==== Front PLoS One PLoS One plos PLOS ONE 1932-6203 Public Library of Science San Francisco, CA USA 10.1371/journal.pone.0287247 PONE-D-22-14108 Research Article Biology and Life Sciences Nutrition Diet Medicine and Health Sciences Nutrition Diet Research and Analysis Methods Mathematical and Statistical Techniques Statistical Methods Metaanalysis Physical Sciences Mathematics Statistics Statistical Methods Metaanalysis People and Places Geographical Locations Africa Ethiopia Biology and Life Sciences Nutrition Medicine and Health Sciences Nutrition Research and Analysis Methods Research Assessment Systematic Reviews People and Places Population Groupings Ethnicities African People Amhara People Biology and Life Sciences Nutrition Diet Food Medicine and Health Sciences Nutrition Diet Food Research and Analysis Methods Database and Informatics Methods Database Searching Minimum acceptable dietary intake among children aged 6–23 months in Ethiopia: A systematic review and meta-analysis Minimum acceptable dietary intake among children aged 6–23 months in Ethiopia https://orcid.org/0000-0003-0736-5769 Kassie Gizachew Ambaw Conceptualization Data curation Formal analysis Funding acquisition Investigation Methodology Project administration Resources Software Supervision Validation Visualization Writing – original draft Writing – review & editing * Gebrekidan Amanuel Yosef Conceptualization Data curation Formal analysis Methodology Writing – review & editing Enaro Eskinder Yilma Data curation Methodology Resources Software Supervision Writing – review & editing https://orcid.org/0000-0001-5226-1200 Asgedom Yordanos Sisay Conceptualization Data curation Formal analysis Methodology Software Supervision Visualization Writing – review & editing School of Public Health, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia Sahin Yasin Editor Liv Hospital Gaziantep, TURKEY Competing Interests: The authors have declared that no competing interests exist. * E-mail: gizachewambawkase@gmail.com 29 6 2023 2023 18 6 e028724714 5 2022 1 6 2023 © 2023 Kassie et al 2023 Kassie et al https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background In the absence of minimum acceptable diet, children aged 6–23 months are vulnerable to malnutrition. Not feeding at least the minimum acceptable diet is a major global problem, particularly in developing countries. Even though many studies have been conducted in Ethiopia there are inconsistencies. Therefore, this review aimed to estimate the pooled prevalence of a minimum acceptable diet in Ethiopia. Methods Published articles from various electronic databases, such as PubMed/MEDLINE, EMBASE, Google Scholar, and Science Direct were systematically searched. All cross-sectional studies conducted on the minimum acceptable diet of children aged 6–24 months and published up to October 30/2021 were included in this review. Data were extracted using an Excel spreadsheet and analyzed using STATA version 14.1. The random-effects model was used to estimate the pooled prevalence, and a subgroup analysis was performed to identify the possible source of heterogeneity. Begg’s and Egger’s tests were used to identify possible publication bias. Results Nine cross-sectional studies involving 4,223 participants were included. Significant heterogeneity was observed across the studies (I2 = 99.4%). The pooled prevalence of minimum acceptable diet in Ethiopia was found to be 25.69% (95% CI: 11.96, 39.41) Conclusion This review revealed that the minimum acceptable dietary intake among children aged 6–23 months in Ethiopia was relatively low; only 1 in 4 of children met the minimum acceptable diet. This indicates that the government should promote child feeding practices according to guidelines to increase the proportion of children with a minimum acceptable diet. The author(s) received no specific funding for this work. Data AvailabilityAll relevant data are within the manuscript and its Supporting Information files. Data Availability All relevant data are within the manuscript and its Supporting Information files. ==== Body pmcIntroduction Proper feeding practice in children aged 6–24 months significantly reduces the morbidity and mortality caused by malnutrition [1, 2]. The age of 6–24 months is a critical window for improving child nutrition because deficits acquired by this age are difficult to reverse [3]. Therefore, providing a minimum acceptable diet including the recommended diversification and frequency of foods according to age is cost-effective strategy for proper growth and development of children [4]. Appropriate supplementation of breastfeeding with nutritious commentary foods can reduce stunting among children by approximately 20% [5]. The World Health Organization (WHO) recommends that appropriate complementary feeding should start with semi-solid, or soft foods, minimum meal frequency, minimum dietary diversity, minimum