- Research article
- Open Access
Complementary feeding practices, dietary diversity, and nutrient composition of complementary foods of children 6–24 months old in Jimma Zone, Southwest Ethiopia
© The Author(s). 2019
- Received: 15 August 2018
- Accepted: 7 May 2019
- Published: 3 June 2019
Mothers and caregivers typically feed infants according to their culture, purchase power and level of awareness with no due diligence to nutritional quality of the diet. Scientific evidence on nutritional adequacy of predominant complementary foods is critical for planning and prioritising interventions. The purpose of the current study was to evaluate the quality of complementary foods and the optimality of complementary feeding practices in Southwest Ethiopia.
In this cross-sectional study, a stratified multistage sampling procedure was used to sample 433 children, 6–24 months old. A semi-structured questionnaire was used to collect demographic, socio-economic and dietary data. Dietary diversity score was measured using a 24-h dietary recall. Six customary complementary food types were assayed for proximate composition, energy and mineral density using standard methods. Adequacy of the complementary foods in nutrients for complementary feeding purposes was assessed as a ratio between actual composition and recommended composition of complementary foods.
Only 16.1% of the children get the minimum dietary diversity. The children were reported to be fed with cereals & grains (68.8%), discretionary calories (53.6%), protein-rich foods (44.6%), oils and fat (40.5%), vegetables (38.5%), dairy products (17.9%) and fruits (28.1%). The sampled foods contained 4.3–24.4%, 0.9–8.5%, 8.2–11.9%, 27.9–162.6 Kcal/100 g, 168.4–250.4 mg/100 g, 1.8–4.1 mg/100 g and 22.5–42.4 mg/100 g of total carbohydrate, crude fat, protein, energy content, calcium, zinc and iron, respectively. All the complementary food samples predominantly fed to children were not composed of adequate protein, fat, carbohydrate, energy and calcium as recommended for complementary feeding purposes. However, most of the complementary foods are composed of adequate iron and zinc.
The nutrient density and diversity of complementary foods of 6–24-month-old children in the study area were found to be sub-optimal. Upgrading the nutritional composition of the starchy complementary foods should be of highest priority to improve nutrition of the infants and young children.
- Dietary diversity
- Nutrient adequacy
- Complementary foods
- Proximate composition
Complementary feeding refers to supplementing breastfeeding with feeding children aged between 6 and 24 months with a wide range of foods . The period between 6 and 24 months of age is a time of nutritional vulnerability because during this period, nutrients especially micronutrients and energy obtained only from breast milk will not be sufficient to meet the requirements of the child . Ensuring adequate nutrition during the period between 6 and 24 months of age is a major global health priority .
Among the immediate causes of undernutrition among children is consumption of too few nutrients . In most low-income countries, including Ethiopia, the beginning of growth faltering coincides with the start of complementary feeding; age-specific malnutrition rates generally increase until about 24 months of age and then level off . The sharp rise in the occurrence of stunting in young children from the age of 6 months is usually associated with suboptimal complementary feeding practices . As children younger than 24 months old do not consume a sufficient amount of food to cover the high nutrient needs for growth and development, food given to them should be of high nutrient density .
Theoretically, infants should receive the most nutrient-dense diet in the family. Infants in low-income countries, however, are typically fed with nutrient-poor foods like thin porridges . Complementary foods should contain high-biological value protein, furthermore, vitamins and minerals .
The National Nutrition Strategy (NNS) of Ethiopia gives considerable emphasis for nutrition of children younger than 2 years old in particular as nutrition received during this period influences how the children develop, grow and learn now or later. There is no documented evidence of overall complementary feeding practices and adequacy of the complementary foods in nutrients in Jimma Zone. This information is critically needed to be able to judge and plan the mechanisms to upgrade traditional diets. Therefore, this study aimed to evaluate the complementary feeding practices, dietary diversity and nutrient adequacy of complementary foods of children 6–24 months old in Jimma Zone, Southwest Ethiopia.
