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Abstract

Objective:

This study aimed to determine the association of nutritional status with food group consumption and complementary feeding practices in 6 to 23 month old children.

Methods:

A community-based cross-sectional study design was done among 279 mother-child pairs in Arusha, Tanzania. Bivariate and multivariate analyses were conducted to analyze the association.

Results:

The overall proportion of anemia, wasting, stunting, and underweight was 85.66, 15.41, 46.27, and 24.37 respectively. Children who consumed flesh foods had lower odds of having underweight and anemia compared to their counterparts (AOR = 0.16, 95% CI = 0.04-0.73, P < .05 and AOR = 0.16, 95% CI = 0.07-0.41, P < .01 respectively). The odds of being anemic were higher for children who consumed dairy products (AOR = 10.24, 95% CI = 2.79-37.57, P < .01).

Conclusion:

Prioritizing animal-source foods is essential in low-income areas like Arusha, Tanzania, as it plays a crucial role in improving the nutritional status and overall health of the children.

Keywords

complementary feeding nutrition status children aged 6 and 23 months Tanzania

Introduction

The age between 6 and 23 months is the longest period of 1000 days for a child “critical window” in which adequate feeding is essential to ensure proper growth, health, behavioral, and cognitive development.¹ Inadequate dietary practices during this critical developmental window can lead to suboptimal physical and cognitive development. These sequelae can exert lifelong repercussions, manifesting as increased morbidity, delayed neurocognitive maturation, and substantial economic burden due to childhood illness and, in severe cases, mortality.^2,3 Notably, the prevalence of malnutrition, encompassing stunting, wasting, underweight, and anemia, remains a significant global challenge impacting a multitude of nations⁴ An estimated 149 million children under 5 years old were stunted globally in 2020. Additionally, 45 million children were estimated to be wasted, and undernutrition contributed to nearly 45% of deaths in this age group.⁵ These challenges are particularly prevalent in low- and middle-income countries (LMICs) where inadequate dietary intake and frequent infections create a distressing scenario for child health.⁶ Studies conducted in LMICs consistently report that less than 25% of children aged 6 to 23 months meet the Minimum Dietary Diversity (MDD), Minimum Acceptable Diet (MAD), and Minimum Meal Frequency (MMF) standards for optimal complementary feeding.^7-10

Previous research investigating the influence of complementary feeding indicators (MDD, MMF, and/or MAD) on various nutritional status outcomes has yielded mixed results. Studies among infant and young children in India and Cambodia have demonstrated a significant association between increased dietary diversity (consuming 4-5 food groups daily) and reduced stunting risk.^11,12 Additionally, a study among children age 6 to 23 months in India reported a lower risk of underweight and stunting among children meeting the MAD criteria compared to those who did not.¹³ However, another study conducted in Myanmar among children 6 to 23 months has reported no statistically significant association between complementary feeding practices and nutritional status.¹⁴ Similarly, a study in Indonesia among children aged 6 to 23 months found no significant association between MAD and child stunting.¹⁵ Despite the strong evidence on the impact of CF on young child mortality, the evidence on the association between feeding practices and child growth indicators such as underweight, wasting, stunting, and anemia remains unclear.

Like other low- and middle-income countries, Tanzania is also facing a similar malnutrition challenge, as 32% of children under 5 years of age were stunted, 14.8% were underweight, 5% were wasted, and 42% were anemic.¹⁶ Compared to the previous nutrition surveys, the decline has been steadily increasing to reach the 2030 Sustainable Development Goals. The steady decline might be caused by several factors, including improper complementary feeding of children aged 6 to 23 months. According to the Tanzania Demographic and Healthy Survey (TDHS) 2015-16, Arusha region reported a higher prevalence of stunting (36%), wasting (6.5%), underweight (20.1%), and anemia (57.3%), which was higher than the national prevalence.¹⁷ These prompt the need for this study to determine the association between the indicators of food groups, complementary feeding practices, and children’s nutritional status: underweight, wasting, stunting, and anemia. The results obtained through this study will be useful for all stakeholders within and outside the Arusha region to design, plan, and implement important nutrition interventions focusing on improving complementary feeding practices as well as preventing all forms of malnutrition, contributing to achieving Sustainable Development Goal No. 2.

Methodology

Study Design

The study was a community-based cross-sectional study design.

Study Area

The study area was Arusha Rural District which shares similar social-economic characteristics with other rural districts in Tanzania, demonstrates cultural diversity and experiences high prevalence of malnutrition. A systematic random sampling was used to select 1 district and 3 wards out of 20 wards with at least 1 Reproductive and Child Health (RCH) clinic, namely Oldonyosambu, Oturumeti, and Seliani.

