Gender and dietary diversity among children aged 6-24months – evidence from a nationally representative survey

Abstract

Background

Malnutrition among children remains a critical public health challenge in India. WHO’s IYCF model recommends that children should feed on five out of eight food categories daily. The objective of the study is to assess dietary diversity and associated risk factors among children, focusing on complex interplay of socio-economic and demographic factors.

Methods

The study utilized nationally representative data from the National Family Health Survey (NFHS-5) conducted in 2019–2021, focusing on a sample of 62,553 children aged 6–24 months. Minimum Dietary Diversity (MDD) was assessed using children received foods from ≥ 5 food group out of eight specified food groups over the 24 h preceding the survey. Logistic regression employed to examine the association between DD and its predictors (p value < 0.05).

Results

Overall, 52% of the children were male, while the remaining 48% were female. Only 23.3% of the children across India achieved MDD. Mother’s education was positively associated with dietary diversity (OR:1.15; 95% CI:0.92–1.4). Factors significantly associated with dietary diversity were children aged 19–23 months (OR:4.03; CI:3.46–4.69), working mothers (OR:1.30; 95% CI:1.14–1.5) and children belonged to middle (OR:1.22; CI:1.05–1.43) and rich socio-economic status (OR:1.48; CI:1.26–1.8) as compared to their counterparts. Additionally, no difference found in dietary diversity among male and female children (OR:1.01; CI:0.9–1.11) and urban and rural areas (OR:101; CI:0.87–1.17). Those children belonged to Northeast region had around 70% higher dietary diversity as compared to Central region.

Conclusion

This study highlights a concerning low prevalence of dietary diversity among young children in India. Interventions and policies should target on implementing comprehensive nutrition education programs for caregivers, coupled with targeted financial support and community engagement.

Introduction

More than half of all child fatalities caused by undernutrition, which lead to 300,000 deaths annually [1]. Although, the prevalence of Malnutrition reduced, it still affects 200 + millions children across globe [2]. Global nutritional programs being suggested as a preventive measure, potentially sparing 3 million lives, and reducing 20% various effects of malnutrition among under-5-year-olds [3]. Millions of children suffered from malnutrition, which included under nutrition, overweight/obesity, and micronutrient deficiencies, particularly highly prevalent in low- and middle-income countries (LMICs) [4] adding up to 21% to the Disability Adjusted Life Years (DALY), globally [5]. Micronutrient deficiencies, such as iron, vitamin A, zinc, folate, vitamin B12, vitamin D, and iodine were associated with serious health consequences [6]. Human potential was hampered by micronutrient deficiencies, which raised the prevalence of morbidity and mortality [3]. According to FAO, the prevalence of undernourished in southern Asia was 15.6% in the year 2022 [7]. In India, recent national estimates of 2020 reported widespread burden of stunting, wasting and underweight [8].

The importance of proper nutrition during the first two years of a child’s life considered crucial for optimal growth and development, making it of paramount importance for global health [9]. The World Health Organization’s Infant and Young Child Feeding recommends that children should consume at least five out of eight food categories including breast milk on every day [10].

Globally, only 28% of children between the ages of 6 and 23 months received the diversified diet [9, 11]. Undernutrition induced due to low diet diversity was one of the nutritional problems in LMICs. A retrospective cohort study reported 74% of low diet diversity, exposing its burden in LMICs [12]. Additionally, 37% of the children in South Asia met with minimum dietary diversity (MDD) [13]. In India, various studies utilized the fourth round of National Family Health Survey (NFHS) data to explore regional wise prevalence of dietary diversity. The results revealed that MDD ranged from 12% in central region to 33% in southern region of the country [14, 15].

As per several studies, the role of gender in diet diversity plays no significant role [16, 17]. The gender specific determinants of diet diversity among eight Asia Pacific countries found no disparity or evidence of gender’s role in diet diversity [13]. However, there were significant difference in micronutrients levels between male and female children [18, 19].

In developing countries, impoverished populations faced significant challenges in achieving dietary diversity. Many researchers from low-and middle-income countries (LMICs) have documented differences in dietary diversity and socioeconomic classes by urban rural population. Evidence from other countries found the relationship between wealth and place of residence with dietary diversity. However, none of the studies have examined this association in India [3, 20, 21]. Urbanization induced substantial changes in urban food systems, and lifestyles, contributing significantly to the differences in access to diversified dietary intake [21].

