Low-burden metrics for monitoring healthy diets across contexts: A multi-country validation analysis using quantitative 24-hour dietary intake data

BackgroundUnhealthy diets are a major public health concern. However, a lack of available and up-to-date quantitative dietary intake data, accurate low-burden data collection methods, and valid and interpretable metrics across contexts has hindered frequent monitoring of diets globally. MethodsIn this multi-country validation study, we compared the relationships between low-burden metrics of a healthy diet, identified by the FAO, UNICEF, and WHO Healthy Diets Monitoring Initiative, and a suite of reference metrics of dietary intake. To this end, we used harmonized open access quantitative 24-hour recall and food record data collected from 77,118 adolescent and adult females across 27 countries. FindingsOn any given day, non-consumption of sweet foods or sweet beverages was associated with greater population-level adherence to <10% energy from free sugars in available upper-middle income countries [odds ratio (95% CI): 5.35 (5.05, 5.66)]. Food group diversity score (FGDS) was positively associated with mean adequacy ratio of micronutrients [{beta} of 1-SD change (95% CI): [~]11 percentage points (9, 12)], while NCD-Protect score best predicted consumption of [&ge;]400 g/day of fruits and vegetables [range odds ratio of 1-SD changes (95% CI): 2.56 to 3.01 (2.40 to 3.13) in lower-middle and high income countries, respectively]. FGDS and Global Diet Quality Score Positive were associated with achieving [&ge;]25 g/day of fibre and [&ge;]3,510 mg/day of potassium across contexts. No indicator accurately predicted adherence to WHO guidelines for sodium intake or energy intake ranges for carbohydrates, lipids, and proteins. InterpretationAccurate low-burden dietary assessment methods can provide valid metrics that enable timely monitoring of key characteristics of healthy diets globally. Specifically, avoiding sweet foods or sweet beverages serves as an indicator for population-level adherence to the WHO guideline for free sugar intake, while metrics reflecting nutritious food group diversity are strongly predictive of better micronutrient adequacy and adherence to WHO guidelines for fruits and vegetables, fibre, and potassium intakes across settings. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSUnhealthy diets are a common cause of all forms of malnutrition and are the major risk factor for non-communicable diseases. However, a lack of up-to-date nationally representative quantitative dietary intake data, and a lack of consensus on fit-for-purpose lower-burden data collection methods and metrics, based on comparative epidemiological evidence, has hindered monitoring of healthy diets globally. Added value of this studyUsing open access quantitative 24-hour recall and food record data collected in 27 countries, our validation analyses compared the relationships between measures of a healthy diet, deemed most promising for global surveillance by the FAO, UNICEF, and WHO Healthy Diets Monitoring Initiative, and a suite of reference metrics of dietary intake, both within and across countries. Implications of all the available evidenceNationally representative quantitative dietary intake assessments remain the reference for nutrition. Nevertheless, complementary low-burden methods can yield metrics that are suitable for high-frequency monitoring of healthy diets. Specifically, on any given day, avoiding sweet foods or sweet beverages is an accurate population-level indicator for achieving the WHO guideline of <10% kcal/day from free sugars, while metrics capturing nutritious food group diversity are associated with better micronutrient adequacy, as well as, higher probabilities of reaching WHO guidelines of [&ge;]400 and [&ge;]25 g/day for fruits and vegetables and fibre, respectively, and [&ge;]3,510 mg/day of potassium across contexts.