acceptable diet, and consumption of iron-rich or iron-fortified foods at the age of six months [6]. The minimum acceptable diet is a composite indicator comprising minimum dietary diversity and minimum meal frequency indicators. It is an indicator used to assess infant and young child feeding practices during childhood [7]. The minimum acceptable diet feeding practices for infants and children is not met in many developing countries including Ethiopia. For example, in Africa less than one-third and one-half of the children aged between 6 and 23 months met the minimum criteria for dietary diversity and meal frequency, respectively. Therefore, the prevalence of stunting in many developing country including African countries is still increasing by threefold during the first two years of life [1]. In Ethiopia, the minimum acceptable diet has increased slightly from 7% to 11% from the 2016 EDHS to 2019 EMDHS reports. The proportion minimum acceptable dietary intake among children is highest in Addis Ababa (28%) and lowest in Somali (1%) followed by Afar (4%) and Amhara (6%) [8]. The global burden of stunting, wasting and overweight among children under five years of age was 149 million, 45 million and 38.9 million by the year 2020, respectively [2]. In Ethiopia, 37% of children under the age of five are stunted, of which 12% are severely stunted, 7% are wasted, and approximately 2% are overweight [8]. Most of the burden of childhood undernutrition can be explained by the absence of proper infant and young child feeding practices during the first two years. In Ethiopia 50–70% of deaths in children under-five years of age are attributable to inappropriate complementary feeding practices. This indicates that feeding of the minimum acceptable diet is a major problem in Ethiopia [9, 13]. Healthy nutrition is one of the vital preconditions for the achievement of sustainable development goals; because the first three icons of seventeen Sustainable Development Goals (SDGs) are directly related to nutrition [10]. To end child under nutrition by 2030 the government of Ethiopian has been tried to improve child feeding practices by implementing the national nutrition program of child feeding practices and a multi-sectoral plan of nutrition intervention [11]. In addition, the recently endorsed 2019 Food and Nutrition Policy is one of the strategy which is aimed to achieve optimal nutritional status throughout the life cycle via coordinated implementation of nutrition-specific and nutrition sensitive interventions were the major activities under implementation [12]. Although, many studies were conducted on minimum acceptable diet to determine the magnitude and determining factors in Ethiopia. However, there were discrepancy and inconsistent across those studies and offered district level data. The results from those studies indicated that children aged 6–23 months which meets minimum acceptable diet in Ethiopia ranges from 8.4%-74% [13, 14]. As a result of that variability across studies pooled prevalence of minimum acceptable diet is needed. Moreover, inclusive estimates of the extent of minimum acceptable diet are needed for the programmatic intervention of malnutrition within the context of ensuring minimum acceptable diet. Therefore, the aim of this meta-analysis was to estimate the pooled prevalence of minimum acceptable diet in Ethiopia. The evidences from this study will give the update pooled estimate of minimum acceptable diet to policy makers and health planners of Ethiopian government relevant bodies. Those concerned bodies as input to design appropriate interventions to improve minimum acceptable diet (minimum dietary diversity and minimum meal frequency) of children aged 6–23 months. Methods Searching strategy and study identification A systematic review and meta-analysis was designed to estimate the pooled prevalence of a minimum acceptable diet among children aged 6–23 months in Ethiopia. All published research reports on the minimum acceptable diet among children aged 6–23 months in Ethiopia until October 2021 were searched. We systematically and thoroughly explored to identify published and unpublished research findings related to prevalence and associated factors of minimum acceptable diet among children aged 6–23 months in Ethiopia from all electronic databases, including Medline, Google Scholar, HINARI, AJOL, direct Google search for gray literature and Cochrane library. Our searches were restricted by age (children 6–23 months age) and by country (studies conducted only in Ethiopia). The search was carried out using the following key words “prevalence”, “minimum acceptable diet among children”, OR “meal frequency” OR “dietary diversity score” AND “Ethiopia”. All published articles until October 30, 2021 were included in the systematic review and meta-analysis. