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BACKGROUND: Women's Dietary Diversity Score (WDDS) is an indicator of dietary diversity, a key component of diet quality in women of reproductive age (WRA). Limited information is available regarding its applicability in other population groups. OBJECTIVE: To examine the ability of the Minimum Dietary Diversity for Women (MDD-W) of 5-food groups cutoff to predict micronutrient adequacy in men and women 15 to 65 years old from 8 Latin American countries. METHODS: We used a 24-hour recall from 9216 participants in the Latin American Study on Nutrition and Health (ELANS) to determine Dietary Diversity Score (DDS) based on the consumption of 10 food groups. The Mean Probability of Adequacy (MPA) was associated with DDS for the overall sample, for men, WRA, and women of nonreproductive age (WNRA). Sensitivity and specificity analyses were performed to determine if the 5-food groups cutoff point for MDD can be used to correctly identify men, WRA, and WNRA with adequate micronutrient adequacy (MPA ≥ 0.70). RESULTS: We found a mean DDS of 4.78 ± 1.33 and an MPA of 0.64 ± 0.16, with 59% of participants showing a diverse diet (DDS ≥ 5). The 5-food groups-cutoff point showed a better balance between sensitivity and specificity predicting an MPA ≥0.70 in men, WRA, and WNRA. MPA was significantly associated with DDS in WRA and for men and WNRA, as well. CONCLUSION: The 5-food group MDD, originally intended to be used in WRA, performed equally well in predicting MPA ≥0.70 in men, WRA, and WNRA, and can be used as a proxy of micronutrient adequacy in Latin American population.

Plain language titleAssessment of the FAO Minimum Dietary Diversity Index to Estimate Micronutrients Intake in Urban Cities of 8 Latin America CountriesPlain language summaryThe Women's Dietary Diversity Score (WDDS) proposed by the Food and Agriculture Organization is an indicator that measures the variety of foods consumed by women of reproductive age (WRA), and it has been reported in several studies that the more diverse the diet, the greater the probability of meeting micronutrients requirements. This indicator has not been validated in other population, but few studies have been conducted in the Latin American region. So, we aimed to investigate whether the Minimum Dietary Diversity for Women (MDD-W) established for WRA could also predict sufficient micronutrient intake in men and women aged 15 to 65 years in the Latin American population. To accomplish this objective, we used data from the Latin American Study of Nutrition and Health (Estudio Latino Americano de Nutrición y Salud­ELANS) that collected dietary data from 24-h recalls from 9216 participants and analyzed the association between DDS and the Mean Probability of Adequacy (MPA). Additionally, we determined if the MDD cutoff point could correctly identify individuals with appropriate vitamin and mineral intake. We found that the overall mean DDS was 4.78 ± 1.33, the MPA was 0.64 ± 0.16, and approximately 59% of participants had a diverse diet. The MDD of 5-food groups cutoff point was demonstrated to be useful in predicting sufficient micronutrient intake for men, WRA, and women over 50 years. Respondents with a DDS ≥5 had higher micronutrient adequacy. These findings suggest that DDS can serve as a proxy for assessing micronutrient adequacy in urban populations beyond WRA. The effect of promoting diverse diets on micronutrient adequacy as part of intervention programs can be captured by the DDS in urban Latin American populations.

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Introduction: Energy imbalance gap (EIG) is defined as the average daily difference between energy intake (EI) and energy expenditure (EE). This study aimed to examine the associations between EIG and sociodemographic and anthropometric variables in the adolescent population of eight Latin America countries. Methods: A total of 680 adolescents aged 15 to 18 were included in this study. The estimation of EI was based on two non-consecutive 24-h dietary recalls. EE was predicted from Schofield equations using physical activity level obtained through the long version of the International Physical Activity Questionnaire. Sociodemographic data and anthropometric measurements were also obtained. A descriptive analysis and multilevel linear regression models were used to examine associations between variables. Results: The mean EI, EE, and EIG were 2091.3 kcal, 2067.8 kcal, and 23.5 kcal, respectively. Argentina had the highest EI and EIG, whereas Chile had the lowest EI and EIG. Males had a higher EI (2262.4 kcal) and EE (2172.2 kcal) than females (1930.1 kcal and 2084.5 kcal), respectively (p < 0.05). Overweight subjects had a lower EIG than did underweight and normal-weight subjects (p < 0.05). Subjects with low socioeconomic status (SES) had a lower EE (2047.0 kcal) than those with a high SES (2164.2 kcal) (p < 0.05). Conclusion: Sex and BMI were associated with EIG in adolescents from Latin America.

