As mentioned at the beginning of Section 1.3, diet quality is a multifaceted construct, comprising diversity, adequacy, moderation and overall balance. A Diet Quality Questionnaire (DQ-Q) has been developed with the aim of measuring diet quality at the population level in a way that is comparable across countries.121 It takes five minutes or less to administer.
It is designed to gather data on consumption of food groups, which is then used to create a suite of healthy diet indicators.
Three of the indicators of diet quality, described in greater detail in Annex 2, are:
Food Group Diversity Score (FGDS)
Score of consumption of nutritious foods that contribute to healthy diets (FLAVOURS)
Score of consumption of dietary components that should be limited or avoided (FAD)
The FGDS reflects dietary diversity for the general population.* The other two indicators reflect the likelihood of meeting current WHO global dietary recommendations.** These indicators can be used to identify problem areas of diets at the population level, such as too-low consumption of fruits and vegetables, whole grains, legumes, nuts and dietary fibre (FLAVOURS), or excessive intake of free sugars, salt, total fat and saturated fat (FAD).
In 2019, the Gallup© World Poll (GWP)
implemented both the DQ-Q and the FIES in Ghana and United Republic of Tanzania.*** Preliminary analyses are presented here to assess the association
between food security status and diet quality (see Annex 2 for more details). The models controlled for household size, age, gender, marital status, education and income.
In both countries, those who are food insecure consume less diverse diets and fewer nutritious foods that contribute to healthy diets. Diet quality worsens with increasing severity of food insecurity.
In addition, food insecure individuals in these two countries are also less likely to consume dietary components that should be limited, such as highly processed, energy-dense foods high in fats, sugars and/or salt. In other countries that have different socio-economic contexts, food insecurity could be associated with greater consumption of these foods. All three indicators of diet quality are important to monitor, especially in light of evidence pointing to dietary and nutrition transitions and the multiple burden of malnutrition in lower-middle and upper-middle-income countries.122 In the United Republic of Tanzania, gender is also associated with differences in diet quality. Women consumed less diverse diets, fewer nutritious foods and also fewer energy-dense foods high in fats, sugars and/or salt than men.****
In summary, the findings show that in both countries, food insecurity is associated with lower diet quality in terms of both food group diversity and nutritious foods. In the United Republic of Tanzania, being female is associated with the same reduction in diet quality.
* FGDS uses the same ten food groups as the Minimum Dietary Diversity for Women of reproductive age (MDD-W).
** These recommendations are based on WHO (2018)73 in addition to IARC (2018).123
*** The DQ-Q was implemented as part of the Global Diet Quality Project, which aims to measure diet quality across countries globally through the Gallup© World Poll (GWP). The DQ-Q survey module can be adopted and implemented by other survey mechanisms, enabling capacity for diet quality monitoring at country level.
**** In Ghana, there is no notable association between gender and diet quality; being female is associated with only slightly higher diet diversity.
In Kenya, Samoa and Sudan, food consumption information was collected at the household level in Household Consumption and Expenditure Surveys (HCES).i In Mexico, it was captured at the individual level using an individual-level food consumption survey. Individual-level surveys provide detailed quantitative individual food and nutrient intake information that can be disaggregated at many levels (e.g. sex and age). Due to their high cost and complexity, the number of recent, nationally representative surveys is relatively small. Food consumption data from HCES, on the other hand, are more widely available, across countries and over time.
However, HCES are not purposefully designed to capture food consumption. Instead, they provide information at the household level, albeit not for individual household members. For this reason, while the food insecurity status in the analysis that follows is comparable across countries, the food consumption levels should be compared with caution (see Annex 2 and Alvarez-Sanchez et al. [forthcoming]120 for a full description of the methodology and the results).
Overall, the analysis reveals that people who experience moderate or severe food insecurity consume less meat and dairy products (in all four countries) and less fruits and vegetables (Kenya and Sudan) than those who are food secure or mildly food insecure (from here on, referred to as
“food secure”) (Figure 24). Consumption of cereals, roots, tubers and plantains, and pulses, seeds and nuts either decreases slightly, remains similar, or increases, resulting in a higher proportional contribution of these food groups to the total diet. The more food insecure people are, the larger the share of staples in their diet. This holds true even if food insecure people in Kenya and Sudan reduce their consumption of staples, because they reduce consumption of other food groups even more.
i The three HCES used in this analysis (from Kenya, Samoa and Sudan) collected information on food consumed at the household level (i.e. apparently consumed; this may include food waste at the household level). This is in contrast to the individual-level food consumption survey from Mexico that collected information on individuals’ food intake (i.e. food ingested). However, for simplicity, herein, we use the term “consumption” to refer to food estimates and
“intake” to refer to dietary energy estimates, from both household and individual-level data. Our use of the term “consumption” differs from that of economists who refer to “consumption” as food and non-food expenditures.133
In Kenya and Sudan, those who experience moderate food insecurity consume lower
quantities of all food groups than those who are food secure – with the exception of cereals in both countries and fish in Kenya – and have a lower dietary energy intake. People experiencing severe food insecurity consume lower quantities of roots, tubers and plantains, dairy, vegetables, fats and oils, sweets and sugars (Kenya and Sudan), cereals, fruits, eggs and fish (Kenya) than those who are moderately food insecure.
