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NEWS AND VIEWS

DOI: 10.1111/nbu.12076

Diet modelling: How it can inform the

development of dietary recommendations and
public health policy
J. L. Buttriss*, A. Briend, N. Darmon, E. L. Ferguson, M. Maillot and A. Lluch
*British Nutrition Foundation, London, UK;

Department for International Health, University of Tampere, Finland;

Mixt Research Unit Nutrition Obesity and Thrombotic Risk, Aix-Marseille University, France;

Department of Population Health, London School of Hygiene and Tropical Medicine, UK;

Danone Nutricia Research, Global Nutrition Department, Palaiseau, France

Summary

With the global population expected to increase to 9 billion by 2050 coupled with
concerns about food security in relation to climate change and increasing prosperity
in many parts of the world causing desire for a less monotonous diet, efficient use
of resources such as food becomes ever more important. While the prevalence of
obesity is a cause for concern in many parts of the world, many people still go to
bed hungry, and in many communities, obesity co-exists with poor diet quality. The
result is a series of complex and challenging nutrition problems, such as the access
to nutritionally adequate and affordable diets and the development of dietary
recommendations. Diet modelling is a useful tool to help identify solutions to such
complex questions and this paper summarises a session on this topic at the International Congress of Nutrition that took place in September 2013.
Keywords: diet modelling, linear programming, nutrition, public health

Introduction
This paper summarises a series of presentations in a
session focusing upon diet modelling, sponsored by
Danone Nutricia Research,1 from the International
Congress of Nutrition that took place in Granada
(Spain) in September 2013. The session was introduced
by Dr Anne Lluch from Danone Nutricia Research and
chaired by Dr Andr Briend who also gave an introduction to the history of mathematical modelling of diets.

Correspondence: Professor Judith L Buttriss, Director General,

British Nutrition Foundation, Imperial House, 1519 Kingsway,
London, WC2B 6UN, UK.
E-mail: j.buttriss@nutrition.org.uk
1

Since the International Congress of Nutrition in Granada, Danone

Research has become Danone Nutricia Research.

2014 British Nutrition Foundation Nutrition Bulletin, 39, 115125

Other speakers in the session were Professor Judith

Buttriss, who set the scene by summarising the global
public health challenges in the field of nutrition; Dr
Nicole Darmon, who described the added value of the
use of linear programming to examine public health
nutrition questions, drawing upon examples from highincome countries; Dr Elaine Ferguson, who discussed
the application of linear programming in low-income
countries; and Dr Matthieu Maillot, who discussed the
application of linear programming techniques to the
diets of individuals in high-income countries.

Public health nutrition challenges

It is now widely recognised that a number of global
food, nutrition and health challenges exist, and that
these are very complex and often inter-related. Even in
the 21st century, 1 billion people go to bed hungry

115

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J. L. Buttriss et al.

and another billion have micronutrient deficiencies

(Foresight 2011). Insufficient energy and poor diet
quality result in poor growth and development in childhood, infection and inter-generational effects. Yet alongside this, more than 1 billion adults are overweight or
obese and, in many cases, excessive energy intake is
accompanied by poor diet quality and inadequate
intakes of essential nutrients. By 2050, a global population of over 9 billion is predicted as a result of
increased life expectancy, improved child mortality rates
and continued increase in birth rates in some parts of the
world. In Western countries such as the UK, life expectancy has been increasing by two years per decade for
some time, and birth rate is still rising slightly (Office for
National Statistics 2012), but healthy life expectancy is
not keeping pace with increases in overall life expectancy (Salomon et al. 2012), emphasising the importance, now more than ever, of promoting a healthy diet
and lifestyle.
A high profile focus upon the importance of achieving
food security, not just now but for future generations,
has been triggered by these trends coupled with
increased prosperity in previously low-income countries
(and consequent desire for a less monotonous or more
Western diet), concerns about the impact on the environment of climate change, and growing concerns about
future needs for land to grow food, for water and also
for energy. Food security has been defined by the UKs
Global Food Security Programme as occurring when
everyone has access to safe, affordable and nutritious
food, all of the time and in ways the planet can sustain
into the future (Global Food Security 2012). The reality
is that food availability is unevenly distributed around
the globe, and wastage along the food chain, from production through to consumption, remains high. If less
food were to be wasted [it is estimated that about 30%
is wasted (Foresight 2011)] and people ceased to eat in
excess of their energy needs, we could be more food
secure from a worldwide perspective (Global Food
Security 2013). A recent report from WRAP, responsible
for the Love Food Hate Waste campaign in the UK that
highlighted the level of household food wastage, has
revealed that the amount of food and drink thrown
away in the UK that could have been eaten fell by 21%
between 2007 and 2012 (Quested et al. 2013), so progress can be made.
In contrast, obesity levels continue to rise in many
parts of the world, affecting over 30% of the population
in the USA and 2025% in many European countries
(Central Intelligence Agency 2013). But it is not a phenomenon restricted to high-income countries, and in
many developing low-income and middle-income coun-

Table 1 Contribution of specific foods to nutrient intakes (i.e.

selected vitamins and minerals) in the UK diet
Contribution (%) of food types to average daily
intake of specific nutrients

Food type
Meat and meat
products
Fish and fish dishes
Milk and milk products

Zinc (34%), vitamin A (28%), vitamin D (22%),

iron (17%), potassium (15%), riboflavin (15%),
magnesium (12%)
Vitamin D (25%), iodine (11%)
Calcium (43%), iodine (38%), riboflavin (33%),
zinc (17%), vitamin A (14%), potassium (13%),
magnesium (11%)