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline during the systematic review [15]. The protocol of this systematic review and meta-analysis was not registered Inclusion criteria Population Study conducted on children aged 6–23 months Study setting Only studies conducted in Ethiopia were included in this review. Publication All articles published both in peer-reviewed journals and grey literature. Study design and language All original cross-sectional articles that report the prevalence of minimum acceptable diet among children aged 6–23 months published by English language in Ethiopia were included. Exclusion criteria Studies unable to access full text, not in the English language, and studies which did not report specific primary outcomes of interest were excluded from this study. Outcomes measurement The outcome of the current study was the prevalence of children with a minimum acceptable diet which is a composite indicator of minimum dietary diversity and minimum meal frequency. The proportion of children aged 6–24 months who received a minimum diversified diet and minimum meal frequency (apart from breast milk) [16]. Data abstraction All studies retrieved from all databases were imported into Endnote Version X7 and duplicate articles were manually removed. Data were extracted by two independent reviewers (GA and AY) using Excel spreadsheet software. Initially title and abstract of the papers were screened for eligibility criteria. After screening of the abstract and titles full text of papers were also screened for eligibility criteria. The data extraction format includes primary author, publication year, region where the study was conducted, sample size, total number of cases, prevalence of minimum acceptable diet, response rate, and quality rating. Quality assessment of the studies The Joanna Briggs Institute (JBI) tool adapted for cross-sectional studies quality assessment was used to assess the quality of each study [17]. The tool has the following items as criteria for appraisal: includes; appropriateness of the sample frame to address the source population, appropriate recruiting of study participants, sample size sufficiency, description of study subjects and setting, data analysis with sufficient coverage of sample, valid method for identification of the condition, measuring the condition using a standard reliable and consistent method for all participants, use of appropriate statistical analysis, and response rate adequacy or appropriate handling of low response rate. Two independent reviewers (GA and AY) critically evaluated each study. Disagreements between the reviewers were resolved through discussion. If they did not agree, a third reviewer (YS) was engaged to resolve discrepancies between the independent reviewers. Then after, studies with a total score of ≥50% of the quality assessment checklist criteria were considered as low risk and were included in the final review and analysis. Statistical analysis After extraction, the data were entered into a computer using an Excel spreadsheet and then imported to STATA 14 software for further analysis. Heterogeneity across the studies reporting prevalence was checked using the inverse variance (I2) statistical test. I2 with Cochran Q statistic values of 0%, 25%, 50%, and 75% were assumed to represent no, low, medium, and high heterogeneity, respectively at p-value of <0.05. Since, significant heterogeneity was detected between studies (p<0.01, I2 >99.4%), random effects meta-analysis model was used to estimate the pooled prevalence of minimum acceptable diet. To visualize the presence of heterogeneity subjectively forest plot was used. To examine potential discrepancies across the studies included in the analysis and to identify sources of variation subgroup analyses and meta-regression were conducted. The findings of the study are presented using forest plots with corresponding prevalence and 95% confidence intervals. Evidence of publication bias was also assessed using both Egger’s and Begg’s tests with p-value of less than 0.05 as a cut-off point. Results Selection of studies A total of 325 articles were retrieved from the electronic databases and other sources. Titles and abstracts were screened and duplicated or irrelevant articles were removed using EndNote × 7. Thus, 260 duplicate articles were removed. Of the remaining 65 articles, 35 articles were excluded because their titles and abstracts were not in- line with our inclusion criteria (not reporting the outcome of the interest, studies conducted outside Ethiopia), and 21 articles were excluded for reasons (studies conducted outside Ethiopia, insufficient data, study designs other than cross-sectional, study objective not related and outcome of interest is not reported). Finally, a total of nine articles were included in this systematic review and meta-analysis. The detailed selection procedures were described in (Fig 1). 