
==== Front
Sci Rep
Sci Rep
Scientific Reports
2045-2322
Nature Publishing Group UK London

39237525
68381
10.1038/s41598-024-68381-z
Article
Micronutrient intake inadequacies in Northwest Ethiopian children aged 6–23 months
Menber Yonatan nataniem21@gmail.com

1
Belachew Tefera 2
Fentahun Netsanet 1
1 https://ror.org/01670bg46 grid.442845.b 0000 0004 0439 5951 Department of Nutrition and Dietetics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar City, Ethiopia
2 https://ror.org/05eer8g02 grid.411903.e 0000 0001 2034 9160 Department of Nutrition and Dietetics, Faculty of Public Health, College of Public Health, Jimma University, Jimma City, Ethiopia
5 9 2024
5 9 2024
2024
14 2073219 4 2024
23 7 2024
© The Author(s) 2024
2024
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The early stages of childhood are a crucial period of life for health, with inadequate nutrition impacting physical growth, cognitive development, and the immune system. A considerable proportion of children are affected by micronutrient intake inadequacy and deficiency across the globe. Evidence on micronutrient intake among children aged 6–23 months is limited in Northwest Ethiopia, where there is a divergence between production and dietary consumption practices compared to other regions of the country. This study aimed to determine micronutrient inadequacy and associated factors among children aged 6–23 months. From February 1 to February 18, 2023, 435 children aged 6–23 months participated in a community-based cross-sectional study in the North Mecha District of the Amhara Region, Northwest Ethiopia. The study participants were selected using a multistage sampling technique. A multiphasic interactive 24-h dietary recall was used to collect dietary intake data via an interviewer-administered questionnaire. The interviews were conducted with the mothers of the selected children. Nutrient values for the selected 12 micronutrients were calculated using the NutriSurvey 2007 software and food composition tables from Ethiopia, Tanzania, and Kenya. SPSS version 25 was used for the remaining parts of the analysis. The Nutrient Adequacy Ratio and Mean Adequacy Ratio were calculated to evaluate the nutrient intakes. To identify the factors associated with overall micronutrient intake inadequacy, a binary logistic regression analysis was performed, with statistical significance determined at a p-value < 0.05. The overall prevalence of micronutrient intake inadequacy was 64.7% (95% CI 59.9, 69.2). The odds of inadequacy of micronutrient intake were 2.8 times higher among children aged 6–8 months than children aged 9–23 months (AOR = 2.80, 95% CI 1.71, 4.59). Children with paternal education unable to read and write and primary school incomplete were 3.1 (AOR = 3.12, 95% CI 1.26, 7.70) and 2.4 (AOR = 2.40, 95% CI 1.01, 5.73) times more likely to have micronutrient intake inadequacy, respectively, compared to children with paternal education of primary school completed and above. The likelihood of micronutrient intake inadequacy was 1.8 times higher among children from mothers who had an unfavorable nutrition-related attitude than those from mothers who had a favorable attitude (AOR = 1.76, 95% CI 1.02, 3.05). Inadequate intake of micronutrients was shown to be highly prevalent among children aged 6–23 months. Child age, paternal education, and maternal nutrition-related attitude were significantly associated with micronutrient intake inadequacy. Integrating community-guided nutrition interventions targeting nutrition-related knowledge and attitudes of parents is critical in addressing the inadequate micronutrient intake of children in the study community, where production is not a major problem.

Keywords

Dietary intake
Nutrient inadequacy
Young children
North Mecha
Northwest Ethiopia
Subject terms

Epidemiology
Paediatric research
issue-copyright-statement© Springer Nature Limited 2024
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pmcIntroduction

The early stages of childhood are the most sensitive and crucial period of life where they have a unique window of opportunity that holds immense significance in their cognitive, physical, social, and emotional development1,2. The nourishment they receive during this crucial period is essential to meet their increased nutritional needs. It plays a vital role in ensuring the necessary growth and development while also shaping their future health and productivity. Even though micronutrients are needed in small quantities, they play a vital role in promoting healthy growth, supporting essential cellular processes, and ensuring overall well-being1,3,4.

Nutritional inadequacy refers to the inadequate consumption of essential nutrients necessary to meet the body’s nutritional needs for optimal health5. The consequences of this nutritional inadequacy can be both short-term and long-term, significantly impacting a child's physical growth, cognitive development, and immune system6–8.

