1. Diet Matters: Approaches and Indicators to Assess Agriculture's Role in Nutrition Diego Rose, Brian Luckett, and Adrienne Mundorf School of Public Health & Tropical Medicine Tulane University

2. Main objectives Outline plausible mechanisms in which agriculture and food-based interventions can improve nutrition through the diet pathway Identify approaches and indicators to measure progress in this area

3. Outline Augmented Causal Framework Indicators –Individual –Household –National Data Collection Systems Recommendations

4. Disease Maternal and child undernutrition Inadequate dietary intake Unhealthy household environment and inadequate health services Household Food Insecurity Inadequate care and feeding practices Household access to adequate resources: land, education, employment, income, technology Inadequate financial, human, physical and social capital Underlying causes Immediate causes Basic causes Outcomes Sociocultural, economic, and political context Short-term consequences Long-term consequences A Standard Framework Outlining Causes of Undernutrition

5. (Adapted from WFP, 2005) Food purchases Food receipts Gathering Fishing Hunting Cash income Own production ( food & cash crops, livestock, fish farm) Sales Employment Non- agricultural production Cash receiptsTradingDebts Zoom-in on determinants of household food security Household Food Security

6. Disease Maternal and child undernutrition Inadequate dietary intake Unhealthy household environment and inadequate health services Household Food Insecurity Inadequate care and feeding practices Household access to adequate resources: land, education, employment, income, technology Inadequate financial, human, physical and social capital Underlying causes Immediate causes Basic causes Outcomes Sociocultural, economic, and political context Short-term consequences Long-term consequences A Standard Framework Outlining Causes of Undernutrition

7. Individual-Level Measures Dietary outcomes are challenging due to multi- dimensionality –many nutrients, all essential So, aggregation of data into a single index –e.g. Mean Probability of Adequacy Measurement is also challenging, costly –diet is a complex set of behaviors –'Gold standard' methods are costly Proxies for diet quality –simple indicators of diet diversity

8. Dietary Proxy Validation Research Different indicators –Foods, food groups, fd grp systems ± min quantity Many different benchmarks –MAR, MPA, MMDA –Several different cutoff points – 50%, 75%, etc Different collection methods –Weighed food record, 24-hour recall, food frequency Different criteria –Correlations, sensitivity, specificity, area under ROC, prediction equations Lack of universal approaches

9. Diet Proxy Validation Research Outcomes Modest predictive power –good for population monitoring: project process, trends over time, or general planning –not good for evaluating impact Best proxies tend to be country-specific Elimination of 'minimum quantities' improves estimates –can it be implemented in a low-cost field method?

10. Household Level Measures Food Expenditure Modules Energy availability, food poverty –household food security interventions Food group availability –biofortification studies –other specific crop/livestock interventions

11. Household Level Measures Diversity Proxy Indicators Household Diet Diversity Score –16 groups in data collection collapsed to 12 –24 hr recall (not quantitative) –1 point for each group Food Consumption Score –8 groups –1 week food frequency –weights used in calculation

12. Country Level Measures Using Food Supply Data Prevalence of undernourishment –energy per capita + distributional measure + threshold Micronutrient densities –micronutrients per 1000 kilocalories –compared to micronutrient density goals Healthy eating index –score based on U.S. diet guidelines –food groups, negative components (fats, sugars)

13. Data Collection Systems Demographic and Health Surveys –Measure USAID Multiple Indicator Cluster System –UNICEF Living Standard Measurement Study –World Bank Vulnerability Analysis and Mapping Surveys –World Food Program FAOSTAT –National food supply data, other info

14. Recommendations Best Practices To evaluate agricultural programs & policies: assess outcomes proximal to interventions Continue to foster a diverse set of indicators for population monitoring –Women's Diet Diversity Score on DHS, MICS –Food Consumption Score on VAM, LSMS –Pilot-test 24-Hr Recall on LSMS –Food Balance Sheet indicators

15. Recommendations Research & Development New proxy validation research should –integrate several indicators –include information on costs Focus on making 'gold standards' less costly, rather than on making more low-cost proxies New research is needed on developing indicators of energy expenditure

16. Recommendations Nutritional Diplomacy Seek inter-agency collaboration in –survey implementation –instrument, indicator development Use representative expert panels to develop consensus on –specific indicators, overall measurement approach –thresholds to count the affected