10.1371/journal.pone.0287247.g001 Fig 1 PRISMA flow diagram of articles screened and the selection process on minimum acceptable diet among children aged 6–23 months in Ethiopia. Characteristics of included studies Nine cross-sectional studies were included in the final systematic review and meta-analysis. All the studies included in this meta-analysis were published between 2017 and 2021. A total of 4,223 children aged 6–23 months participated in the analysis with a minimum sample size of 200 [18] and a maximum of 662 [19]. Of the nine articles included in this systematic review and meta-analysis only three regions and one administrative city of Ethiopia was represented. Of the total studies included; four studies were conducted in Amhara regional state [20–23]; two studies in South Nations Nationalities and Peoples of Ethiopia national regional state (SNNPR) [14, 19]; two studies at Oromia national regional state [18, 24] and one study from Addis Ababa city administration [13]. Three studies were conducted in the urban areas and the rest six were conducted at the rural areas (Table 1). 10.1371/journal.pone.0287247.t001 Table 1 Summary of characteristic of nine studies included in the systemic review and meta-analysis on minimum acceptable diet among children aged 6–23 months in Ethiopia, 2022. No Authors Publication Year Region Study setting Study design Sample size Children who met MAD Prevalence of MAD (%) 1 Yisak et al. [23] 2021 Amhara Urban Cross-sectional 287 100 34.8 2 Birie et al. [20] 2021 Amhara Urban Cross-sectional 430 54 12.6 3 Abebe et al. [13] 2021 Addis Ababa Urban Cross-sectional 575 419 74.6 4 Mulat et al. [21] 2019 Amhara Rural Cross-sectional 505 49 8.6 5 Molla et al. [22] 2021 Amhara Urban Cross-sectional 531 168 31.6 6 Gizaw et al. [18] 2019 Oromia Rural Cross-sectional 200 27 13 7 Feleke et al. [19] 2020 SNNPR Rural Cross-sectional 662 235 35.5 8 Dangura et al. [14] 2017 SNNPR Rural Cross-sectional 417 35 8.4 9 Kassa et al. [24] 2016 Oromia Rural Cross-sectional 626 75 12.3 Pooled prevalence of minimum acceptable diet in Ethiopia The pooled prevalence of minimum acceptable diet in Ethiopia was 25.69% (95% CI 11.96, 39.41). As shown in the forest plot, statistically significant heterogeneity was observed (I2 = 99.4%; p < 0.001). Therefore, we estimated the pooled prevalence using random effects models. In addition, the significant magnitude of heterogeneity also indicates the need to conduct subgroup analysis to identify the sources of heterogeneity across the studies (Fig 2). 10.1371/journal.pone.0287247.g002 Fig 2 Forest plot for pooled prevalence minimum acceptable dietary intake among children aged 6 to 23 months in Ethiopia. Subgroup analysis In this meta-analysis subgroup analysis was performed based on the study area (region), study years, and study setting to identify possible sources of heterogeneity (Table 2). Regarding the pooled prevalence by region the lowest pooled prevalence of minimum acceptable diet was reported in Oromia regional state 12.47% (95% CI 10.19, 12.74) and the highest was both in Amhara regional state 21.74% (95% CI 9.63, 33.86) and SNNPR region 21.92% (95% CI 4.64, 48.5) in which the prevalence is almost similar on the two regions (Fig 3). Subgroup analysis by study setting also indicated that the pooled prevalence of the minimum acceptable diet was 47% (17.3. 76.8) among those studies employed in urban areas and 15% in rural areas. There was increment of minimum acceptable diet starting from the studies published before 2020 15.5% (6.74, 24.3) and after 2020 38.4% (9.41, 47.39) (Table 2). In addition to subgroup analysis, publication bias was assessed using both Begg’s and Egger’s tests. The results of the Begg and Egger tests indicated that there was no identified among studies included to estimate the pooled prevalence of minimum acceptable diet at p–value of (p = 0.055) and (p = 0.066), respectively. The graphical distribution of the funnel plot also shows evidence of symmetry (Fig 4). 10.1371/journal.pone.0287247.g003 Fig 3 Subgroup analysis forest plot for pooled prevalence of minimum acceptable dietary intake by regions among children aged 6 to 23 months in Ethiopia. 10.1371/journal.pone.0287247.g004 Fig 4 Funnel plot for publication bias on minimum acceptable dietary intake among children aged 6 to 23 months in Ethiopia. 10.1371/journal.pone.0287247.t002 Table 2 Subgroup analysis for the pooled prevalence of minimum acceptable diet among children aged 6–23 months in Ethiopia. 2022. Subgroups Number of studies Prevalence(95%CI) Heterogeneity statistics p-value I2 Tau-squared Regions Amhara 4 21.74 (9.63, 33.86) 144.12 0.0000 97.9 148.8 Oromia 2 12.47 (10.19, 12.74) 0.07 0.0001 0 0 SNNPR 2 21.92 (4.64, 48.5) 138.46 0.0001 99.4 364 Years of publication Before 2020 5 15.5 (6.74, 24.3) 669.2 0.0000 99.6 870.75 After 2020 4 38.4(9.41, 47.39) 170.3 0.0001 97.7 97.71 Study setting Urban 3 47.0(17.28. 