Study Population

The study population consisted of mother–child pairs aged between 6 and 23 months. Inclusion criteria consisted of mothers with children aged 6 to 23 months. Exclusion criteria included children who had a disability or serious illness 2 weeks prior the survey or whose parents refused to participate.

Procedure for Data Collection

The primary data on child feeding practices (quantitative and qualitative) was collected with a pretested structured questionnaire adopted from World Health Organization (WHO) indicators for assessing Infant and Young Child Feeding (IYCF) practices, which was modified to capture common foods consumed in Arusha, Tanzania, along with the social demographic characteristics of the study participants.

Sample Size Determination

The statistical power analysis formula n = z2p (1–p)/d2, was used to determine sample size where n = sample size, p = prevalence of stunting for under 5 (44%), z = z-value at 95% confidence (=1.96), d = level of significance (5%). With an anticipated attrition of 18% to follow-up yielded a total of 436 mother–child pairs aged 6 to 59 months were included in a large study; however, for the specific objective of analyzing children aged 6 to 23 months, only 279 eligible mother–child pairs were chosen for this study.

Conceptual Framework

Compelling evidence, including studies on complementary feeding practices, demonstrates a causal relationship with undernutrition in pediatric populations. Conceptual models posit a hierarchical framework to analyze this complex interplay. At the individual level, child-specific factors like biological age, gestational age, sex, birth type, birth weight, congenital anomalies, and postnatal health status influence nutritional outcomes. Additionally, maternal biological factors like age, health status, weight gain during pregnancy, micronutrient status, and complications, combined with interacting factors like education, employment, feeding frequency, and duration, all contribute to a child’s nutritional trajectory. Beyond individual factors, macro-level environmental, cultural, household, and psychological factors further influence feeding practices and nutritional status^18-20.

Dependent Variables

This study included 4 dependent variables: underweight [weight-for-age (WAZ)], wasting [weight-for-height (WHZ)], stunting [height-for-age (HAZ)], and anemia. The measurement of anthropometric indicators; stunting, underweight and wasting were aligned with international standards. The recumbent length for children was done by placing her/him horizontally on a wooden measuring board (Perspective Enterprises™, Portage, MI, USA) facing upward with the head toward the fixed end and the body parallel to the long axis of the board. The subject’s knees were pressed onto the board so that the legs were straight and the toes pointed directly upward, and then the movable footboard was brought to rest firmly against the heels and measured to the nearest 0.1 cm.²¹ The weight measurement was taken by using A Seca™ electronic scale placed on a flat floor and standardized to zero each day. Children who could not stand alone were measured by measuring the weight of the mother on the scale, then tared (zero out) and the mother carried the child by allowing the scale to display the child’s weight directly. The weight was read to the nearest 0.1 kg in all case with minimal or light clothing. Children were classified as underweight, wasted or stunted if their Z-scores were < −2 Standard Deviation (SD).²² Data points for Height-for-Age Z-score (HAZ), Weight-for-Age Z-score (WAZ), and Weight-for-Height Z-score (WHZ) were excluded if they fell outside the −6 to +6 range for HAZ and WAZ, or the −5 to +5 range for WHZ. This exclusion strategy aimed to minimize the influence of potential data entry errors or measurement inaccuracies associated with extreme outlier values²³ The HemoCue^® Hb 201+ was used to screen for anemia in children by collecting a finger prick blood sample with safety lancets. The finger was cleaned with an alcohol swab and the first drop of blood was wiped off with a piece of cotton wool, while the second was taken for hemoglobin measurement. Anemia was defined as hemoglobin level below 10.9 g/dl.²⁴

Independent Variables

In this study, independent variables were food groups consumed by children and complementary feeding practices indicators namely; time of initiation of complementary feeding (CF), MMF, MDD, and MAD.⁵ MMF was considered as the number of meals and snacks given to the children in a day and it was considered good/met if it was twice or more for children aged 6 to 8 months, 3 times or more for children aged 9 to 23 months. MDD was considered as the type of foods (food groups) given to children per day and was considered good/met if children consumed 4 out of 7 food groups; cereals and tubers, legumes, dairy products (milk, yogurt, cheese), flesh food (meat, fish, poultry, organ meat), eggs, vitamin A-rich fruits and vegetables, and other fruits and vegetables. These food items were categorized into 7 major food groups based on the World Health Organization’s Infant and Young Child Feeding guidelines.⁵ MAD was considered as a combination of MMF and MDD (considered good/met if children met both MMF and MDD).

