Some of the most popular dietary indices, such as the HEI, AHEI, and DASH Score indices, are most relevant to high-income countries that have access to plentiful food sources and food imports; therefore, these indices may not be relatable or applicable for low-income countries that struggle with food security ^[15]. The DQI-I is an index that allows users to customize measurements based upon country-specific guidelines. This customizability provides a foundation for additional considerations that could include other social and environmental contextual factors to provide a more holistic assessment. The DQI-I is used as a focused example index within this entry, specifically because of its applicability to various contexts. Other indices could also be modified using the conceptual framework suggested to incorporate other holistic factors. The process of how contextual considerations could be incorporated into dietary quality assessment through alterations, exclusions, modifications, and additions to the DQI-I are shown in Figure 1: Holistic Dietary Quality Assessment Process.

Figure 1. Holistic Dietary Quality Assessment Process.

The first step in the conceptual Holistic Dietary Quality Assessment Process is to identify the purpose or goal of the assessment to provide direction for the contextualization of overall dietary quality and how the assessment might be applied. Once the goal of the assessment has been identified, the next step is to select the most appropriate dietary index, including its components and scoring methods. For the examples researchers have provided, they used the DQI-I due to its applicability to different populations and settings ^[16] where this assessment process might be used ^[17]. The next step is to select a contextual factor or factors that are thought to potentially influence overall dietary quality. The factors listed in the assessment process model are nowhere near exhaustive of the biomedical, social, or environmental factors that could be present in a population. Additionally, it is understood that these factors are highly interconnected. Once the contextual factors have been identified for measurement, critical analysis of each index component should be conducted to determine what aspects of dietary quality may be influenced by the selected contextual factor, whether that be variety, adequacy, moderation, balance, or another index component. In other words, what components of the dietary index are being negatively affected due to the additional social or environmental factors. These considerations may add valuable context for evidence-based practices, allowing for translation of dietary quality scores to appropriate post-assessment recommendations, based on the social and environmental factors that influence dietary quality.

The following examples are hypothetical illustrations of how this conceptual assessment process might be use in different settings; specifically at the individual and community or societal levels of influence on health ^[18]. Table 2: Holistic Dietary Quality Assessment Process, Example 1: Community or Societal level, illustrates an example of a hypothetical community leader identifying potential reasons for poor dietary quality in their respective geographic location. Specifically, here researchers highlight rural areas where accessibility to healthful foods might be lacking, and how programming or policy changes might help to improve dietary quality at the community level. In order to determine accessibility, the United States Department of Agriculture: Economic Research Service’s “Food Data Atlas," ^[19] represents one way to identify areas of low income and areas of low accessibility to healthful foods. After completing the assessment process steps, the community leader could then determine what feasible, immediate, or minor changes could be made to increase the accessibility of healthful foods in their community. For example, reducing sales taxes on fresh produce or creating pop-up farmers markets within low-income, low-accessibility areas.

Table 2. Holistic Dietary Quality Assessment Process, Example 1: Community or Societal level.

To further demonstrate the assessment process, Table 3: Holistic Dietary Quality Assessment Process, Example 2: Individual level, illustrates a hypothetical practitioner helping an individual client who has lactose intolerance, and is living in a northern geographic area during winter. Through identification of barriers to achieving high dietary quality, such as decreased Vitamin D intake, the practitioner may focus on strategies to help increase dietary quality, such as switching to lactose-free dairy products, taking a Vitamin D supplement, or focusing on fortified foods. Additionally, by adding contextual factors the practitioner may identify a “ceiling” for the dietary quality that the client could potentially achieve, considering the factors that are in or out of that client’s control. This process could help to determine potential facilitators to improving dietary quality, making achievable recommendations to increase overall dietary quality. The goal would be able to maximize the potential dietary quality, recognizing that some factors would not be controllable and may not be easily modified.

Table 3. Conceptual Holistic Dietary Quality Assessment Process, Example 2: Individual level.

6. Cross-Population Comparisons

The flexibility for dietary quality scoring to be based on country-specific guidelines, when used within the context of a larger, uniform scale, provides a foundation for a holistic conceptual framework for evaluation across different cultures and populations. A more holistic and useful analysis of dietary quality may be possible when evaluation of dietary quality: 1) includes contextual social and environmental factors according to country or region, based on their specific dietary guidelines or the Food and Agriculture Organization of the United Nations (FAO) guidelines; and 2) considers variety, adequacy, moderation, and balance. Further, this more contextualized and holistic approach may allow insights regarding explanatory mechanisms behind dietary quality differences than are typically gleaned from assessments of dietary quality. For example, if a study were to evaluate the dietary quality of high-income countries (e.g., Canada) or populations where there is access to a large variety of imported foods, versus populations from a desert climate, low-income country (e.g., Libya) with few imported food products, dietary intakes and guidelines would likely differ drastically. While it is possible that indices of dietary quality could be modified to add biomedical, social, and environmental factors in order to provide a more holistic assessment, another potential approach would be to utilize previously designed dietary quality indices, with minor modifications, alongside separate tools that assess social and environmental factors anytime dietary quality is assessed. For example, if a practitioner suspects that a social or environmental factor may be a barrier to achieving high dietary quality scores, this conceptual framework may be used to determine what contextual factors are present, thereby allowing alterations to post-assessment recommendations and potential interventions.

7. Conclusions

The purpose of the current entry was not to offer a definitive solution for the problem of poor dietary quality, but rather to shine a light on the need to further inquire about how researchers might accomplish the inclusion of contextual factors when seeking to understand the barriers and facilitators for optimizing dietary quality. Considering contextual factors alongside adherence to dietary guidelines in dietary quality assessment could strengthen the core of evidence-based practices. Evidence-based practices are essential for providing high-quality care, guiding development of policy, determining preventive practices, and much more. Improved understanding of individual and population-level goals, expectations, preferences, accessibility, and resources, through evidence-based nutrition practices, will produce reasonable, applicable, and beneficial nutritional recommendations. A holistic approach to dietary quality assessment may allow nutrition professionals to better identify areas for improvement, such as potential barriers contributing to poor adherence to guidelines within dietary intervention studies, or specific population needs for overcoming barriers to positive health outcomes. If dietary quality is substantially hindered due to social or environmental factors, public health officials could use these data to work toward mitigating barriers to the extent possible. Further, identification of populations who are doing well with regard to dietary quality, even while facing social or environmental challenges, could assist nutrition scientists in advising government agency professionals developing future dietary guidelines.