In Kenya, food insecure people consume a slightly higher amount of fish, compared with those who are food secure. This could be explained by the fact that subsistence fishing is practiced by some of the poorest and most food insecure communities in the country.124
In Mexico and Samoa, notable variations in the diet are also observed between the food secure and the food insecure groups, but they follow a different pattern than Kenya and Sudan. As food insecurity becomes more severe, dietary energy intake remains relatively stable in Samoa and declines less markedly in Mexico compared to Kenya and Sudan. There is a reduction in the consumption of some animal source foods (such as dairy and meat), but minimal change (or even an increase) in the consumption of some plant-based foods (such as cereals, roots, tubers and plantains, pulses, seeds and nuts, and vegetables) and sweets and sugars.
In Mexico, fruit consumption decreases with food insecurity, whereas in Samoa it increases.
Conversely, consumption of eggs in Mexico is higher for those who are food insecure.
The finding that diet quality worsens with increasing severity of food insecurity is consistent with the theoretical construct of food insecurity on which the FIES is based:
people experiencing moderate food insecurity face uncertainties about their ability to obtain food and have been forced to compromise on the nutritional quality and/or quantity of the food they consume. On the other hand, people experiencing severe food insecurity have
typically run out of food and, at worst, gone one or more days without eating.125
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NOTES: Food consumption estimates shown for selected food groups only. In Kenya, Sudan and Samoa, food insecurity was measured with the FIES, and food group and dietary energy consumption were calculated excluding food items reported only in terms of monetary value (with no food quantities attached). In Samoa, the prevalence of severe food insecurity was very low, thus, the prevalences of moderate and severe food insecurity were combined. In Mexico, food insecurity was measured with the “Escala Latinoamericana y Caribeña de Seguridad Alimentaria” (ELCSA), and food group and dietary energy consumption were calculated considering all food items. For details about the food groupings, see Annex 2.
SOURCE: FAO, with data from from the Kenya Integrated Household Budget Survey 2015, the Sudan Study of Consumption Patterns and Nutrition 2018, Mexican Encuesta Nacional de Salud y Nutrición (ENSANUT) 2012, and the Samoa Household Income & Expenditure Survey 2018.
0 50 100 150 200 250 300 350 400
Sweets and sugars Fats and oils Fruits and their products Vegetables and their products Meat and meat products Fish, shellfish and their products Eggs and their products Dairy products Pulses, seeds and nuts and their products Roots, tubers, plantains and their products and their products
Sweets and sugars Fats and oils Fruits and their products Vegetables and their products Meat and meat products Fish, shellfish and their products Eggs and their products Dairy products Pulses, seeds and nuts and their products Roots, tubers, plantains and their products and their products
G/CAPITA/DAY
0 50 100 150 200 250 300 350 400
G/CAPITA/DAY
0 500 1 000 1 500 2 000 2 500
Dietary energy
KCAL/CAPITA/DAY
0 500 1 000 1 500 2 000 2 500 3 000
Dietary energy
KCAL/CAPITA/DAY
0 100 200 300 400 500 600
Sweets and sugars Fats and oils Fruits and their products Vegetables and their products Meat and meat products Fish, shellfish and their products Eggs and their products Dairy products Pulses, seeds and nuts and their products Roots, tubers, plantains and their products Cereals and their products
G/CAPITA/DAY
SAMOA
0 500 1 000 1 500 2 000 2 500 3 000
Dietary energy
KCAL/CAPITA/DAY
0 50 100 150 200 250 300
Sweets and sugars Fats and oils Fruits and their products Vegetables and their products Meat and meat products Fish, shellfish and their products Eggs and their products Dairy products Pulses, seeds and nuts and their products Roots, tubers, plantains and their products Cereals and their products
G/CAPITA/DAY
MEXICO
0 500 1 000 1 500 2 000 2 500
Dietary energy
KCAL/CAPITA/DAY
Food secure or mildly food insecure Moderately food insecure Severely food insecure
The ways in which moderately food insecure people modify their diets vary according to the income level of the country. In the two lower-middle-income countries studied (Kenya and Sudan), there is a marked decrease in consumption of most food groups, and an increase in the share of staples in the diet.