Factors contributing to dietary diversity include family characteristics, birth order, birth weight and socioeconomic status. Adequate diet diversity among children was influenced by breastfeeding and child-rearing practices followed by mother, cooking practices, and their socioeconomic position of the household [22]. Mother’s dietary diversity was linked with the growth and development of the child. In countries with low maternal dietary diversity, the prevalence of MDD among children was insufficient [1, 14, 23].

Inadequate dietary practices were higher in rural regions (38.4%), among Muslim children (37.9%), those belonging to scheduled caste and tribes (40.8%), and those from low-income families (47.9%) [24, 25]. Over the past decade, India has seen a 6.8% reduction in the failure of MDD, dropping from 87.4% in 2005-06. In addition to the most consistent factors mentioned hitherto, community healthcare services and more than four antenatal visits were indirectly proportional with MDDF [26].

Based on available literature, there are potential gaps and requirement to extensive understanding of risk factors. These includes MDDF (minimum dietary diversity failure), demographic burden, luxuries, role of gender and influence of maternal nutrition. Additionally, there is a need to explore their association with MDD and malnutrition among children.

This study aims to assess dietary diversity and its associated risk factors among children aged 6–24 months in India, shedding light on the complex interplay of socio-economic, cultural, and demographic factors affecting children’s nutritional status.

Methods

The present study utilized the most recent and nationally representative NFHS data (2019-21). The study included 62,610 children aged 6–24 months. The NFHS is a nationally representative household survey that provides country, state and district-level information about health and nutrition profile of the population in the country. The NFHS (2019-21) was the fifth round of the national survey conducted by the International Institute of Population Science (IIPS), Mumbai [8]. Technical assistance was provided by ICF International. A cross-sectional survey with multistage random sampling was used for household selection.

Study variables

Outcome variable: Minimum Dietary Diversity was assessed using children receive foods from 5 or more food group out of eight specified food groups over the 24 h preceding the survey. Children with dietary diversity scores ≥ 5 were classified as they attained adequate dietary diversity, whereas those with scores < 5 were classified as inadequate dietary diversity.

Independent Variables: The study included determinants of maternal, individual, and household characteristics.

Maternal Characteristics – Mother’s education was categorized as no education, primary, secondary, and higher secondary and above. Similarly, mother’s working status (yes, no), mother’s age at first birth (< 18 years, > 18 years), mother’s age at first marriage (< 18 years, > 18 years) and mother’s BMI (underweight, normal BMI, overweight & obese).

Individual characteristics – Child age in months (6-11 months, 12-18 months and 19-23 months) , sex (male, female), birth order (first, second, third and above), birth weight (underweight, normal, overweight) and current breastfeeding status (yes, no).

Household Characteristics – Household-related factors were wealth status (poor, middle, rich), religion (Hindu, muslim and others), region (north, central, east, northeast, west and south), caste (schedule caste, schedule tribe, OBC and others), number of living children in household (1–2, 3–4, 5 and above), place of residence (urban, rural) and sex of household head (male, female). Wealth status was categorized into three categories based on family’s socio-economic status as per NFHS-5 guidelines. Wealth status was determined using Principal Component Analysis (PCA).

Statistical analysis

Fifth round of National Family Health Survey data were analysed using software STATA version 16.0 to fulfil the study objective. Descriptive statistics was employed to examine the background characteristics of children. Multivariate logistic regression was employed to examine the association between dietary diversity and its predictors among children. The odds ratio (OR) with 95% confidence interval was calculated in order to assess the risk of independent variables. The coefficient with p value < 0.05 were considered as statistically significant. Additionally, the absolute difference was calculated to examine the disparity in dietary diversity between males and females.

Ethical approval

The National Family Health Survey (2019-21) is the fifth round of national survey which was conducted by International Institute for Population Sciences, Mumbai. The technical assistance on this survey is provided by ICF international. The study used a secondary dataset of NFHS from the Demographic Health Survey, which contains no information that may be used to identify the survey participants personally. This survey used the usual questionnaire to get consent before and throughout the investigation. This dataset is freely available online in public domain on the Demographic and Health Survey site; however, access is only permitted after registering and submitting the required research interest.

