Marieke Vossenaar

Background: The Global Diet Quality Score application (GDQS app) enables standardized collection of dietary data across settings. The GDQS app allows for the use of 3-dimensional (3D)-printed cubes and playdough to estimate the amounts of food groups consumed for a 24-h reference period. This paper reports on the feasibility and acceptability of using a set of ten 3D cubes and playdough to estimate amounts consumed at the food group level among study participants. Methods: Enumerators conducted face-to-face interviews using the GDQS app with 170 study participants (71% female; aged 18–73 years) living in the Washington DC metropolitan area. The participants reported their consumption for the prior 24-h and used 3D cubes and playdough to estimate the amount of each food group consumed. The order in which participants were offered the cubes and playdough was randomized. Respondent feedback on use of the 3D cubes and playdough was collected through a 5-point Likert scale and open-ended questions. Results: Fewer than 2% of the study participants described either the cube or playdough method as ‘very difficult’. There was no statistically significant difference in preference between the two methods (45% preferred cubes and 55% preferred playdough, p = 0.167). The preference for method varied by food group. Some patterns emerged, such as a preference for cubes for estimating liquids consumed and playdough for estimating fruits and irregularly shaped foods. Conclusion: Both 3D cubes and playdough are feasible and acceptable methods for estimating GDQS food group intake, strengthening the evidence for the practicality of using the GDQS app for dietary data collection. Given the high acceptability of both methods, the choice of method—or the use of both in combination—for data collection should be guided by the operational context and resource availability. These findings reinforce the value of simplified, standardized tools for assessing diet quality across diverse field settings.

Background/Objectives: The Global Diet Quality Score (GDQS) was developed to provide crucial information on diet quality. The GDQS app standardizes the collection of GDQS data using portion size estimation at the food group level with 3D cubes of pre-defined size. Playdough was proposed as a possible alternative method. This validation study assessed whether the GDQS obtained using cubes or playdough with the GDQS app was equivalent to the GDQS estimated by weighed food records (WFRs) for the same 24 h reference period. Methods: We used a repeated measures design where 170 participants aged 18 years or older estimated portion sizes using both the WFR and the GDQS app with cubes and playdough. To assess the equivalence between the GDQS-WFR and GDQS-cubes or GDQS-playdough, we utilized the paired two one-sided t-test (TOST), with 2.5 points pre-specified as the equivalence margin. We used the Kappa coefficient to quantify agreement between WFR, risk of poor diet quality outcomes, and food group consumption using the cubes or playdough. Results: GDQS-WFR, GDQS-cubes, and GDQS-playdough were all equivalent within the pre-specified 2.5-point margin (p = 0.006 for cubes and p < 0.001 for playdough). The cubes (κ = 0.5685, p < 0.0001) and playdough (κ = 0.5843, p < 0.0001) showed moderate agreement with WFR when classifying individuals at risk of poor diet quality outcomes. There was substantial to almost perfect agreement between the cubes and playdough methods and WFR for 22 out of the 25 GDQS food groups. Liquid oils exhibited the lowest agreement (κ = 0.059, 27.7% agreement, p = 0.009). Conclusions: Using the GDQS app with cubes or playdough was equivalent to the WFR in assessing diet quality as measured by GDQS. These findings contribute to the growing body of research, validating simplified tools for dietary assessment and paving the way for more frequent evaluations of diet quality.

The nutrient adequacy of a diet is typically assessed by comparing estimated nutrient intakes with established average nutrient requirements; this approach does not consider total energy consumed. In this multinational survey investigation in Indonesia, Mexico, and South Africa, we explore the applications of the “critical nutrient-density approach”—which brings energy requirements into the equation—in the context of public health epidemiology. We conducted 24 h dietary recalls in convenience samples of normal-weight (BMI 18.5–25 kg/m²) or obese (BMI > 30 kg/m²), low-income women in three settings (n = 290). Dietary adequacy was assessed both in absolute terms and using the nutrient density approach. No significant differences in energy and nutrient intakes were observed between normal-weight and obese women within any of the three samples (p > 0.05). Both the cut-point method (% of EAR) and critical nutrient density approach revealed a high probability of inadequate intakes for several micronutrients but with poor concordance between the two methods. We conclude that it may often require some approximate estimate of the habitual energy intake from an empirical source to apply a true critical nutrient density reference for a population or subgroup. This will logically signify that there would be more “problem nutrients” in the diets examined with this nutrient density approach, and efforts toward improved food selection or food- or biofortification will frequently be indicated.

