Relative validity and reproducibility of WHO indicators for assessment of feeding practices in children under two years of age

Oliveira, Juliana Martins; Silva, Ana Carolina Feldenheimer da; Moraes, Milena Miranda de; Cardoso, Letícia de Oliveira; Castro, Inês Rugani Ribeiro de

doi:10.1590/1413-81232023284.13792022

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ARTICLE • Ciênc. saúde coletiva 28 (4) • Apr 2023 • https://doi.org/10.1590/1413-81232023284.13792022 copy

Relative validity and reproducibility of WHO indicators for assessment of feeding practices in children under two years of age

Validade relativa e reprodutibilidade de indicadores da OMS para avaliação da alimentação de crianças menores de dois anos

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

The study aimed to evaluate relative validity and reproducibility of seven WHO indicators of dietary practices in children aged 6-23.9 months. Data from probabilistic sample of children who used primary healthcare services in Rio de Janeiro, Brazil were collected using a 24h dietary recall (24HR) and a closed questionnaire (Q1) on feeding in the day before the study. The last one was reapplied (Q2) around 16 days later. Validity was assessed by comparing the prevalence rates estimated by 24HR and Q1 and calculating the positive (PPV) and negative (NPV) predictive values, sensitivity (Se), specificity (Sp), and accuracy index (AI) for the resulting indicators. For reproducibility, estimated prevalence rates based on Q1 and Q2 were compared and the kappa index and prevalence-adjusted bias-adjusted kappa were estimated. Of the seven estimated indicators, the prevalence of two was overestimated (Continued breastfeeding: 50.0% vs 40.0%; Sweet beverage consumption: 65.1% vs 52.7%) and the prevalence of one was underestimated (Zero vegetable or fruit consumption: 6.5% vs 18.1%). For most indicators, Se and PPV were higher than Sp and NPV. The prevalence rates determined with Q1 and Q2 were similar for 6 indicators. More than half showed good, very good or excellent agreement.

Key words:
Data accuracy; Validity; Reproducibility; Breastfeeding; Complementary feeding

WHO/UNICEF indicators*		Study
Indicator	Description	Questions used to compose the indicator in the study (referred to the previous day)
Continued breastfeeding 12-23 months	Definition: percentage of children 12-23 months of age who were fed breast milk during the previous day. Numerator: children 12-23 months of age who were fed breast milk during the previous day. Denominator: children 12-23 months of age.	Did the child receive breastmilk?
Introduction of solid, semi-solid or soft foods 6-8 months	Definition: percentage of infants 6-8 months of age who consumed solid, semi-solid or soft foods during the previous day. Numerator: infants 6-8 months of age who consumed solid, semi-solid or soft foods during the previous day. Denominator: infants 6-8 months of age. Note: For this indicator, we considered only natural and minimally processed foods.	Did the child receive… Mango, papaya, or guava? Other fruits besides mango, papaya, or guava? Regular foods (e.g. stews, purees, soups)?
Minimum dietary diversity 6-23 months	Definition: percentage of children 6-23 months of age who consumed foods and beverages from at least five out of eight defined food groups during the previous day. Numerator: children 6-23 months of age who consumed foods and beverages from at least five out of eight defined food groups during the previous day. Denominator: children 6-23 months of age. Note: The eight food groups: 1. breast milk; 2. grains, roots, tubers and plantains; 3. pulses (beans, peas, lentils), nuts and seeds; 4. dairy products (milk, infant formula, yogurt, cheese); 5. flesh foods (meat, fish, poultry, organ meats); 6. eggs; 7. vitamin-A rich fruits and vegetables; and 8. other fruits and vegetables.	Did the child receive… For Group 1: Breastmilk? For Group 2: Rice, potato, yam, cassava? Pasta? For Group 3: Beans or other types of grains like lentils, peas? For Group 4: Other milk besides breastmilk? Porridge with milk? For Group 5: Any kind of meat (beef, chicken, pork, fish, other)? Liver? Giblets, like gizzard or heart? For Group 6: Egg? For Group 7: Mango, papaya, or guava? Carrot, squash, sweet potato? Dark greens: kale, spinach, taro, broccolis? For Group 8: Other fruits besides mango, papaya, guava? Vegetables, not including potato/yam/cassava? Other greens besides kale, spinach, taro, broccolis?
Egg and/or flesh food consumption 6-23 months	Definition: percentage of children 6-23 months of age who consumed egg and/or flesh food during the previous day. Numerator: children 6-23 months of age who consumed egg and/or flesh food during the previous day. Denominator: children 6-23 months of age. Note: for this indicator, we considered only natural and minimally processed food.	Did the child receive… Egg? Any kind of meat (beef, chicken, pork, fish, other)? Liver? Giblets, like gizzard or heart?
Sweet beverage consumption 6-23 months	Definition: percentage of children 6-23 months of age who consumed a sweet beverage during the previous day. Numerator: children 6-23 months of age who consumed a sweet beverage during the previous day. Denominator: children 6-23 months of age. Note: sweet beverages include: • commercially produced and packaged, sweetened beverages such as soda pop, fruit-flavoured drinks, sports drinks, chocolate and other flavoured milk drinks, malt drinks etc. • 100% fruit juice as well as fruit-flavoured drinks, whether made at home, by informal vendors or packaged in cans, bottles, boxes, sachets, etc. • home-made drinks of any kind to which sweeteners (e.g. sugar, honey, syrup, flavoured powders) have been added.	Did the child receive… Industrialized juice in carton, bottle, or powdered form? Soda? Matte tea or natural guaraná? Was the milk chocolate-flavored?
Unhealthy food consumption 6-23 months	Definition: percentage of children 6-23 months of age who consumed selected sentinel unhealthy foods during the previous day. Numerator: children 6-23 months of age who consumed selected sentinel unhealthy foods during the previous day. Denominator: children 6-23 months of age. Note: Unhealthy foods are: - Candies, chocolate and other sugar confections, including those made with real fruit or vegetables like candied fruit or fruit roll-ups. - Frozen treats like ice cream, gelato, sherbet, sorbet, popsicles or similar confections. - Cakes, pastries, sweet biscuits and other baked or fried confections which have at least a partial base of a refined grain, including those made with real fruit or vegetables or nuts, like apple cake or cherry pie. - Chips, crisps, cheese puffs, French fries, fried dough, instant noodles and similar items which contain mainly fat and carbohydrate and have at least a partial base of a refined grain or tuber. These foods are also often high in sodium.	Did the child receive… Candy, lollypops, or other sweets? Hamburger, nuggets, sausage, ham, or baloney? Cookies or crackers? Packaged salty snacks? Any milk-based sweets (pudding, flan and/or ice cream)? Instant noodles?
Zero vegetable or fruit consumption 6-23 months	Definition: percentage of children 6-23 months of age who did not consume any vegetables or fruits during the previous day. Numerator: children 6-23 months of age who did not consume any vegetables or fruits during the previous day. Denominator: children 6-23 months of age.	Did the child receive… Mango, papaya, or guava? Other fruits besides mango, papaya, guava? Vegetables, not including potato/yam/cassava? Carrot, pumpkin or sweet potato? Dark greens: kale, spinach, taro, broccolis? Other greens besides kale, spinach, taro, broccolis? Was there fruit in the milk?

