Advocacy,  Children,  Demographic and Health Surveys,  Multiple Indicator Cluster Surveys

Quantifying the nutrition transition among children in low- and middle-income countries

© 2012 Akintunde Akinleye/NURHI, Courtesy of Photoshare

Over 25 years ago, Dr. Barry Popkin described a global “nutrition transition” – a shift of diets high in fruits, vegetables, and healthy fats to diets high in sugar, saturated fat, and processed foods [1]. This nutrition transition was an “emerging crisis” for low-income countries and linked to changes in demography, epidemiology, and the food industry [2]. Dr. Popkin described the challenges of a limited data landscape to support this new idea in 1993:

Most low-income countries…have no national survey systems for collecting dietary intake data. In others, household survey data are not readily available. Thus, to understand the dietary patterns of most countries, we must rely primarily on food balance sheets from the Food and Agriculture Organization, supplemented by comparable food disappearance data for the United States and selected data from individual and household food consumption surveys, which are often small and nonrepresentative.” [3]

Has our data on dietary intake among children changed since then?

Dietary intake data is increasingly collected in many low- and middle-income countries (LMIC), particularly among children. Both Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) collect the recall data needed to report on most of the 2008 WHO-UNICEF Infant and Young Child Feeding Indicators (IYCF) including [4]:

1. Minimum Dietary Diversity (MDD) for children 6-23 months old: Proportion of children 6-23 months of age who receive foods from 4 or more food groups.*

2. Minimum Acceptable Diet (MAD) for breastfed/non-breastfed children 6-23 months old: Proportion of children 6-23 months of age who receive a minimum acceptable diet (minimum dietary diversity and minimum meal frequency).

*7 food groups for tabulation: (1) grains, roots, tubers; (2) legumes and nuts; (3) dairy products; (4) flesh foods; (5) eggs; (6) vitamin-A rich fruits and vegetables; and (7) other fruits and vegetables.

However, DHS and MICS do not consistently collect data on consumption of sugar-sweetened beverages (SSB) or unhealthy snacks/junk food among children.

Available data shows that consumption of SSB and unhealthy foods among children is high in LMIC [5]. The DHS-5 (2003-2008) core questionnaire asked about “any sugar foods such as chocolates, sweets, candies, pastries, cakes, or biscuits” children consumed in the past 24 hours. A 2014 analysis of this data revealed that more than 20% of infants 6-8 months across 18 countries in Asia and Africa consumed sugary snacks. In Asia, 28-62% of children 9-11 months old and 42-75% of children 12-23 months old ate sugary snacks. In Africa, 4-36% of children 9-11 months old and 11-46% of children 12-23 months old ate sugary snacks [6].

Consumption of these foods in place of and/or in addition to more nutritious foods can reduce micronutrient intake and is linked to increase risk of overweight and obesity [7-9]. These dietary preferences can extend into adulthood, increasing the risk of chronic diseases later in life [10]. Globally, a majority of the 38 million children under 5 years of age that are overweight or obese live in LMIC [11].

Capturing sugar-sweetened beverages and unhealthy foods in DHS

By the end of 2019, WHO and UNICEF are expected to release updated IYCF guidelines that reflect the nutrition transition. Data for Decisions to Expand Nutrition Transformation (DataDENT) has been working with a diverse group of lead authors and technical reviewers from the nutrition community to develop a set of recommendations for the DHS-8 core questionnaire, including a recommendation to modify and add to the current 24-hour food group recall questions to capture several new unhealthy eating indicators: 1) zero fruits and vegetables, 2) sugar-sweetened beverages, and 3) “junk food.”

You can review and add a comment in support of this recommendation on the DHS-8 questionnaire forum here. To access all of the nutrition-focused recommendations for DHS-8 including nine other recommendations coordinated by DataDENT, please visit the DHS-8 questionnaire forum nutrition section here.

[1] Popkin BM. Nutritional patterns and transitions. Population and development review. 1993 Mar 1:138-57.
[2] Popkin BM. The nutrition transition in low-income countries: an emerging crisis. Nutrition reviews. 1994 Sep 1;52(9):285-98.
[3] Popkin BM. Nutritional patterns and transitions. Population and development review. 1993 Mar 1:138-57.
[4] World Health Organization. Indicators for assessing infant and young child feeding practices : Part 2 Measurement. 2010.
[5] Huffman SL, Piwoz EG, Vosti SA, Dewey KG. Babies, soft drinks and snacks: a concern in low‐and middle‐income countries?. Maternal & child nutrition. 2014 Oct;10(4):562-74.
[6] ibid
[7] Bhargava A, Amialchuk A. Added sugars displaced the use of vital nutrients in the National Food Stamp Program Survey. The Journal of nutrition. 2007 Feb 1;137(2):453-60.
[8] Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. The Lancet. 2001 Feb 17;357(9255):505-8.
[9] Malik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. The American journal of clinical nutrition. 2013 Aug 21;98(4):1084-102.
[10] Birch LL, Doub AE. Learning to eat: birth to age 2 y. The American journal of clinical nutrition. 2014 Jan 22;99(3):723S-8S.
[11] United Nations Children’s Fund, World Health Organization, World Bank Group (2018). Levels and trends in child malnutrition: Key findings of the 2018 Edition of the Joint Child Malnutrition Estimates.

Leave a Reply

%d bloggers like this: