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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  1. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 2008; 371: 243–260. doi: 10.1016/S0140-6736(07)61690-0

  2. Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, et al. Maternal and child undernutrition: consequences for adult health and human capital. Lancet 2008; 371: 340–357. doi: 10.1016/S0140-6736(07)61692-4

  3. Ndekha M, Kulmala T, Vaahtera M, Cullinan T, Salin M, Ashorn P. Seasonal variation in the dietary sources of energy for pregnant women in Lungwena, rural Malawi. Ecology Food Nutr 1999; 38: 605–622. doi: 10.1080/03670244.2000.9991599

  4. Nyambose J, Koski KG, Tucker KL. High intra/interindividual variance ratios for energy and nutrient intakes of pregnant women in rural Malawi show that many days are required to estimate usual intake. J Nutr 2002; 132: 1313–1318. doi: 10.1093/jn/132.6.1313

  5. Gibson RS, Huddle JM. Suboptimal zinc status in pregnant Malawian women: its association with low intakes of poorly available zinc, frequent reproductive cycling, and malaria. Am J Clin Nutr 1998; 67: 702–709. doi: 10.1093/ajcn/67.4.702

  6. Brown L. Nutrition requirements during pregnancy. In: Edelstein S, ed. Life cycle nutrition: an evidence-based approach, 2nd edn. Jones and Bartlett Publishers; Massachusetts, USA: 2014.

  7. Ruel MT, Deitchler M, Arimond M. Developing simple measures of women’s diet quality in developing countries: overview. J Nutr 2010; 140: 2048S–2050S. doi: 10.3945/jn.110.123695

  8. Arimond M, Wiesmann D, Becquey E, Carriquiry A, Daniels MC, Deitchler M, et al. Simple food group diversity indicators predict micronutrient adequacy of women's diets in 5 diverse, resource-poor settings. J Nutr 2010; 140: 2059S–2069S. doi: 10.3945/jn.110.123414

  9. Ruel MT. Is dietary diversity an indicator of food security or dietary quality? A review of measurement issues and research needs. FCND Discussion Paper. Food Nutr Bull. 2003; 24: 231–232. doi: 10.1177/156482650302400210

  10. FAO, FHI 360. Minimum dietary diversity for women: a guide for measurement 2016. Available from: [cited 18 October 2018].

  11. Kirkwood BR, Sterne JA. Essential medical statistics, 2 edn. Blackwell Publishing; Oxford, UK: 2003.

  12. Hjertholm K, Iversen PO, Holmboe-Ottesen G, Mdala I, Munthali A, Maleta K, et al. Maternal dietary intake during pregnancy and its association to birth size in rural Malawi – a cross-sectional study. Matern Child Nutr 2018; 14(1): e12433. doi: 10.1111/mcn.12433.

  13. Gibson R, Ferguson E. An interactive 24-hour recall for assessing the adequacy of iron and zinc intakes in developing countries. International Food Policy Research Institute. Washington, DC: ILSI Press; 2008.

  14. Kamudoni P, Maleta K, Shi Z, Holmboe-Ottesen G. Infant feeding practices in the first 6 months and associated factors in a rural and semiurban community in Mangochi District, Malawi. J Hum Lact 2007; 23: 325–332. doi: 10.1177/0890334407307567

  15. USDA Nutrient Data Laboratory. USDA National Nutrient Database for standard reference. United States Department of Agriculture; Beltsville 2011.

  16. Food and Agriculture Organization of the United Nations. West African food composition table. Rome: FAO; 2012.

  17. Department of Agricultural Research. Lesotho food composition table. Maseru: Department of Agricultural Research; 2006.

  18. Institute of Medicine. Dietary reference intakes: Applications in dietary assessment. Washington, DC: The National Academies Press; 2000, 306 p.

  19. FAO. Guidelines for measuring household and individual dietary diversity. Rome: Food and Agriculture Organization of the United Nations; 2012.

  20. Savy M, Martin-Prevel Y, Traissac P, Eymard-Duvernay S, Delpeuch F. Dietary diversity scores and nutritional status of women change during the seasonal food shortage in rural Burkina Faso. J Nutr 2006; 136: 2625–2632. doi: 10.1093/jn/136.10.2625

  21. van Liere MJ, Ategbo EAD, Den Hartog AP, Hautvast JGAJ. The consequences of seasonal food insecurity for individual food-consumption patterns in north-western Benin. Food Nutr Bull 1995; 16: 147–154. doi: 10.1177/156482659501600208

  22. Stevens B, Watt K, Brimbecombe J, Clough A, Judd J, Lindsay D. The role of seasonality on the diet and household food security of pregnant women living in rural Bangladesh: a cross-sectional study. Publ Health Nutr 2017; 20: 121–129. doi: 10.1017/S136898001600183X

  23. Ferguson E, Gibson R, Opare-Obisaw C, Osei-Opare F, Lamba C, Ounpuu S. Food consumption patterns and dietary diversity of rural preschool Ghanaian and Malawian children. Ecol Food Nutr 1993; 29: 219–234. doi: 10.1080/03670244.1993.9991307

  24. Arsenault JE, Nikiema L, Allemand P, Ayassou KA, Lanou H, Moursi M, et al. Seasonal differences in food and nutrient intakes among young children and their mothers in rural Burkina Faso. J Nutr Sci 2014; 3: e55. doi: 10.1017/jns.2014.53

  25. Nguyen PH, Huybregts L, Sanghvi TG, Tran LM, Frongillo EA, Menon P, et al. Dietary diversity predicts the adequacy of micronutrient intake in pregnant adolescent girls and women in Bangladesh, but use of the 5-group cutoff poorly identifies individuals with inadequate intake. J Nutr 2018; 148: 790–797. doi: 10.1093/jn/nxy045

  26. Caswell BL, Talegawkar SA, Siamusantu W, West KP, Jr, Palmer AC. A 10-food group dietary diversity score outperforms a 7-food group score in characterizing seasonal variability and micronutrient adequacy in rural Zambian children. J Nutr 2018; 148: 131–139. doi: 10.1093/jn/nxx011.

How to Cite
Hjertholm K. G., Holmboe-Ottesen G., Iversen P. O., Mdala I., Munthali A., Maleta K., Shi Z., Ferguson E., & Kamudoni P. (2019). Seasonality in associations between dietary diversity scores and nutrient adequacy ratios among pregnant women in rural Malawi – a cross-sectional study. Food & Nutrition Research, 63.
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