The 2023 edition of the UNICEF-WHO-World Bank Group Joint Malnutrition Estimates showed that significant percentages of children worldwide suffered from malnutrition caused by inadequate nutrient intake9. Other studies conducted in Guatemala10, the Philippines11, China12, India13, Ghana14, and Tanzania15,16, showed that micronutrient intake inadequacies remained public health problems. A study conducted in the rural regions of southern Kenya revealed that children aged between 6 and 23 months did not reach the recommended levels of four to nine essential micronutrients, which varied based on their age sub-group and geographical location17.

A study conducted in Butajira District, South Ethiopia, showed that 84.4%, 33.8%, 27.0%, and 70.7% of children aged 12–23 months were at risk of inadequacy for vitamin B1, B2, B6, and B9, respectively, while none of them were vitamin A deficient. Furthermore, the prevalence of inadequacy of calcium and zinc was 76.8% and 67.30%, respectively18. A study conducted in Ethiopia's Tigray region revealed that the prevalence of vitamin A, B1, B3, B6, B12, and C intake inadequacy among children aged 12 to 23 months was 67.6%, 71.6%, 91.5%, 95.8%, 99.1%, and 90.1%, respectively. Furthermore, iron intake was 75% and zinc intake was 95.3%, respectively19. Approximately one to two-thirds of children aged 6–23 months in West Oromia, Ethiopia, do not consume enough vitamin A, vitamin C, calcium, and zinc. However, it is important to note that all children in this region meet the recommended iron intake20.

Adequate nutrition and stimulation are supported by policies, programs, and practices that promote and support nutritious diets and responsive feeding1. The Sustainable Development Goals (SDGs) have objectives that have a direct impact on the essential services required for the optimal growth and development of young children, encompassing aspects like nutrition. Simultaneously, early childhood development plays a vital role in achieving many of the targets set by the SDGs21. As stated in Global Targets 2025, the World Health Organization (WHO) has set global targets for improving the nutrition of infants and young children, and countries that are members have committed to achieving these targets22. The Ethiopian government has made significant strides in combating various forms of malnutrition. In pursuit of this objective, the government of Ethiopia has also crafted a comprehensive Food and Nutrition Policy (FNP)23. The Seqota Declaration reflects the commitment to ending undernutrition by 203024,25.

Even though worldwide efforts are being exerted, there is a lack of advancement towards achieving the 2025 World Health Assembly global nutrition targets in the reduction of wasting and stunting among children as a result of adequate dietary intake22. Additionally, there is a significant challenge in meeting the 2030 SDGs, specifically SDG 2: End hunger, achieve food security, and improve nutrition21. This progress is lagging most in low- and middle-income countries, including Ethiopia9. Similarly, despite the diverse range of measures enacted by the Ethiopian government, progress in tackling malnutrition is moving at a sluggish pace, and a substantial number of children are still enduring the distressing consequences of malnourishment26–28. Micronutrient inadequacy poses a notable issue for the health and well-being of children, which is a matter of great importance to public health. In the northwest parts of Ethiopia, where there is fairly good agricultural productivity and a considerable sociocultural difference in dietary consumption practices compared to other regions of the country, Ethiopia, evidence is scarce regarding the inadequate intake of micronutrients among young children29,30. Hence, the objective of this study is to determine the prevalence of micronutrient inadequacy and identify its associated factors among children aged 6–23 months residing in the rural areas of North Mecha District of Amhara Region, Northwest Ethiopia.

Materials and methods

Study setting and study design

The study was carried out in the North Mecha District of the Amhara Regional State, Northwest Ethiopia. This district is located 530 km away from Addis Ababa, the capital city of Ethiopia. Agriculture plays a dominant role in the district, serving as a primary source of livelihood for 85% of the population. The district is renowned for its crop production, which includes teff, maize, barley, wheat, beans, and peas. These crops are cultivated through a combination of rainfall and irrigation methods31. Among the notable irrigation systems in the district is the Koga Dam, which can irrigate 7,000 acres of land. The Koga Irrigation and Watershed Management Project, initiated by the government, aims to enhance agricultural productivity and water management in the Koga watershed area of Ethiopia. This project specifically focuses on poverty reduction and improving food security. Its implementation is expected to positively impact food consumption and dietary practices, as well as foster human and economic development in the region32. To collect data for the study, a community-based cross-sectional study design was employed between February 1 and 18, 2023.

Population and eligibility criteria

The source population for this study consisted of children between the ages of 6–23 months who resided in the North Mecha District. The study population, on the other hand, comprised children within the same age group who lived in the specifically selected kebeles within the district. The study enrolled all the breastfed and non-breastfed children between the ages of 6 and 23 months who had been living in the designated study area for a minimum of 6 months before the survey and were living with their biological mother.