Area and subjects
This study was conducted in Jimma Zone, Southwest Ethiopia. The study area is year-round green but unfortunately characterised by household food insecurity . Three districts were purposively selected based on their agricultural production; Omo Nada, Dedo and Mana are cereal, vegetable and cash crop producer areas, respectively.
This study is a component of a more prominent cross-sectional study which assessed the nutritional status and associated factors among children younger than 2 years old. The study population for the original research included all children younger than 2 years old in the study area. A multistage stratified sampling procedure was used to sample 558 children who were 0–24 months old . For the current study, only those children 6–24 months old were included.
Data were collected from mothers or caregivers of the infants and children using face-to-face interviews using a semi-structured questionnaire.
The variables were categorised as dependent and independent variables. The dependent variable was the dietary diversity score of the 6–24-month-old children. The independent variables included several socio-economic and demographic factors like family composition, household size, educational level attained by mothers and fathers, the occupation of mothers and fathers, the wealth of the household and education or training received on health and nutrition. Additionally, the infant- and young child-feeding (IYCF) practices were also assessed.
A single 24-h dietary recall was used to obtain data on dietary diversity. Dietary diversity was assessed with a scale of seven food groups namely cereals and grains, vegetables, fruits, dairy products, oil and fat, protein-rich foods and discretionary calorie foods. Dietary diversity score (DDS) was found to be optimal when a child is fed greater than four food groups per day .
Nutrient composition of complementary foods
First, the complementary foods fed to 6–24-month-old children were identified from the questionnaires. Complementary food samples (25 g) were collected from 217 households. The collected food samples were labelled and stored at − 18 °C and eventually transferred to Jimma on the same date of collection. Based on the ingredients used for making the complementary foods, 6 assays were identified. The gross sample was then reduced in size and homogenised to create the laboratory sample . The samples were then analysed for proximate composition (protein, fat, carbohydrate, moisture, ash and fibre), energy content, mineral (iron, zinc, calcium and phosphorous) and anti-nutritional factors (phytate and tannin) following the respective standard methods of analysis .
Nutrient adequacy of the complementary foods
Adequacy of the complementary foods in nutrients for complementary feeding purposes was assessed as a ratio between actual composition and recommended composition of complementary foods .
The data were analysed using Statistical Package for Social Sciences software version 20 (SPSS Inc., Chicago, IL, USA). Descriptive statistics such as percentages were calculated. Bivariate analysis was conducted for the dietary diversity data. P values of less than 0.05 were regarded as statistically significant.
Characteristics of the sample
Description of the study participants (Jimma Zone, Southwest Ethiopia, 2014)
Frequency (N = 558)
Sex of index child
Age of index child (months)
11.41 ± 6.5
Birth order of index child
Third & above
Age of the mother (years)
26.6 + 5.1 years
No formal education
Complementary feeding practices
Complementary feeding practices of children 6–24 months old in three districts of Jimma Zone, Southwest Ethiopia, from March to May 2014
Continued breastfeeding ≥ 2 years olda
Time of initiation of complementary feeding
Before 6 months
Just at 6 months
After 6 months
Preparation of special additional food
Particular food during sickness or recovery
> 2 times a day
3–4 times a day
3–4 times + 1–2 snack
Dietary diversity score
< 4 food groups per day
> 4 food groups per day
Food groups fed to childrenb
Cereals and grains
Oil and fat
Regarding dietary intake, two thirds (68.8%) of the study participants consumed cereal-based gruel (made of barley, oat, teff, wheat, sorghum). Nearly half (44.6%) of the study participants reported that they fed their children with protein-rich food before the survey and (53.6%) of the study subjects consumed discretionary calories in the previous 24 h. Fruits, vegetables and dairy products were consumed by 28.1%, 38.5% and 17.9% of the participants, respectively.