Micronutrient powders (MNP) are recommended by the World Health Organization as an effective intervention to address anaemia in children. A formative process evaluation was conducted to assess the viability of a model using free vouchers in two districts of Mozambique to deliver MNP and motivate adherence to recommendations regarding its use. The evaluation consisted of (a) an examination of programme outcomes using a cross‐sectional survey among caregivers of children 6–23 months (n = 1,028) and (b) an ethnographic study to investigate delivery experiences and MNP use from caregiver perspectives (n = 59), programme managers (n = 17), and programme implementers (n = 168). Using a mixed methods approach allowed exploration of unexpected programme outcomes and triangulation of findings. The survey revealed that receiving a voucher was the main implementation bottleneck. Although few caregivers received vouchers (11.5%, CI [9.7, 13.6]), one‐fourth received MNP by bypassing the voucher system (26.3%, CI [23.6, 29.0]). Caregivers' narratives indicated that caregivers were motivated to redeem vouchers but encountered obstacles, including not knowing where or how to redeem them or finding MNP were not available at the shop. Observing these challenges, many programme implementers redeemed vouchers and distributed MNP to caregivers. Virtually, all caregivers who received MNP reported ever feeding it to their child. This study's findings are consistent with other studies across a range of contexts suggesting that although programmes are generally effective in motivating initial use, more attention is required to improve access to MNP and support continued use.

Background and Objectives: The failure of infants in developing countries to meet nutrient intake recommendations is well documented. The objective of this study was to assess the nutritional adequacy and identify problem nutrients of the diets of Guatemalan infants with continued breastfeeding. Methods and Study Design: A single previous-day dietary recall was collected from a convenience sample of 94 mothers of infants aged 6-11 mo attending a public health clinic in the urban area of Quetzaltenango, Guatemala. Energy and nutrient content of complementary feeding (CF) and breastmilk, modelled by subtracting estimated energy intakes from CF from energy requirements, were calculated and nutrient adequacy of the diet was assessed. Nutrient densities and critical nutrient densities of CF were computed to identify "problem nutrients" and main food sources of these nutrients. Results: Complementary diets were adequate for protein, but likely to be inadequate for pantothenic acid and vitamins C, A, D, E, and K, as well as calcium, iron and zinc. In the worst-case scenario, i.e. for small girls with limited energy allowances, riboflavin, niacin, vitamin B-6 and magnesium were identified as "problem nutrients" as well. Formula milk, cow milk and Incaparina (R) were main food sources of "problem nutrients". Conclusions: The intake of micronutrients during the first six months of the recommend CF period in Guatemala has a number of notable inadequacies, but the gaps are narrower than traditionally reported for this age group in low-income settings.

The objective of this study was to examine the influence of improved information and educational messages on outer packaging of a micronutrient powder (MNP), locally known as “Taburia”, on knowledge and adherence to recommended use. A community-based cluster randomized controlled trial was conducted among 1149 caregivers and their children aged 6–36 months. Caregiver–child dyads were randomized by their villages to receive 30 sachets of Taburia with the: (i) original outer packaging; (ii) improved outer packaging; or (iii) improved outer packaging combined with cooking demonstrations. Adherence to Taburia use was assessed through caregiver interviews and observation of unused sachets during home visits; “high” adherence was defined as consuming 13–17 sachets in the previous month. Data collection included surveys and focus groups discussions. The majority of caregivers (>80%) preferred the improved packaging because it was more attractive and contained more comprehensive information. Caregivers who received the improved packaging had better knowledge regarding the recommended use of Taburia (p < 0.001) and higher adherence with the prescribed use of Taburia (43% with “high” adherence) (p < 0.001) than those who received the original packaging (29% with “high” adherence). Caregivers who participated in cooking demonstrations generally had better knowledge regarding the benefits of Taburia and recommended use, but this did not lead to higher adherence to recommended use. “Underconsumption” of Taburia (≤7 sachets) was much less prevalent than “overconsumption” (≥23 sachets), and original packaging users were more likely to consume Taburia daily instead of every two days as recommended. We conclude that the design of the outer packaging and comprehensiveness of information provided are important influencers of recommended MNP use by caregivers.