Sample size and sampling techniques

The sample size for the study was determined using a single population proportion formula. This calculation took into account the following assumptions: a 95% confidence level, a 5% margin of error, and a 78% pooled prevalence of inadequate dietary intake among children aged 6–23 months in Ethiopia, as determined by a systematic review and meta-analysis33. Applying a design effect of 1.5 and the inclusion of a 10% non-response rate gave a final sample size of 435. Seven kebeles (local administrative units) were selected randomly from a total of 38 kebeles using a lottery system. The sample size was proportionally allocated to each kebele based on the North Mecha District Health Office report. A systematic random sampling approach was employed to select the participants from the selected kebeles. The value of ‘K’ was calculated from N/n; where N = study population, n = sample size. Accordingly, every K-th child participated in the study.

Operational and term definitions

Recommended dietary allowances/reference nutrient intake (RNI)

This represents the recommended daily consumption of nutrients that satisfy the nutritional needs of nearly all (97.5%) children between 6 and 23 months old34.

Nutrient adequacy ratio (NAR)

It refers to the ratio of a subject’s micronutrient intake to the current recommended daily allowance for each sex and age category35.

Mean adequacy ratio (MAR)

It is a comprehensive measure that serves as an indicator of overall diet quality. It was derived by dividing the sum of all Nutrient Adequacy Ratio (NAR) values by the total count of computed micronutrients35.

Micronutrient intake inadequacy

The occurrence occurred when children aged 6–23 months consumed less than 100% of the RDA for a specific micronutrient and the NAR for that micronutrient was less than one35.

Overall micronutrient intake inadequacy

The ideal MAR cut-off for nutrient intake inadequacy should be one (100%), which would mean that the intake of all 12 nutrients, namely vitamin A, vitamin B1, vitamin B2, vitamin B3, vitamin B6, vitamin B9, and vitamin B12, vitamin C, calcium, iron, zinc, and selenium, is equal to or greater than the RDA and the requirements for all the nutrients are met. In this study, since there was only one participant who had a MAR score of 1, overall micronutrient intake inadequacy was operationalized to be < 0.7535–37.

Household Food Insecurity Accesses Scale (HFIAS) score

Each household's score was determined by the sum of the frequency of occurrences of the nine food insecurity-related conditions that occurred within the past four weeks. This score was then used to classify the household as either food-secure, mildly food-insecure, moderately food-insecure, or severely food-insecure38.

Wealth Index

The household wealth index was calculated using Principal Component Analysis (PCA) by taking into account various household assets, housing conditions, access to services, and other variables adapted from the 2019 Ethiopian Mini Demographic and Health Survey26,39,40.

Nutrition-related knowledge and attitude

The nutrition-related knowledge and attitudes of the children's mothers were assessed using a questionnaire developed by FAO41–44. The details of the analysis can be found in the article that was published earlier40.

Data collection tools and procedures

An interviewer-administered structured questionnaire was used to collect data on socio-demographic and economic factors; water sanitation and hygiene; household food security; knowledge and attitude of mothers on nutrition; and health-related factors. The mothers of the selected children were interviewed, and the data were gathered using the Kobo Tool Box, an electronic data collection toolkit. The FAO-standardized tool was used to assess the dietary data and nutrition-related knowledge and attitude data41,45. A team of 10 skilled data collectors, along with two expert supervisors with backgrounds in public health nutrition, were actively engaged in data collection and supervision.

24-h dietary recall assessment

Market inspection and home surveillance were done before actual data collection to collect data on the types of foods eaten, cooking methods, and household utensils used in the study area. During the surveillance, photographs of household utensils and food portions were taken, and each item was assigned a code. In the nutrition laboratory, food serving utensils were standardized by weighing food portions and measuring water using a digital food portion weighing scale and a graduated cylinder.

During the process of collecting the actual data, the children's mothers were asked about the specific utensils they utilized based on the photographic atlas. Visual aids in the form of photographs featuring various household utensils such as spoons, ladles, cups, glasses, and plates were used to aid the participants in recalling and determining the types and portion sizes of the items their children had consumed. To quantify the amount of food consumed, household utensils and numerical units (such as oranges, bananas, mangoes, potatoes, etc.) were employed. Foods that were expressed in numerical terms were categorized as either large, medium, or small and were subsequently gathered as such. This was done through the implementation of an interactive multiple-pass 24-h recall method.

