Seasonality in associations between dietary diversity scores and nutrient adequacy ratios among pregnant women in rural Malawi – a cross-sectional study

  • Katrine G. Hjertholm
  • Gerd Holmboe-Ottesen
  • Per O. Iversen
  • Ibrahimu Mdala
  • Alister Munthali
  • Kenneth Maleta
  • Zumin Shi
  • Elaine Ferguson
  • Penjani Kamudoni
Keywords: dietary diversity score, nutrient adequacy ratio, pregnancy, seasonality, sub-Saharan Africa


Background: Dietary diversity scores (DDS) are simple indicators often used as proxies for nutrient adequacy. A 10-food group indicator is proposed by the Food and Agriculture Organization of the United Nations as a global standard for measuring dietary diversity among women in low-resource settings. However, its validity as a proxy for nutrient adequacy across different agricultural seasons for pregnant women has not been determined.

Objective: We studied associations between DDS and nutrient adequacy ratios (NAR) across two different agricultural seasons (pre- and post-harvest seasons) for pregnant women in rural Malawi and assessed whether a 1-day DDS or a 3-day DDS would be the best indicator of nutrient adequacy.

Design: Dietary intakes of 330 pregnant women were assessed between gestational weeks 28 and 35. Intakes of energy, macronutrients, and 11 micronutrients were estimated using three repeated interactive 24-h diet recalls, and DDS were also calculated from these days. Correlation coefficients (r) between DDS, NAR, and mean adequacy ratio (MAR) of the 11 micronutrients were determined.

Results: After energy adjustments, we found significant correlations between DDS and MAR with both DDS indicators in the preharvest season (r = 0.22–0.23; p < 0.001) but not in the post-harvest season (p > 0.05). For individual energy-adjusted NARs, correlations were not consistently significant across the two seasons and the two DDS indicators.

Conclusions: Our results suggest that DDS could be used to predict overall nutrient adequacy during the preharvest season. As similar correlations were found using both the 1- and 3-day indicators, we recommend using a 1-day DDS, for simplicity. However, as the indicators are sensitive to seasonality they should be used with care in this study setting.


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How to Cite
Hjertholm K, Holmboe-Ottesen G, Iversen P, Mdala I, Munthali A, Maleta K, Shi Z, Ferguson E, Kamudoni P. Seasonality in associations between dietary diversity scores and nutrient adequacy ratios among pregnant women in rural Malawi – a cross-sectional study. fnr [Internet]. 2019Feb.27 [cited 2019Mar.20];630. Available from:
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