Assessment of Dietary Diversity of Mothers and Children of 6–24 Months from Eastern and Southern Provinces of Zambia

In-depth information on dietary diversity and food consumption patterns in Zambian households is still scarce. This study, therefore, probed dietary intakes of mothers and their children living in households of two Zambian districts, Chipata and Monze, located in the eastern and southern provinces of Zambia, respectively. After assessing their diet, Dietary Diversity Scores (DDSs) were calculated and classified into low and high categories, while correlations were used to test determinants of DDS. The assessment revealed that the consumption of cereal-based products ranked highest in frequency. Specifically, the consumption of maize-based foods was highest in Chipata (55.43%) and then in Monze (43.56%) households. There was an observed low preference for mixed dishes that were not either maize or groundnut porridges. We also found positive and negative correlations of DDS with the educational level of household heads and age of mothers, respectively. We, therefore, suggest that increased nutrition education may improve dietary preferences, so also further investigation into other factors hindering low choices for mixed recipes will be useful in increasing overall diet quality.


Introduction
Food consumption data are essential sources for tracking information on household food insecurity and nutrition outcomes, especially when the quality of diet is highlighted.One of the key elements of assessing diet quality of populations is to measure the variety and type of their consumed foods [1]..isvariety of food consumption is usually referred to as dietary diversity.Dietary diversity is a qualitative measure of food consumption that shows nutrient adequacy of the diet of individuals and households [2,3].Considering that over 40 nutrients are needed in the human diet for best nutrition and well-being [4], a different combination of foods from various food groups is required to help meet individual nutritional requirements and promote good health [2,5].Measuring dietary diversity has been found as a useful tool for the rapid assessment of food security and nutritional status in low-income settings [6,7].Increasing dietary diversity is a proven intervention that improves nutrient adequacy in children aged 6 months to 2 years [2].Nutrient-rich foods from different diets are essential elements in child feeding that support dietary needs and adequate growth during their early years of life.Dietary diversity has been established as a significant predictor of growth, as illustrated by an analysis of Demographic and Health Survey data from children aged 6-24 months in 11 countries in Africa and Latin America [3].Intake of a diverse variety of foods has been a recommendation for achieving adequate nutrient intake, and the advice appears in the dietary guidelines of many countries.Several factors can hinder diversification of diets, especially among poor populations of developing countries.
In most cases, it hinges on the availability of food and the corresponding economic or physical access.While there is evidence that socioeconomic constraints can affect eating a varied diet [8,9], it is unclear if the sociodemographic characteristics of a population influence the choice of food and dietary diversity.A survey evaluating the nutrition and food diversity among smallholder farmers found high food insecurity and low crop and diet diversity among farmers three months after harvest [10]..ereis, however, an association between improved child dietary diversity and increased maternal nutritional diversity knowledge and practice [10]..estudies were either limited in sampling only some regions or targeted farming households only and did not probe the diversification of diets in mother-child pairs..isstudy, therefore, aimed to assess mother-child pairs with a focus on dietary intake, food frequency, and associated factors affecting dietary in children aged 6-24 months in Chipata and Monze districts in the Eastern and Southern provinces of Zambia, respectively.

Study Design.
A cross-sectional study design was used, and households with children aged 6-24 months were randomly selected from the database of children (<5 yrs) registered at the respective district clinic; a total of 200 households were selected from each of the two districts making a total of 400 households..isselection was based on random sampling with the criteria being voluntary participation.A structured questionnaire was used to collect information on household demographics and food consumption twice at 3-month intervals.

Sampling and Sample Size.
.e sampling unit for the study was households with children aged 6 to 24 months..eyoungest child within the household was selected, and if there were more than a mother/caregiver in the household, the most senior was selected..e two districts were chosen purposely, due to their high stunting levels, and the eight camps from each district were randomly selected..eselected households (400) for the study were verified and registered at 16 camps from both Chipata and Monze districts in Eastern and Southern Zambia, respectively..ehouseholds were accorded household numbers purposely for first and subsequent data collections..eeight camps from Chipata were coded 01 to 08 and those from Monze camps were coded 09 to 16.Each household was assigned a unique household number.