Adapted from Henderson et al. (2003)

tries, obesity can be found alongside undernutrition and

poor micronutrient intakes.
Even in Europe, there are inadequate intakes of some
essential vitamins and minerals in some population
groups, particularly teenage girls (Mensink et al. 2013),
and excess intakes of saturated fatty acids, sugars and
salt are widespread. Clearly, there is a need for clear and
evidence-based dietary advice that can help steer people
towards healthier diets and, increasingly, emphasis is
being placed on the need for diets now and in the future
to be more sustainable too.
The challenges faced in harnessing sustainability
alongside good nutrition are considerable and, in considering and shaping recommendations, it is essential
that unintended consequences are avoided, or at least
their potential recognised and mitigated (Buttriss 2013).
This can be illustrated by the information presented in
Table 1. A number of vitamins and minerals have been
identified as in short supply in the diets of some people
in the UK (SACN 2008; Bates et al. 2012) and elsewhere
in Europe (Mensink et al. 2013), using the lower reference nutrient intake (the amount sufficient for only
2.5% of a population) as a point of reference. Using
data from the UK (Henderson et al. 2003), Table 1
shows the current UK dietary sources of these
micronutrients and it is evident that several of the foods
that are currently in the spotlight from a sustainability
perspective (meat, milk and fish) are important sources
of a number of these micronutrients.
Diet modelling is a useful tool to help solve complex
questions, not least because we need nutrients but eat
foods, nutrients are not evenly distributed in the foods
available to us, a wide variety of foods exists and there
is a broad spectrum of food consumption patterns and
contexts. As well as being a tool to explore more traditional diet and nutrition questions in both low-income
and high-income countries, it is already being used to
define sustainable dietary guidelines from a global food

2014 British Nutrition Foundation Nutrition Bulletin, 39, 115125

Diet modelling

security perspective and could also be used to help identify sustainable food systems. But, first, what is the
history of mathematical modelling of diets?

Introduction to mathematical modelling

of diets
Mathematical modelling of diets can be defined as the
use of mathematical techniques to formulate and optimise diets. Its origin can be traced back to the 1940s,
when George Stigler, a US economist, tried the technique
to determine the minimum cost of a diet providing the
amounts of energy, proteins, minerals and vitamins considered as adequate (Stigler 1945). This diet could
include any of 77 foods available on the US market at
that time with a known nutrient composition and cost.
Although he was a bright mathematician (he was
awarded the Nobel Prize in Economic sciences in
1982), Stigler could not find the exact solution to this
problem, which turned out to be incredibly complex.
The Stigler diet problem is a typical question of
resource optimisation or, in mathematical terms, of
minimisation of a linear function subject to multiple
linear constraints, also called linear programming.
During World War II, this question became of prime
importance to mathematicians involved in the war
efforts. The question was also pursued in the USSR, for
the purpose of economy planning and distribution of
food supplies (Dorfman 1984). Among the mathematicians who contributed to the solution of this problem,
George Dantzig had the idea of testing an algorithm he
had developed as a means to solving Stiglers diet
problem and he was the first to provide the exact mathematical solution in 1947 (Dantzig 1990).
The basic mathematical notions behind linear programming are simple and boil down to combining
several inequalities, which implies solving several linear
equations simultaneously, a problem within the reach of
secondary school mathematics. The difficulty, however,
is that the number of equations increases exponentially
with the number of variables that require optimisation
and rapidly become very time-consuming to solve.
Although Dantzigs simplex algorithm considerably
reduced the number of equations to solve, finding the
solution required several weeks, with clerks working
with mechanical calculators. In practice, diet modelling
became possible only with the advent of computers.
Optimisation modules based upon linear programming
are now part of standard spreadsheets.
Despite the role of the diet problem in the history of
linear programming, this approach received little attention in human nutrition until recently. The need to have

2014 British Nutrition Foundation Nutrition Bulletin, 39, 115125

117

computers and easy-to-use software is only part of the

explanation, as animal nutritionists have been using
these optimisation techniques for years. Key to the challenge is the need to introduce among the model constraints some functions that take into account the
acceptability of different foods and food groups, making
sure the proposed diet is realistic. In other words,
Stiglers diet problem is a very simplified version of real
life, and food acceptability constraints, ideally based
upon the findings of food consumption surveys in a
relevant population, should be added to the constraints
he initially introduced. With these caveats, linear programming can be used to identify ways to minimise the
cost of nutritionally and culturally acceptable diets, to
see whether it is affordable to low-income social groups
or to predict the effect of cost constraints on diet quality
(Darmon et al. 2002).
Food-based recommendations are formulated in
terms of the different food groups that constitute a
healthy, balanced diet and are needed every day, such as
a minimum daily number of servings of fruit and vegetables or dairy products, or twice a week in the case of
fish. Nutrient recommendations are formulated in terms
of intakes of energy, protein, essential fatty acids, vitamins and minerals. These two sets of recommendations
(food and nutrient recommendations) are often developed independently and their consistency is difficult to
assess. This is a major public health challenge because
when dietary intakes are inconsistent with food-based
recommendations, it is difficult to determine whether
this is because of poor compliance or because following
the recommendations requires dietary changes that are
difficult to implement. Linear programming can be used
as a rigorous approach to formulate food-based recommendations that are consistent with nutrient recommendations and current food habits. The approach used to
achieve this is to minimise a mathematical function that
measures the deviation of the recommended diet from
the diet currently consumed, while taking into account
nutritional constraints, such as the need to achieve an
appropriate energy intake or to achieve recommendations for salt or saturated fatty acid intake (Santika et al.
2009).
Setting limits of acceptability for different foods and
food groups improves the formulation of food-based
recommendations, but this alone is not enough to reproduce the complexity of human food behaviour. To
improve food-based recommendations, more advanced
techniques may be considered, particularly simulation
techniques reproducing the variability of intake of different foods in the population within observed limits
(Katamay et al. 2007). However, the difficulties associ-

