Integrating Food Safety, Nutrition Security, and Sustainability Indicators for Food System Monitoring in Low- and Middle-Income Countries: A Structured Methodological Review and Framework Development Study.

Access to safe, nutritious, and sustainable food remains a major challenge in many Low- and Middle-Income Countries (LMICs), where food insecurity, malnutrition, and foodborne diseases frequently coexist. Despite growing recognition of the interconnections between food safety, nutrition security, and sustainability, monitoring systems often assess these dimensions separately, limiting the effectiveness of policy interventions. This study conducted a structured methodological review and framework development study of indicators used to monitor food safety, nutrition security, and sustainability within food systems, with particular emphasis on LMIC contexts. Peer-reviewed literature and internationally recognized monitoring frameworks, drawn from Scopus, Web of Science, PubMed, Google Scholar, and institutional repositories including FAO, WHO, World Bank, and GAIN, were systematically reviewed, yielding 75 sources encompassing 54 peer-reviewed articles and 21 institutional reports, from which 47 indicators were identified and assessed. Indicators were evaluated according to relevance, data availability, methodological robustness, and policy actionability. The review identified a core set of ten operationally relevant indicators, including the Global Diet Quality Score (GDQS), Minimum Dietary Diversity for Women (MDD-W), Food Insecurity Experience Scale (FIES), foodborne disease burden indicators, cost of a healthy diet, and post-harvest loss rates. Building on these findings, an integrated indicator selection framework is proposed to support context-specific monitoring and decision-making in LMICs. The results suggest the value of a One Health approach that links human, animal, and environmental health, and three One Health interface indicators, antimicrobial resistance prevalence in food chain isolates, zoonotic disease incidence attributable to food, and pesticide residue exceedance rate in fresh produce, are explicitly integrated into the proposed framework with LMIC-specific implementation pathways. A key limitation of this review is that it did not employ formal systematic methods and may not have exhaustively identified all relevant indicators across the full breadth of the published literature.