongly associated with HAZ among children who were no
effect of dietary diversity was not significant in the multivar- longer breast-fed.
TABLE 4
Adjusted differences in mean HAZ between highest and lowest dietary diversity terciles, by country for subgroups
of each variable that interacted significantly with dietary diversity in multivariate analyses1
Latin
Africa Asia America/Caribbean
Age category
6–11 mo 0.22 0.67 0.34 0.07
12–17 mo ⫺0.26 0.08 ⫺0.14 0.54
18–23 mo 0.16 0.42 0.49 0.41
Location
Urban ⫺0.07 0.44
Rural 0.45 0.07
1st wealth/welfare factor
Low 0.15
Middle 0.11
High 0.22
2nd wealth/welfare
factor
Low ⫺0.12 0.58
Middle 0.61 0.39
High 0.83 0.06
Still breast-fed
Yes 0.15 0.21 0.34
No ⫺0.01 1.15 1.53
1 Interactions were considered to be significant when P ⬍ 0.05. There were no significant interactions in Benin, Ethiopia, Zimbabwe, or Colombia.
Positive values for differences indicate that HAZ was highest in the high diversity tercile.
stronger association between dietary diversity and HAZ for and diversity score cutoffs) and to explore the potential to
nonbreast-fed children (4,19). Dietary diversity may be more harmonize measurement tools and indicators for universal use.
important for nonbreast-fed children because they rely on If research does establish that indicators of dietary diversity
complementary food to meet all of their energy and nutrient are good and consistent predictors of nutrient adequacy, these
needs. indicators could become invaluable tools with which to assess
Other observed interactions are less consistent, and some dietary quality as it relates to nutrient deficiencies, and to
are difficult to interpret. There may be a variety of reasons why monitor and evaluate progress aimed at improving diet quality
diversity appears to be more strongly associated with HAZ in for young children.
subgroups. Depending on local diet patterns, high diversity
scores may be more or less nutritionally meaningful. For ex- ACKNOWLEDGMENTS
ample, if many food groups are given, but in extremely small
quantities, diversity scores are less nutritionally meaningful. In The authors thank Altrena Mukuria, Casey Aboulafia, and Noah
some subgroups, there may be a lack of nutritionally important Bartlett of ORC Macro, International for sharing information on the
DHS data sets and for discussions of preliminary results. We thank
variation; for example, low, middle, and high terciles may all Eunyong Chung of USAID, and Anne Swindale and Paige Harrigan
in fact reflect quite low diversity (among the youngest children of the Food and Nutrition Technical Assistance Project (FANTA)
in Mali and Ethiopia the age- and sample-specific terciles managed by the Academy for Educational Development for USAID
defined high diversity as 2 or more food groups, and very few for their helpful comments on a preliminary report. We are also
children consumed ⬎2). There may also be 3-way interac- grateful to Wahid Quabili of the International Food Policy Research
tions; this was not assessed because subgroups become too Institute (IFPRI) for assistance with data analysis.
small. Interactions do indicate that more complex relation-
ships were present, and that coefficients for main effects were LITERATURE CITED
misleading.
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