Data Collection.
.e trained local field workers performed data collection with a pretested questionnaire.A total of 16 field workers from the two districts were trained on the 24-hour multipass recall dietary assessment tool.Data on dietary intake were assessed using the multipass 24-hour dietary recall method..einterview was repeated twice at 3month intervals.Field workers carried various samples of foods, scales, spoons, cups, small food containers, etc. and used these to estimate amounts consumed..edata collected for the two periods were used to generate dietary diversity scores (DDSs) as a measure of diet quality..emothers supplied the dietary intake information and pattern for the children.Total DDSs amounted to a minimum of one to a maximum of eight.From the repeated dietary recall, the number of times a food was consumed was taken as a single count..edifferent foods were accounted for, and the portion sizes averaged.
2.4.Ethics.Ethical clearance approval was obtained from the University of Zambia Biomedical Research Ethics Committee (UNZABREC) with assurance no.FWA00000338 and approval no.IRB00001131 of IORG0000774, and the final authority was obtained from the Ministry of Health..e mother of the selected child was informed about the nature of the study.Respondent participation in the study was voluntary with voluntary informed consent requested from households.Questionnaires were administered after the families agreed to participate in the study.

Data Processing and Statistical Analysis
.e data were analysed using SAS version 9.3.Food frequency, amounts of foods consumed (g), and DDS were calculated by summing the number of unique food groups consumed by the child in the 24-hour period.Pearson's correlations analysis of DDS and sociodemographic characteristics were run.A food frequency of 10 was used as the cutoff point, which accounted for 95% of the food consumed by the participants.Mean ± SD value for the weight of each food variety consumed was computed..eclassification of the Dietary Diversity Score (DDS) into low and high categories was adapted from [2] with slight modifications..eranges used were 1 to 4 foods for Low DDS and 5 to 8 foods for High DDS.   2).A preference for groundnut + leafy vegetables was observed to have the highest positive response of 48.69% and 39.17% in Chipata and Monze districts, respectively..econsumption of porridge made from combinations of groundnut with staple crops, such as rice, cassava, and sweet potato, was very low..emajor foods consumed were maize + groundnut based, and this could be because they are the major crops grown in the two districts and thus formed a major part of their diet.

Food Frequency (N) and Weight (Grams) of Foods
Consumed by Mothers and Children..e food frequency and weight of foods consumed by children from Chipata and Monze districts are presented in Tables 3 and 4. From the dietary intake assessment, seven categories of food were found: cereals and cereal-based products, legumes and legume-based products, starchy roots and tubers, fruits and vegetables, meat and fish products, eggs and egg products, and milk and milk products..emost commonly consumed food category was the cereals and cereal-based products followed by fruits and vegetables, even though the latter category had a greater variety of foods.Nshima and porridge (maize-based foods) were the most frequently consumed foods by children from the two districts with consumption of 130. .efood frequency and weight (grams) of food consumed by mothers from Chipata and Monze districts are summarised in Tables 5 and 6. .edistribution and category of foods were like those obtained for the children, with the fruit and vegetable group having the highest number of food varieties (10 to 13 types) compared to other food groups.Mothers from Chipata had more foods under the legume and legume products and fruit and vegetable food groups for mothers from Monze..iswas similar to fish products.Although meat and fish products consumption was deficient, those consumed included kapenta, fish, chicken, fish relish, and pork.