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Diet diversity becomes especially relevant during adolescence to satisfy the adequate micronutrient intake. Diet diversity (DD) and micronutrient probability of adequacy (PA) were studied in 818 Costa Rican (CR) and 1202 Mexican (MX) adolescents aged 13-18 years. DD was compared using the Minimum Dietary Diversity (MDD) score. Receiver-operating characteristic (ROC) curves were employed to identify the optimal MDD for each sample from the respective countries. The mean MDD for the overall CR sample was 4.17 ± 1.43 points, and for the MX sample, the mean MDD was 4.68 ± 1.48 points. The proportion of adolescents with a DD was significantly higher in Costa Rica than in Mexico (66.5% vs. 55.6%; p < 0.0001). Also, DD was higher in rural Costa Rican adolescents, while no difference was found in the MX adolescents by area of residence. CR adolescents reported significantly higher PA than MX participants for 6 of the 11 micronutrients assessed. The calcium PA in MX adolescents was significantly higher than in the CR sample (MX: 0.84 vs. CR: 0.03; p < 0.0001), while low PA was obtained for iron in both countries (CR: 0.01 vs. MX: 0.07; p < 0.0001). In Costa Rica and Mexico, nutritional interventions and assessing the compliance of food-fortifying programs are needed to improve the PA of diverse micronutrients.

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BACKGROUND: Latin American countries have shifted from traditional diets rich in micronutrients to a Westernized diet rich in high energy-dense foods and low in micronutrients. OBJECTIVE: This study aimed to determine the prevalence of adequate micronutrient intakes in urban populations of 8 Latin American countries. METHOD: Micronutrient dietary intake data were collected from September 2014 to August 2015 from 9216 men and women aged 15.0 to 65.0 years living in urban populations of 8 Latin American countries. Dietary intake was collected using two 24-hour recalls on nonconsecutive days. Micronutrient adequacy of intake was calculated using the Estimated Average Requirement cut-off method. RESULTS: In general terms, the prevalence of inadequate intake of thiamine, riboflavin, niacin, folate, cobalamin, iron, phosphorus, copper, and selenium ranged from 0.4% to 9.9%. In contrast, the prevalence of inadequacy of pyridoxine, zinc, vitamin C, and vitamin A ranged from 15.7% to 51.5%. The nutrients with a critical prevalence of inadequacy were magnesium (80.5%), calcium (85.7%), and vitamin D (98.2%). The highest prevalence of inadequate intakes was observed in the low educational level, participants with overweight/obesity, in men, and varies according to socioeconomic status. CONCLUSIONS: There is an urgent need to define direct regional actions and strategies in Latin America aimed at improving micronutrient adequacy, either through staple food fortification programs, agronomic biofortification, or food policies that facilitate economic access to micronutrient-rich foods.