Data quality control

To ensure consistency, the questionnaire was written in English, translated into Amharic, and then back into English. The data collection tool included FAO-developed standard questions as well as questions adapted from other sources and added to the tool after validation by field experts. Any necessary changes were made in response to their recommendations.

A pretest was conducted on approximately 5% of the sample. Supervisors and data collectors received training. The data collection process was closely supervised, and the completeness of the data was verified as required. To assist participants in recalling and identifying the types and quantities of food they consumed, photographs of food portions and household utensils such as spoons, ladles, cups, glasses, etc. were utilized. A multiple-pass 24-h recall was conducted with three passes to collect dietary intake data. The multiple passes consisted of three sequential stages: a "quick list," a "detailed description of food and beverage items consumed," and a "review."

Data processing and analysis

After collecting the necessary data, the food consumption data were transformed into nutrient intake data in NutriSurvey software. To determine the nutrient values per 100 g of each food item, the Ethiopian food composition tables were used46,47. In cases where specific food items were not listed in the Ethiopian food composition tables, alternative tables from other African countries, such as Kenya48 and Tanzania49, were used for reference. The volume of breast milk intake of study participants was estimated using the results of a systematic review and meta-analysis that incorporated a total of 167 studies to provide global breast milk intake estimates50. The analysis was carried out using SPSS version 25, specifically utilizing NutriSurvey 2007 software for the nutrient intake analysis.

To determine the nutrient intake inadequacy of selected 12 micronutrients (vitamin A, vitamin B1, vitamin B2, vitamin B3, vitamin B6, vitamin B9, vitamin B12, vitamin C, calcium, iron, zinc, and selenium), both the Nutrient Adequacy Ratio (NAR) and Mean Adequacy Ratio (MAR) were calculated. The details of the analysis used to assess nutrient intake inadequacy in this study were similar to those described in a previously published article40. The adequacy of micronutrient intake data was assessed using the Kolmogorov–Smirnov and Shapiro–Wilk tests of normality. The findings, which were obtained from a skewed distribution, were presented using the median and interquartile range.

To determine the factors associated with inadequate overall micronutrient intake in children aged 6–23 months, bivariable and multivariable binary logistic regression analyses were performed. The variables identified in the bivariable binary logistic regressions with a p-value of ≤ 0.25 were included in the multivariable analysis to assess their independent effects. The fitness of the model was evaluated using the Hosmer–Lemeshow goodness-of-fit test. A p-value greater than 0.05 suggests that the multivariable binary logistic regression models are a good fit. In the multivariable binary logistic regression analysis, variables with a p-value less than 0.05 were considered statistically significant. To measure the strength of the relationship between the dependent variable and independent variables, the Adjusted Odds Ratio (AOR) with a 95% Confidence Interval (CI) was used. The final results were presented through text, tables, and graphs.

Ethical declarations

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethical Review Board of the College of Medicine and Health Science at Bahir Dar University (protocol code: 631/2023 and date of approval: February 2, 2023). Amhara Public Health Institute (APHI) provided a letter of permission, and the North Mecha District administration office offered a formal letter of cooperation to the chosen kebeles. Before the data collection, the children's mothers were asked for their informed verbal consent. The confidentiality of the data and the privacy of the study participants were maintained.

Results

Socio-demographic and socioeconomic characteristics

A total of 430 children aged 6–23 months participated in the study, with a 98.8% response rate and a mean age of 10.9 ± 3.5 months. A little below half (48.8%) were males. The mean number of under-five children in the household and maternal parity were 1.3 ± 0.5 and 3.9 ± 2.0, respectively. Eighty-six (20.0%) children were from households with the poorest wealth index (Table 1).Table 1 Socio-demographic characteristics among children aged 6–23 months in North Mecha District, Northwest Ethiopia, 2023 (N = 430).