Results

Participant characteristics

The socio-demographic characteristics of children included in the survey are summarized in Table 1. Out of 62,610, male children were slightly higher than female children. More than half of the mothers (53.5%) were secondary educated and 19% of the mothers had no formal education. There were 57.2% of mothers got married at the age of 18 years and above whereas most of the mothers (81.6%) were > 18 years at the time of first birth. Around 60.7% of the mothers had normal BMI and around 63% children born with normal birth weight. Three fourth (74%) proportion of mothers were belonged to Hindu religion and had one to two children (74.6%). Around half of the mothers (49.2%) were belonged to poor socio-economic status. The proportion of mothers residing in rural area and belonged to central region were 79.7% and 25.4%, respectively. Most of the households (84.8%) were headed by male. Children between the age of 12–18 months were 40.7%. Around 38.6% of the children were born first in their family. The proportion of children who were currently breastfed were 86.0%.

Table 1 Distribution of socio-demographic characteristics of household, mothers and their children aged 6–23 months

Table 2 represents the prevalence of adequate and inadequate dietary diversity as per individual, household and maternal characteristics. The dietary diversity among children increased with the increase in mothers’ educational status (5.0%) from non-educated to highly educated, mother’s Nutritional status (5.1%) from undernourished to over nourished and mother’s wealth status (2.3%) from poor to rich. Children of working mothers (7.5%) had more dietary diversity than non-working. The highest dietary diversity, at 28.2%, was found among children belonged to scheduled tribes. Children in urban areas had a slightly higher dietary diversity (1.5%) compared to those in rural areas. The highest dietary diversity, at 31.6%, was observed among children from the Northeast region, while the lowest was found among those from the central region, at 16.5%. The gender of the child did not impact the consumption of a diversified diet. The dietary diversity among female headed households (2.6%) were more as compared to male headed households. As the age of the child increased, along with a higher birth weight, there was a noticeable increase in the consumption of a diversified diet. Children born as the second child in the family exhibited greater dietary diversity compared to those born as the first child or as the third child and beyond. Dietary diversity was higher among currently breastfed children (5.1%) in comparison to those who were not breastfed.

Table 2 Prevalence of Minimum Dietary Diversity by selected socio-demographic characteristics in children aged 6–23 months

Table 3 describes result of logistic regression analysis showing association between dietary diversity among children and their risk factors. The analysis confirms that education was positively associated with the diversified diet in children (OR = 1.15; 95% CI = 0.92–1.4). The dietary diversity was significantly higher in those children, whose mothers were working (OR = 1.30; 95% CI = 1.14–1.5), who were born second in the family (OR = 1.26; CI = 1.11–1.42), living in female headed household (OR = 1.19; CI = 1.03–1.38) and currently breastfed (OR = 1.96; CI = 1.67–2.32) as compared to their counterparts. Children those belonged to Muslim religion (OR = 1.36; CI = 1.06–1.51) and scheduled tribes (OR = 1.43; CI = 1.19–1.71) community had more dietary diversity as compared to those children belonged to other categories of religions and caste, respectively. The multivariate analysis also confirms that dietary diversity was higher among children belonged to middle (OR = 1.22; CI = 1.05–1.43) and rich (OR = 1.48; CI = 1.26–1.8) wealth status as comparted to other wealth categories. Bivariate analysis found significant association between place of residence and dietary diversity where multivariate analysis found almost no difference in dietary diversity among those residing in urban and rural areas (OR = 1.01; CI = 0.87–1.17). Additionally, no difference in dietary diversity among male and female children (OR = 1.01; CI = 0.90–1.11). Multivariate analysis confirmed that those children belonged to Northeast region (OR = 1.47; CI = 1.71–1.84) had more dietary diversity whereas those belonged to west region (OR = 0.82; CI = 0.67–1.03) had low dietary diversity. Children aged 19–23 months had more dietary diversity as compared to other age groups (OR = 4.03; CI = 3.46–4.69).

Table 3 Results of logistic regression analysis of Minimum Dietary Diversity by selected socio-demographic characteristics in children aged 6–23 months

Table 4 presents the percentage distribution of food consumption among children in different age groups (6–11 months, 12–18 months, and 19–23 months). Results indicates that children aged 6–11 months minimally consumed flesh foods, eggs, legumes, and nuts, while the highly consumed food item was breast milk. Children aged 12–18 months predominantly consumed all the food groups, ranging from 40 to 47%. Among children aged 19–23 months, dairy products were minimally consumed at 29.1%, while the highest consumption was observed for flesh food, reaching 37.6%. The observed differences in food group consumption among age groups were statistically significant (p-value < 0.001).