Plain language titleDescription of the Vitamin and Mineral Consumption Status in Urban Cities of Latin America: Results of the Latin American Health and Nutrition Study.Plain language summaryVitamins and minerals are essential for maintaining good health. However, traditional Latin American diets are changing to include foods that have a lot of sugar and fat but fewer vitamins and minerals. This study was designed to analyze the consumption of these nutrients in urban cities of 8 Latin American countries. We collected food consumption information from September 2014 to August 2015 from 9216 men and women between 15 and 65 years old using a method called 24-hour recall. To find out if participants were consuming the necessary daily amounts of vitamins and minerals, intakes were compared with the daily recommended amounts suggested by the Institutes of Medicine of the United States. We found that Latin American urban populations consume fewer vitamins and minerals than recommended. In some cases, few people do not consume the required amounts of vitamins and minerals, but in other cases, many do not. For example, few do not consume enough thiamine, riboflavin, niacin, folate, cobalamin, iron, phosphorus, copper, and selenium. However an intermediate number of people do not consume enough pyridoxine and zinc, a high number consume little vitamin C and vitamin A, and many people consume very little magnesium, calcium, and vitamin D. We found that the people who consume fewer vitamins and minerals are mostly males, overweight/obese, have lower education and varies according to their financial resources. A deficient intake of vitamins and minerals showed up in most age groups, from adolescence to adulthood. To improve vitamins and minerals intake, it is important that some foods that are frequently eaten are fortified or that the price of foods that are high in vitamins and minerals is lowered.

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BACKGROUND: In countries where sugar fortification with vitamin A is mandatory, strategies to reduce the prevalence of overweight/obesity in adolescents that involve lowering added sugar intake could lead to vitamin A inadequate intakes, since vitamin A-fortified sugar for home consumption contributes to a high proportion of this vitamin intake in the adolescent diet. METHODS: The study employed a hierarchical linear model to perform a mediation analysis on a cross-sectional sample of adolescents (13-18 years old) in the province of San José, Costa Rica. RESULTS: Lowering the total energy intake derived from added sugars to less than 10% significantly increases the prevalence of vitamin A inadequate intake in adolescents by 12.1% (from 29.6% to 41.7%). This is explained by the mediation model in which, the reduced adequacy of vitamin A intake is mediated by a reduction in total energy intake derived from added sugars fortified with vitamin A. CONCLUSIONS: The vitamin A fortification of sugar for household consumption should be reassessed according to the current epidemiological profile in Costa Rica to promote strategies that reduce the prevalence of overweight/obesity in adolescents by lowering the consumption of added sugars without affecting vitamin A intake.

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Sugar-sweetened beverages (SSBs) are implicated in weight gain and adverse cardiometabolic heath. Social networks of stakeholders involved in providing potable water and sugar-sweetened beverages (SSBs) in high schools in Costa Rica were studied using social analysis network. In public and private schools, the interactions between the stakeholders in charge of providing beverages are fragmented and their role in preventing the availability of SSBs is weak. School canteen owners ultimately decide what beverages are available at school, which may cause students to choose beverages that increase the risk of overweight/obesity. It is therefore urgently necessary to improve the capacity for two-way interactions between the stakeholders to enhance their roles in the provision of beverages. Hence, it is essential to reinforce the stakeholders' leadership, and set up innovative ways to exert it in order to develop a shared vision of the types of drinks that should be available in the school environment.

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Parenting styles are a risk factor for adolescents overweight/obesity worldwide, but this association is not well understood in the context of Latin America. This study examines the association between the parenting styles of mothers and fathers and the risk of overweight/obesity among Costa Rican adolescents. Data are cross-sectional from a sample of adolescents (13-18 years old) enrolled in ten urban and eight rural schools (n = 18) in the province of San José, Costa Rica, in 2017. Hierarchical logistic regression analyses were performed to assess the likelihood of adolescents being overweight according to the mothers' and fathers' parenting styles. A significant association was found between the risk of adolescent overweight/obesity and the paternal authoritarian style only in rural areas (B = 0.622, SE = 0.317, Wald = 3.864, ExpB = 1.863, p = 0.04), and between said risk and the paternal permissive style only in male adolescents (B = 0.901, SE = 0.435, Wald = 4.286, ExpB = 2.461, p = 0.038). For maternal parenting styles, no associations reached significant levels once logistic regression models were adjusted for the fathers' parenting styles. These findings underscore the importance of further studying the role of fathers' paternal parenting styles on Latin American adolescent weight outcomes. Expanding our understanding of the parenting styles of fathers has important implications for the design and implementation of culturally- and gender-appropriate family interventions.