Variables	Categories	Frequency	Percentage	
Child age in months	6–8	137	31.9	
9–12	152	35.3	
13–23	141	32.8	
Child sex	Male	210	48.8	
Female	220	51.2	
Maternal age in years	18–25	119	27.7	
26–35	258	60.0	
36–50	53	12.3	
Religion	Orthodox	430	100	
Maternal education	Unable to read and write	319	74.2	
Primary School incomplete	40	9.3	
Primary school completed	42	9.8	
Secondary school completed	24	5.6	
University or college completed	5	1.2	
Maternal occupation	Farmer	333	77.4	
Merchant	17	4.0	
Housewife	78	18.1	
Employee	2	0.5	
Maternal marital status	Married	423	98.4	
Widowed	7	1.6	
Paternal education (N = 423)	Unable to read and write	193	44.9	
Primary school incomplete	165	38.4	
Primary school completed	44	10.2	
Secondary school completed	17	4.0	
University or college completed	4	0.9	
Paternal occupation (N = 423)	Farmer	390	90.7	
Merchant	15	3.5	
Student	4	0.9	
Daily laborer	7	1.6	
Other#	7	1.6	
Family size	≤ 4	123	28.6	
5–7	224	52.1	
≥ 8	83	19.3	
Parity	≤ 2	123	28.6	
3–5	209	48.6	
≥ 6	98	22.8	
Number of < 5 children	1	300	69.8	
≥ 2	130	30.2	
Wealth Index	Poorest	86	20.0	
Poor	84	19.5	
Medium	85	19.8	
Rich	90	20.9	
Richest	85	19.8	
#Driver, Soldier, Veterinarian.

Nutrition-related knowledge and attitude and household food security

Seventy-six (17.7%) and 288 (67%) children’s mothers had adequate nutrition-related knowledge and a favorable nutrition-related attitude, respectively. Only two (0.47%) children were not breastfed. One hundred nine (25.4%) of the children were from food-insecure households (Table 2).Table 2 Nutrition-related factors among children aged 6–23 months in North Mecha District, Northwest Ethiopia, 2023 (N = 430).

Variables	Categories	Frequency	Percentage	
Maternal Nutrition-related knowledge	Adequate	76	17.7	
Inadequate	354	82.3	
Maternal Nutrition-related attitude	Favorable	288	67.0	
Unfavorable	142	33.0	
Breastfeeding status	Breastfed	428	99.53	
Not breastfed	2	0.47	
Household food security	Food Secure	321	74.7	
Mildly food insecure	33	7.7	
Moderately food insecure	64	14.9	
Severely food insecure	12	2.8	

Micronutrient intake inadequacy of children

Only one child meets the recommended levels of all 12 nutrients (MAR of one). The overall prevalence of micronutrient intake inadequacy, MAR < 0.75, was 64.7% (95% CI 59.9, 69.2) (Fig. 1).Figure 1 MAR of micronutrient intake among children aged 6–23 months in North Mecha District, Northwest Ethiopia, 2023 (N = 430).

The median intake of vitamin A and calcium among participants was 463.0 μg (IQR: 93.9) and 232.4 mg (IQR: 124.6), with an inadequacy prevalence of 22.3% (95% CI 18.5, 26.6), 7.0% (95% CI 4.8, 9.8), and 89.1% (95% CI 85.7, 91.9), respectively. The median NAR of nutrients ranges from 0.3 to 1.4. Of all studied nutrients, the highest prevalence of micronutrient inadequacy was encountered in zinc inadequacy among 92.1% (95% CI 89.1, 94.5) participants; in contrast, vitamin C intake inadequacy was the lowest that was encountered among 7.0% (95% CI 4.8, 9.8) participants (Table 3).Table 3 Micronutrient intake among children aged 6–23 months in North Mecha District, Northwest Ethiopia, 2023 (N = 430).

Micronutrient	RDA (≤ 12 months)	RDA (> 12 months)	Actual Intake	NAR	Prevalence of micronutrient inadequacy (%) (95% CI)	
Median	IQR (Q3–Q1)	Median	IQR (Q3–Q1)	
Vitamin A (μg RE)	400	400	463.0	93.9	1.2	0.2	22.3 (18.5, 26.6)	
Vitamin B1 (mg)	0.3	0.5	0.2	0.2	0.4	0.4	84.0 (80.1, 87.3)	
Vitamin B2 (mg)	0.4	0.5	0.3	0.2	0.7	0.4	75.1 (70.7, 79.1)	
Vitamin B3 (mg)	4	6	1.5	3.1	0.3	0.6	86.0 (82.4, 89.2)	
Vitamin B6 (mg)	0.3	0.5	0.2	0.4	0.6	1	66.5 (61.8, 71.0)	
Vitamin B9 (mcg)	80	160	58.3	20.0	0.7	0.2	85.3 (81.6, 88.6)	
Vitamin B12 (mcg)	0.5	0.9	0.7	0.2	1.3	0.7	28.6 (24.4, 33.1)	
Vitamin C (mg)	30	30	42.1	10.6	1.4	0.35	7.0 (4.8, 9.8)	
Calcium (mg)	400	500	232.4	124.6	0.5	0.3	89.1 (85.7, 91.9)	
Iron (mg)	9.3	5.8	4.5	21.7	0.5	2.8	59.1 (54.3, 63.8)	
Zinc (mg)	4.1	4.1	1.2	1.2	0.3	0.3	92.1 (89.1, 94.5)	
Selenium (mcg)	10	17	8.3	18.6	0.7	1.5	61.2 (56.4, 65.8)	
MAR (< 75%)	NA	NA	NA	NA	67.0	32.4	64.7 (59.9, 69.2)	
NA: Not Applicable.

