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        Not all dietary diversity scores can legitimately be interpreted as proxies of diet quality
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        Not all dietary diversity scores can legitimately be interpreted as proxies of diet quality
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Please note a correction has been issued for this article.

Madam

We read with great interest the recently published article ‘Farm production, market access and dietary diversity in Malawi’ by Koopmair and colleagues( 1 ). This work directly follows on another article from the same research group on the link between farm species diversity and dietary diversity in several developing countries( 2 ), which had triggered a rich and constructive debate( 3 6 ). With reference to the recent paper, we would like to raise a new point regarding the use of dietary diversity indicators which we believe is crucial in the context of studies of linkages between agriculture, markets and nutrition.

In their study, Koopmair and colleagues collected 24 h dietary recall data of household members combined, as well as of individual children below the age of 5 years and of their mothers( 1 ). They calculated dietary diversity scores at household and individual levels using the twelve food groups recommended for calculation of the Household Dietary Diversity Score (HDDS)( 7 ) and interpreted these scores as proxies of dietary quality( 1 ). As public health nutritionists, we strongly question this interpretation.

As stated by FAO guidelines( 7 ), as well as in a recent review by Leroy and colleagues( 8 ), the HDDS is a proxy indicator of household economic access to food whereas individual dietary diversity scores were developed as proxies of diet quality. More precisely, the Women Dietary Diversity Score (WDDS)( 7 ) and the Minimum Dietary Diversity for Women of Reproductive Age (MDD-W)( 9 ) were validated as indicators of micronutrient adequacy of women’s diets, and the Infant and Young Child Dietary Diversity Indicator( 10 ) was validated as an indicator of adequacy of micronutrient density of complementary foods for infants and young children aged 6–23 months.

Three food groups included in the HDDS, namely Oils and fats, Sweets and Spices/condiments/beverages, are not included in any of the recommended individual diversity scores because they do not provide any essential micronutrients. Moreover, micronutrient-rich foods groups of the individual dietary diversity indicators are categorised differently compared with the HDDS. For example, the food groups ‘Vegetables’ and ‘Fruits’ of the HDDS are disaggregated into the groups of ‘Dark green leafy vegetables’, ‘Other vitamin A-rich fruits and vegetables’, ‘Other vegetables’ and ‘Other fruits’ in the MDD-W in order to better reflect the different content in micronutrients of these food groups. Therefore, we invite Koopmair and colleagues to use a food group classification recommended for individual dietary diversity scores in order to legitimately interpret their results in terms of dietary quality.

Furthermore, it would be interesting to see whether their suggestion that ‘household-level food consumption data (...) can be used for broader questions of dietary quality without introducing a significant bias’ still holds when appropriate individual dietary diversity scores are used.

More generally we recommend that researchers who study the complex linkages between agriculture and nutrition in developing countries by using dietary diversity proxies use the validated indicators described in consensus publications such as the WHO guidelines regarding infants and young children aged 6–23 months and the FAO–Food and Nutrition Technical Assistance Project manual regarding the indicator for women( 11 , 12 ).

Acknowledgements

Financial support: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflict of interest: None. Authorship: All authors contributed equally to the writing and editing of this manuscript. Ethics of human subject participation: Not applicable.

References

1. Koppmair, S, Kassie, M & Qaim, M (2016) Farm production, market access and dietary diversity in Malawi. Public Health Nutr (Epublication ahead of print version).
2. Sibhatu, KT, Krishna, VV & Qaim, M (2015) Production diversity and dietary diversity in smallholder farm households. Proc Natl Acad Sci U S A 112, 1065710662.
3. Berti, PR (2015) Relationship between production diversity and dietary diversity depends on how number of foods is counted. Proc Natl Acad Sci U S A 112, E5656.
4. Sibhatu, KT, Krishna, VV & Qaim, M (2015) Reply to Berti: Relationship between production and consumption diversity remains small also with modified diversity measures. Proc Natl Acad Sci U S A 112, E5657.
5. Remans, R, DeClerck, FA, Kennedy, G et al. (2015) Expanding the view on the production and dietary diversity link: scale, function, and change over time. Proc Natl Acad Sci U S A 112, E6082.
6. Sibhatu, KT, Krishna, VV & Qaim, M (2015) Reply to Remans et al.: Strengthening markets is key to promote sustainable agricultural and food systems. Proc Natl Acad Sci U S A 112, E6083.
7. Kennedy, G, Ballard, T & Dop, MC (2011) Guidelines for Measuring Household and Individual Dietary Diversity. Rome: FAO.
8. Leroy, JL, Ruel, M, Frongillo, EA et al. (2015) Measuring the food access dimension of food security: a critical review and mapping of indicators. Food Nutr Bull 36, 167195.
9. Martin-Prevel, Y, Allemand, P, Wiesmann, D et al. (2015) Moving Forward on Choosing a Standard Operational Indicator of Women’s Dietary Diversity. Rome: FAO.
10. Working Group on Infant and Young Child Feeding Indicators (2006) Developing and Validating Simple Indicators of Dietary Quality and Energy Intake of Infants and Young Children in Developing Countries: Summary of Findings from Analysis of 10 Data Sets. Washington, DC: Food and Nutrition Technical Assistance Project/Academy for Educational Development.
11. World Health Organization (2008) Indicators for Assessing Infant and Young Child Feeding Practices. Part 1: Definitions. Geneva: WHO.
12. Food and Agriculture Organization of the United Nations & FHI 360 (2016) Minimum Dietary Diversity for Women: A Guide for Measurement. Rome: FAO.