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J. L. Buttriss et al.

ated with this should not be underestimated. The challenge is to obtain intake distributions for each food that
are realistic and also capable of resulting in an overall
energy intake that is consistent with the observed energy
intake distribution in the population. This is difficult to
achieve because individuals adjust their total energy
intake over time, meaning that intakes of individual
foods are not independent of one another. Randomly
assigning an intake to each food within observed limits,
without taking this complex regulation of food consumption into account, will result in unrealistically high
variability in energy intake.
The remaining sections of this article discuss how
linear programming can add value in a public health
context and provide examples of how linear programming can be used in a variety of public health settings to
establish practical and nutritionally robust food-based
dietary guidelines (FBDGs).

Linear programming: what is the added

value for public health nutrition?
Public and private stakeholders involved in public
health nutrition often develop tools and guidelines to
promote healthy eating. Within such efforts, the very
challenging ambition is to make the healthy choice the
easy choice for everybody, everywhere, and to take into
account food security and sustainability principles.
Linear programming can help tackle such a complex
task because of its ability to integrate a large number of
different kinds of variables and constraints.

Testing the compatibility of sets of recommendations

or public health goals
A particular strength of linear programming concerns its
ability to test the compatibility of sets of recommendations or public health goals, provided they can be
expressed as mathematical constraints. This is carried
out by evaluating the feasibility and/or the realism of
diets designed with linear programming models, including such constraints. In some countries, linear programming has been used to assess the relevance of nutritional
recommendations. In France (Martin 2001) and
Australia/New Zealand (Australian Government et al.
2006), the committees in charge of defining the national
nutrient-based reference intakes used linear programming to verify their feasibility and to identify the most
limiting nutrients [i.e. the nutrient(s) for which needs
will be the most difficult to achieve given the foods
currently available and the actual food habits of the
population].

Moreover, linear programming is the relevant tool to

explore which food changes are needed to fulfil an entire
set of nutrient recommendations. Taking France as an
example, the changes in food intake indicated by the
optimisation process as necessary to achieve nutrient
recommendations were shown to be in line with usual
dietary advice (Darmon et al. 2006).
Linear programming can also be used to verify the
implications of FBDGs in terms of nutrient intakes. For
example, in the USA, Gao et al. used linear programming to simulate the fulfilment of the food-serving recommendations of the 2005 Food Guide Pyramid. The
results showed that adhering to the Food Guide Pyramid
food-based recommendations would ensure adequate
intakes of most nutrients, except for potassium and
vitamin E (Gao et al. 2006).
Linear programming was also used to estimate the
deviation of existing American diets from the WCRF/
AICR (World Cancer Research Fund/American Institute
of Cancer Research) recommendations, which include
both general guidelines on maximal energy density,
daily intake of sodium, fibre and some key food groups,
and a final recommendation to meet all nutritional
needs through diet alone. The results showed that
achieving the general goals required little modification
of existing diets and had minimal impact on diet quality,
but that the final recommendation required a large
increase in food volume and dramatic shifts from the
observed food intake patterns (Masset et al. 2009).
The capacity of linear programming to translate
nutrient recommendations into concrete and quantified
advice may have very tangible public health implications. For instance, in an analysis of the French diet,
current nutrient recommendations were compatible
with consumption of some foods with an unfavourable
nutrient profile (together comprising one-fifth of the
basket weight), provided that almost two-thirds of the
diet comprised foods with the most favourable profile
(Maillot et al. 2011a). In the USA, energy allowances
for solid fats and added sugars in nutritionally adequate
American diets were estimated at 1733% by a linear
programming model (Maillot & Drewnowski 2011).

Combining nutritional constraints and other

dimensions of foods and diets
As well as affording the possibility of testing the compatibility between nutritional constraints, linear programming also provides an opportunity to look at the
compatibility between nutritional constraints and constraints on other dimensions of food and diets. For
instance, linear programming was used to help identify

2014 British Nutrition Foundation Nutrition Bulletin, 39, 115125

Diet modelling

125

45
Vitamin C

7
6.5
6

Vitamin C (mg/day)

Energy density (MJ/kg)

7.5

100

% Lipids

75

40

35

50

Energy density

30

Percentage energy from fat

8.5
8

119

5.5
5

25

Figure 1 Impact of a cost constraint on

dietary quality of modelled diets (adapted from
Darmon et al. 2002).

sustainable food patterns, which means food choices

that are socially acceptable, affordable, healthy and also
environmentally friendly. Data on food consumption,
food composition, food price and the carbon impact of
food were introduced in linear programming models to
derive nutritious diets with a low carbon impact, first
for the UK (Macdiarmid et al. 2012), then for France,
Sweden and Spain (Thompson et al. 2013) and lastly for
New Zealand (Wilson et al. 2013).

Diet affordability
A particular example of the strength of linear programming for analysing the relationships between different
dimensions is its role in the study of diet affordability, a
paramount question both in public health nutrition and
in the diet sustainability field. In the USA, the USDA
(United States Department of Agriculture) has been
applying diet modelling since 1975 to generate balanced, cheap menus: the Thrifty Food Plan (TFP)
(Carlson et al. 2007). A French study has combined diet
modelling and nutrient profiling approaches to identify
foods with a very good nutritional quality/price ratio
(i.e. the foods that should be preferentially selected to
provide a healthy diet on a low food budget) (Maillot
et al. 2008).

