Dietary diversity and associated factors among children (6–23 months) in Gedeo zone, Ethiopia: cross - sectional study

Dietary diversity is the sum of food groups that is consumed by any individual within a period of 24 h [1], which has been documented as a valid and reliable indicator of dietary adequacy. Currently, available scientific evidence revealed that dietary diversity is strongly associated with dietary quality and nutrient adequacy. In fact, there is no single food which contains all required nutrients for optimal health [2].

Different foods and food groups are good sources for various macro and micronutrients to ensure nutrient adequacy [3]. Adequate nutrition is important to meet both known and as yet unknown needs for human health. For example, it is fundamental for physical and mental, growth and development of children, healthy living, associated with reduction of risk of mortality and morbidity for children and highly correlated with caloric and protein adequacy and consumption associated with improved nutritional status of children [4‐6].

The first 2 years of life are a critical window to promote optimal child growth and development of the child. World Health Organization (WHO) recommends to initiate nutritionally adequate, safe, and appropriate complementary food at the age of sixth month [7]. After the age of sixth month, the energy and nutrient content of breast milk alone is not enough to meet the nutritional demand of the growing infant to prevent stunting among children. Therefore, providing sustainable diets rich in micronutrients and macronutrients is vital in the effort to combat malnutrition to children [8].

Globally, around 5.9 million under-five age children are dead annually, majority of them are in Africa, especially in sub-Saharan Africa including Ethiopia. Childhood malnutrition is the most pressing public health problem [9], predominantly in developing countries as it has primarily has been directly or indirectly for 45% which is 5.9 million deaths of under-five children globally, majority of this death occurs in Africa. In Ethiopia, more than 38.4% of children are stunted, 9.9% are wasted, and 23.6% are underweight indicating the persistence of both acute and chronic under nutrition according to the 2016 Ethiopian Demographic and Health Survey [10]. Greater than two-thirds of malnutrition-related child deaths are associated with inappropriate feeding practices during the first 2 years of life in such a way that infants and young children received inadequately nutritious diets and were poorly diversified [11]. In Sub-Saharan African Regions, suboptimal infant feeding practices, poor quality of complementary foods, micronutrient deficiencies, and frequent infections have mainly contributed to the high mortality among infants and young children [12].

Furthermore, malnourished children are at higher risk for childhood illness like diarrheal diseases and infections, impaired cognitive development, growth retardation, smaller adult stature, and a consequence of compromised educational achievement and low economic productivity which become impossible to reverse later in life [13‐16]. Child under-nutrition is caused by numerous and multidimensional factors; however, lack of diversified or adequate food is the major factor for the problem [13, 17].

Inadequate or lack of dietary diversity is the major cause of malnutrition, it does not provide adequate calories and micronutrients for individuals [18]. Micronutrient deficiency is a risk to children and is referred to as hidden hunger [19]. It is caused by chronic deficiency of vitamins and minerals as a consequence of nutrient inadequacy [20].

Therefore, appropriate, safe, adequate and frequent child feeding practice is fundamental for optimal growth, better health and development of children. Available scientific evidence revealed that consumption of a diversified diet is important in the reduction of under-nutrition among infants and young children aged 6 to 23 months [21, 22] and also, World Health Organization (WHO) and Infant and Young Child Feeding (IYCF) recommend that both breastfed and non-breastfed children should consume four or more food groups among the seven food groups, which provide sufficient energy, protein, and micronutrients for infants and young children aged 6 to 23 months. These food groups are: grains roots and tubers, legumes and nuts, dairy products (milk, yogurt, cheese), flesh foods (meat, fish, poultry, and liver/organ meats), eggs, vitamin- A rich fruits and vegetables and other fruits and vegetables [7, 23].

Furthermore, because of the perceived importance of dietary diversity for health and nutrition, indicators of dietary diversity have become increasingly popular in recent years [24]. World Health Organization (WHO) uses dietary diversity as one of the key indicators to assess child feeding practices [7] i.e., individuals consuming more diverse diets are considered more likely to meet their nutrient needs [25]. Besides the national nutrition program of Ethiopia, the country declared at Seqota declaration which pays particular attention to the importance of nutrition in pregnancy and in the first years of a child’s life to stop the cycle of under nutrition [26].