Dietary Diversity Scores (DDSs) for Mothers and Children.
.e DDS of children across the two districts is presented in Table 7. .emean DDS for the children was 4.1 ± 1.38 (range 1 to 8), but males had 4.1 ± 1.42 and females had 4.1 ± 1.32 with no significant difference seen (P < 0.05).Most (62.69%, n � 247) of the children consumed food items from 1 to 4 food groups, and only 37.31% (n � 147) consumed a diversified diet from 5 to 8 food groups showing low dietary diversity (LDD) and high dietary diversity (HDD), respectively.However, 27.92% (n � 110) consumed 4 food groups showing mid-dietary diversity (MDD), while 0.76% (n � 3) with HDD consumed most of the 8 food groups..echildren from Monze district had a slightly higher DDS   7 also shows the distribution of DDS of mothers from Chipata and Monze districts..emean DDS of mothers (4.8 ± 1.33, n � 396) was slightly above the low cutoff (4.0), thus indicating that most women consumed foods from >4 different groups.However, mothers from Chipata had a mean DDS (range 2 to 8) of 5.1 ± 1.47 (n � 219) with the majority (64.38%) in the high category of DDS (5 to 8), while those from Monze had 4.6 ± 1.08 (n � 177) with 50.85% in the low class of DDS (1 to 4)..efrequency of the scores shows that no mother had a DDS of 1 across the districts, but the highest number of mothers (26.94%) from Chipata was found to have a DDS of 5 and Monze (36.16%) had a DDS of 4. No woman from Monze District had a DDS of 8, but 5% (n � 11) was recorded for Chipata, and this shows that mothers from Chipata consumed a more diversified diet than their Monze counterparts..eobservation was contrary to what was observed among the children, where a higher percentage of Monze children consumed a diet from more food groups than those from Chipata.

Correlation of DDS and Sociodemographic Characteristics
of Household Heads (HHs) and Mothers..e correlation coefficient (r) of DDS (Chipata and Monze) and sociodemographic characteristics of HHs and mothers are presented in Table 8. .erewas a significant positive correlation between the DDS and educational levels of HHs in Chipata (r � 0.15268, P < 0.01) and Monze (r � 0.15271, P < 0.05)..eDDS of mothers sampled from Chipata was correlated and significant with their educational level (r � 0.21265, P < 0.001) and age (r � −0.16728, P < 0.01).However, the age of HHs was .e cutoff point of the frequency is 10 (accounts for 95% of food commonly consumed). 6 Journal of Nutrition and Metabolism correlated and significant (r � 0.15209, P < 0.05) with DDS among Monze respondents, and this shows that the level of education of the HHs, education level, and age of mothers influenced the diet diversity of food consumed by the households.Of note is the negative correlation between DDS and age of the mothers sampled from Chipata (r � -0.16728, P < 0.01) and Monze (r � −0.08110, P < 0.01), and this could mean that improved knowledge through education in younger women compared to older women in the sampled districts contributed to the choice of foods consumed.

