Overcoming the challenges: analyzing Cambodian 24-hour dietary recalls

Presented by Vashti Verbowski (MSc student at UBC)

Presented at the International Food Security Dialogue 2014:“Enhancing Food Production, Gender Equity and Nutritional

Security in a Changing World”

Sponsored By: Hosted By:

• The Fish on Farms project is being jointly conducted by the University of British Columbia (UBC) and Helen Keller International (HKI), with technical assistance from World Fish, in Prey Veng Province, Cambodia.

• This randomized control trial investigates an integrated Homestead Food Production models in relation to poverty, gender empowerment, and food and nutrition security, particularly among women and children.

• This is the first project known to rigorously measure the effectiveness of different models of Homestead Food Production at reducing undernutrition using biochemical and anthropometric measurements.

• University of British Columbia Ministry of Health, Cambodia

• Dr. Tim Green, Associate Professor, Human Nutrition Ministry of Planning, Cambodia• Dr. Judy McLean, Assistant Professor, Human Nutrition• Dr. Susan Barr, Professor, Human Nutrition• Dr. Larry Lynd, Professor & Director, Collaboration for Outcomes Research & Evaluation• Dr. Tony Farrell, Professor, Centre for Aquaculture and Environmental Research• Dr. David Kitts, Professor, Food Science & Associate Dean of Research• Dr. Ian Forster, Centre for Aquaculture and Environmental Research• Jen Foley, Fish on Farms Program Coordinator

• Helen Keller International - Cambodia Graduate Students• Dr. Zaman Talukder Kyly Whitfield (PhD, Nutrition)• Mr. Hou Kroeun Crystal Karakochuk (PhD, Nutrition)• Ms. Ly Sokhoing Vashti Verbowski (MSc, Nutrition)• Field Research Team Pardis Lakzadeh (MSc, Public Health)

Jeff Tang (BSc, Science)

Outline

• 24-hour dietary recall review• International nutrition research• Research project overview

BackgroundData collection

• Challenges encounteredPossible solutionsHelpful tools

• Summary

24-hour dietary recalls (Lee & Nieman, 2012)

• StrengthsQuick & inexpensiveMore objective Less participant burdenCan estimate population intake

• LimitationsOmitted/forgotten foodsUnder/over-reportingPoor descriptor of individual usual intake Data entry is labor intensive

multiple-pass method unknown in Cambodia

volunteers? repeat recalls

International nutrition research

• Food diversity: dietary diversity indices (Olney, 2009)• Food availability: food balance sheets (Hop, 2003)• Adherence: garden maintenance rates (Bushamuka, 2005)

• Current research lacking…

What do Cambodians eat?

What do Cambodians eat?

We need 24-hour recall data!

We need 24-hour recall data!

Evidence for food-based strategies

Evidence for food-based strategies

Research project overview: background

• Malnutrition among rural Cambodians (CDHS, 2010)Women

• 20% underweight (BMI <18.5)• 47% anemic

Children• 30% underweight (low weight-for-age)• 11% wasted (low weight-for-height)• 42% stunted (low height-for-age)• 57% anemic

Research project overview: background

• Diet low in fat (FAO, 2009; Health Canada, 2006; Barba, 2008)2382 kcal/capita/d 62.4g protein/capita/d (10.5% kcal) vs. 10-35% RDA36.9g fat/capita/d (13.9% kcal) vs. 20-35% RDA

vs. 40-57g/d SEA-RDA

Potential to improve nutrition

status

Potential to improve nutrition

statusAquaculture

(small fish ponds)Aquaculture

(small fish ponds)

Homestead Food Production (HFP)Homestead Food Production (HFP)

24-hour dietary recalls

24-hour dietary recalls

Research project overview: Fish on Farms

• 90 villages x 10 households each (n=900)• Each village randomly assigned to:

① Plant-based HFP② HFP + aquaculture (fish pond)③ Control

• Outcomes Food security & gender equality Income generation Dietary intake, blood, urine, & anthropometrics

Data collection: completed by HKI* staff

• 24HR data (woman & child) Trained interviewers Structured dietary recalls Baseline & endline data

• Nutrient analysis: 6 fish species

Vitamin A?*HKI: Helen Keller International

Spoon #1 Spoon #2 Spoon #3

Data collection: completed by HKI staff

• Household measures (props)

• Weighed portions

• Translations

Data analysis: 24-hour dietary recall (#325)Kangkong:

Rambutan:

Amaranth:

?