Covariates

The social demographic characteristics of the children, the mother, and the household were considered as covariates during this analysis. The child characteristics include age, sex, and mother’s perceived birth size (birth weight), immunization, fever and diarrhea in the last 2 weeks before the interview. The mother’s and father’s characteristics include age, education level, as well as marital status. Household characteristics included place of residence and family size^18,19

Data Analysis

The Statistical Package Social Science (SPSS IBM version 25) was used during data analysis. A descriptive statistic was done for the frequency of social demographic characteristics of the study participants. Multivariable logistic regression analysis was employed to estimate the adjusted odds ratios (AORs) and their corresponding 95% confidence intervals (CIs) for the associations between complementary feeding practices and the nutritional status of the children.

Results

Demographic Characteristics

Table 1 presents the demographic characteristics of the participants enrolled in this study. More than half of the children involved in this study were male aged between 11 and 23 months. A small proportion (12.9%) of children were born with low birth weight, defined as weighing less than or equal to 2.5 kg. Almost all children involved in this study (99.64%) completed immunization. Most households consisted of 5 members, with the majority of parents being married and having attained primary level education.

Table 1.

Descriptive Characteristics of the Children Aged 6 to 23 months Included in the Study (N = 279).

Variables	Frequency (N)	Percentage (%)
Sex
Female	113	40.50
Male	166	59.50
Child’s age
6-11	163	41.58
12-23	116	58.42
Birth weight
<2.5 kg	36	12.9
2.5 and above	243	87.1
Family size
<5	201	72
>5	78	28
Marital status of mother
Single	24	8.6
Married	255	91.4
Education level of mother
No formal education	47	16.8
Primary education	180	64.5
Tertiary education	52	18.6
Mother’s age (years)
15-24	136	48.85
25-34	126	45.18
Above 34	17	5.96
Education level of father
No formal education	26	9.3
Primary education	217	77.8
Tertiary education	36	12.9
Presence of diarrhea
No	145	48.03
Yes	134	51.97
Presence of fever
No	169	60.57
Yes	110	39.43
Immunization
No	1	0.36
Yes	278	99.64

Nutritional Status

The overall proportional of anemia, wasting, stunting and underweight was 85.66, 15.41, 46.27, and 24.37 respectively. Anemia was the most prevalent (85.66) condition but all nutritional status was found to be high than the national nutritional status (Figure 1).

Figure 1.

Prevalence of underweight, wasting, stunting, and anemia.

Food Consumption

This study found a high proportion (over 80%) of the participating children consumed foods from at least 4 out of the defined food groups. Consumption of flesh foods (including meat, poultry, and fish) was observed in a relatively low proportion (13.26%) of the study population. All participating children (100%) were found to consume foods from the vitamin A-rich fruits and vegetables group, as well as the grains, roots, and tubers group.

Complementary Feeding Practices

Complementary feeding practices revealed suboptimal dietary diversity among the study population. While a high proportion of children (85.7%, n = 239) initiated complementary feeding before 6 months of age, adherence to MMF (86%, n = 240), MAD (69.9%, n = 195) and MDD (19.7%, n = 224; Table 2).

Table 2.

Complementary Feeding Practices Indicators.

Variable	Category	N (%)
Time of initiation of complementary feeding	At 6 month	40 (14.4)
Time of initiation of complementary feeding	<6 months	239 (85.7)
Minimum meal frequency	Meet	240 (86)
Minimum meal frequency	Not meet	39(14)
Minimum dietary diversity	Meet	55(19.7)
Minimum dietary diversity	Not meet	224 (80.3)
Minimum acceptable diet	Poor	84 (30.1)
Minimum acceptable diet	Good	195 (69.9)

Association Between Dietary Diversity (Food Groups Consumption) and Nutritional Status (Stunting, Wasting, Underweight and Anemia)

Table 3 presents the results of an association between dietary diversity and nutritional status (stunting, wasting, underweight and anemia). The likelihood of underweight (AOR = 0.16, 95% CI = 0.04-0.73, P < .05) and anemia (AOR = 0.16, 95% CI = 0.07-0.41, P < .01) was lower to children who consumed flesh foods compared to their peers. The odds of anemia were higher for children who consumed dairy products compared to their counterpart (AOR = 10.24, 95% CI = 2.79-37.57, P < .01).

Table 3.

Association Between Dietary Diversity (Food Groups Consumption) and Nutritional Status (Stunting, Wasting, Underweight and Anemia).