Factors associated with micronutrient intake inadequacy

Child age, paternal education, and maternal nutrition-related attitude were significantly associated with micronutrient intake inadequacy (MAR < 0.75). The odds of micronutrient intake inadequacy were 2.8 times higher among children aged 6–8 months as compared to children aged 9–23 months (AOR = 2.80, 95% CI 1.71, 4.59). Children with paternal education of unable to read and write and able to read and write were 3.1 (AOR = 3.12, 95% CI 1.26, 7.70) and 2.4 (AOR = 2.40, 95% CI 1.01, 5.73) times more likely to have micronutrient intake inadequacy than children with paternal education of primary school completed and above, respectively. The likelihood of micronutrient intake inadequacy was 1.8 times higher among children from mothers who had an unfavorable nutrition-related attitude than those from mothers who had a favorable attitude (AOR = 1.76, 95% CI 1.02, 3.05) (Table 4).Table 4 Factors associated with micronutrient intake inadequacy among children aged 6–23 months in North Mecha District, Northwest Ethiopia, 2023 (N = 430).

Variables	Inadequate	Adequate	COR (95% CI)	AOR (95% CI)	
Child age in months	
 6–8	106 (77.4%)	31 (22.6%)	2.41 (1.51, 3.82)**	2.80 (1.71, 4.59)**	
 9–23	172 (58.7%)	121 (41.3%)	1	1	
Child sex	
 Male	127 (60.5%)	83 (39.5%)	1	1	
 Female	151 (68.6%)	69 (31.4%)	1.43 (0.96, 2.13)	1.50 (0.98, 2.31)	
Maternal education	
 Unable to read and write	219 (68.7%)	100 (31.3%)	2.13 (1.26, 3.59)**	1.05 (0.42, 2.63)	
 Able to read and write	23 (57.5%)	17 (42.5%)	1.32 (0.60, 2.87)	0.62 (0.22, 1.75)	
Primary school completed and above	36 (50.7%)	35 (49.3%)	1	1	
 Paternal education (423)	
 Unable to read and write	140 (72.5%)	53 (27.5%)	3.28 (1.83, 5.87)**	3.12 (1.26, 7.70)*	
 Able to read and write	105 (63.6%)	60 (36.4%)	2.17 (1.21, 3.89)**	2.40 (1.01, 5.73)*	
 Primary school completed and above	29 (44.6%)	36 (55.4%)	1	1	
Paternal occupation	
 Farmer	258 (66.2%)	132 (33.8%)	2.08 (1.02, 4.24)*	1.48 (0.65, 3.36)	
 Others#	16 (48.5%)	17 (51.5%)	1	1	
Parity	
 ≤ 2	75 (61.0%)	48 (39.0%)	1	1	
 3–5	143 (68.4%)	66 (31.6%)	1.39 (0.87, 2.21)	0.84 (0.46, 1.53)	
 ≥ 6	60 (61.2%)	38 (38.8%)	1.01 (0.59, 1.74)	0.54 (0.26, 1.11)	
Household food security	
 Food secure	200 (62.3%)	121 (37.7%)	1	1	
 Food insecure	78 (71.6%)	31 (28.4%)	1.52 (0.95, 2.44)	1.34 (0.81, 2.23)	
Maternal nutrition-related knowledge	
 Adequate	35 (48.6%)	37 (51.4%)	1	1	
 Inadequate	243 (67.9%)	115 (32.1%)	2.23 (1.34, 3.73)**	1.49 (0.84, 2.64)	
Maternal nutrition-related attitude	
 Favorable	209 (62.2%)	127 (37.8%)	1	1	
 Unfavorable	69 (73.4%)	25 (26.6%)	1.68 (1.01, 2.79)*	1.76 (1.02, 3.05)*	
*p value < 0.05.

** p value < 0.01.

1: reference group, COR: Crude Odds Ratio, AOR: Adjusted Odds Ratio, #Merchant, Student, Daily laborer, Driver, Soldier, Veterinarian.