Other applications
Besides the classical application of diet modelling for
designing low-cost nutritious diets, linear programming
has also been used to explore the causal link between the
nutritional quality of diets and their cost. Using a model
where all the nutritional constraints (except energy)
were replaced by social acceptability constraints,

2014 British Nutrition Foundation Nutrition Bulletin, 39, 115125

25

Cost constraint (/day)

Mean pop.
diet

Darmon et al. showed unambiguously that economic

constraints have a negative impact on food choices
(Darmon et al. 2002, 2003). When the cost constraint
increases, it induces a reduction in the quantity of fruit,
vegetables, meat and fish in the baskets modelled, and
an increase in refined cereal products and fatty and
sweet products, which, in turn, induces a steep decline in
the nutritional quality, with a reduction in the level of
almost all protective nutrients (Darmon et al. 2002), an
increase in the percentage of fat, and a very steep
increase in the energy density (in kcal/100 g) (Darmon
et al. 2003) (see Fig. 1).
This work suggests that economic factors play a role
in the less healthy food choices associated with poverty.
In particular, the increase in energy density supported
the hypothesis that economic constraints play a role in
the high prevalence of obesity among low-income
people.

Nutrition intervention programme planning

and policy in low-income countries
Undernutrition in low-income countries contributes to
high rates of maternal and child morbidity, mortality
and poor development outcomes. To help address
undernutrition, tools based upon mathematical modelling have been developed recently to strengthen and
inform nutrition programmes and government policy
decisions and support advocacy efforts. Focusing upon
low-income countries, illustrations of user-friendly tools
based upon mathematical modelling that are currently
available for these purposes are described, namely Save
the Children UKs Cost of Diet tool, World Health
Organization (WHO)s Optifood and WHOs IMAPP
(www.side.stat.iastate.edu). Owing to time constraints,

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J. L. Buttriss et al.

a fourth tool based upon linear programming analysis

Nutri-survey was not described in detail. However,
interested readers are referred to its website
(www.nutrisurvey.de).
The first of these tools, the Cost of Diet tool, has
been used by field practitioners from both Save the
Children and the UN World Food Programme to
examine the role of the economic constraints as a
driver of malnutrition and to inform feasibility studies
for fortification programmes and for advocacy purposes. It can be used to identify the lowest cost of a
nutritionally adequate diet, the limiting nutrients and
to compare economic implications of fortifying different foods (Frega et al. 2012). Inputs into the model are
a list of foods and their average serving sizes, an
acceptable food pattern range and the average household composition. The model identifies the minimum
cost of a nutritious diet for a household, using constraints to ensure energy and nutrient requirements are
met, in a realistic diet (defined by its food patterns)
without exceeding upper tolerable nutrient levels. It
also identifies the percentage achievement of the reference nutrient intakes (RNIs) and the cost of each food
in the lowest cost diet.
Such information can be used to inform social protection programmes, for advocacy purposes, or to
compare the cost implications of fortifying alternative
food vehicles. For example, in Mozambique, Frega
et al. (2012) showed that the minimum cost of a nutritious diet exceeded the average weekly food expenditures of households from all socio-economic groups,
except the highest quintile group. Furthermore, they
predicted that the minimum cost of a nutritious diet
would be lower when maize flour instead of wheat
flour was fortified with iron, zinc, folic acid and
vitamin B12 (i.e. 544 vs. 584 metical per week); and in
both cases, it was lower than a diet without fortified
foods (i.e. 664 metical per week). However, even if
fortified foods were made available, the lowest cost of
a nutritious diet would exceed the average weekly food
expenditure of the three lowest socio-economic quintile
groups (Frega et al. 2012).
This example from Mozambique illustrates how
mathematical modelling can be used to show when
diet affordability must be addressed (e.g. via food subsidies or social protection programmes) to ensure
dietary adequacy for a population because even the
lowest cost nutritionally adequate diet exceeds the
average food expenditure of most socio-economic
groups in this population. It also shows how the Cost
of Diet tool can be used to inform fortification programme decisions from a cost perspective. However,

many other criteria would also be taken into account

in the final decisions.
The second of these tools, Optifood, was developed
by the London School of Hygiene and Tropical Medicine in collaboration with WHO and the Food and
Nutrition Technical Assistant III project (FANTA III)
(Daelmans et al. 2013). It has been used to inform food
value chain interventions, design food-based interventions for women and young children, and develop a
regional micronutrient strategy in Southeast Asia
(Santika et al. 2009; Berger et al. 2013).
The inputs required in the Optifood model are
similar to Cost of Diet except it is applied at an individual instead of a household level. It requires information on the foods commonly consumed by the
target population and, for each food, an estimated
average serving size (per meal or per day) and the
minimum and maximum number of times per week
this serving size could be consumed by any individual.
Also required is information on food patterns in a
realistic range (lower, median and upper) for the
number of servings per week that individuals in the
target population might consume foods from different
food groups and subgroups.
Unlike the Cost of Diet tool, which runs one linear
programming model, Optifood runs hundreds of different linear programming models to answer different
questions; and all of these modelled diets must be realistic to draw correct conclusions. In Optifood, there are
four modules of analysis: one to check that model
parameters ensure realistic diets; one to select the nutritionally best diet for the target population; one to test
alternative sets of food-based recommendations (FBRs);
and one to run a cost analysis. This last module is
similar to the Cost of Diet model, except it models at
the individual instead of household level and so will not
be described in detail here. In all models, there are
constraints to ensure modelled diets are realistic for the
target population, and in the third and fourth modules,
there are additional constraints to define the FBRs being
tested (third module) or to ensure the lowest cost diet
achieves or exceeds a desired level for each nutrient
(fourth module). This desired level is the RNI, unless
the RNI is unachievable, in which case, it is the
highest nutrient content achieved in the best diet for
that nutrient.
Optifood has been specifically created to formulate
and test FBRs to help inform decisions when planning a
food-based intervention. By modelling the nutritionally
best diet (module 2), it shows whether or not locally
available foods together can provide all the nutrients
needed by a target population; and when it is not fea-