In the two upper-middle-income countries examined (Mexico and Samoa), people who are moderately food insecure consume more foods that are typically cheaper on a per-calorie basis (cereals, roots, tubers and plantains), and consume lesser amounts of expensive foods (meat and dairy), compared with those who are food secure. Mexico in particular shows a decrease in fruit and dairy consumption as the severity of food insecurity increases. This is in line with studies that show that the purchase of fruits and milk is sensitive to changes in income and prices.126 The increase in fruit consumption with worsening food insecurity in Samoa may be explained by the fact that those who are food insecure consume more fruits from their own-production instead of purchasing it.127 There are several plausible reasons why food insecurity, as measured by experience-based scales like the FIES, may contribute to different dietary outcomes in lower-middle- and
upper-middle-income countries, to the extent that these countries may be exemplary of other countries in the same income-level groups.
First, healthy diets may generally be less affordable in lower-middle-income countries than in
upper-middle-income countries. As discussed in Section 2.1 of this report, healthy diets are unaffordable to many people, especially the poor, in every region of the world. Second, social protection programmes may receive less funding in lower-middle-income countries.128 Lastly, vulnerable people’s access to food, especially perishable nutritious foods, may be more compromised in lower-middle-income countries than in upper-middle-income countries, due to lack of physical infrastructure and food processing and storage technology, as well as food safety issues.129 Problems like these associated with the food supply chain tend to drive up the cost of nutritious foods, as discussed in Section 2.3 of this report.
One possible reason the difference in dietary energy intake between food secure and
moderately food insecure people is smaller in Mexico and Samoa than in Kenya and Sudan is that Mexico and Samoa are well into the nutrition transition, which is characterized by a rapid shift in diet composition towards a higher intake of highly processed, energy-dense foods that have minimal nutritional value and are cheap and widely available.97
As more countries collect good quality household- or individual-level food security and food consumption data, this analysis can be expanded to shed more light on the links between food insecurity and diet quality around the world. Combined with ongoing efforts to develop national FBDGs and address the challenges of global monitoring of diet quality, more and better evidence will soon be available to guide actions aimed at guaranteeing universal access to enough nutritious foods for healthy diets. n
1.4
CONCLUSIONS
With ten years to go until 2030, the world is off track to achieve the SDG targets for hunger and malnutrition. After decades of long decline, the number of people suffering from hunger has been slowly increasing since 2014. The trends shown by the prevalence of undernourishment and the prevalence of severe food insecurity based on the FIES both point to failed progress.
Beyond hunger, a growing number of people have been forced to compromise on the quality and/or quantity of the food they consume, as reflected in the increase in moderate or severe food insecurity since 2014. Projections for 2030, even without considering the potential impact of COVID-19, serve as a warning that the current level of effort is not enough to reach Zero Hunger ten years from now.
As for nutrition, progress is being made on decreasing child stunting and low birthweight and increasing exclusive breastfeeding for the first six months of life. However, prevalence of wasting is notably above the targets and the prevalence of both child overweight and adult obesity is increasing in almost all regions, a worrisome trend that will add to the global burden of disease and increase public health
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service and health care costs. These trends in hunger, food insecurity and malnutrition must be reversed. COVID-19 is expected to exacerbate these trends, rendering vulnerable people even more vulnerable. Urgent action is needed in order to meet the 2030 targets, even as the world braces for the impact of the pandemic.
Increasing availability of and access to nutritious foods that make up healthy diets must be a key component of stronger efforts to achieve the 2030 targets. The availability of dietary energy per person has increased globally over the past two decades. However, this has not translated into an increase in the availability of nutritious foods that contribute to healthy diets. There are large discrepancies in the per capita availability of foods from different food groups across countries of different income levels. Low-income countries rely more on staple foods and less on fruits and vegetables and animal source foods than high-income countries. An increase in per capita availability of fruits and vegetables has been observed since 2000. And yet, according to the analysis presented, only upper-middle-income countries
and Asia have a daily per capita availability above the recommended level of consumption.
Worldwide, less than a third of young children are eating foods from the minimum number of five food groups needed to meet their energy and nutrient needs.
The quality of people’s diets worsens with increasing constraints on their access to food, putting them at higher risk of undernutrition as well as overweight and obesity. Among other factors, cost is a key determinant of access to food. Part 2 of this report sheds light on how food prices and affordability of diets contribute to food insecurity and inequalities in diet quality. It also maps out actions needed to reshape food systems in ways that guarantee universal access to enough nutritious foods that contribute to healthy diets. The remaining years of the UN Decade of Action on Nutrition 2016–2025 present an opportunity for
policymakers, civil society and the private sector to work together and accelerate efforts.
There is still time to get back on track towards achieving Zero Hunger and ending all forms of malnutrition by 2030. n