76.78) 294.49 0.0000 99.3 684.1 Rural 6 15.0(7.8, 22.22) 170.46 0.0001 97.1 78.39 Meta regression Meta regression was performed by considering continuous variables to identify associated factors with the pooled prevalence of minimum acceptable diet. Sample size and years of publication were considered in the meta-regression analysis. However, the meta-regression indicated that there was no a significant association between the pooled prevalence of the minimum acceptable diet with years of publication and sample size (Table 3). 10.1371/journal.pone.0287247.t003 Table 3 Meta regression to identify source of heterogeneity for the pooled prevalence of minimum acceptable diet among children age 6–23 months in Ethiopia, 2022. Variables Coefficient 95% CI p-value Sample size 7.03 (-1.36, 15.4) 0.086 Years of publication 0.05 -0.05, 0.15 0.26 Sensitivity analysis Sensitivity analysis was done to evaluate the effect of single study on the pooled prevalence of minimum acceptable diet among children aged 6–23 months by excluding each study step-by-step. The results showed that no single studies make a significant difference in the pooled prevalence minimum acceptable dietary intake (Fig 5). 10.1371/journal.pone.0287247.g005 Fig 5 Sensitivity analysis on minimum acceptable dietary intake among children aged 6 to 23 months in Ethiopia. Discussion This systematic review and meta-analysis aimed to estimate the pooled prevalence of minimum acceptable diet in Ethiopia. This study revealed that the pooled prevalence of minimum acceptable diet in Ethiopia was found to be 25.69% (95% CI 11.96, 39.41). This Indicates that most children aged 6–23 months in Ethiopia were not taking the minimum acceptable diet according to global recommendations [29]. The result of this meta-analysis was consistent with the national Demographic and Health surveys in China (27.4%) [25], Democratic Republic of Congo (33%) [26], Ghana (14%) [27], and Indonesia based on DHS data (29%) [28]. However, it was higher than according to the 2019 mini Ethiopian demographic and health survey report (11%) [8], a national survey conducted in low- and middle-income countries (10.1%) [29] and multilevel analysis conducted in sub-Sahara Africa (9.98%) [30]. This might be the fact that all the above studies were conducted based on demographic and health survey data of the countries in which they were conducted by including a sampled data from all regional state of Ethiopia despite of that, in this meta-analysis only four regions and one administrative city was represented in this meta-an1aysis. In addition, this could be due to differences in the socio-demographic characteristics of the study population. The subgroup analysis of this systemic review and meta-analysis revealed that the pooled prevalence of minimum acceptable dietary intake among children aged 6–23 months is significantly different across regional state of Ethiopia. The lowest prevalence of minimum acceptable dietary intake of Ethiopian children aged 6–23 months were observed in Oromia regional state with the prevalence of 12.58% while the highest pooled prevalence was observed in Amhara regional state regions (21.76%). The possible reasons for these variations is due to the difference in study area and may other reasons like young infant and child feeding practice cultural variations and the number of studies include in the analysis in which Oromia regional state of Ethiopia were represented by only two studies. And also it might be due to the study settings of the included study; because study setting was one of the sources of heterogeneity in this meta-analysis. Regarding study setting higher prevalence of MAD was observed in studies conducted in urban (47%) settings compared to studies conducted in rural settings. The finding from this review is supported by result from EMDHS report of 2019; in which children in urban area (14%) are more likely to be fed the MAD standard as compared to rural areas (10%) [8]. This could be due the difference in socio economic status such as educational level and income and also it might be related with the access of information on the benefit of health eating habit and child feeding practices. Subgroup analysis by years of publication in this systemic review and meta-analysis also indicated that the pooled prevalence of minimum acceptable diet was relatively high on the studies published after the year 2020 was (38.4%) as compared to the studies published before 2020 (15%). This may be due to different activities and programs that have been undertaken to increase the infant and young child feeding practice. such as the recently endorsed 2019 Food and Nutrition Policy under implementation aimed to achieve optimal nutritional status throughout the life cycle by coordination nutrition-specific and nutrition sensitive interventions as their major activities [12]. Limitation and strength of the study The first limitations of the study was only English