Distribution of child DDS by different variables in Jimma Zone, South West Ethiopia
Child age group
Birth order of the child
Third and above
Place of residence
Wealth of households
Nutrient composition of complementary foods
The proximate composition and calorific value of sampled complementary foods (Atmits) in three districts of Jimma Zone, Southwest Ethiopia from March–May, 2014
The mineral and anti-nutritional factor content of sampled complementary foods (Atmits) in three districts of Jimma Zone, Southwest Ethiopia, from March to May, 2014
Nutrient adequacy of complementary foods for complementary feeding purposes
Adequacy of the complementary foods in nutrients for complementary feeding purposes
Complementary feeding practices
Studies in developing countries showed that both too early and a too late introduction of complementary food is familiar. Mothers in South Africa start complementary feeding within 2–3 months. In Uganda, 44.1% and 27% mothers began complementary feeding within 2–3 months in 1997 and 2005, respectively . Our findings oppose these reports because for the majority of the children in the study area complementary feeding is initiated just at the appropriate time.
Contrary to the recommended practice of complementary feeding, the majority of the mothers do not prepare particular food during sickness or recovery. During an illness, the need for fluid often increases, so a child should be offered and encouraged to take more . However, feeding frequency in the study area was optimal for children in the age group of 6–12 but not for those in the age group of 13–24 months. The recommended number of meals per day for a healthy breastfed baby should be 2–3 times at 6–8 months, 3–4 times at 9–11 months and 3–4 times with 1–2 additional nutritious snacks at 12–23 months of age .
The predominant complementary food fed to children in the study areas is gruel (a liquid drink made of cereals), locally named Atmit, ranking first in the all of the three districts. In Ethiopia, 70% of children aged 6–23 months, predominantly consume foods made of grains . Similarly, a study conducted in Nigeria reported that the dominant food groups in the children’s diet were cereal/grains . Nutritional problems are common among populations whose diets are predominantly based on starchy staples , and these plant-based foods are low in micronutrient contents, high in phytate and high in dietary fibre which inhibits the absorption of micronutrients .
The results of the current study showed that nearly half of the children had sub-optimal dietary diversity. A survey of community-based production complementary foods in four regions of Ethiopia has reported that the highest mean diversity score of 3.4 was observed in Oromia region, followed by Tigray (2.9) Amhara (2.7) and SNNP (2.6) regions. In Oromia region, nearly half (49.4%) of the children had a suboptimal diet diversity .
According to our results, children from wealthier households consumed more diversified diets. The ability to produce sufficient food for one’s household at home and generate enough revenue to purchase foods on the market are ways that a family could achieve food security .
The results of this study also indicated that girls are fed with less diversified diet compared to their male counterparts. Male gender bias in the intra-household distribution of food and other resources has been reported from Ethiopia  indicating that girls are less favoured in the resource-constrained environments.
Composition of diets
The complementary foods were predominantly made of starch-based cereals and hence of poor nutritional value, and do not satisfy the infant’s basic needs of protein because they have limited levels of protein both qualitatively and quantitatively. As well, macro- and micronutrients may be insufficient to maintain growth and development, this results in reduced nutritional status in children .
Nutrient adequacy of the complementary foods for complementary feeding purposes
Complementary foods should contain the following amount of estimated macronutrients: moisture content of ≤ 5%, an ash content of ≤ 3%, a crude protein content of ≥ 15%, a crude fat content of 10–25%, a crude fibre content of ≤ 5% and a carbohydrate content of 64 ± 4%. Additionally, the energy content of 400–425 kcal/100 g, a calcium content of 500 mg/100 g, the iron content of 16 mg/100 g and zinc content of 3.2 mg/100 g are also required . Children younger than 2 years old and living in developing countries should consume approximately 137–187 g/day, 206–281 g/day and 378–515 g/day of complementary foods at the age of 6–8 months, 9–11 months and 12–24 months, respectively to meet their energy needs . The total nutrient and energy requirements of healthy breastfeeding infants have been established . The average nutrient and energy that a given complementary food should provide are estimated by subtracting average nutrient and energy content of breast milk from the total nutrient and energy requirement at each age . The complementary food samples were not adequate in nutrients for complementary feeding purposes.