Food Groups	Underweight	Wasting	Stunting	Anemia
Food Groups	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)
Legumes
Not consumed	Ref.	Ref.	Ref.	Ref.
Consumed	1.39 (0.6-3.25)	1.15 (0.45-2.97)	1.61 (0.74-3.5)	0.39 (0.11-1.35)
Flesh foods
Not consumed	Ref.	Ref.	Ref.	Ref.
Consumed	0.16 (0.04-0.73)*	0.47 (0.13-1.75)	0.66 (0.29-1.48)	0.16 (0.07-0.41)**
Dairy products
Not consumed	Ref.	Ref.	Ref.	Ref.
Consumed	1.21 (0.29-4.99)	0.68 (0.16-2.92)	0.62 (0.21-1.89)	10.24 (2.79-37.57)**

Adjusted for age, gender, fever, diarrhea, mother’s education, father’s education, and marital status.

Abbreviations: AOR, adjusted odd ratio; Ref, reference category.

P < .01. *P < .05.

Association Between Complementary Feeding Practices and Nutritional Status

The association of complementary feeding practices with the nutritional status of the study participants was investigated. However, no statistically significant associations (P > .05) were observed between the employed indicators of complementary feeding practices and the children’s nutritional status (Table 4).

Table 4.

Bivariate and Multivariate Analysis of Feeding Practice and Nutritional Status.

Feeding practices indicators	Underweight	Wasting	Stunting	Anemia
Feeding practices indicators	AOR
Time of initiation of CF
At 6 month	Ref.	Ref.	Ref.	Ref.
Less than 6 months	1.96 (0.69-5.6)	3.49 (0.74-16.46)	1.08 (0.50 -2.3)	0.83 (0.29-2.38)
MMF
Meet	Ref.	Ref.	Ref.	Ref.
Not meet	0.46 (0.08-2.46)	0.17 (0.03-1.02)	0.84 (0.19-3.78)	2 (0.38-10.53)
MDD
Meet	Ref.	Ref.	Ref.	Ref.
Not meet	0.57 ( 0.1-3.24)	0.62 (0.11-3.53)	1.09 (0.24-4.96)	2.11 (0.4-11.25)
MAD
Poor	Ref.	Ref.	Ref.	Ref.
Good	3.21 (0.46-22.33)	3.06 (0.4-23.16)	0.9 (0.17-4.88)	0.6 (0.09-4.13)

Adjusted for child’s age, gender, birth weight, having diarrhea, and fever.

Abbreviations: Ref, reference category; AOR, adjusted odd ratio; CF, complementary feeding; MMF, minimum meal frequency; MDD, minimum dietary diversity; MAD, minimum acceptable diet.

Discussion

This study was aimed at finding the association of food groups and complementary feeding practices on the nutritional status of children aged 6 to 23 months. The study found that the absence of meat and meat products in the diet was associated with underweight status, while dairy product consumption, particularly milk, was linked to a higher likelihood of anemia. No significant association was observed between complementary feeding practices indicators and the nutritional status of the children involved.

This study observed a concerning prevalence of underweight (24%), wasting (15%), stunting (46%), and anemia (85%) among the study population. These prevalence are significantly higher compared to the national malnutrition status reported in the TDHS 2015-16, which documented a prevalence of underweight (14%), wasting (5%), stunting (34%), and anemia (58%)¹⁷ as well as the one reported by Khamis et al.²⁵ The differences might be attributed to differences in regional cultural practices, socio-economic circumstances, and dietary patterns as well as the different research methods employed.

Similar to studies conducted in Tanzania, Burkina Faso, and Nigeria,^25-27 this study found that 100% of children consumed staple foods like grains, roots, and tubers, alongside fruits and vegetables. This highlights the universality of these food groups in children’s diets across various regions. However, flesh food (meat, fish, poultry, or organ meats) consumption differed. While our findings align with studies in Kenya, South Asia, and Ethiopia^27-29 demonstrating low flesh food intake, this contrasts with reports from other regions where children consumed higher amounts.³⁰

The observed low flesh food intake in this study likely relates to affordability, particularly for low-income households. This aligns with established knowledge that animal-source foods are often more expensive than plant-based staples. Notably, our analysis revealed a positive association between flesh food consumption and reduced risk of underweight and anemia. This finding reinforces the established role of animal-source foods in providing highly bioavailable iron, crucial for hemoglobin synthesis and oxygen transport, potentially explaining the observed lower anemia prevalence among children with higher flesh food intake. Our findings support previous research by Thomson et al³⁰ which demonstrated a link between red meat consumption and a lower risk of persistent anemia and underweight. To address the issue of low flesh food intake and improve iron intake, promoting nutrition-sensitive interventions such as encouraging families to raise small animals like poultry, goats, and rabbits could be highly beneficial. This approach would enhance accessibility and affordability of animal-source foods within the household.