However, meeting minimum standards of dietary diversity is a major challenge in many developing country settings including Ethiopia which is as low as 7% [27]. According to the recent study conducted in the world revealed that occupation of mothers, women’s empowerment, household food security, father’s educational status, exposure to media age of the child in months, age of the mother, socio-economic status number of under-five children in the household has a significant association with chilled dietary diversity [6, 28, 29].

The causes of childhood malnutrition are diverse, multidimensional, and interrelated. Even if people get enough to eat, good nutrition requires access to a sufficient supply of varied, safe and nutritious food to meet daily nutritional requirements. An essential element of food-based approach involves dietary diversification. However, food access may be affected by different conditions, like market conditions, cultural and religious practices. The aim of this study was to assess children dietary diversity and association factors. Which might be essential for program managers and stakeholders in identifying specific strategies to improve child nutrition. It plays a major role to reduce child mortality and morbidity. Furthermore, it provides baseline information to formulate program for accelerating malnutrition intervention activities and help governmental and nongovernmental organizations /NGO/ which work on food-based approaches to meet the micronutrient needs of mothers and children in the study area.

This study has investigated the dietary diversity and associated factors among children(6–23 months) in Gedeo zone, SNNPR, Ethiopia. FAO proposed the minimum dietary diversity for children consisting of 7 food groups and a dichotomous indicator to indicate minimum dietary diversity when consuming at least four food groups out of seven. However, in this study only 29.9%(199) of children were consumed a minimal dietary diversity before 24 h preceding the survey, this is slightly similar to the study conducted in Wolaita Sodo, Ethiopia (27.3%) [31]. The findings of this study were highly lower than the studies conducted in Kenya (45%), Zambia (37%), Indonesia (65%), Morocco (66%), Addis Abeba (59.9%) and Nepal of Asian country (30.4%) [32‐34]. On the other hand, the result of this study was higher than previous studies conducted by WHO 2010 reports in Eretria (19%), Guinea (18%), India (12%) and Niger (5%) [33]. This discrepancy and similarity might be due to the variations of like geographical location, seasonal variability, sample size and other sociodemographic factors.

This study also indicated that the wealth index had a significant association with consuming of a diversified meal for children. Children living in the richest households were 10.4 times more likely to fed a diversified meal group than thus who were living in the poorest households [AOR4.390(2.300–8.380)]. This study is supported by the studies conducted in Nepal DHS, Dejen District, North West Ethiopia, Philippines and study conducted in 9 sub-Saharan African countries [35, 36]. This may indicate that family income has a direct association with household food security, since food consumption is believed to be heavily influenced by income of the household. This means that they may have ability to afford to have diversified foods as compared to children’s living in poorest households.

According to this study, educational status of mothers had statically significant association with dietary diversity of children. Children born from mothers who had formal education were 2.8 times more likely to consume the recommended minimum dietary diversity than those born from their mothers who can’t read and write [AOR 2.864(1.156–7.094)]. The finding of this study is in line with the study conducted in Ethiopia, Nepal, Indonesia, Bangladesh, five South Asian countries, Sri-Lanka and India [6, 37, 38]. Possible explanation for this might be due to the fact that those who had formal education would have an increased chance to get information regarding to nutritional requirement for their children’s and understand educational messages delivered through different media outlets. For this, as the educational level increases, the level feeding adequate dietary diversity for their children’s is expected to increase.

Furthermore, children born in families who had less than four children were 2.8 more likely to consume the recommended minimum dietary diversity than those who had four and above child [AOR 2.865(1.776–4.619))]. The finding of the present study is smellier with the finding of studies conducted at Kenya and Ethiopia [30, 39]. This could partly be explained by the fact that as the number of family member’s increases, the intrahousehold food distribution is affected and food may become more limited, which in turesprn would limit access to different food groups [30].

Moreover, Children who had between 9 and 11 months’ age group were 4.2 times more likely to consume the recommended minimum dietary diversity than those who had age between 6 and 8 months [AOR 4.237(1.743–10.295)]. The finding of the present study is smellier with the findings of other studies conducted at Dangila town, Gorche district in rural Ethiopia and 2016 Nepal DHS analysis [6, 37, 40, 41]. This might be due to infant’s mothers during 6–8 months who did not introduce solid and semisolid food; they are only introducing simply feeding milk along with breast milk. This is might be the perception of mothers, the poor ability of child’s intestine to digest solid, semisolid and soft foods. However, studies conducted at kemba woreda, southern Ethiopia, secondary Analysis of Ethiopian Demographic and Health Survey at 2011were controversial with this study [42, 43].