Discussion

Micronutrient inadequacy poses a notable issue for the health and well-being of children. This matter is of great importance to public health. In the northwest parts of Ethiopia, evidence is scarce regarding the inadequate intake of micronutrients among young children. This study aimed to determine the prevalence of micronutrient inadequacy and identify its associated factors among children aged 6–23 months residing in the rural areas of the North Mecha District of the Amhara Region, Northwest Ethiopia.

This study revealed that only one child met the recommended levels of all 12 nutrients (MAR of one). The overall prevalence of micronutrient intake inadequacy, MAR < 0.75, among children aged 6–23 months was 64.7%. The significant occurrence of inadequacy in the intake of essential nutrients can be attributed to various factors. One of these factors is the excessive consumption of cereals like teff, maize, sorghum, and others, which have a low concentration of vital micronutrients. Additionally, there is an inadequate consumption of food items from diverse food groups, such as animal-source foods, pulses, fruits, vegetables, nuts, and seeds. These food groups are rich in crucial micronutrients necessary for a healthy diet51.

Vitamin A intake inadequacy was prevalent among 22.3% of children aged 6–23 months, according to this study. This is comparable to a study conducted in Ghana14. In contrast, this study finding is lower than studies conducted in the Tigray region, Ethiopia19, Butajira District, Ethiopia18, Tanzania15, and Guatemala10, and higher than reports from studies conducted in the Oromia region, Ethiopia20. Potential disparities in the production and consumption of foods abundant in vitamin A, such as green leafy vegetables, may offer a rationale for the observed variability.

This study showed that among certain B vitamins (vitamins B1, B2, B3, B6, B9, and B12), the prevalence of micronutrient intake inadequacy ranges from 28.6 to 86.0%. Inadequate intake of vitamin B1 was found to be consistent with a study conducted in Butajira District, Ethiopia18. Except for vitamins B3, B6, and B12, which had lower levels of inadequacy compared to a study in the Tigray Region, Ethiopia19, and vitamin B12, which also had lower levels compared to studies in Ghana14 and the Philippines11, this study revealed that inadequate intake of all six vitamins studied was more prevalent in the rest of the results compared to reports from studies conducted in Butajira District, Ethiopia18, Ghana14, the Philippines11, and Guatemala10. Dietary consumption habits and the lack of compulsory enrichment of basic food items have a significant impact on vitamin intake, resulting in a high prevalence of inadequacies and variations from other study findings. Staple foods in the area consist mainly of cereals and grains, with a significant portion of meals being made with maize, which is low in tryptophan and niacin. Consumption of animal-source foods, dark green leafy vegetables, and fruits is relatively low in the designated study area and many parts of Ethiopia2,52–54.

Vitamin C intake inadequacy was prevalent among 7.0% of participants, which represents the lowest proportion among all the vitamins studied. This is lower than studies in the Tigray region, Ethiopia19, Oromia Region, Ethiopia20, Ghana14, Tanzania15, the Philippines11 and Guatemala10. The differences in the consumption of fruits and vegetables and the references used to estimate the volume of breast milk could explain this discrepancy.

Inadequate calcium intake was observed among 89.1% of study participants. The result was lower than the study results in the Tigray region, Ethiopia19, Ghana14, and higher than the study results in the Oromia region, Ethiopia20, Butajira District, Ethiopia18, Tanzania15, the Philippines11 and Guatemala10. The potential discrepancy could be attributed to variations in the intake of dairy products and other foods that are abundant in calcium, which were found to be low in this study area.

In this study, about 59.1% of the children had inadequate iron intake. This finding is lower than studies in the Tigray region, Ethiopia19, Ghana14, Tanzania15, the Philippines11 and Guatemala10. However, this finding exceeds the research findings conducted in the Oromia region of Ethiopia20. Teff and millet are staple foods that are often consumed in the study area and are rich sources of iron. The significant differences in these food intakes may be an explanation for the variation.

This study revealed that zinc intake inadequacy was 92.1%. It aligns with the study conducted in Tanzania15 and Ghana14, but is lower than the study conducted in the Tigray region of Ethiopia19 and Guatemala10. This finding surpasses the findings of studies conducted in the Oromia region20 and Butajira District of Ethiopia18, as well as in the Philippines11. The reason behind this difference could be associated with the variances in food choices across different regions, resulting in corresponding variations in zinc levels.

