Measuring the Nutrition Transition among Adolescents in India Open Access

Shaikh, Nida Izhar (2016)

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Nutrition transition, shifts in dietary patterns accompanying globalization and urbanization, are contributing to the emergence of nutrition-related chronic diseases in low- and middle-income countries, including India. Nutrition transition-related changes are believed to comprise shifts towards diets high in fat, sugar, and salt; these are also risk factors for chronic diseases. Little is known about the nutrition transition among adolescents, partly due to lack of appropriate data and metrics. The aim of this dissertation was to measure the nutrition transition among adolescents in India, home to 13.5% of the world's adolescents. First, dietary patterns were assessed in a representative sample of 399 school-going adolescents ages 13-16 years in a globalizing region in South India. Next, a comprehensive Nutrition Transition-Food Frequency Questionnaire (NT-FFQ), including a 125-item semi-quantitative FFQ and 27-item eating behavior questionnaire, was developed and evaluated for its reproducibility and validity to measure nutrition transition against three 24-hour dietary recalls in a sub-sample of 198 adolescents. Lastly, a pre-defined Nutrition Transition-Diet Score was developed using nutrition transition literature and dietary guidelines to measure nutrition transition, and evaluated for its validity against empirical dietary patterns derived from responses to the NT-FFQ. Adolescents' dietary patterns reflect a combination of global/non-local and traditional foods and can be categorized into three patterns; global, animal-source, and traditional (factor loadings ≥0.4). Compared with recommended guidelines, adolescents consumed higher-than-recommended energy-dense foods and lower-than-recommended dairy, fruits, and vegetables. Gender and school type were the main predictors of dietary patterns. The NT-FFQ showed good reproducibility and validity for most foods and eating behaviors and can measure nutrition transition among adolescents. The Nutrition Transition-Diet Score (mean 5.6 ± 1.2, range 0-10) included 10 components (7 food groups and 3 nutrients) and had good construct validity against empirical Global Diet pattern (factor 1; 60% concordance, 5% discordance, and Pearson correlation=.59, p<.0001). Based on the results, adolescents' dietary patterns in a globalizing Indian region reflect unhealthy and healthy nutrition transition features. Validated instruments, NT-FFQ and Nutrition Transition-Diet Score can effectively measure nutrition transition and can be utilized in programs and policies to improve adolescent health.

Table of Contents

CHAPTER 1: Introduction 1

Research Aim 1 5

Research Aim 2 6

Research Aim 3 6

CHAPTER 2: Background 17

Global Nutrition Transition 17

Nutrition Transition in India 20

Adolescent Health and Nutrition Transition 27

Nutrition Transition among Adolescents in India 29

Eating Behaviors of Adolescents in India 31

Measuring Nutrition Transition 33

Summary 38

CHAPTER 3: Methods 56

CHAPTER 4: Going global: Indian adolescents' eating patterns 61

Abstract 62

Introduction 64

Methods 67

Results 71

Discussion 74

Conclusions 79

Acknowledgements 80

References 81

Tables 87

CHAPTER 5: Development and Evaluation of a Nutrition Transition-Food Frequency Questionnaire for Adolescents in South India 93

Abstract 94

Introduction 96

Methods 97

Results 105

Discussion 108

Conclusions 114

Acknowledgements 115

References 117

Tables and Figures 124

CHAPTER 6: Development and Validation of a Nutrition Transition-Diet Score for Adolescents in India 136

Abstract 137

Introduction 139

Methods 142

Results 150

Discussion 152

Conclusions 156

Acknowledgements 157

References 158

Tables and Figure 167

CHAPTER 7: Summary and Conclusions 173

Main findings 173

Limitations 175

Strengths and Innovations 177

Next steps in developing validated dietary instruments to measure nutrition transition 178

Public Health Implications 180

Future Directions 182

Summary 184

References 185


Appendix A: Nutrition Transition-Food Frequency Questionnaire (NT-FFQ) 190

Appendix B: 24-hour Dietary Recall template 205

Appendix C: Article Attachment 210

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