Variables	Frequencies						Qui-square^a
	All		Only 1 interview		2 interviews
	n	%	n	%	n	%
Sex (n = 187)
Female	88	47.1	56	53.8	32	38.6	0.037*
Male	99	52.9	48	46.2	51	61.4	0.037*
Age group (n = 187)
6-11.9 months	48	25.7	26	25.0	22	26.5	0.815
12-23.9 months	139	74.3	78	75.0	61	73.5	0.815
Maternal age group (n = 168)
14-19 years	13	7.7	5	5.5	8	10.4	0.237
20+ years	155	92.3	86	94.5	69	89.6	0.237
Maternal schooling (n = 184)
Primary	88	47.7	53	52.5	35	42.2	0.164
Secondary or University	96	52.2	48	47.5	48	57.8	0.164
Monthly family income (n = 169)
Less than $310.72	24	14.2	12	12.8	12	16.0	0.550
$310.72 or more	145	85.8	82	87.2	63	84.0	0.550
Government benefit (n = 185)
Yes	52	28.1	29	28.4	23	27.7	0.914
No	133	71.9	73	71.6	60	72.3	0.914
Food and nutrition security (n = 173)
Security	102	59.0	56	56.5	46	62.2	0.459
Insecurity	71	41.0	43	43.4	28	37.8	0.459

Indicators	Prevalence (%)		McNemar^a	Sens^b (%)	Espec^c (%)	AI^d (%)	PPV^e (%)	NPV^f (%)
Indicators	Q1	24HR
Continued breastfeeding	50.0	40.0	0.001*	98.1	82.9	89.1	79.7	98.5
Introduction of solid, semi-solid or soft foods	70.0	65.0	1.000	84.6	57.1	75.0	78.5	66.6
Minimum dietary diversity	80.3	76.6	0.311	90.2	52.2	81.3	86.0	62.1
Egg and/or flesh food consumption	83.0	78.7	0.134	95.2	62.5	88.1	90.3	78.1
Sweet beverage consumption	65.1	52.7	0.001	96.9	76.3	88.0	84.2	95.0
Unhealthy food consumption	97.3	92.6	0.146	98.2	18.1	93.5	95.00	40.0
Zero vegetable or fruit consumption	6.5	18.1	0.000	34.3	99.3	88.1	91.6	87.8

Indicators	Prevalence (%)		McNemar^a	Kappa	Agreement	BI^b	PI^c	PABAK^d	Agreement^e
Indicators	Q1	Q2
Continued breastfeeding	49.2	46.8	1.000	0.97	Excelent	0.01	0.03	0.97	Excelent
Introduction of solid, semi-solid or soft foods	80.0	40.0	0.219	-0.07	Poor	0.40	0.20	-0.20	Superficial
Minimum dietary diversity	81.4	67.4	0.029*	0.23	Superficial	0.13	0.48	0.40	Fair
Egg and/or flesh food consumption	81.4	79.1	0.804	0.41	Fair	0.02	0.60	0.63	Good
Sweet beverage consumption	61.6	59.8	1.000	0.52	Fair	0.01	0.20	0.54	Fair
Unhealthy food consumption	94.1	94.0	1.000	0.74	Good	0.00	0.90	0.95	Excelent
Zero vegetable or fruit consumption	4.7	7.3	0.219	0.22	Superficial	0.04	0.90	0.85	Very Good

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[1] Chief editors:

Romeu Gomes, Antônio Augusto Moura da Silva