In the current study, it was found that there was a high prevalence of selenium intake inadequacy among 61.2% of children. This percentage is significantly greater than what has been reported in previous studies conducted in the Philippines11 and Guatemala10. The significant difference in prevalence suggests that there are distinct factors contributing to this disparity. One potential explanation could be variations in dietary practices and selenium availability across geographical regions. Factors like soil composition, agricultural practices, and local food preferences can have a significant impact on the selenium content of food sources that children consume.

In a wider context, a variety of factors might contribute to the diversity shown in research findings regarding micronutrient intake in children. These include variations in the measurement of dietary intake, the methods used for assessment, and the thresholds for indicator scores; population characteristics that are explained by variances in demographic traits like socioeconomic status, cultural practices, and education levels; regional variations in the kinds of food produced and consumed; and nutrient concentration in the soil.

The odds of micronutrient intake inadequacy were 2.8 times higher among children aged 6–8 months as compared to children aged 9–23 months. The delayed introduction of complementary feeding could be part of the explanation, and this in turn may be attributed to various factors such as knowledge, attitude, culture, and beliefs. The transition from exclusive breastfeeding to semi-solid or solid food can also pose challenges for both the child and the caregiver. Infants at this stage are often cautious about consuming certain foods, have small appetites, and are exploring new flavors and textures. This can result in insufficient nutrient intake, and in some cases, the introduction of solid foods may lead to a decrease in milk consumption. This is supported by other studies conducted on the dietary intake of children55–59

Children with paternal education of unable to read and write and able to read and write were 3.1 and 2.4 times more likely to have micronutrient intake inadequacy than children with paternal education of primary school completed and above, respectively. The education level of parents is associated with limited knowledge about nutrition, parenting habits, and socioeconomic issues. Parents with low levels of education might not possess the necessary understanding of proper dietary requirements for their children and might be less likely to provide a balanced and nutritious diet. An educated parent may readily accept and practice the IYCF counseling and education services offered by healthcare providers. Financial difficulties and food insecurity are common problems for families with lower educational attainment, which may restrict their access to a wide variety of wholesome dietary options. Additional studies on children's dietary intake support this56,59.

The likelihood of micronutrient intake inadequacy was 1.8 times higher among children from mothers who had an unfavorable nutrition-related attitude than among children from mothers who had a favorable attitude. The attitude of mothers towards nutrition greatly influences their children's dietary habits and choices. Mothers may unintentionally overlook key nutrients needed for the growth and development of their children. Moreover, the eating habits and attitudes of mothers can influence their children's food preferences and behaviors.

The present study presents a comprehensive overview of the intake of essential micronutrients among children aged 6–23 months. The quantity of these nutrients consumed by children during this period plays a crucial role in their growth, development, and future well-being. Nonetheless, relying solely on a single recall spanning 24 h may introduce certain inaccuracies at the individual level due to day-to-day and seasonal variations in dietary patterns and memory biases. However, to address this potential bias, great efforts were made to incorporate standardized quality-control procedures throughout the entire study, involving highly trained nutrition experts. In addition, the study does not include dietary intake data from the days of special events. For low- and middle-income countries, the validity of this method has been established60.

Conclusions

Inadequate intake of micronutrients was shown to be highly prevalent among children aged 6–23 months. This problem can have a significant short- and long-term impact on the overall health and development of these young individuals since these specific micronutrients play a crucial role in various body functions. Child age, paternal education, and maternal nutrition-related attitude were significantly associated with micronutrient intake inadequacy. Integrating community-guided nutrition interventions is critical to address the issue of inadequate intake of micronutrients. To empower parents to make informed choices regarding their children′s dietary habits, it is critical to raise their nutrition-related knowledge and attitude toward better nutrition.

Acknowledgements

We thank the Healthy Food Africa project for providing the funds to cover the study costs. We also appreciate the efforts exerted by the supervisors and data collectors to collect reliable data. The information that study participants contributed at the cost of their time is also greatly appreciated. We also express our sincere gratitude to the Faculty of Food and Chemical Engineering at Bahir Dar University, where standardization was implemented.

Author contributions

YM: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. TB: Conceptualization, Investigation, Methodology, Supervision, Validation, Visualization, Writing – review & editing. NF: Conceptualization, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – review & editing.

Funding

The author(s) declare that financial support was received for the research, but not for authorship and/or publication of this article.

Data availability

The datasets discussed in this article are currently inaccessible as they are required for additional analysis. However, upon a justified request, the data set containing particular variables will be provided. For inquiries about accessing the datasets, kindly reach out to YM at nataniem21@gmail.com.

Competing interests

The authors declare no competing interests.

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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