The Global Diet Quality Score Is Inversely Associated with Nutrient Inadequacy, Low Midupper Arm Circumference, and Anemia in Rural Adults in Ten Sub-Saharan African Countries

Abstract

Background: Key nutrient deficits remain widespread throughout sub-Saharan Africa (SSA) whereas noncommunicable diseases (NCDs) now cause one-third of deaths. Easy-to-use metrics are needed to track contributions of diet quality to this double burden.

Objectives: We evaluated comparative performance of a novel food-based Global Diet Quality Score (GDQS) against other diet metrics in capturing nutrient adequacy and undernutrition in rural SSA adults.

Methods: We scored the GDQS, Minimum Dietary Diversity-Women (MDD-W), and Alternative Healthy Eating Index-2010 (AHEI-2010) using FFQ data from rural men and nonpregnant, nonlactating women of reproductive age (15-49 y) in 10 SSA countries. We evaluated Spearman correlations between metrics and energy-adjusted nutrient intakes, and age-adjusted associations with BMI, midupper arm circumference (MUAC), and hemoglobin in regression models.

Results: Correlations between the GDQS and an energy-adjusted aggregate measure of dietary protein, fiber, calcium, iron, zinc, vitamin A, folate, and vitamin B-12 adequacy were 0.34 (95% CI: 0.30, 0.38) in men and 0.37 (95% CI: 0.32, 0.41) in women. The GDQS was associated (P < 0.05) with lower odds of low MUAC [GDQS quintile (Q) 5 compared with Q1 OR in men: 0.44, 95% CI: 0.22, 0.85; women: 0.57, 95% CI: 0.31, 1.03] and anemia (Q5/Q1 OR in men: 0.56, 95% CI: 0.32, 0.98; women: 0.60, 95% CI: 0.35, 1.01). The MDD-W correlated better with some nutrient intakes, though associated marginally with low MUAC in men (P = 0.07). The AHEI-2010 correlated better with fatty acid intakes, though associated marginally with low MUAC (P = 0.06) and anemia (P = 0.14) in women. Overweight/obesity prevalence was low, and neither the GDQS, MDD-W, nor AHEI-2010 were predictive.

Conclusions: The GDQS performed comparably with the MDD-W in capturing nutrient adequacy-related outcomes in rural SSA. Given limited data on NCD outcomes and the cross-sectional study design, prospective studies are warranted to assess GDQS performance in capturing NCD outcomes in SSA.

Keywords: GDQS; Millennium Villages Project; diet quality metrics; dietary diversity; double burden of malnutrition; noncommunicable disease; nutrient adequacy; nutrition transition; nutritional epidemiology; sub-Saharan Africa.

FIGURE 1

Age-adjusted associations between quintiles of the GDQS (red) and MDD-W (blue) compared with overall nutrient adequacy, low midupper arm circumference (MUAC), and anemia in rural sub-Saharan African adults. Overall nutrient adequacy (ONA) defined as energy-adjusted number of adequate nutrients (out of 8). Low MUAC defined as <25.5 cm in men and <24.5 cm in women. Anemia defined as <13 g/dL in men and <12 g/dL in women (altitude-adjusted). GDQS quintiles correspond to scores <18.8,  18.9–21.3, 21.3–23.5, 23.5–26.5, and >26.5 in men; and <19.0,  19.0–21.3, 21.3–23.5, 23.5–26.3, and >26.3 in women. MDD-W quintiles correspond to scores <5,  5.0, 6.0, 7.0, and >7 in men and women. All Wald tests comparing linear trends across quintiles between the GDQS and MDD-W were nonsignificant (P ≥ 0.05). EMM, estimated marginal mean, GDQS, Global Diet Quality Score; MDD-W, Minimum Dietary Diversity–Women; Q, quintile.