Over and under-reporting of infant dietary intakes is among the reasons that made quantifying infants’ diets difficult. Parents tend to over-report intakes for they do not wish to be seen either to be under-feeding babies or on the one hand not being able to distinguish between food offered to young children and the amount consumed .
The feeding practices of 6–24-month-old children in the study area were not satisfactory. Dietary diversity and macronutrient, energy and overall nutrient composition of the complementary foods were below the recommendations. The complementary foods were found to contain adequate amounts of iron. Improving the nutrient adequacy of the locally available customary diets through food processing techniques and a community-based nutritional education on optimal child feeding are recommended.
The authors would like to thank all the mothers and children who participated in this study. We are very grateful to the health extension workers.
This research was funded by the German Federal Ministry of Education and Research [grant number 031A247A] within the framework of the GlobE initiative through the Reduction of Post-Harvest Losses and Value Addition in East African Food Value Chains (RELOAD) project.
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
SFF, TB and OH conceived and designed the experiments. NK and SFF collected the data. SFF, NK and TB analysed the data. SFF, TB and OH contributed reagents/materials/analysis tools. SFF prepared the draft manuscript. TB and OH finalised the manuscript and provided a critical review. All authors have read and approved the final manuscript.
Ethics approval and consent to participate
Ethical clearance was obtained from the Research and Ethical Review Board of Jimma University. Permission to undertake the study was obtained from every relevant authority in Jimma Zone. Each study participant was briefed about the study and offered the opportunity to ask questions. Then oral informed consent was obtained from each participant prior to participation in the study and data was kept confidential. The Ethical Review Board decided to have oral consent as the study was not intervention. In addition, the data collection and consent process were randomly checked by the Ethical Review Board to ensure the ethical undertaking of the research.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Addis Ababa University. Rapid assessment of community-based production of complementary food in Tigray, Amhara, Oromia and SNNP regions. Addis Ababa: Addis Ababa University; 2010.Google Scholar
- Ajani SR. An assessment of dietary diversity in six Nigerian states. Afr J Biomed Res. 2010;13:161–7.Google Scholar
- AOAC International. Official methods of analysis of AOAC International (18th ed.). Gaithersburg: AOAC International; 2005.Google Scholar
- Belachew T, Lindstrom D, Gebremariam A, Hogan D, Lachat C, Huybregts L, Kolsteren P. Food insecurity, food-based coping strategies and suboptimal dietary practices of adolescents in Jimma Zone Southwest Ethiopia. PLoS One. 2013;8(3):e57643. https://doi.org/10.1371/journal.pone.0057643.View ArticlePubMedPubMed CentralGoogle Scholar
- Black RE, Allen LH, Bhutta Z a, Caulfield LE, de Onis M, Ezzati M, et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008;371(9608):243–60. https://doi.org/10.1016/S0140-6736(07)61690-0.View ArticlePubMedGoogle Scholar
- Brown K. A rational approach to feeding infants and young children with acute diarrhoea. Pediatric gastroenterology and nutrition in clinical practice. New York: Marcel Dekker Inc; 2001.Google Scholar
- Central Statistical Agency [Ethiopia], CSA, Central Statistical Agency, ORC Macro, Central Statistical Agency [Ethiopia], & ORC Macro. Ethiopia demographic and health survey. Addis Ababa and Calverton; 2006. Retrieved from http://www.dhsprogram.com/pubs/pdf/FR179/FR179[23June2011].pdf.