Challenge #1: finding nutritional information

• Purchased ESHA Uses latest USDA data Includes Canadian Nutrient File Errors minimized with quality control reviews Contains ~55,000 foods

• Use local food composition data www.FAO.org Vietnamese East Asia

1. Bảng thành phần dinh dưỡng thực phẩm Việt Nam năm 2000

1. Sheet nutrient composition of food Vietnam in 2000

3. Cơ sở dữ liệu thành phần thực phẩm Mỹ - USDA Food Composition 3. Databases U.S. Food ingredients – USDA Food Composition Database, Version 18, 2006…

Challenge #1: finding nutritional information

www.translate.google.com…

Challenge #2: dealing with unknowns

Estimate unknown nutrients: www.fishbase.org Step 1: Classify Labeo rohita (carp or minnow)Step 2: Search database for similar fish

Vitamin A?

Challenge #2: dealing with unknowns

Liaise with experts

Challenge #2: dealing with unknowns

Red ant egg

Rabutan leaves Sakura (crab)Red ants

Frogs

Challenge #3: questionable reliability Reliability: “we are producing the same estimates every time”

•Develop set of assumptions Replace “water lily” with “kangkong” (no nutrition info)

•Use the 5-step multiple-pass 24-hour dietary recall for endline 1st pass: quick list 2nd pass: forgotten foods 3rd pass: time & place 4th pass: detailed description 5th pass: final review idea: take pictures of labels

portion size & additions

snacks & beverages food from previous day

sort chronologically

Challenge #4: assessing validity

Validity: “we are measuring what we intended to measure”

•Energy & fat intake: monitor height & weight

•Compare nutrient intakes against biomarkers Iron: hemoglobin, ferritin Vitamin A: retinol, carotenoids Zinc: serum zinc

Summary of the challenges & solutions

• Finding nutritional information Use local resources when possible

• Dealing with unknowns Develop relationships with “experts” Consider “road-blocks” beforehand

• Improving reliability Develop a set of assumptions Use validated techniques

• Improving validity• Compare dietary intake data against biomarkers

References:•Barba, C.V.C. & Cabrera, M.I.Z. (2008). Recommended Dietary Allowances harmonization in Southeast Asia. Asia Pacific Journal of Clinical Nutrition, 17(S2): 405-408.•Bushamuka, V.N., de Pee, S., Talukder, A., Kiess, L., Panagides, D., Taher, A., & Bloem, M. (2005). Impact of a homestead gardening program on household food security and empowerment of women in Bangladesh. Food and Nutrition Bulletin, 26(1), 17-25. •FAO (2009). FAOSTAT: Cambodia. Retrieved from http://faostat.fao.org/site/368/DesktopDefault.aspx?PageID=368#ancor •FAO (1972). Food Composition Table for use in East Asia 1972. Retrieved from http://www.fao.org/docrep/003/X6878E/X6878E00.htm •FAO (2014). International Network of Food Data Systems (INFOODS). Retrieved from http://www.fao.org/infoods/infoods/tables-and-databases/asia/en/ •FishBase (2014). Retrieved from http://fishbase.org/search.php •Google Translate. Retrieved from http://translate.google.com/ •Health Canada (2006). Dietary Reference Intakes. Retrived from http://www.hc-sc.gc.ca/fn-an/nutrition/reference/table/ref_macronutr_tbl-eng.php•Hop, L.T. (2003). Animal Source Foods to Improve Micronutrient Nutrition and Human Function in Developing Countries. Journal of Nutrition, 133(11:2), 4006S-4009S. •Lee, R.D. & Nieman, D.C. (2012). Nutritional Assessment. Sixth edition. McGraw-Hill. •National Institute of Statistics, Directorate General for Health, & Measure DHS. (2010). Cambodia Demographic and Health Survey (CDHS) 2010. Phnom Penh, Cambodia & Calverton, Maryland, USA. Retrieved from http://www.measuredhs.com/pubs/pdf/FR249/FR249.pdf •Olney, D.K., Talukder, A., Iannotti, L.L., Ruel, M.T., & Quinn, V. (2009). Assessing impact and impact pathways of a homestead food production program on household and child nutrition in Cambodia. Food and Nutrition Bulletin, 30(4), 355-369. •Vietnamese Food Composition Table (2007). Retrieved from http://www.fao.org/fileadmin/templates/food_composition/documents/pdf/VTN_FCT_2007.pdf

* Photos from the Fish on Farms blog: http://fishonfarms.landfood.ubc.ca/topics/blog/

Acknowledgements

Thank you to my committee members & HKI: Dr. Tim Green, Associate Professor, UBC LFS Human NutritionDr. Judy McLean, Senior Instructor, UBC LFS Human Nutrition

Dr. Susan Barr, Professor, UBC LFS Human NutritionDr. Larry Lynd, Associate Professor, UBC Pharmaceutical SciencesHelen Keller International in Cambodia (Zaman Talukder et al.)

Sponsored By: Hosted By: