q 7 0 Guidelines for the Development of a Simplified Dietary Assessment to Identify Groups at Risk for Inadequate Intake of Vitamin A A Report of the Intcrnational Vitamin A Consultative Group (IVACG)® Authors/Task Force Members Barbara A. Inderwood, Ph.D., Chairperson Miriam Chavez, M.P.H. Jean Ilankin, Dr. P.IH., RI). Jane A. Kusin, M.D., Phil). A. Omoiolu, M.D. Francesca Ronchi-Proja, Ml). Rirva Butrum, Ph.). (ad hoc) Sue Ohata, M.S. (technical assistance) IVACG Abraham H orwitz, M.D.. MP. I., Chairman Frances R. Davidson, Ph.D., Secretan, IVACG Steering Committee Barbara Undervood, Ph. D., Chairperson Edouard NI. I)eMaever, M.!). Demissie I labte, M.D. Florentino Solon, M.I)., N.P.1 I Alfred Sommer, M.D., N.H.Sc. IVACG Secretariat CO. Chichester, Ph.D. L uric Lindsay, RI). July 1989 lle purpose of tilet International Vitunin A Comnsultative GrUp (IVACG) isto guide internatio;ial actiVities ;Limed :treducing vitamin A dehciency in world. The group ile ofIteiN, con:tultatio i and gtid1niic to various oper;ting id donor agencies that are seeking to reduce vitamin Adelicienc'v ald its accompa. nying blindness As part of this service, IVACG has prepared guidelines and recolmnlendations flr * Assessing tihe regioniI distrihution and nugi de of vitarnin A dehicienicv " D)eveloping intr-ventliio strategies 1nd metholo(.hgtes to control vitamin A dticftenaC * Evaluaitig the effectiveness of implemetnted pro)grams oi)a coitinuing Io basN that fte evaluat I tf the effecttvettess of interention teCtt'IlquLeN Is3 1ntltlO1 ig ald dynamiic procedure * Researcth needed 10 support the assesstmtent, int'enenttin, and evalu;1ioll If programs NilnograplhN pub)ished hy the Internationl Vitamitn A Consultative Group 'ire * (;utd/Itth.\fi r Ih l-radicatio, ("Viinin A l)iiceno-antd Xeophlbalmia ( 19-7) " Recent Ahancets in tlt, ,Ielihoh/LvmaidFunction of Vitaunjn A and 7h'ir Re/aliti hJup)to Applwid Nitrition( 19"9) * '11' .Sal,I 'eof Vitamin A (1980) * 7the .lA'tn/otn aidd..tiqns of Vital A I )Picien'aldmtir Relations0p to AVpIted Nutritio, (1981, * Ichem0cal ,(Iethohologvfor the ,Assc.ment of Vitamin A Stiim (1982) * Rtprints o/Selected ,hds 'rthe Anal.tsu of Vitamin A and (,'jrolteoitd in A'utrttion tit-.- (1982) * I'eriodic la4rge (al I)s.e of Vilrtmt Afor t, Pret w'ition of Vilaeni,, A l)ciJicen' andA.\erophi/talni A Suimnla, of 1'r&' ,s ( 1984 ) * Ibe Saftc I 'seo/ Vitam A.i Women, )iring the,Reprolticli, )'an (1980) * fltxiiemiad Methoolog, for the .­ Ysmeitt;lY"'d roteie. ( 1987) " A )decatde ( 'Aa)ietetlllt 7e i ml'?7atitj io Ii Vitlwylinl A CotLiutil1 Grot UIVAC.G) 17) -19H5 ( 198") " Guhti'lmtvefir trt I se of Vitraini A itn l:mergenc-,, and Relicf Operatios ( 1988) " Vilamin A Supple. -nis A Guide to Ieir Ise in the "reatnitaind 'rev ntion of Vitatnin A l)e/ictit,'cp ad .\.erophhlbianttthlwwli' the World Ilei/ib Orgaemzation in t(nfiaictto t-lilb IVACG and I 'NII-: 1 )'I) * Ih'thioIlogie'sJr.thonnor'ngantd E'auatiingVitamin A )Dtficien't, huml1 lniit/'rograie"L These repIrts are availahlc tree of charge toidevelhping countries and for S3.50 hS ) to develiped countries copies canl he tirdered from tite IVACG Secretariat. IVACG Secretarialt Internatiaonal Life Sciences Institute-Nutrifnion Foundation 1126 16th Street, N W W1ashilngton),1)( 2(X)3( I!SA The puhlicatiii these if guidelines is made p issihle thro)ugh a c ilnoprative agreement htween tileOffice of Nutritio in,Bure:IU iif ScietICe 1tid*echnthiiii,-, Agency ftr I nternif ina1 I)eveh ipmenItI Of tileI 'nited States tif America, and The Nutrition Ituntlitolin). Inc.Washigliont, I).C ISBN Nti 0.9+0-98.(03 July 1989 ibrary of Congress Nii 89(-8 .i Printed in tileI nited States cilAmerica. Contents FOREW O RD ................................................................................ v I. A DIETARY APPROACH TO REDUCING VITAM IN A DEFICIENCY ............................................... 1 The Problem Defined Purpose of These Guidelines Appropriate Uses of a Simplified Dietary Approach Intended Users 11. FACTORS TO CONSIDER IN ESTIMATING THE DIETARY INTAKE OF VITAMIN A .............. 7 Food Availability Food Preparation Practices Cultural Practices Physiology III. FOOD SOURCES OF VITAMIN A AND DETERMINATION OF THEIR VITAMIN A ACT IVITY .......................................................................... 11 IV. DEVELOPMENT OF A SIMPLIFIED APPROACH TO DIETARY ASSESSMENT OF VITAM IN A INTAKES ................................................ 15 Assumptions in Developing a Model for Dietary Assessment Developing and Interpreting a Locally Useful Dietary Questionnaire to Assess Usual Dietary Intake of Vitamin A Some General Considerations V. INTERVENTION OPTIONS THROUGH FOOD SOURCES OF VITAMIN A ....................................... 