Monitoring Nutrition - Women

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Food and Nutrition Security is an important aspect of sustainable livelihoods and is often seen as a first step towards poverty alleviation. Nutrition security is defined by adequate nutritional status of individuals. Together with infants and young children, adolescent girls and women of reproductive age are among the most vulnerable for under nutrition. It can be assumed that once the nutrition outcomes for these groups have been improved the nutritional status of the whole household has improved.

The nutritional status of a woman before and during pregnancy has direct impact on the development and nutritional status of her baby. Malnutrition before and during pregnancy increases the risk of low birth weight and malnutrition during infancy. That’s why The Lancet 2008 Maternal and Child Nutrition Series identified the need to focus on the crucial period from conception to a child’s second birthday – the 1000 days in which good nutrition and healthy growth have lasting benefits throughout life1.

The role and importance of women goes beyond infant and child nutrition. They make up 43% of the overall agricultural workforce2, and in many societies they have the main responsibility for food production as opposed to growing cash crops. Much processing of food is done by women, whether for sale or use within the household, and across the world women still do most of the cooking. Women however often have weaker access to productive resources and are more likely than men to be malnourished.

To define the nutritional status of women of reproductive age the so-called Body Mass Index is used, which is based on anthropometric measurements. The BMI is a simple index of weight-to-height to classify underweight, overweight and obesity in adults. It is defined as the weight in kilograms divided by the square of the height in meters (kg/m²).

For example, an adult who weighs 58 kg and whose height is 1.70 m will have a BMI of 20.1:

BMI = 58 kg/(1.70 m x 1.70 m) = 20.1

  • BMI < 17.0 indicates moderate and severe thinness
  • BMI < 18.5 indicates underweight
  • BMI 18.5 – 24.9 indicates normal weight
  • BMI ≥ 25.0 indicates overweight
  • BMI ≥ 30.0 indicates obesity

Besides the BMI the level of anemia, vitamin A and Iodine deficiency are important indicators for the nutrition status of the population. All above indicators usually form part of National Demographic and Health Surveys3, which are managed by the public sector, based on large sample sizes and typically conducted about every 5 years, to allow comparisons over time. The results of these surveys are publicly available for almost every country and provide an important source of secondary data for problem and/or context analyses.

Given the complexity of taking anthropometric measurements as well as defining levels of vitamin A and hemoglobin (iron) in the blood, these type of indicators are in general not suitable for development programs. That’s why actors like FAO and the USAID supported FANTA project have worked on simple proxy indicators for global use in assessing the quality (micronutrient adequacy) of diets and appropriateness of feeding practices. Recent developments – including increased attention and funding for nutrition-sensitive interventions4 – have increased the demand for such indicators.

Dietary Diversity Score

In answer to the lack of (proxy) indicators on nutritional status of adults, the so-called Dietary Diversity Score has been developed and validated. In resource-poor environments, low quality monotonous diets are the norm. When grain- or tuber-based staple foods dominate and diets lack vegetables, fruits and animal-source foods, risk for a range of micronutrient deficiencies is high. In these settings dietary diversity is a useful proxy indicator for overall diet quality. The dietary diversity questionnaire is to be applied at individual level. The data are to be collected through a face2face interview with a targeted girl or woman, who preferably is responsible for (involved in) preparation of meals.

The interviewer asks for each meal and in-between moments if the respondent consumed anything. If so, the respondent is asked to describe the foods that have been eaten or drunk and which ingredients were used. The interviewer checks all different ingredients included in the meal (whenever the quantity is > 15 g per serving). On the spot the interviewer has to register per meal which foods have been consumed by ticking the related food group from the list of 10 or more different food groups shown below. It should be noticed that for this ‘transcription’ the interviewer needs solid knowledge on nutrition.

As of 2010 this indicator is being applied broadly for assessment, advocacy, and accountability purposes. In July 2014 an international expert meeting defined the Minimum Dietary Diversity for Women (MDD-W)5, with a threshold of at least five food groups out of ten predefined food groups (presented in the table below), to assess the quality of diets for adolescents girls and women of reproductive age.

MDD-W food groups

1. All starchy staple foods 6. Eggs
2. Beans and peas 7. Vitamin A-rich dark green leafy vegetables
3. Nuts and seeds 8. Other vitamin A-rich vegetables and fruits
4. Dairy 9. Other vegetables
5. Flesh foods 10. Other fruits

Women consuming foods from five or more food groups have a greater likelihood of meeting their micronutrient needs than women consuming foods from fewer food groups. Therefore the threshold is at least five food groups out of these ten. Depending on the context and the character of the project one could amplify the number of food groups.

Applying a Dietary Diversity Score is more time consuming than the HFIAS and, as mentioned before, requires a solid level of food and nutrition knowledge among the interviewers. However, the combination of HFIAS and DDS provides a solid and valuable source of information for FNS programs. Based on broad hands-on experience ICCO-Cooperation recommends to use Akvo FLOW for gathering and processing data for both indicators.

Experiences from the Field

The ICCO-Cooperation managed Profitable Opportunities for Food Security (PROOFS) program in Bangladesh6 focuses among other things on nutrition improvement for women of reproductive age. During 2013 a broad baseline was conducted, including the dietary diversity score for this specific target group. Besides insights on the adequacy of their diets we found that on the whole the consumption of oils and fats was very low as demonstrated in the figure below.

The table presents the % of respondents that consumed one or more foods from the 12 different food groups during the day before the questionnaire was applied. This means e.g. that 99,7% (almost all) respondents have consumed a cereal, such as rice or a food item made of cereals, such as bread or noodles.

The WHO recommends minimum total fat intake for adults as % of the total energy intake:

  • 15% to ensure adequate consumption of total energy, essential fatty acids, and fat soluble vitamins for most individuals.
  • 20% for women of reproductive age and adults with Body Mass index <18.5, especially in developing countries.

Based on this experience and recommendations we suggest to include ‘Oils and Fats’ as an additional food group to the list of food groups, making sure that eventual ‘low’ consumption of these foods are being registered.

Please refer to the Dietary Diversity Questionnaire for Women for more detailed information on the application of the dietary diversity score.


  1. The Lancet. Maternal and Child Nutrition Series 2013.
  2. FAO, The state of food and agriculture 2010-11. Rome: FAO, 2011, p7.
  3. USAID. The Demographic and Health Surveys Program.
  4. The Lancet. Maternal and Child Nutrition Series 2013.


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