2014 British Nutrition Foundation Nutrition Bulletin, 39, 115125

Diet modelling

0.07 $/day
Figure 2 Comparison of how well food-based
recommendations ensure diet adequacy.
FBR = food-based recommendations.
None no recommendations.
4 FBR dairy 21 servings/week; vegetables 21
servings/week; meat-fish-eggs 5 servings/week;
legumes 7 servings/week.
7 FBR dairy 21 servings/week; vegetables 21
servings/week; green leafy vegetables 7 servings/
week; meat-fish-eggs 5 servings/week; fish 3
servings/week; legumes 7 servings/week; fortified
cereal 7 servings/week..

0.22 $/day

0.24 $/day

120

121

Ca
Vit C

100

Vit A
B1

80

B2

60

B3
40

Folate

20

B12

Fe
None

sible, it identifies the nutrient gaps. As such, it informs

behaviour change strategies by identifying the food patterns (e.g. the number of servings per week of vegetables) or individual foods (e.g. liver) that will best ensure
a nutritious diet. It identifies micronutrients whose
requirements are unlikely to be met in the available diet,
indicating when programmes need to address issues
related to the availability, accessibility and/or
affordability of nutritious foods.
As mentioned, Optifood can also be used to test and
compare alternative FBRs, in terms of their ability to
ensure dietary adequacy. It simulates the lower tail of
each nutrient intake distribution (i.e. worst-case scenario) for up to 12 nutrients; and for each set of FBRs
tested, it compares their worst-case scenario levels
expressed as a percentage of their RNIs. If these tails
exceed 65% or 70% of the RNI, then there would be a
low percentage of the population at risk of inadequate
intakes. This process is illustrated in Figure 2, which
shows the comparative nutritional advantages of promoting seven FBRs versus four FBRs versus no recommendations and their cost implications. In this
example, successful adoption of the set of seven FBRs
would be likely to ensure dietary adequacy (defined as
worst-case scenario >65% RNI and illustrated using the
horizontal line in the histogram; Fig. 2) for 8 of the 10
nutrients modelled, compared with five and zero nutrients for the set of 4 FBRs or no FBRs, respectively.
Programme planners can use such information to help
select a set of FBRs to promote.
The third tool, IMAPP (Intake, Monitoring, Assessment and Planning Programme), was developed by the
University of Hawaii, Iowa State University, USDA
Agriculture Research Service, UC Davis and WHO. It
does not use linear programming analyses but is based
upon mathematical simulations. It informs fortification
programmes, particularly choice of food vehicle and

2014 British Nutrition Foundation Nutrition Bulletin, 39, 115125

4 FBR

7 FBR

Zn

level of fortification, and provides information on the

predicted shifts in the percentage of the population
at risk of inadequate intakes for the nutrient(s) of interest associated with different fortification strategies.
Required inputs are daily nutrient intakes (ideally for
two independent days for each person or at least a
subgroup), daily intake of each food vehicle (including
ingredients disaggregated from composite foods) and
possible fortification levels. The outputs of the programme are the prevalence at risk of inadequate intakes
at baseline and at different fortification levels, and the
prevalence at risk of excessive intakes above the UL at
baseline and at different fortification levels. Programme
planners can use this information to select fortification
levels and combinations of food vehicles that are likely
to maximally reduce the percentage of the population at
risk of inadequate nutrient intakes without unduly
increasing the percentage of the population at risk of
excessive nutrient intakes.
In summary, tools are now freely available that are
able to inform nutrition planning and policy decisions.
In fortification programmes, they can be used to identify
appropriate food vehicles and fortificant levels. They
can help determine whether a nutritious diet is affordable, to justify a social protection or food subsidy programme, and help identify the lowest cost of a
nutritionally adequate diet. In food value chains and
agriculture programmes, these tools can identify locally
available foods that together provide all the nutrients
needed by a target population and/or identify what
types of food need to be produced or introduced to help
achieve nutritional adequacy by addressing nutrient
gaps in local diets. Finally, in behaviour change programmes, linear modelling can identify which foodbased recommendations could be promoted to improve
the nutritional quality of diets consumed by a target
population.

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J. L. Buttriss et al.