Table 4 Distribution of intake of eight food groups for children aged 6–23 months during the previous day (in last 24 h)

Table 5 shows the proportion of children aged 6–23 months who consumed adequate dietary diversity, categorized by gender (male vs. female), in various states and union territories (UTs) of India. The “Absolute Difference” column represents the absolute difference between the proportions for males and females in each region. Results indicates that there is a small gender difference at the national level, with male children (23.0%) having a slightly lower proportion of adequate dietary diversity compared to females (23.3%). Overall, the table highlights the state wise variations in the dietary diversity among children aged 6–23 months in India, with gender disparities present in several states and UTs. Understanding and addressing these differences are crucial for targeted interventions to improve nutritional outcomes for children across the country.

Table 5 Proportion of children aged 6–23 months consuming adequate dietary diversity (Male vs. Female) by State and Union territories in India

Figure 1 shows percentage distribution of children aged 6–23 months as per the number of food groups received during the previous day (in the last 24 h). A total of 23.2% of children had received five and more food groups during the previous day which indicates adequate dietary diversity.

Fig. 1

Distribution of children aged 6–23 months living with their mothers received number of food groups during the previous day (in last 24 h), (N = 62610)

Figure 2 presents the percentage distribution of children based on the types of food groups they received. Most of the children (86.0%) received breastmilk during the previous day. About half of the children (50.7%) received dairy products, including infant formula, milk, yogurt, and cheese. A smaller percentage of children received other fruits and vegetables (28.4%), legumes and nuts (18.1%) and eggs (17.6%). Lesser proportion of children received flesh foods, such as meat, fish, poultry, and organ meats (9.9%).

Fig. 2

Distribution of children aged 6–23 months living with their mother’s received food groups during the previous day (in last 24 h), (N = 62610)

Discussion

The current study used NFHS 5 data to evaluate the factors contributing to dietary variety. Only 23% of children between the age of 6 and 23 months had viable minimal dietary variety, which suggests that dietary diversity score is below ideal among more than 2/3rd of the study children. In our country, POSHAN Abhiyaan, also known as National Nutrition Mission, is the Government of India’s flagship programme aims to reduce malnutrition amongst children through multi-departmental convergence in a time bound manner with fixed target [27, 28]. Furthermore, we noticed that a relatively small percentage of children consumed food meals derived from animals. Additionally, there was a significant correlation found between children’s MDD and the mother’s education, occupation, age at first marriage, belief systems, caste, number of children in the family, wealth index, geographical area, sex of the head of the household, the age of the child, birth order, birth weight, and the fact that the child is currently breastfed.

Prevalence of MDD was achieved by only quarter of the population; however, it was slightly more when compared to a study conducted in Pune, Maharashtra reported 16.4% of diet diversity in its study population [29]. A study from Pakistan, detailed to have 21% of its respondents achieved minimal dietary diversity [30]. A similar study from India which used NFHS 3 and NFHS 4 data, reported 21.6% of the children aged between 6 and 24 months received MDD [21]. Study from Afghanistan (22%), Bangladesh (27%), Nepal (45%), Sri Lanka (71%) reported range of scores [31,32,33,34,35,36]. This difference on the score could be because of the variation in the calculated points and the number of food groups considered for the estimation of the diet diversity score. The current study meets the requirements of the WHO guidelines for diet diversity scoring.

Multivariate logistic regression analysis showed that dietary diversity was significantly associated with a wide range of maternal characteristics. In our study, education of the mother was not significantly associated with MDD. A meta-analysis assessed the impact of maternal education on nutritional status of children, stated that the link between child growth and mother education differs according to a country’s income and education levels [29]. Employed mothers were found to be significantly associated with MDD among children. Similar to our findings, other studies also displayed a positive association of occupation of mothers with MDD among their children [30, 37]. This could be because of being young and unemployed is linked to ignorance and unawareness, while being older and employed may indicate strict eating regimens and affordability [30, 37, 38].

Our study illustrates that age of the mother during their marriage plays an important role, as women who married after 18 years of age significantly achieved more MDD for their children [37, 38]. In our study, ascending BMI of the mother was in relation with adequate DD. However, it was not significant.

Religion (Muslim: 1.26) and caste (ST: 1.42) of the household increased the odds of achieve the MDD by 1.2 and 1.4 times, respectively. This could be dependent on the frequency and usage of animal-based food groups in the household that delivers micronutrients compared to population in socioeconomically better category give reference [15]. Wealth status of the household had an influence on MDD, as the middle (1.2) and rich (1.4) group were better able to reach MDD compared to poor. This result was corresponding to other studies, this could be due to the financial flexibility and affordability to different sources of food by the household [31]. These outcomes might be attributed to high levels of maternal education, the flexibility to engage with individuals outside of the family at social events and markets and to share information, as well as media exposure [38, 39].