Discussion
Dietary intake assessment was carried out using a quantitative 24-hour dietary recall to generate a frequency of consumption, portion sizes, and Dietary Diversity Scores (DDSs) of foods commonly consumed by mothers and children in the sampled districts..emean Dietary Diversity Score (DDS) calculated in this study shows a low diversity of foods for both mothers and their children, which infers that majority of households consume a monotonous diet that focuses on a limited number of food groups..isDDS suggests a low diet quality as described by Nupo et al. [5] and Vandevijvere et al. [11]..enumbers of foods available for children and mothers in Chipata were more than that of foods available for their Monze counterparts, and this was evident in the DDS of the mothers from Chipata who had a higher DDS.It was not the same as children from Chipata who had a low DDS..ismay suggest that availability may not necessarily indicate consumption of foods by the children..escores of the children from both districts fell below the WHO infant and young child feeding indicator on dietary diversity, which suggests greater or equal to 4 food groups/day [12]..us,nutrition education on the benefits of diversifying diets may be useful to improve the nutrient intake of the mothers and children from Chipata and Monze..e high consumption of cereal-based foods and assorted vegetables are in concordance with similar studies and surveys carried out among Zambian populations [13,14].Furthermore, as discussed by Doko et al. [15] and Mamiro et al. [16], cereals and their products are the main staples of populations in Eastern and Southern Africa..is is particularly so in the mother-child pairs in this study, where maize-based products (nshima and maize porridge) were the most frequently consumed foods.Frequency of consumption of animal source foods was very low and was restricted to milk, fish, and chicken and their products..ereare more diverse sources of dietary energy intake for children in Chipata which were obtained mainly from cereals and starchy roots and tubers, but there were fewer sources of dietary  energy among the Monze children.A similar level of diversity is observed in the foods that chiefly supply protein to children from Chipata, relying on three sources compared to only beans consumed by children from Monze..isdependence on plant sources of foods can have implications on micronutrient intake, which usually results in severe undernutrition [17]..ere is evidence [18], which proves that dietary diversity, as an indicator of micronutrient adequacy, is associated with nutritional outcomes of infants in a Zambian population..esedeficiencies were also established in mother-child pairs assessed in the northern provinces of Zambia [13].An improvement in dietary diversification presents short-and long-term benefits.Even though children in Chipata had more types of foods within groups, their DDS was lower than their counterparts from Monze District, and this could be because of poor knowledge of value addition to staple crops.As observed from the study, responses on whether some recipes were consumed turned out to be negative.In the absence of nutrient-dense foods of animal origin, an understanding of how to maximize available crops for nutrition security could help in improving the quality of the diet, especially for children with vital nutritional needs.Nutrition education, in this regard, has been established to be a high impact intervention to improve nutrient adequacy [19,20].According to results presented in Tables 3 and 6, which show nshima and maize porridge (both maize-based) as the foods with highest food frequency counts, and Table 2, which shows a monotonous preference for maize and groundnut porridge, it is obvious that the sampled populations are highly dependent upon maize-based foods..eseobservations are similar to food consumption data of Zambians, as reported by Nyirenda et al. [21].Worthy of note is the low preferences for maize with fish porridge and maize with beans porridge..esefoods can improve diversity and adequate nutrients if accepted.A feeding trial of biofortified foods in Zambian children carried out by Schmaelzle et al. [22] emphasised education on the usefulness and potential of new recipes as a missing link for poor food choices for diversity.Demographic characteristics, as highlighted, maybe for the cause of the low dietary diversity seen in the sampled populations..eresults of the study, which show an association between the educational level of the household head and DDS in both districts, is a determining factor in improving the overall quality of diet in households in the sampled districts.Associations between mothers' knowledge of diet diversification with sociodemographic factors such as husband's education and age of the mother have been reported in the literature [10]..isassociation is a pointer to the positive impact of an individual's educational status on healthy food choices..isindicates that enlightenment about food may be needed at the household level in Zambia to encourage improved dietary practices.

Conclusion
.e study has shown low diversity in the diet of mothers and children aged 6-24 months in the sampled Zambian eastern and southern provinces.While maize-based foods are often consumed, variety in the recipes is low, and the low preference for mixed foods other than maize and groundnut porridge confirms this observation..ereare suggestions that nutrition education could improve this preference, and it may be beneficial to take a closer look at factors hindering value addition to maize as evident in the low choices for recipes not usually consumed..ecorrelation results obtained in this study are also consistent with those of other researchers who proved that insufficient higher education is a risk factor for not meeting optimum dietary diversity in young children [23]..eserelationships can hurt the nutritional status of the child since, at this stage of development, food choices are limited by general household food security.

Table 1 :
Sociodemographic characteristics of household heads (HHs) and mothers from Chipata and Monze.

Table 3 :
Food frequency and weight (grams) of foods consumed by children in Chipata.

Table 4 :
Food frequency and weight (grams) consumed by children in Monze.

Table 5 :
Food frequency and weight (grams) consumed by mothers in Chipata.

Table 7 :
Dietary diversity scores (DDSs) for children and mothers.

Table 6 :
Food frequency and weight (grams) consumed by mothers in Monze.

Table 8 :
Correlations of DDS of mothers and sociodemographic characteristics of household heads and mothers in Chipata and Monze districts.