An Assessment of Dietary Diversity and Nutritional Status of Preschool Children

Research Article

Austin J Nutri Food Sci. 2014;2(7): 1040.

An Assessment of Dietary Diversity and Nutritional Status of Preschool Children

Sealey-Potts C1* and Potts AC2

1Department of Nutrition and Dietetics, University of North Florida, USA

2Department of Marine and Environmental Sciences, University of Trinidad and Tobago, Trinidad and Tobago

*Corresponding author: : Sealey-Potts C, Department of Nutrition and Dietetics, University of North Florida, 1 UNF Drive, Brooks College of Health, Building #39, Jacksonville, FL 32224, USA

Received: August 19, 2014; Accepted: September 12, 2014; Published: September 17, 2014


Dietary diversity is gaining prominence in assessing diet adequacy of individuals and households in developing countries. Dietary diversity or food variety is not known in Tobago. This study's purpose therefore was to assess dietary diversity, food variety and its relationship to the nutritional status of preschool children. A cross-sectional descriptive study design was implemented and a structured, culturally sensitive questionnaire with a 24-hour recall procedure was used for data collection. A representative sample (n=423), stratified by parish, population density, gender and age, was recruited from public and private pre-schools. Less than half (48%) of the preschoolers met minimum dietary diversity. Approximately 33% consumed food items from 5 or more food groups and 19%had low dietary diversity scores (DDS). Mean scores were obtained for food variety (9.37 ± 2.4) and diversity (4.19 ± .83). Nutrient adequacy ratios (NAR) for eleven nutrients were calculated and correlated with DDS, food variety scores (FVS) and nutrition indices. Notable percentages (11.35%) of the children had acute malnutrition, while 10% were underweight and ~5% exhibited chronic malnutrition. NAR for various micronutrients were significantly (p < 0.01) correlated with DDS. NAR for energy moderately predicted weight-for-age (WAZ) z-scores (r=0.437, p=0.000), height-for-age (HAZ) z-scores (r=0.413, p=0.001) and weight-for-height (WHZ) z-scores (r=0.466, p=0.000). With notable levels of malnutrition and minimum dietary diversity observed among this group of preschoolers, it is important that stakeholders work collaboratively in coming up with integrated approaches to health and nutrition, in order to improve the wellbeing of its children.

Keywords: Dietary diversity; Food variety; Preschool children; Nutrition in Tobago children; Weight status


FVS: Food Variety Score; DDS: Dietary Diversity Score; NAR: Nutrient Adequacy Ratio; MAR: Mean Adequacy Ratio; WHO: World Health Organization; MDD: Mean Dietary Diversity; RNI: Recommended Nutrient Intakes; WAZ: Weight for Height Z-Scores; HAZ: Height-For-Age Z-Scores; WHZ: Weight-For-Height Z-Scores; THA: Tobago House of Assembly


Dietary diversity defined as a quantitative number of food groups is used extensively as a method for ascertaining variety and nutrient adequacy of diets [1-5]. Dietary diversity which is defined here as the number of different food groups consumed over a given reference period, has been identified as a potentially useful indicator. Nutrient rich foods from diverse diets are important elements in child feeding that supports dietary needs and adequate growth during their early years of life [6]. Further, a diverse diet, with foods from all food groups, is necessary for population groups to meet their requirements for essential nutrients. Increasing dietary diversity is a specific recommendation for children 6 months to 2 years of age [6]. Dietary diversity has been established as a significant predictor of growth, as illustrated by an analysis of Demographic and Health Survey data from children aged 6-24 months in 11 countries in Africa and Latin America [7]. In addition, dietary diversity has been linked to the pillars of food security: accessibility, availability and utilization [8]. Nutrition status is seen as an outcome of biological processes that involve adequate nutrient intakes among groups while dietary diversity ensures adequate nutrient intakes in populations [9].