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Dietary diversity might be essential to meet nutritional demands during adolescence. Diet diversity among 818 urban and rural Costa Rican adolescents aged 13−18 years was studied using the Minimum Dietary Diversity Score for Women. The Nutrient Adequacy Ratio (NAR) was calculated for 11 nutrients to estimate the nutrient adequacy of the diet. A NAR < 0.7 was considered inadequate for micronutrient intake. The optimal Diet Diversity Score (DDS) cut-off point for this study was 4, established using receiver-operating characteristic curves. The mean DDS for the overall sample was 4.17 ± 1.43, although DDS was significantly higher in adolescents from rural vs. urban areas (4.33 ± 1.43 vs. 4.00 ± 1.42, p-value = 0.001). The odds of having a diverse diet were 62% higher in rural vs. urban adolescents. Overall, 80−95% of adolescents reached a NAR ≥ 0.70 for 8 nutrients except for calcium, zinc, and vitamin A. The residence area plays a key role in adolescent dietary diversity. Although overall DDS was low, foods that make up the rural adolescent diet were nutritionally dense enough to satisfy the EAR for most micronutrients. A high DDS is not necessarily required for the diet to meet most micronutrient demands in adolescence. Improved dietary adequacy of vitamin A, zinc, and calcium is required due to the importance of these micronutrients in maintaining optimal health.

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BACKGROUND: Whereas parental feeding styles (PFS) influence children's diet, less is known about this relationship in adolescents. METHODS: A cross-sectional study in 686 Costa Rican adolescents (13-18 years) evaluated 4 validated PFS scores: healthy eating verbal encouragement; scolding; directly controlling diet; instrumental/emotional. Diet was evaluated through 3-day food records, deriving a Traditional Costa Rica Adolescents Diet Score (TCRAD). Excess weight (EW) measured by BMI was dichotomized following standards. Regression-based mediation analysis estimated the overall and sex-stratified odds ratios of EW for natural direct (NDE), natural indirect (NIE), and total effects (TE) of the pathway PFS→TCRAD→EW. RESULTS: A one-unit increase in the direct control PFS score was associated with higher EW odds overall [(TE: 1.55; 95% CI: 1.04-2.31; p-value = 0.033), (NDE: 1.52; 95% CI: 1.02-2.27; p-value = 0.039)], and in boys [(TE: 2.13; 95% CI: 1.04-4.38; p-value = 0.039), (NDE: 2.10; 95% CI: 1.03-4.31; p-value = 0.042)]. Non-significant mediation by TCRAD was observed for the healthy eating verbal encouragement PFS overall (p-value = 0.06). Associations for the instrumental/emotional and scolding PFS were not significant. CONCLUSIONS: Direct diet control from parents may contribute to adolescents' excess weight, particularly among boys. Parents encouraging healthy eating might support adolescents' healthy weight through a healthy diet. Longitudinal research should clarify the association between PFS and diet-related outcomes among diverse adolescents.

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Consumption of added sugars, especially from sugar-sweetened beverages (SSBs), has been associated with several negative health outcomes during adolescence. This study aimed to identify dietary intake and food sources of added sugars in the home, school, and neighborhood environments of Costa Rican adolescents. Dietary intake of added sugars was determined using 3-day food records in a cross-sectional study of 818 adolescents aged 12 to 19 and enrolled in rural and urban schools in the province of San José. On average, 90% of adolescents consumed more than 10% of their total energy intake from added sugars. Furthermore, 74.0% of added sugars were provided at home, 17.4% at school, and 8.6% in the neighborhood. Added sugars were primarily provided by frescos (29.4%), fruit-flavored still drinks (22.9%), and sugar-sweetened carbonated beverages (12.3%), for a total contribution of 64.6%. Our findings suggest that Costa Rican adolescents have a plethora of added sugar sources in all food environments where they socialize. However, it is relevant for public health to consider the home and school environments as fundamental units of interventions aimed at reducing added sugars in the adolescent diet. Frescos prepared at home and school and fruit-flavored still drinks must be the focus of these interventions.

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