31 Interventions at the National Level Interventions at the Community Level Interventions at the Individual Family Level VI. IMPEDIMENTS WITHIN HOUSEHOLDS TO DIETARY APPROACHES TO IMPROVE VITAMIN A INTAKES OF CHILDREN ................. 37 Food Availability Food Preparation Practices Cultural Practices Mothers' Nutrition Knowledge and Practices Crucial Considerations in Overcoming Impediments APPENDIX I Evaluating the Vitamin A Activity (RE ) of Diets ............................................. 4 1 APPENDIX II Limitations in the Use of Food Composition Tables .......................... 45 APPENDIX III Illi'stration of the Use of the Simplified Dietary Approach: Pilot Tests in Pahou, Benin, and Madura, Indonesia ............................................. 49 Foreword Increased risk of mortality and of morbidity among chil­ dren is reported to be associated with subclinical vitamin Adepletion Th-sc health-related consequences of an in­ ad( ,jIuic vitamin A status are in addition to the well­ c-tablished consequences for the visual system of vitamin Adeficiency. Tile associations are well known to research­ ers working with depleted and deficient animal models, but must be confirmed among human populations exist­ ing in environments where there are many contributing lectors with potential adverse consequences for health. As part of intervention trials and for other descriptive studies, diettry patterns of vitamin A intake are a desired part of the epiderniologKal data' for intracountr and cross­ cultural comparisons, and for development of appropriate nutrition and health education messages to change ad­ verse situations and practices. These IVACG guidelines to dietary assessment of vitamin A intake were developed with a focus on the problems of nonindustrialized countries. In some com­ munities, the diet is so uniform and low in vitamin A sources that there is no need for a dietary assessment to establish that tiey are at high risk of an inadequate intake. In other communities, the situation is less certain. These guidelines apply to the latter situation. Their purposes are: 1. To assist those who not only wish to group populations by risk of an inadequate intake for research purposes, but also must decide on cost-effective, appropriate follow-up interven­ tions. 2. To assist all types of field workers working with the community for better health, nutrition, and social conditions to give individual mothers with high-risk children appropriate direct ad­ vice in feeding them within the resources they have available locally and can afford as identi­ fied by the locally adapted dietary qucstion­ naire. The information included in chapter I is general, that in chapters 11, I11, and IVuseful to those responsible for developing the dietary assessment tools, and that in V chapters Vand Vl of interest mainly to those responsible for intervention program planning and development. These guidelines have been in the developmental stage for several years. The text reflects the collective experiences of the task force members and the critique of several reviewers too numerous to mention individually. Among those to whom special thanks are due for their helpful critiques are Franz Simmersbach, Rober( Weisell, Walter Willett, Gladys Block, and Erica Wheeler. The step-wise procedure has been tried in several countries (Benin, Indonesia, and Mexico) by some members of the task force and elsewhere (Bangladesh) by a few other professionals (Mohammad Abdullah and Luthfor Ahmed). Refinements have been incorporated based on these experiences. We are grateful to FAO Food Policy and Nutrition Division for partial financial assistance in conducting these field trials. Ongoing field applications of the guidelines incor­ porated into larger vitamin A intervention projects a­ supported by a variety of funding sources The committee is grateful to many agencies that have been eager to incor­ porate the procedure into dieir applications without ex­ pense to IVACG, such as AID, X'ashington, D.C.; the Ford Foundation in India; and the National Eye Institute, Bethesda, Maryland. Those who have experience with the step-wise procedure have found the approach to le moi, educa­ tional and helpful in practical sitiruiios. The validity of the guidelines in caitegorizing "risk" groups is still bcing tested by comtparison to other methods of dietary assess­ mncnt, and in some cases by biochemical and clinical mea­ surLnizJI., in Bangladesh, testing revealed that compared with a three consecutive day weighing method, the IVACG guidelines correlated weil in identifing children as groups at risk of inadequate vitamin Aintake (the identi­ fied purpose of the guidelines) but that the probability of misclassilication of aparticular-child into aparticu/arrisk category for vitamin Astatuswas