Geographical regions of India were also a factor that influenced the MDD among 6 to 24 months children, this could be linked with the rigorous functionality of Anganwadi centres [40,41,42]. Anganwadi centres serve as platforms for delivering take home ration to children under the ICDS program [40].

With increase in every month of age the adherence to MDD increases by 3.1 and 4 times among 12–18 months and 19–23 months, when compared to infants respectively. This was similar with a study using NFHS 3 data [23]. This is evidenced by a study in Bangladesh at two points in time with same samples. It reports older babies had an increased likelihood of reaching the minimum dietary diversity compared to infants, with the 18–23-month age group showing a substantial increase in meeting the minimum dietary diversity. Families’ wealth and the decision making were important predictors during infancy, whereas education and media exposure were important predictors during childhood [43]. This difference could be due to the delayed introduction of complementary diets and contributing to increased breast feedings post 6 months [23].

Diet adequacy was significantly associated with the birth order of the child. Our findings aligned with other studies; this could be because of likelihood of introducing supplemental feeding in contrast to first-birth order. Furthermore, implying that knowledge of suitable supplemental feeding techniques might be enhanced by prior birthing experience [44,45,46]. With increase in every unit of weight, the odds of increase in MDD were 1.2 and 1.27 times among normal and overweight children when compared to underweight children, respectively. This was in contrast with studies conducted in Maharashtra and other similar studies where they stated that the child with very low/ low birth weight was more likely to receive extensively diversified food compared to others [30, 47, 48]. This difference could be because of mothers may find it difficult to achieve nutrition diversity in informal circumstances. Reduced food diversity in underweight children may also have been influenced by lack of awareness and early childcare in mothers [30, 47, 48].

Our study reported that the odds of children currently breastfed receives 1.9 times more diversified food when compared to the non-breastfed children. This was also similar to many other studies across nations. Along with breast milk to satisfy all nutritional needs, supplemental feeding should be initiated. A healthy breastfed infant should eat two to three meals a day at six to eight months of age, three to four times at nine to eleven months, and three to four times plus one or two extra nutrient-dense snacks at twelve to twenty-three months of age. This promotes the children’s healthy development [49,50,51,52].

Conclusion

The present study indicates that there is no difference in dietary diversity among male and female children, except few states showing variations in this regard across the country. The study suggests that there is need for educating mothers and employing them, especially from poor socio-economic background, to improve the dietary diversity prevalence. The region/state specific intervention should be planned based on local based food needs of children. The strategies should address the suboptimal practices including inadequate quality or quantity of foods, poor feeding practices, complementary feeding being initiated too early or too late, or being provided in quantities that are too small or infrequent etc. There is need for behaviour change communication strategies in the community regarding the infant and young child feeding practices. There is also scope for further synthesis of evidence in dietary diversity and micro-nutrients deficiencies.

Limitations of the Study

The study utilizes NFHS-5 2019-21 data collected at single time point. This cross-sectional nature limits the ability to establish causation or capture changes over time. Longitudinal data could provide a more comprehensive understanding of the dynamics of dietary diversity and associated factors. The assessment of MDD relies on self-reported data from mothers about their children’s food intake in the last 24 h. This introduces the potential for recall bias, as memory limitations may affect the accuracy of reported dietary information.

While the study explores socio-economic factors like mother’s education and wealth status, other relevant socio-economic factors such as household income, access to healthcare, and cultural practices may not have been fully accounted for, potentially limiting the depth of the analysis. The abstract briefly mentions that there was no significant difference in dietary diversity between male and female children. However, the scope of gender analysis may be limited, and a more in-depth examination of gender-specific factors influencing dietary diversity could provide richer insights.

The study is based on nationally representative data, but the results may not be fully generalizable to specific regional or local contexts. Regional variations in dietary patterns, cultural practices, and socio-economic conditions could influence the applicability of findings.

Strengths

The study utilized large scale dataset to assess the dietary diversity among less than two-year children. Results found high dietary diversity failure among children which highlights the urgent need for targeted nutrition interventions to integrate behavior change communication for caregivers, families and fostering community mobilization. Study strongly supported that gender and place of residence was not significantly associated with the minimum dietary diversity. Nutrition interventions integrate.