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                                            DIETARY DIVERSITY AS A MEASURE OF NUTRITIONAL ADEQUACY 
                                                                                       THROUGHOUT CHILDHOOD 
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                             Melissa Christensen Daniels 
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                  A dissertation submitted to the faculty of the University of North Carolina at Chapel Hill in 
                                  partial fulfillment of the requirements for the degree of Doctor of Philosophy in the 
                                  Department of Nutrition. 
                                   
                                   
                                                                                                                        
                                                                                                                        
                                                                                                            Chapel Hill 
                                                                                                                  2006 
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                                                       Approved by 
                                                                                                                                            Advisor:  Linda S. Adair 
                                                                                                                                           Reader:  Barry M. Popkin 
                                                                                                                                      Reader:  Anna Maria Siega-Riz 
                                                                                                                                            Reader:  Julie L. Daniels 
                                                                                                                                        Reader:  Young K.N. Truong 
                        ABSTRACT 
                            
          Melissa Christensen Daniels:  Dietary Diversity as a Measure of Nutritional Adequacy 
                       throughout Childhood 
                   (Under the direction of Linda S. Adair) 
                            
                            
          Malnutrition is a widespread concern in developing countries, impacting children’s 
        cognitive and physical development, quality of life and lifetime productivity. Interventions to 
        improve nutritional status in international contexts require identification of at-risk 
        populations and correct conclusions about general nutritional needs. Screening tools are 
        currently being developed to meet these needs.  
          Dietary diversity indicators are promising tools currently being studied. They are 
        typically counts of food groups in the diet (i.e. a sum of defined food groups consumed in a 
        defined time period) and are practical for field use because they are simply measured and 
        positively correlated with nutrient intakes.  
          We created age-specific diversity scores (based on a pre-existing tool) for use in both 
        early childhood and adolescence, and evaluated their relationship to nutritional adequacy, 
        nutritional status (measured by height for age Z-score), and their combined ability to predict 
        adult height. Data were taken from the Cebu Longitudinal Health and Nutrition Survey, a 
        Filipino birth cohort of 3,080 followed from the early 1980s through the present.  
          We found that using minimum portion requirements improved the relationship of scores 
        to nutrient adequacy for the 6 nutrients evaluated (vitamin A, iron, calcium, niacin, 
        riboflavin, iron).  Modified scores also reflected amounts of food consumed, i.e. children 
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        with increasing dietary diversity also ate larger amounts of individual food groups. Related 
        increases in nutrient adequacy were largely due to these increased energy intakes, but there 
        were also small increases in the nutrient density of the diet at both ages. Linear models were 
        used to evaluate the relationship of both scores to height for age z-score. Scores at both ages 
        predicted crude increases in height for age z-score, although this relationship was weaker for 
        adolescents. After adjustment for confounders only the early childhood score was 
        significantly related height for age z-score, and only when mother’s had greater than 6 y of 
        education. In the crude longitudinal model, combined score increases did not predict ultimate 
        height improvements.  
          This research provides important insights about how diversity scores may be improved 
        for international malnutrition screening, and provides a basis for future research on the 
        performance of diversity scores across childhood. 
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                     ACKNOWLEDGEMENTS 
           
          I wish to thank my committee for their expertise and thoughtful comments, which were 
        of great help in improving the content and direction of this project. I am also gratefully 
        indebted to the OPS staff for painstaking data collection over many years, and to Litlit Duazo 
        and Judith Borja for answering many questions about the data. Thanks also to Gina Kennedy 
        for help obtaining early copies of the dietary diversity protocol, as well as for assistance with 
        my related questions. I also offer special thanks to my advisor, Linda Adair, whose insights 
        and thought-provoking questions were indispensable in defining this project from the very 
        beginning.  Thanks to my husband Scott for wonderful moral support as well as editorial 
        assistance.  And thanks most of all to the Lord, without whom none of this would have 
        occurred. 
         
            
                            
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