Dietary Diversity and N utrient Adequacy In Women of Childbearing Age In a Senegalese Peri-urban Community Dina L. Spigelski School of Dietetics and Ruman Nutrition McGill University, Montreal A Thesis submitted to the Faculty of Graduate Studies and Research in partial fulfillment of the requirements for a Master of Science May 2004 © Dina L. 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While these forms may be included Bien que ces formulaires in the document page count, aient inclus dans la pagination, their removal does not represent il n'y aura aucun contenu manquant. any loss of content from the thesis. •• • Canada Acknowledgements Wat gaal yegoo (Together the community raises the pirogue) Lébou expression This research project was made possible through the support and cooperation of a number ofkey institutions. The School of Dietetics and Human Nutrition and the Centre for Indigenous Peoples' Nutrition and Environment (CINE) at McGill University and the Centre de Ressources pour l'Émergence Sociale Participative (CRESP) in Yoffprovided office space and logistical support. The Équipe de Nutrition in the Faculté des Sciences et Techniques at Université Cheikh Anta Diop (UCAD) in Dakar provided valuable advice and technical assistance. The Faculté de Médecine at UCAD kindly provided the HemoCue™ machine. The Centre de Santé Philippe Maguilen Senghor provided important medical counsel and support. The Canadian International Development Agency (CIDA) provided financial support for this project through their Awards Programfor Canadians. Le Fonds de la recherche en santé Québec (FRSQ) provided personal funding through their Bourses de recherche en santé (2e cycle) pro gram. During the course of this research 1 have had the good fortune to work with many remarkable individuals both in Canada and in Senegal. Primary among these are my supervisors and committee members. 1 am deeply indebted to my supervisor Dr. Timothy Johns for his confidence in me. His creativity and passion for exploration fed my mind and spirit. Thank you to my co-supervisor Dr. Katherine Gray-Donald for keeping my feet on the ground and pointed in the right direction. 1 also extend thanks to Dr. Harriet Kuhnlein for her encouragement and thoughtful insight and to the project collaborator, Dr. Marian Zeitlin who introduced me to the very special community ofYoff. ln Senegal, 1 received much support from research colleagues and assistants. 1 thank the staff at CRESP who provided invaluable administrative support. Special thanks to As N'Gala who helped me adapt my methodology to the reality of the village and helped me gain a deeper understanding of the community and the complexity of the village structure. 1 also extend many thanks to Dr. Ly and the support staff at the Centre de Santé Philippe Maguilen Senghor for their encouragement, interest and involvement in this project. 1 thank Aita Sarr from the Équipe de Nutrition at UCAD for her friendly encouragement. 1 would like to express my sincere gratitude to the Lô family who kindly accepted me into their home, offered me their friendship, and acted as key informants throughout the research process. Sarah Klein cannot be thanked enough for her encouragement and words of wisdom when they were most needed. Very special thanks go to Salimata N'Doye my community research partner. Her intelligence, professionalism, sense ofhumor, and commitment to her community made her an ideal partner. 1 am forever grateful that she welcomed me into her life and indebted to her for her candor and patience as we walked the research path together. 1 am deeply thankful to aIl study participants. These women warmly welcomed me into their homes and readily found the time to answer my questions amidst cooking, caring for babies, cleaning the 1 house and eaming a living. These women are truly remarkable and are a testament to the strength of the human spirit. It is my greatest hope that in discovering each other and in problem solving together they have leamed as much as l have. At McGill, l thank Louise Johnson-Down for her invaluable guidance with CANDAT and SAS. l thank all my fellow graduate students who supported me in many ways and were very generous with their time. Thank you very much to Lise Grant and Francine Tardif whose support has never been taken for granted. l am very grateful to Barbara Butler, a true friend who has never stopped supporting me. l thank my mother, father and sisters. It is their faith in me that has allowed me to believe that anything is possible and has given me the courage to challenge myself. 11 Abstract The validity of two measures of dietary diversity derived from a qualitative diversity questionnaire (reference periods of 1 or 7 days) by comparison with nutrient intake from three 24-hour recalls was investigated in 51 women (18 - 45 y) in a peri urban community in Senegal, West Africa. Significant positive correlations (range: r = 0.30 to r = 0.64) were found between intakes of calcium, iron, zinc, vitamin A, vitamin C, thiamine, riboflavin and vitamin B6 and diversity score based on number of different individual foods derived from data obtained from the 7-day reference period. Data from the diversity score from the I-day reference period was less well correlated with the 24-hr recalls. Our data suggest that a diversity measure based on foods derived from a diversity questionnaire would be useful in the monitoring of nutrient intake changes over time within populations. 