This study revealed proportion minimum dietary diversity (MDD) and its predictors among infants and young children in central Ethiopia. More than half (58%) of IYC in Debre Berhan Town consumed the recommended level of MDD in this study. The result is comparable with the result of a study conducted in Addis Ababa, Ethiopia (12), which reported an MDD of 59.9%. However, the finding of this study is higher than that of studies conducted in Dangila town of Northwest Ethiopia (32), at Dabat district of Northwest Ethiopia (33), in Wolaita Sodo of Southern Ethiopia (34), in the predominantly agrarian society of Bale zone of Southeast Ethiopia (35) and Bench Maji Zone of Southwest Ethiopia (36). This finding is lower than a study done in Sri Lanka (30), however, it is much higher than the reported national EDHS findings (42). Furthermore, it is higher than other studies done in Ghana (28), east Delhi, India (29), and Bangladesh (27). In which 14% of children had an adequately diverse diet in which they had been given foods from the appropriate number of food groups.
The discrepancies might be due to the difference in difference in food security, staple food, feeding habit, climate, and agro-ecological factors. Moreover, differences in countries setting, the self-reported measurement, and the recall method could also affect the estimated minimum dietary diversity score. However, in general terms, compared to the target set to positively impact the nutritional health of infants and young children by the Ethiopian government by 2020/25, this MDD is low and makes it difficult to achieve both the local governmental target and the international sustainable development goal target.
The improvement in infant and young child feeding (IYCF) practices plays a critical role in the improved nutrition, health, and development of a child (43) and it is due to this reason that the world health organization recommends the consumption of at least four food groups (22). In this case, if a child fed on, at least from four food groups on the previous day, it is assumed that; in most populations, the child could have a higher probability to consume at least one animal-source food and at least one fruit or vegetable in addition to the usual or staple food items (grain, root or tuber).
Dietary diversity consisting among others of food groups classified as sources of energy (cereals, tubers, roots), protein providers (pulses, solid food of animal origin), mineral suppliers (pulses, other legumes, vegetables, solid food of animal origin, milk), and vitamin sources (vegetables, green vegetables, fruits, solid food of animal origin) can be recommended as the indicator of a healthy diet (13). In this study, grain, roots, and tubers were the most commonly consumed food items 24 hours preceding the survey followed by dairy products. Similarly, in the Republic of the Union of Myanmar, almost all children consumed items from the ‘grains, roots, tubers’ group (24). In addition, food groups consumed by more than 50% of the children in this study were legumes and nuts, dairy products, and other fruits and vegetables. These are similar to food group consumption in a study conducted in other areas of Ethiopia (12,32,34–36,38), in a study done in Sri Lanka (30) and Bangladesh (27), and in the Republic of the Union of Myanmar (24). However, in some of these studies, the consumption of legumes and nuts was lower than that of dairy products while consumption of other fruits and vegetables was very low (32,33,36,38). Food groups consumed by more than 50% of the children in both Halaba and Zeway areas of Ethiopia were only grains, roots, and tubers, and other fruits and vegetables (6). This difference might be attributed to the difference in sociodemographic and economic characteristics, food security, staple food, feeding habit, climate, and agro-ecological factors. While some of these areas are highland and the rest are lowland with the availability of fruits and vegetables.
Moreover, in this study, children were found to take protein source food groups rarely (flesh foods) which can lead them to protein-energy malnutrition and developmental delay. About 15% and 45% consumed flesh foods and vitamin A fruits and vegetables respectively in this study. While this result is comparable for flesh foods consumption with the studies conducted in different areas of Ethiopia (12,33,36), but the consumption of vitamin A fruits and vegetables is variable. In contrast, this result is lower than studies conducted elsewhere in Ethiopia (27,34). Furthermore, in a study conducted in Halaba and Zeway areas of Ethiopia, consumption from flesh foods and vitamin-A-rich fruits and vegetables was minimal or almost nonexistent (6). Similarly, the result of this study is higher for the consumption of flesh foods with the study conducted in different areas of Ethiopia (32,35,38). The difference might be attributed to the complex influence of sociodemographic, economic, environmental characteristics as well as differences in study settings. This implies that the majority of children in Debre Berhan town are not getting animal proteins which can hamper their developmental process and expose them to protein deficiency disorders. However, dairy products were consumed by 57.0% of the children. In Malawi, eggs, flesh foods, and dairy were consumed by only 8.2%, 26.9%, and 27.6% of the children. While consumption of eggs and dairy is greater in this study compared to the result of the study conducted in Malawi (44), the consumption of flesh foods is lower. Cereals oil (but not fat) and alcohol and beverages were consumed always by about 85%, 91%, and 71% respectively while fish was never consumed by about 79% within the last 7 days.
In this study, mother’s education, mother’s and father’s occupations, and the number of ANC visits are variables significantly associated with MDD of infants and young children. It was found that the odds of MDD mothers who cannot read and write are less compared to mothers who had formal education. This finding is consistent with studies conducted in North West Ethiopia (32), South Asian countries (23), Sri-Lanka (30), and secondary data analysis of Demographic Health Survey 2007 in Bangladesh (27) and where mother’s higher educational attainment and the overall literacy rate was a significant determinant factor for appropriate diversified infant feeding practices. That is, children of mothers with no formal education were twice as likely not to meet the minimum dietary diversity criteria as mothers with secondary or higher level of education. Similar positive impact of education on diverse feeding practices is also reported in previous studies in Ethiopia (32,34–36). This could be since educated mothers might be more likely to have more information and knowledge; understood educational messages delivered through different media outlets, engaged in paid works, and might learn about child feeding in the curricula at school. This could increase the purchasing power of different food groups and feeding diversified foods for their children. Therefore, improvements in education leading to higher levels of mothers’ education can result in better minimum dietary diversity practices. Programs to improve minimum dietary diversity need to target mothers with low levels of education and design promotional materials that take account of low mothers’ levels of education.
Our study also showed that occupation was associated with minimum dietary diversity practices. Children whose mothers are housewives (not employed) had less odds to consume from four or more food groups than those children whose mothers were governmental employees and having fathers who are merchants have better minimum dietary diversity practices compared with those children whose fathers were governmental employees. This finding is consistent with studies conducted elsewhere (27,34). This could be because employed mothers and fathers were more likely to have more income. Mothers who are housewives do not earn income and fathers who were government employees may earn less than those who were merchants.
In addition, the frequency of ANC visits (not ANC visits) has a significant association with the attainment of better minimum dietary diversity. Mothers who have less than four ANC visits had less odds to consume from four or more food groups than those IYC whose mothers had four or more ANC visits. There is no previous study that showed such an association but some showed the association between ANC visits and minimum dietary diversity practice (23,36). This may be related to different access to ANC nutritional counseling as it provides more opportunities to get more information and knowledge. Therefore, improving ANC service provision and its frequency and maternal counseling on IYCF practice during frequent ANC visits is recommended.
The findings of this study have a significant contribution in identifying factors associated with dietary diversity practice problems of infants and young children. This study shares the common limitation of the cross-sectional study, difficult to make the causal association. It may not also accurately reflect children’s past feeding experience since it considers only 24-hour feed. Even though adequate training was given to data collectors and supervisors and mothers were informed about the objectives of the study, there, there might still be social desirability and recall bias in reporting the type of food given to children. Moreover, seasonal variations might affect the result and this study does not take account of the quality and quantity of food consumed by the children. Nevertheless, the study has successfully shown important trends that can be used in the formulation of other studies and interventions to improve the IYCF practice in the study area.