Development and Validation of a Nutrition Transition Diet Score for Adolescents in India
Authors: Shaikh Nida , Ramakrishnan Usha , Patil Shailaja , Yount Kathryn , Martorell Reynaldo , Narayan KM Venkat , Cunningham Solveig 
Published: November 2023

BackgroundEmerging research suggests changes in dietary patterns among adults and youth during the global nutrition transition, but there is no dietary score to measure the extent of nutrition transition that may be occurring.ObjectiveTo develop and validate an index‐based Nutrition Transition Diet Score for adolescents in India.MethodsAn evidence‐driven index‐based apriori Nutrition Transition Diet Score for adolescents was developed and validated against an exploratory factor analysis (EFA) derived Diet Score. The EFA with varimax rotation was used to derive dietary patterns from answers to a validated food frequency questionnaire provided by 198 adolescents in Vijayapura, India. The evidence‐driven index‐based Diet Score among adolescents who were in the top quartile (≥75 percentile) of the main dietary pattern were compared using diet score means to the rest of the group.ResultsThe apriori index‐based Nutrition Transition Diet Score (range 0 – 10) included six food groups: fried foods, sugar‐sweetened beverages, dairy, fruits and vegetables, and bread, and four nutrients, namely total dietary fat, saturated fat, cholesterol, and simple sugars (table 1). The Spearman correlations between the index‐based Diet Score and EFA‐driven Diet Score was high (r=0.68, p <0.0001). Among the adolescents, the mean evidence‐driven index‐based Nutrition Transition Diet Score was 4.7 ± 1.1. The following three dietary patterns were identified using EFA: the transition ‘westernized’ pattern (factor loadings >4 for breads, fried foods, processed foods, sugar‐sweetened beverages (fruits juices and carbonated beverages), and sweets and desserts), the animal‐source pattern (factor loadings >4 for egg, lean meat, and red meat), and the traditional ‘Indian’ pattern (factor loadings >4 for grains, fruits and vegetables, dairy, sugar, traditional fried foods, and ghee) (table 2). The loading of traditional fried foods on both traditional and transition patterns indicate that as diets may become more ‘westernized’, this food group may continue to remain as one of the main components of the diet. The mean index‐based Diet Score was significantly higher (p< 0.0001) among adolescents in the upper quartile of the transition pattern (score range: 4–8) when compared to the rest (score range: 1–6) (table 3). This shows that the evidence‐driven index‐based Nutrition Transition Diet Score is valid against an exploratory factor analysis (EFA) derived Diet Score for adolescents.ConclusionThe validated index‐based Nutrition Transition Diet Score can be used to measure nutrition transition among adolescents in India. To our knowledge, this is the first diet score to assess the extent of nutrition transition.Support or Funding InformationNida Shaikh was supported by funding from the Fogarty International Center of the National Institutes of Health (award number 1‐R25 TW009337‐01).
Components of the Index‐based Nutrition Transition Diet Score

Components of the evidence‐driven Nutrition Transition Diet Score
Criteria for Score 1 (Indicates Nutrition Transition)
Criteria for score 0 (Indicates no Nutrition Transition)

1. Processed foods
>30 g/d
< 30 g/d

2. Fried foods
>30 g/d
<30 g/d

3. Sugar‐sweetened beverages
> 0 ml/d
< 0 ml/d

4. Dairy
> 500 g/d
< 500 g/d

5. Fruits and vegetables
< 400 g/d
> 400 g/d

6. Breads
> 25 g/d
< 25 g/d

7. Simple sugars
> 10% of total calories
< 10% of total calories

8. Fat, total
> 30% of total calories
< 30% of total calories

9. Saturated fat
> 10% of total calories
< 10% of total calories

10. Cholesterol
> 300 mg/d
< 300 mg/d

Dietary patterns using exploratory factor analysis and their factor loadings among adolescents in South India (n=198)a

Food group
Factor 1 ‘Transition Pattern’
Factor 2 ‘Animal foods pattern’
Factor 3 ‘Traditional Pattern’

Breads
0.42
—
—

Global Unhealthy Foods
0.61*
—
—

Global Healthy Foods
—
—
—

Processed Foods
0.61*
—
—

Snacks
—
—
—

Fried Snacks
0.76*
—
—

Red Meat
—
0.67*
—

Lean Meat
—
0.80*
—

Eggs
—
0.54*
—

Sweets and Desserts
0.46*
—
—

Dairy
—
—
0.48*

Tea and Coffee
—
—
—

Fruit Juices
0.45*
—
—

Soda and Energy Drink*
0.54*
—
—

Fruits
—
—
0.49*

Vegetables
—
—
0.49*

Pulses and Nuts
—
—
—

Traditional Grains
—
—
0.47*

Fried Traditional Food
0.49*
—
0.42*

Sugar and Jaggery
—
—
0.58*

Ghee
—
—
0.43*

Eigen values
4.8
1.6
1.0

Variance explained (%)
3.0
2.2
20

Loading < 0.4 are designated with ‘—’.
Factor loadings greater than 0.4.

Intake of food groups (g/d) among adolescents with and without Nutrition Transition diets (n=198)

Food group (g/d)
Nutrition Transition diet group (n=49)
No Nutrition Transition diet group (n=149)
T‐test

Mean
SD
Median
Mean
SD
Median

Breads
58.9
41.6
51.4
29.8
34.5
14.8
<.0001

Global Unhealthy Foods
67.9
53.6
50.4
15.4
22.1
8.5
<.0001

Global Healthy Foods
3.5
11.4
0.0
0.5
2.4
0.0
0.003

Processed Foods
59.3
35.5
53.4
25.3
20.2
19.6
<.0001

Snacks
59.1
40.1
52.6
31.2
32.7
22.2
<.0001

Fried Snacks
177.3
91.6
171.3
47.3
36.9
37.7
<.0001

Fried Traditional Food
37.6
23.9
31.6
19.1
15.7
14.2
<.0001

Sweets and Desserts
108.5
57.4
96.0
52.9
47.9
40.6
<.0001

Red Meat
5.7
11.3
0.0
4.1
9.8
0.0
0.33

Lean Meat
20.5
37.9
4.0
9.4
17.7
0.7
0.0058

Eggs
32.1
37.9
25.7
13.4
17.8
6.6
<.0001

Dairy
221.5
155.9
201.3
160.4
181.3
106.0
0.035

Tea and Coffee
202.8
139.3
200.0
144.5
100.5
142.9
<.0001

Soda and Energy Drinks
47.1
44.4
32.9
7.5
15.6
0.0
<.0001

Fruit Juices
109.9
74.2
85.7
46.4
56.6
28.8
<.0001

Fruits
147.4
75.9
136.7
97.2
82.4
78.3
0.0002

Vegetables
128.6
85.2
116.6
110.6
109.7
79.8
0.29

Pulse and Nuts
284.3
117.3
299.7
258.3
147.7
235.9
0.26

Traditional Grains
763.9
228.1
757.8
615.2
269.9
564.7
0.0006

Sugar and Jaggery
4.7
5.2
2.1
4.5
7.1
0.7
0.83

Ghee
1.3
1.9
0.3
1.3
2.9
0.3
0.92

Evidence‐drive Nutrition Transition Diet Score
5.7
0.9
6.0
4.4
1.0
4.0
<.0001

Evidence‐drive Nutrition Transition Diet Score Range
4–8

1–6