Food variety (FV), defined as a simple count of food items consumed has been reported as a good indicator of nutrient adequacy of the diet [10]. Consumption of higher numbers of food items and food groups is associated with improved nutritional adequacy of the diet [10-11]. Evidence also shows that FV is associated with malnutrition and can predict a healthier diet in children [12]. Micronutrient malnutrition remains one of the largest nutrition problems worldwide [13]. Children are especially vulnerable due to their increase nutrient requirements for growth and development. The nutrient density of the diet provided to young children is often inadequate to meet their nutritional needs, as such increasing the diversity of foods provided such as meat, poultry, fish, eggs, fruits and vegetables is recommended to improve micronutrient intakes [6].

Evidence on dietary intake research, including FV and dietary diversity, for the island of Tobago, Republic of Trinidad and Tobago is sparse or non-existent. Data from the English-speaking Caribbean, on a whole, shows that iron deficiency anemia adversely affects young and school age children(1-16 years old) [14]. Strategies for promoting appropriate diets and healthier lifestyles for the Caribbean include, promoting consumption of a variety of foods [13-14]. Obesity is also a growing trend in the region and using the individual dietary diversity and FVS indicators as proxy measures of nutritional quality may provide practical and useful data that can be used to implement strategies for providing nutrition education and lifestyle disease prevention for this population. This study's purpose therefore was to assess dietary diversity, FV and its relationship to nutritional indices among Tobago preschool children.

Methods and Materials

A representative sample (n=423), stratified by parish, population distribution, gender and age, was recruited from public and private pre-schools located in Tobago, one of the southeasterly most islands of the English-speaking Caribbean. Parents or caregivers with children ages 2 to 4 years who were enrolled in a preschool program were eligible to participate in the study. Formal approval for the study was obtained from administrators of the Tobago Regional Health Administration and written consent was acquired from parents and/ or caregivers of the children. The University's Institutional Review Board approved the protocol for the study. Data collection was carried out using a structured, culturally sensitive questionnaire which was pretested and modified accordingly.

Dietary 24-hour recalls were conducted with parents or caregivers of each child by trained interviewers who visited the homes of each participant. Standardized culturally-sensitive protocol with dietary aids consisting of household utensils, wax models, and picture prompts were utilized for portion sizes and quality control. Researchers carried various samples of food models and traditional cooking vessels and utensils such as spoons, cups, bowls, glasses, tin cans, empty bottles, small food containers, samples of slices of roots and tubers, and packages of commercial foods and used these to help establish portion size. Relative validity was determined by comparison with data obtained from the same participants using a food frequency questionnaire. In addition, recalls were repeated in 10% of the sample.

Anthropometric measurements including heights and weight for each participant was determined using standardized techniques [15-17]. Detailed results of all the anthropometric data are published elsewhere [18]. Anthropometric measurements were compared to age and used to determine nutritional status of the children. EPI Info 2002 version 3.5.1 software was used to compute nutrition indices and the results were interpreted according to World Health Organization (WHO) cut off points [19].

Dietary diversity (DDS) and food variety scores (FVS) which were constructed based on the recall of parents or caregivers of the child's intake within the past 24 hours using World Health Organization (WHO) country-specific adaptation guidance [20,21]. Foods were categorized into six food groups as recommended by the WHO and included: (1) staples (grains/cereals, roots and tubers), (2) legumes and nuts, (3) dairy products (milk, yogurt and cheese), (4) animal/flesh foods (eggs, meat, fish, poultry and liver/organ meats), (5) vitamin A-rich fruits and vegetables; and (6) other fruits and vegetables.

Response options were scored and one point was awarded if food item was consumed and 0 point for food items not consumed [20,21]. Dietary diversity indicator was the sum of scores in the six food groups and is therefore ranged from 0-6. FV was calculated as the number of food items consumed over a 24-hour period from a possible 45 food items [10,22]. The minimum dietary diversity (MDD) indicator is calculated based on consumption of at least four of the following six food groups: (1) staples (cereals/grains, roots and tubers); (2) legumes and nuts; (3) dairy products; (4) animal/flesh foods; (5) vitamin A-rich fruits and vegetables; and (6) other fruits and vegetables. Consumption of < 3 food groups was considered as low dietary diversity, while 4 food groups is considered minimum and ≥ 5 food groups is classified as high dietary diversity [23].

