GAIN Discussion Paper n°9 
                                                                                                                                                    FOOD GROUP DIVERSITY AND 
                                                                                                                                                    NUTRIENT ADEQUACY 
                                                                                                                                                    DIETARY DIVERSITY AS A PROXY FOR MICRONUTRIENT 
                                                                                                                                                    ADEQUACY FOR DIFFERENT AGE AND SEX GROUPS IN MEXICO 
                                                                                                                                                    AND CHINA 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
                                                                                                                                                     
                                                                                                                                                      GAIN Discussion Paper Series n°9 
                                                                                                                                                     
                                                                                                                                                    June, 2021 
                                                                                                                                                    Mary Arimond, Doris Wiesmann, Sonia Rodríguez Ramírez, Teresa Shamah Levy, 
                                                                                                                                                    Sheng Ma, Zhiyong Zou, Anna Herforth, and Ty Beal 
                                                                                                                                                     
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
                                                                                           GAIN Discussion Paper n°9 
                ABOUT GAIN 
                The Global Alliance for Improved Nutrition (GAIN) is a Swiss-based foundation launched at the UN in 
                2002 to tackle the human suffering caused by malnutrition. Working with governments, businesses 
                and civil society, we aim to transform food systems so that they deliver more nutritious food for all 
                people, especially the most vulnerable.  
                 
                Recommended citation 
                Arimond M, Wiesmann D, Ramírez SR, Levy TS, Ma S, Zou Z, Herforth A, and Beal T. Food group 
                diversity and nutrient adequacy: Dietary diversity as a proxy for micronutrient adequacy for different 
                age and sex groups in Mexico and China. Global Alliance for Improved Nutrition (GAIN). Discussion 
                Paper #9. Geneva, Switzerland, 2021. DOI: https://doi.org/10.36072/dp.9  
                 
                © The Global Alliance for Improved Nutrition (GAIN) 
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                Acknowledgements 
                We thank María Concepción, Medina-Zacarias, Andrys Valdez-Sánchez, Ruyi Li, and Hanxu Shi for 
                supporting data cleaning and processing and Stella Nordhagen and Flaminia Ortenzi for reviewing 
                drafts of this manuscript. This work was supported by the Government of Canada, as part of the 
                Business Platform for Nutrition Research (BPNR) hosted by the Global Alliance for Improved 
                Nutrition, and the Global Diet Quality Project which is financially supported by the Rockefeller 
                Foundation and the Swiss Federal Department Of Foreign Affairs.  
                Cover photo credit: © Shutterstock/lunamarina 
                 
                GAIN DISCUSSION PAPER SERIES 
                The GAIN Discussion Paper series is designed to spark discussion and debate and to inform action 
                on topics of relevance to improving the consumption of nutritious, safe foods for all, especially the 
                most vulnerable. 
                 
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                                                                                                                   1 
                 
                                                                                                      GAIN Discussion Paper n°9 
                SUMMARY
                Poor diet quality is a major cause of morbidity and mortality at all country income levels. Yet 
                to date, low-cost, feasible metrics for population-level assessment and monitoring of diet 
                quality are scarce. High-quality diets are safe, meet nutrient needs for healthy growth and 
                development at all ages, and reduce risks of non-communicable disease. While 
                comprehensive metrics covering multiple dimensions are desirable, there is also a role for 
                simpler indicators reflecting nutrient adequacy. This is particularly so in contexts where diets 
                lack diversity and deliver inadequate micronutrients.  
                To meet these needs, several simple food group diversity indicators have been developed. 
                These include the Minimum Dietary Diversity (MDD) indicator for infants and young children, 
                and a similar indicator, MDD-W, developed for women of reproductive age. However, there 
                is demand for indicators for other demographic groups. This paper thus tests the relevance 
                and performance of the MDD-W indicator and its underlying 10-point food group diversity 
                score (FGDS) for various demographic groups using data from two large upper-middle-
                income countries, Mexico and China. 
                We found that the FGDS was consistently and reasonably strongly associated with a summary 
                measure of micronutrient adequacy in both countries and for all age groups. The MDD-W 
                cut-off of five or more food groups allows expression of the indicator in terms of population 
                prevalence meeting this minimum, rather than as a score. This may have advantages for 
                communication and target setting. However, while this cut-off worked well for most 
                demographic groups in Mexico, it did not in China. We conclude that when more resource-
                intensive measurement is infeasible, FGDS is a meaningful proxy indicator of micronutrient 
                adequacy for diverse demographic groups and in diverse country income settings. The issue 
                of universal cut-offs remains challenging and unresolved, and additional studies in middle-
                income countries and with diverse age groups are warranted. 
                                                                KEY MESSAGES 
                       •   Low-cost, feasible, population-level indicators of diet quality are needed for all 
                           demographic groups and for a variety of country income levels. 
                       •   A simple 10-food group dietary diversity score was consistently associated with 
                           micronutrient adequacy for all age and sex groups (two years and older) in two 
                           upper middle-income countries (China and Mexico). 
                       •   A cut-off of five or more food groups, currently in use for women of reproductive 
                           age, gave inconsistent results across the two countries. 
                       •   When low-cost dietary measurement is an imperative, a simple 10-food group 
                           score can be recommended as a proxy indicator of micronutrient adequacy of the 
                           diet, for all groups two years of age and older. 
                   
                                                       
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                                               GAIN Discussion Paper n°9 
         Acronyms 
         AUC       Area under the receiver operating characteristic curve 
         BMI       Body mass index 
         BMR       Basal metabolic rate 
         CHNS      China Health and Nutrition Survey 
         ENSANUT   Encuesta Nacional de Salud y Nutrición (Mexican National Health and 
                    Nutrition Survey) 
         FGDS      A food group score with one point for each of ten food groups 
         MDD-W     Minimum dietary diversity indicator for women of reproductive age 
         MPA       Mean probability of adequacy across eleven micronutrients 
         NRV       Nutrient reference value 
         PA        Probability of adequacy 
         ROC       Receiver operating characteristic 
         WRA       Women of reproductive age, defined as 15–49 years 
          
                          
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