Using linear programming to translate

nutrient recommendations into realistic
and individual-specific food choices
Linear programming is usually used to design one
optimal diet for one given population (Fletcher et al.
1994; Gao et al. 2006; Rambeloson et al. 2008) or a
subgroup of a population (Wilde & Llobrera 2009;
Maillot & Drewnowski 2011) (e.g. by gender or age
classes). Population-based optimisation is based upon
the average consumption estimated in a dietary survey.
This approach (which does not need complex dietary
data) is a practical way to allow researchers to investigate many public health questions. To bring added value
to diet modelling in public health nutrition, by integrating diversity of eating behaviours, an individual diet
model (ID model) has been developed for which linear
programming is applied to data from each individual of
a given population in order to translate a whole set of
nutrient recommendations into individual specific food
choices. This methodology requires precise dietary consumption data at the individual level. The individual
diet model (Maillot et al. 2010) has been developed
based upon the French INCA1 dietary survey in which
1171 adults (>20 years old) reported their dietary intake
with a 7-day food record. Individual diet models were
developed to design, for each INCA participant, a new
weekly diet that met current nutritional recommendations and that was as close as possible to his or her
individual food intake pattern (Maillot et al. 2010,
2011b).

Parameters of the linear programming model

For each individual, the objective function was aimed at:
(1) preferentially choosing foods from his or her food
repertoire; (2) minimising only the decrease in the quantity of each repertoire food; and, if necessary, (3) introducing non-repertoire foods, preferentially selecting the
most frequently consumed foods by the French population. The set of nutritional constraints were imposed to
keep total energy equal to the observed energy intake
(isocaloric), and allowed an increase in total weight of
foods up to 115% of the observed total weight. The
WHO recommendations were used for total carbohydrates, free sugars and saturated fatty acids; the Nordic
Nutrient Recommendations were used for the sodium
upper limit; and the French recommendations were used
as targets for all other nutrients (protein, total fat, polyunsaturated fatty acids, dietary fibre, vitamins, minerals
and cholesterol). Social acceptability constraints placed
an upper limit [i.e. 95th percentile of observed intake
(OI)] on the quantity of each food variable and each

food group, subgroup and category. However, when, for

a given individual, the OIs of foods, food groups, subgroups or categories exceeded the 95th percentiles (i.e.
the upper boundary), the OIs defined the upper constraint limits in the corresponding model (Maillot et al.
2010).

Public health concerns investigated using the

ID model
The French INCA dietary survey (n = 1171) was used to
illustrate the potential of this new individual diet modelling approach to: (1) estimate the feasibility of achieving
a whole set of nutrient recommendations by restricting
the list of foods to the individual food repertoire; (2)
identify the foods needed to reach nutrient goals; and (3)
show how foods with different nutrient profiles can fit
into nutritionally adequate diets. Firstly, individual diet
models were run for all subjects by restricting the list of
foods to the individual food repertoire. Among the 1171
modelled diets, only 22% (27% for men and 19% for
women) were mathematically feasible, showing that
78% of French adults would need to expand their weekly
food repertoire in order to fulfil their nutrient needs
(Maillot et al. 2009). Compared with unfeasible diets,
feasible diets were characterised by a higher observed
energy intake, a higher food diversity in the repertoire, a
higher observed energy cost and a lower energy density.
Regarding the foods consumed, fruits and vegetables
made the most important contribution to overall feasibility (i.e. they were positively associated with feasibility).
These results were consistent with evidence that low
energy density and high fruit and vegetable consumption
(Ledikwe et al. 2006; Schroder et al. 2008), high energy
cost (Maillot et al. 2007) and high food variety (Foote
et al. 2004; Murphy et al. 2006) are important indicators
of nutritional quality.
Secondly, individual diet models were run for all subjects by expanding the food repertoire. Nutritionally
adequate diets (n = 1171) were obtained and the food
changes between observed and optimised diets were
analysed. Among individual repertoires, the amount of
unsalted nuts, unrefined grains, legumes, fruit, fish and
vegetables increased significantly, whereas the amount
of red meats, mixed dishes, cheeses, deli meats and
animal fats significantly decreased; other categories
remained stable (Maillot et al. 2010, 2011b). Unsalted
nuts, unrefined grains, legumes, fruits and fish were
frequently added in the modelled diets when they were
not present in the observed diet. This meant that
plant-based foods as well as seafood products were key
foods to reach nutrient goals.

2014 British Nutrition Foundation Nutrition Bulletin, 39, 115125

Diet modelling

Observed diets

123

Optimised diets
Class 4

Class 4

22 %
32 %

Class 1
51 %

Class 1
7%

Class 3

10 %

9%
Class 3
Figure 3 Relative contributions of each
nutrient profiling class to total diet weight
among the observed and optimised diets.

61 %

Class 2

8%
Class 2

Contribution to total weight (%)

Lastly, individual diet modelling was matched to the

French SAIN,LIM nutrient profiling system (Darmon
et al. 2009). The SAIN,LIM system is based upon two
independent scores and enables the classification of individual foods into four classes according to their nutritional quality. Class 1 represents foods with favourable
nutrient profiles [e.g. (most) fruits and vegetables and
low-energy-dense dairy products], whereas class 4 represents foods with unfavourable nutrient profiles (e.g.
animal fats, biscuits, cream). Class 2 (e.g. refined grains)
and class 3 (e.g. fatty fish, cheeses, red meats) are intermediate. The percentage contribution of all classes to
total weight of food was computed among observed and
optimised diets. On average, subjects consumed 51% of
foods with a favourable nutrient profile (class 1), and
they consumed 32% of foods with an unfavourable
nutrient profile (class 4) (Fig. 3). Foods from classes 2
and 3 represented 8% and 9% of the total weight of
food consumed, respectively. In optimised diets, the contribution of class 1 increased up to 61%, whereas the
contribution of class 4 decreased down to 22% of total
weight (Maillot et al. 2011b). Class 3 slightly decreased
(from 9% to 7%) and class 2 slightly increased (from
8% to 10%). These results showed that all foods can fit
in a nutritionally adequate diet, but the maximal contribution of foods with an unfavourable nutrient profile
was estimated to be 22% of total weight on average.
Nutrient profiling systems may be an easy way to characterise nutritional quality of individual foods in order
to help people to make healthier food choices.