111 Résumé La validité de deux mesures de diversité alimentaire dérivé d'un questionnaire de diversité qualitatif (périodes de référence étant de 1 ou 7 jours) en comparaison avec l'apport nutritif de trois rappels de 24 heures a été examiné chez 51 femmes (18 - 45 ans) d'une communauté peri-urbaine du Sénégal. Des corrélations positives (r = 0.30 à r = 0.64) ont été établies entre la consommation de calcium, de fer, de zinc, de vitamine A, de vitamine C, de thiamine, de riboflavine et de vitamine B6 et le score de diversité basé sur le nombre d'aliments obtenus de la période de référence de 7 jours. Le score de diversité obtenu de la période de référence de 1-jour corrélait moins avec les rappels de 24 heures. Nos résultats suggèrent qu'une mesure de diversité estimée des aliments rapportés sur un questionnaire de diversité puisse être utile pour le monitorage de changements temporels d'apport de nutriments chez des populations. IV Contribution of Authors The candidate worked with Dr. T. Johns, the thesis supervisor and Dr. K. Gray Donald, the thesis co-supervisor to deve10p the research question and project objectives. The candidate sought out and obtained funding for the project. Subsequently, the candidate deve10ped the questionnaire tools, hired a local research partner, and collected all data with the research partner. The candidate was responsible for data management, which included coding of raw data, verifying data, and building CANDAT and SAS files. The candidate conducted all analyses and prepared initial draft ofmanuscript. For further data analysis and interpretation, Dr. T. Johns and Dr. K. Gray-Donald provided guidance. The paper Dietary Diversity and Nutrient Adequacy in Women ofChildbearing Age in a Peri-Urban Community in Senegal, West Africa was co-authored by the members of the committee. v List of Tables Table 2.1 Summary of studies in developing countries that have investigated dietary diversity and nutrient adequacy .......................................... 32 Table 3.1 Characteristics of study participants .............................................. 59 Table 3.2 Frequency of food items cited for diversity questionnaire (Id and 7d periods) and 24-hour recall (3d period) ............................. 60 Table 3.3 Distribution of adjusted nutrient intakes from mean of three 24-hour recalls compared to the F AO/WHO vitamin and mineraI recommended nutrient intakes (FAO/WHO, 2002) .............................................. 63 Table 3.4 Food diversity scores (FDS) and group diversity scores (GDS) for IdDQ, 7dDQ and 24-hour recall ................................................6 4 Table 3.5 Correlation statistics for adjusted micro- and macronutrient intakes and food diversity score (FDS) for IdDQ, 7dDQ and 24-hour recaI1.. ..... 65 Table 3.6 Mean and percent contribution of most important contributors from mean of three 24-hour recalls ...................................................6 6 List of Figures Figure 3.1 Distribution ofhemoglobin (Hb) concentrations (n=59) .......................6 9 Figure 3.2 Frequency bar chart for Food Diversity Score (FDS) for IdDQ (no fatloil, sweets, spices, supplements) .........................................7 0 Figure 3.3 Frequency bar chart for Group Diversity Score (GDS) for IdDQ (no fatloil, sweets, spices, supplements) .........................................7 1 Figure 3.4 Frequency bar chart for Food Diversity Score (FDS) for 7dDQ (no fatloit, sweets, spices, supplements) .......................................... 72 Figure 3.5 Frequency bar chart for Group Diversity Score (GDS) for 7dDQ (no fat/oil, sweets, spices, supplements) .......................................... 73 VI Table of Contents 1.0 Introduction ..................................................................................... 1 2.0 Review of the Literature ..................................................................... .4 2.1 Estimating Dietary Intake ................................................................... .4 2.2 Dietary Diversity: Terms Defined ........................................................ 8 2.3 Dietary Diversity: Developing Country Studies ........................................ 10 2.4 Dietary Diversity: The Urban Setting ...................................................2 1 2.5 Iron Intake and Millet ......................................................................2 2 2.6 Target Population ........................................................................2 5 2.7 Study Rationale ........................................................................... 30 2.8 Study Objectives .......................................................................... 31 3.0 Manuscript ..................................................................................... 35 Dietary Diversity and Nutrient Adequacy in Women of Childbearing Age in a Peri-Urban Community in Senegal, West Africa 3.1 Abstract .................................................................................... 36 3.2 Introduction .............................................................................. 37 3.3 Subjects and Methods ................................................................... .38 3.4 Results .....................................................................................4 5 3.5 Discussion ................................................................................. 52 4.0 Conclusion .................................................................................... 74 5.0 References ..................................................................................... 77 6.0 Appendices ...................................................................................A -l 6.1 Consent Form for Study Participants ................................................... A-3 vu 6.2 Socio-demographic Questionnaire ...................................................... A-6 6.3 Diversity Questionnaire .................................................................. A-9 6.4 24-Hour Recall Questionnaire .......................................................... A-II 6.5 McGill University Ethics Certificate .................................................A -13 viii