The study observed that most children were initiated on complementary feeding before 6 months of age. While breast milk remains a valuable source of iron, this finding deviates from the World Health Organization’s (WHO) recommendation of introducing complementary foods at 6 months.³¹ Similar early initiation practices were reported by the University of Indonesia and UNICEF.³² In addition, a study by Barrera et al on the timing of the introduction of complementary foods to US infants revealed that almost one-sixth of US infants were introduced to complementary foods before 4 months, and nearly two-fifths between 4 and less than 6 months.³³ This discrepancy suggests potential knowledge gaps among mothers regarding optimal IYCF practices. Early initiation of complementary feeding may reflect a perception that breast milk alone is insufficient for their children’s needs. Educational interventions promoting optimal IYCF practices, including the importance of exclusive breastfeeding for the first 6 months, are crucial.

Our study found that a majority of children met the minimum meal frequency, aligning with results from Myanmar, Indonesia, and Northern Ghana.^14,34,35 However, this contrasts with studies from South Asia, and Nigeria, where lower adherence to minimum meal frequency was reported.^27,28 Interestingly, a study in Malawi found that children meeting the minimum meal frequency had a lower risk of underweight,³⁶ highlighting the potential benefits of adequate feeding frequency for child growth.

Furthermore, this study demonstrated that most participants did not achieve the recommended minimum dietary diversity. This finding mirrors studies in Indonesia, Malawi, and Burkina Faso.^26,34,36 Conversely, other research has shown a positive association between higher dietary diversity and reduced stunting in children.^26,37 Additionally, studies in Burkina Faso and Malawi observed links between dietary diversity and underweight.^26,36 These contrasting findings suggest that the impact of minimum meal frequency and minimum dietary diversity on child growth indicators may vary across different contexts.

This study observed adherence to the MAD (a combination of minimum meal frequency and minimum dietary diversity) by a majority of participants. This is similar to Sri Lanka but higher than reports from Malawi, South Asia, Indonesia, Nepal, and Ethiopia.^28,34,36,38 These variations likely reflect differences in socio-cultural practices surrounding food habits and preferences across regions.

While our study observed high adherence to the MAD, previous research suggests a strong positive impact on child growth indicators like weight-for-age and height-for-age for children meeting this criterion.³⁶ The MAD ensures children receive essential nutrients for healthy growth and development. Insufficient nutrient intake can have long-term consequences for a child’s physical and cognitive development.

Limitation of the Study

This study is strengthened by its adherence to the WHO-recommended IYCF standards when analyzing CF practices for children aged 6 to 23 months. However, its limited sample size from one region and its cross-sectional nature both limit its ability to generalize the results to the entire country and to establish causal effects, respectively. The study only recorded the consumption of specific food groups without quantifying the amounts of food consumed. Additionally, recall bias of mothers during the reporting of complementary practices to their children may have also influenced the results.

Conclusion

This study found an association between food groups and nutritional status for children aged 6 to 23 months; children who consume flesh foods were less likely to be underweight and anemic compared to their peers. Therefore, promotion of infant and young child feeding practices should be strengthened, and much effort should be geared toward increasing animal-source foods in children’s meals.

Footnotes

Acknowledgements

The authors express their gratitude to Edgar Pallanjo for his valuable assistance during the data analysis process. Additionally, the authors extend their thanks to the mothers of children aged 6 to 23 months who willingly participated in this study. Furthermore, the authors acknowledge the contributions of all research assistants involved in data collection for this research

ORCID iD

Kaunara Ally Azizi

Ethical Considerations

This study was approved by the National Institute for Medical Research (NIMR), Ethical Review Committee (Reference Number NIMR/HQ/R.08a/Vol. IX/1969). Written and verbal consent was obtained from all study participants [parents or legally authorized caregivers of children]. All procedures followed were in accordance with the ethical standards of the Declaration of Helsinki of 1975.

Author Contributions

Moshi, C led study conception and design; contributed to data acquisition, analysis and interpretation; wrote the first draft of the manuscript; and revised the manuscript. Katana, D contributed to study conception and design, data acquisition and analysis, and reviewed and contributed to the revised manuscript. Mwana, E contributed to data acquisition, analysis, and interpretation and reviewed and contributed to the revised manuscript. Kejo, D contributed to study conception and design, data acquisition and analysis, and reviewed and contributed to the revised manuscript. Mzimbiri, R and Azizi, K provided scientific oversight, led study conception and design, contributed to data interpretation, and reviewed and contributed to the revised manuscript. All authors gave approval for the final manuscript.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All data included in this study are available upon request by contact with the corresponding author.

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