Conclusions
In summing up the presentations and associated discussion, the chairman of the session, Dr Andr Briend,
made some observations about the limitations of linear
programming. The first limitation of linear program-

2014 British Nutrition Foundation Nutrition Bulletin, 39, 115125

Contribution to total weight (%)

ming and indeed other modelling approaches is that

they are very sensitive to the quality of the data entered
in the model. Such approaches are also influenced by the
quality of the data on the nutrient composition of foods,
as given in food composition tables, and by the nutrient
requirements entered in the model. Given the uncertainties related to both food composition and nutritional
requirements, the interpretation of diet modelling
should be cautious.
A second limitation of the models is that they are
unable to handle some very important factors, which
have an impact on food constraints, particularly variations in behaviour and the influence of social pressures.
Although these tools are very effective in handling the
mathematical complexity of making sure that foodbased recommendations are consistent with existing
food patterns and nutritional composition, users should
be aware of their limitations if they are used to examine
the broader picture. Many of these limitations can be
overcome, by performing sensitivity analysis and utilising expert consultation to design the models and interpret the results.
In conclusion, diet modelling is a flexible and robust
approach to translate nutrient recommendations into
realistic food choices. It can be adapted to different
forms of dietary data and it can include a very large
spectrum of constraints, not only nutritional ones but
also, for example, constraints on cost, habits and
environment. Dr Andr Briend concluded that diet modelling can inform the development of dietary recommendations and public health policy in many different
contexts.

References
Australian Government, Department of Health and Ageing,
National Health et al. (2006) Nutrient Reference Values for Aus-

124

J. L. Buttriss et al.

tralia and New Zealand including Recommended Dietary Intakes.

Available at: http://www.nhmrc.gov.au/_files_nhmrc/publications/
attachments/n35.pdf (accessed 2 December 2013).
Bates B, Lennox A, Prentice A et al. (2012) National Diet and
Nutrition Survey. Headline Results from Years 1, 2 and 3 (Combined) of the Rolling Programme (2008/092010/11). Department
of Health & Food Standards Agency, London.
Berger J, Blanchard G, Ponce MC et al. (2013) The SMILING
project: a North-South-South collaborative action to prevent
micronutrient deficiencies in women and young children in Southeast Asia. Food and Nutrition Bulletin 34: S1339.
Buttriss J (2013) Food security through the lens of nutrition. Nutrition Bulletin 38: 25461.
Carlson A, Lino M & Fungwe T (2007) The Low-Cost, ModerateCost, and Liberal Food Plans (CNPP-20). Available at: http://
www.cnpp.usda.gov/Publications/FoodPlans/MiscPubs/
FoodPlans2007AdminReport.pdf (accessed 2 December 2013).
Central Intelligence Agency (2013) The World Factbook 2013
2014. Obesity Adult Prevalence Rate. Central Intelligence
Agency, Washington, DC. Available at: https://www.cia.gov/
library/publications/the-world-factbook/fields/print_2228.html
(accessed 2 December 2013).
Daelmans B, Ferguson E, Lutter CK et al. (2013) Designing appropriate complementary feeding recommendations: tools for programmatic action. Maternal & Child Nutrition 9: 11630.
Dantzig G (1990) The diet problem. Interfaces 20: 437.
Darmon N, Ferguson EL & Briend A (2002) A cost constraint
alone has adverse effects on food selection and nutrient density:
an analysis of human diets by linear programming. The Journal
of Nutrition 132: 376471.
Darmon N, Ferguson E & Briend A (2003) Do economic constraints encourage the selection of energy dense diets? Appetite
41: 31522.
Darmon N, Ferguson EL & Briend A (2006) Impact of a cost constraint on nutritionally adequate food choices for French women:
an analysis by linear programming. Journal of Nutrition Education and Behavior 38: 8290.
Darmon N, Vieux F, Maillot M et al. (2009) Nutrient profiles discriminate between foods according to their contribution to nutritionally adequate diets: a validation study using linear
programming and the SAIN,LIM system. The American Journal
of Clinical Nutrition 89: 122736.
Dorfman R (1984) The discovery of linear programming. Annals of
the History of Computing 6: 28395.
Fletcher LR, Soden PM & Zinober ASI (1994) Linear programming
techniques for the construction of palatable human diets. The
Journal of the Operational Research Society 45: 48996.
Foote JA, Murphy SP, Wilkens LR et al. (2004) Dietary variety
increases the probability of nutrient adequacy among adults. The
Journal of Nutrition 134: 177985.
Foresight (2011) The Future of Food and Farming: Challenges and
Choices for Global Sustainability. London. Available at: http://
www.bis.gov.uk/assets/foresight/docs/food-and-farming/11-546future-of-food-and-farming-report.pdf (accessed 2 December
2013).
Frega R, Lanfranco JG, De Greve S et al. (2012) What linear programming contributes: world food programme experience with
the cost of the diet tool. Food and Nutrition Bulletin 33: S228
34.