Nutrient adequacy of the diet was established by calculating nutrient adequacy ratios (NAR) for 11 micronutrients and energy. NAR is defined as the intake of nutrient divided by the recommended nutrient intake (RNI) for that specific nutrient [13]. A mean adequacy ratio (MAR) was calculated as the sum of NARs for all evaluated nutrients divided by the number of nutrients evaluated, and expressed as a percentage. Pearson's correlation coefficients between FVS, DDS, and NAR were performed to establish relationships between variables at a significance level of p < 0.05. Simple regression analyses were computed to establish which nutritional indices are most significantly influenced by DDS, FVS and/or NAR. IBM® SPSS® Statistics version 22.0, 2014 was used to perform all statistical analyses.


Diversity by food groups

A mean DDS of 4.19 ± .83 (range 1 to 6) was obtained. Majority (48.23%) of the preschool children consumed food items from 4 food groups in the preceding 24 hours of the survey thus indicating aMDD in this population. A smaller percent of the sample, 19.15%, consumed < 3 food groups therefore indicating low dietary diversity. Only 6.15% (n=26) of the participants consumed a diversified diet from the six food groups; while 26% (n=112) consumed food items from five food groups. Fruits, vegetables and legumes were the food groups least consumed by the preschoolers. More than half (58.67%) ate zero servings of vegetables; 50.59% consumed zero fruits, and 70.3% did not consume legumes over the 24-hour period. Food groups such as staples, dairy products and animal flesh foods were highly consumed by most of the participants.

Food variety score

Findings from this study indicated that the highest number of food items consumed by this population within the previous 24- hour period was seventeen. Six to12 food items were consumed by most (83.69%) of the children. A mean FVS of 9.37 ± 2.45 (range 2 to 17) was obtained. Food items consumed frequently by many of the children included boiled dumplings made from cassava, wheat or cornmeal flour, saltine crackers, rice, dasheen, sweet potatoes, yams, green bananas, plantains, sweetened beverages, juice drinks, hamburgers, hotdogs, corned beef, salted pigtail, fresh fish/ seafood, eggs, sweet biscuits(cookies, filled and unfilled varieties), commercially and locally made milk-based drinks, callaloo, pumpkin, cucumbers, christophene, tomatoes, carrots, oranges, mangoes, grapes, and apples. Further descriptive analysis on items consumed revealed that most preschoolers (99%) consumed grains, roots and tubers, fish (92%), vitamin A-rich plant foods (80%), eggs (76%), dairy ( ≥ 60%), foods cooked in fats and oils (99.8%) and fatty-meats 46%. Food-groups less frequently consumed were fruits (50.5%), vegetables (50.67%), and legumes (70.3%).

Nutrient adequacy ratio

Nutrient Adequacy Ratios (NAR) for 11 nutrients was calculated. Significant relationships were found between NARs (%) for energy and several nutrients. NAR for energy showed significant moderately strong relationships with thiamin (r=.679; p=0.00), zinc (r=.657; p=0.00), calcium (r=.655; p=0.00), niacin (r=.564; p=0.00), riboflavin (r=.507; p=0.00) and folate (r=.502; p=0.00). A moderate relationship was found for vitamin B6 (r=.416; p=0.00), vitamin A (r =.459; p = 0.00) and iron (r =.416; p =0.00). Weaker relationships were found for energy and vitamin C (r=.212) and B12 (r=.188).

Nutritional status

Anthropometric characteristics of the sample were summarized and the z-scores used to determine nutrition status of the group. Data showed that the majority (≥ 50%) of the preschoolers were within normal/average height-for-age, weight-for-age and weight-for-height nutritional status. A distribution of the children by age and normal nutrition status is shown in Table 1. Smaller percentages of the participants were skewed towards being underweight, overweight, wasted and stunted or tall using standard nutrition indices.