- Conn JA, Davies MJ, Walker RB, Moore VM. Food and nutrient intakes of 9-month-old infants in Adelaide, Australia. Public Health Nutr. 2009;12(12):2448–56. https://doi.org/10.1017/S1368980009005552.View ArticlePubMedGoogle Scholar
- Daelmans B, Ferguson E, Lutter CK, Singh N, Pachón H, Creed-Kanashiro H, et al. Designing appropriate complementary feeding recommendations: tools for programmatic action. Matern Child Nutr. 2013. https://doi.org/10.1111/mcn.12083.View ArticleGoogle Scholar
- Dewey KG. The challenge of meeting nutrient needs of infants and young children during the period of complementary feeding: an evolutionary perspective. J Nutr. 2013;143(12):2050–4. https://doi.org/10.3945/jn.113.182527.View ArticlePubMedPubMed CentralGoogle Scholar
- Dewey KG, Brown KH. Update on technical issues concerning complementary feeding of young children in developing countries and implications for intervention programs. Food Nutr Bull. 2003;24. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/12664525.View ArticleGoogle Scholar
- EHNRI. (1998). Food composition table for use in Ethiopia. Part IV. 1995–1997. Addis Ababa: Ethiopian Health and Nutrition Research Institute.Google Scholar
- FAO/WHO. 1991. CODEX CAC/GL 08, 1991. Codex Alimentarius: Guidelines on Formulated Supplementary Foods for Older Infants and Young Children. Vol. 4, FAO/WHO Joint Publications; 1991. p. 144.Google Scholar
- Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioural, and biomedical sciences. Behav Res Methods. 2007;39:175–91. https://doi.org/10.3758/BF03193146.View ArticleGoogle Scholar
- Hadley C, Lindstrom D, Belachew T, Tessema F. Ethiopian adolescents’ attitudes and expectations deviate from current infant and young child feeding recommendations. J Adolesc Health. 2008;43:253–9. https://doi.org/10.1016/j.jadohealth.2007.01.015.View ArticlePubMedPubMed CentralGoogle Scholar
- Hadley C, Linzer DA, Belachew T, Mariam AG, Tessema F, Lindstrom D. Household capacities, vulnerabilities and food insecurity: shifts in food insecurity in urban and rural Ethiopia during the 2008 food crisis. Soc Sci Med. 2011;73(10):1534–42. https://doi.org/10.1016/J.SOCSCIMED.2011.09.004.View ArticlePubMedPubMed CentralGoogle Scholar
- Lopez H, Leenhardt F, Remesy C. New data on the bioavailability of bread magnesium. Magnes Res. 2004;17(4):335–40.PubMedGoogle Scholar
- Pan American Health Organization. Guiding principles for complementary feeding of the breastfed child: World Health Organization; 2003. Retrieved from http://www.who.int/maternal_child_adolescent/documents/a85622/en/.
- Pomeranz Y, Meloan CE. Food analysis: theory and practice (third). Gaithersburg: ASpern Publishers, Inc; 2000.Google Scholar
- Shrimpton R, Victora CG, de Onis M, Lima RC, Blössner M, Clugston G. Worldwide timing of growth faltering: implications for nutritional interventions. Pediatrics. 2001;107(5):E75 Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11331725.View ArticleGoogle Scholar
- Steyn NP, Nel JH, Nantel G, Kennedy G, Labadarios D. Food variety and dietary diversity scores in children: are they good indicators of dietary adequacy? Public Health Nutr. 2006;9(5):644–50 Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16923296.View ArticleGoogle Scholar
- Udoh EE, Amodu OK. Complementary feeding practices among mothers and nutritional status of infants in Akpabuyo Area, Cross River State Nigeria. SpringerPlus. 2016;5(1):2073. https://doi.org/10.1186/s40064-016-3751-7.View ArticlePubMedPubMed CentralGoogle Scholar
- USDA. (2005). USDA Food Guide Pyramid (MyPyramid). Retrieved 2 Jan 2014, from https://www.diet.com/g/usda-food-guide-pyramid-mypyramid?get=usda-food-guide-pyramid-mypyramid.
- WHO/UNICEF. Complementary feeding of young children in developing countries: a review of current scientific knowledge. Geneva: World Health Organization; 1998.Google Scholar
- WHO/UNICEF. WHO | global strategy for infant and young child feeding: WHO; 2003. Retrieved from http://www.who.int/nutrition/publications/infantfeeding/9241562218/en/.