Gao X, Wilde PE, Lichtenstein AH et al. (2006) The 2005 USDA

Food Guide Pyramid is associated with more adequate nutrient
intakes within energy constraints than the 1992 Pyramid. The
Journal of Nutrition 136: 13416.
Global Food Security (2012) Global Food Security Programme A
survey of public attitudes. Available at: http://www.foodsecurity
.ac.uk/assets/pdfs/gfs-survey-public-attitudes.pdf (accessed 2
December 2013).
Global Food Security (2013) Global Food Security Programme
Food waste within global food systems. Available at: http://
www.foodsecurity.ac.uk/assets/pdfs/food-waste-report.pdf
(accessed 2 December 2013).
Henderson L, Irving K, Gregory J et al. (2003) The National Diet
& Nutrition Survey: Adults Aged 19 to 64 Years: Volume 3:
Vitamin and Mineral Intake and Urinary Analytes. The Stationery
Office: London.
Katamay SW, Esslinger KA, Vigneault M et al. (2007) Eating well
with Canadas Food Guide (2007): development of the food
intake pattern. Nutrition Reviews 65: 15566.
Ledikwe JH, Blanck HM, Khan LK et al. (2006) Low-energydensity diets are associated with high diet quality in adults in the
United States. Journal of the American Dietetic Association 106:
117280.
Macdiarmid JI, Kyle J, Horgan GW et al. (2012) Sustainable diets
for the future: can we contribute to reducing greenhouse gas
emissions by eating a healthy diet? The American Journal of
Clinical Nutrition 96: 6329.
Maillot M & Drewnowski A (2011) Energy allowances for solid
fats and added sugars in nutritionally adequate U.S. diets estimated at 1733% by a linear programming model. The Journal
of Nutrition 141: 33340.
Maillot M, Darmon N, Vieux F et al. (2007) Low energy density
and high nutritional quality are each associated with higher diet
costs in French adults. The American Journal of Clinical Nutrition 86: 6906.
Maillot M, Ferguson EL, Drewnowski A et al. (2008) Nutrient profiling can help identify foods of good nutritional quality for their
price: a validation study with linear programming. The Journal of
Nutrition 138: 110713.
Maillot M, Vieux F, Ferguson EF et al. (2009) To meet nutrient recommendations, most French adults need to expand their habitual
food repertoire. The Journal of Nutrition 139: 17217.
Maillot M, Vieux F, Amiot MJ et al. (2010) Individual diet modeling translates nutrient recommendations into realistic and
individual-specific food choices. The American Journal of Clinical
Nutrition 91: 42130.
Maillot M, Drewnowski A, Vieux F et al. (2011a) Quantifying the
contribution of foods with unfavourable nutrient profiles to nutritionally adequate diets. The British Journal of Nutrition 105:
11337.
Maillot M, Issa C, Vieux F et al. (2011b) The shortest way to reach
nutritional goals is to adopt Mediterranean food choices: evidence
from computer-generated personalized diets. The American
Journal of Clinical Nutrition 94: 112737.
Martin A (2001) Nutritional recommendations for the French population. Sciences Des Aliments 21: 317458.
Masset G, Monsivais P, Maillot M et al. (2009) Diet optimization
methods can help translate dietary guidelines into a cancer prevention food plan. The Journal of Nutrition 139: 15418.

2014 British Nutrition Foundation Nutrition Bulletin, 39, 115125

Diet modelling
Mensink G, Fletcher R, Gurinovic M et al. (2013) Mapping low
intake of micronutrients across Europe. The British Journal of
Nutrition 110: 75573.
Murphy SP, Foote JA, Wilkens LR et al. (2006) Simple measures of
dietary variety are associated with improved dietary quality.
Journal of the American Dietetic Association 106: 4259.
Office for National Statistics (2012) 2011 Census: Key Statistics for
England and Wales, March 2011. Available at: http://www.ons
.gov.uk/ons/dcp171778_290685.pdf (accessed 2 December 2013).
Quested T, Ingle R & Parry A (2013) Household food and drink
waste in the United Kingdom 2012. WRAP. Available at: http://
www.wrap.org.uk/sites/files/wrap/hhfdw-2012-main.pdf (accessed
2 December 2013).
Rambeloson ZJ, Darmon N & Ferguson EL (2008) Linear programming can help identify practical solutions to improve the
nutritional quality of food aid. Public Health Nutrition 11: 395
404.
SACN (2008) The Nutritional Wellbeing of the British Population.
The Stationary Office: London.
Salomon JA, Wang H, Freeman MK et al. (2012) Healthy life
expectancy for 187 countries, 19902010: a systematic analysis
for the Global Burden Disease Study 2010. Lancet 380: 214462.

2014 British Nutrition Foundation Nutrition Bulletin, 39, 115125

125

Santika O, Fahmida U & Ferguson EL (2009) Development of

food-based complementary feeding recommendations for 9- to
11-month-old peri-urban Indonesian infants using linear programming. The Journal of Nutrition 139: 13541.
Schroder H, Vila J, Marrugat J et al. (2008) Low energy density
diets are associated with favorable nutrient intake profile and
adequacy in free-living elderly men and women. The Journal of
Nutrition 138: 147681.
Stigler G (1945) The cost of subsistence. Journal of Farm Economics 27: 30314.
Thompson S, Gower R, Darmon N et al. (2013) LiveWell for Life.
A balance of healthy and sustainable food choices for France,
Spain, and Sweden. WWF Report. Available at: http://
livewellforlife.eu/livewell-plate/reports (accessed 2 December
2013).
Wilde PE & Llobrera J (2009) Using the thrifty food plan to assess
the cost of a nutritious diet. Journal of Consumer Affairs 43:
274304.
Wilson N, Nghiem N, Ni Mhurchu C et al. (2013) Foods and
dietary patterns that are healthy, low-cost, and environmentally
sustainable: a case study of optimization modeling for New
Zealand. PLoS ONE 8: e59648.