articles were considered for the analysis. Moreover, this meta-analysis represented only studies reported from five regions of the country. Even though we are doing sensitivity, subgroup, and meta-regression analyses to minimize the effect of heterogeneity, the degree of heterogeneity among the reviewed articles were high. Therefore, researcher and policymakers should consider effects of heterogeneity and result of filled meta-analysis during the interpretations of results. Conclusion and recommendation The result of this systemic review and meta- analysis indicated that minimum acceptable diet among children aged 6–23 months was found to be low in Ethiopia; only 1 in 4children met minimum acceptable diet. Therefore, the government of Ethiopia should give greatest emphasis to meet minimum acceptable diet in order to decrease children mortality due to malnutrition as well as later consequence of in appropriate feeding practices. In relation to the global standard national nutrition food based dietary guideline should developed by including guidance on feeding how to feed infants and young children is also recommended. Supporting information S1 Checklist PRISMA 2020 checklist. (DOC) Click here for additional data file. S1 File Searching strategy. (DOCX) Click here for additional data file. Abbreviations CI Confidence Interval EDHS Ethiopia Demographic Health Survey JBI Joanna Briggs Institute MAD Minimum Acceptable Diet SDGs Sustainable Development Goals PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses SNNPR South Nations Nationalities and Peoples regional of Ethiopia WHO Word Health Organization 10.1371/journal.pone.0287247.r001 Decision Letter 0 Pillay Yogan Academic Editor © 2023 Yogan Pillay 2023 Yogan Pillay https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version0 20 Jun 2022 PONE-D-22-14108Minimum Acceptable Dietary intake among Children Aged 6-23 Months in Ethiopia: a Systemic Review and Meta-Analysis PLOS ONE Dear Dr. Kassie Thank you for submitting your manuscript to PLOS ONE. 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We have highlighted the changes within the manuscript please find for your kind consideration the following: In the Response to Reviewers, we copy each of the comments / suggestions and provide the RESPONSE hereunder. We also provide a marked-up copy of the manuscript that highlights changes made to the original version and this is uploaded as a separate file labelled “Revised Manuscript with Track Changes”. Finally, we provide an unmarked version of the revised manuscript without tracked changes and this is uploaded as a separate file labelled 'Manuscript'. We have been carefully through the peer review and have revised our paper accordingly. We feel that the paper is much improved as a result of this peer review process, and thank you for taking it to this stage. While hoping that these changes would meet with your favorable consideration, we hold ourselves at your entire disposition for any further information or other changes you might require. The authors welcome further constructive comments. Sincerely yours! Gizachew Ambaw Kassie on behalf of the co-authors POINT BY POINT RESPONSE TO THE EDITOR AND REVIEWER COMMENTS RESPONSE TO ACADEMIC EDITOR: 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. RESPONSE: We have checked and have ensured that the manuscript met the journal’s requirements. 2. Please ensure that you refer to Figure 4 in your text as, if accepted, production will need this reference to link the reader to the figure RESPONSE: Thank you for pointing out this point. We accept and revision has been made in the main document. Please include captions for your supporting information files at the end of your manuscript, and update any in-text citations to match accordingly RESPONSE: Thank you; we have included captions as supporting information at the end of our manuscript POINT BY POINT RESPONSE TO REVIEWER Well written and methodological sound manuscript. A few minor corrections: RESPONSE: We thank the reviewer for kind work and constructive comments. We have revised our manuscripts based on the reviewer’s comments as below. Line 45: Better to say 1 in 4 children rather than one fourth of children RESPONSE: Thank you, we have replaced the term as suggested Line 81: Sentence needs restructuring to read as follows:- ‘This indicates that feeding of the minimum acceptable diet is a major problem in Ethiopia. You cannot say global problem when you have only presented data for Ethiopia RESPONSE: Agree, we have modified accordingly Line 170: Capital letters for Egger’s and Begg RESPONSE: Thanks for this comment, corrected Line 191: Define cases and Prevalence in your table. What cases and prevalence of what? RESPONSE: Thanks for the this suggestion, we have defined cases in the main document as “children who met Minimum Acceptable Diet (MAD)” and prevalence as “Prevalence of MAD” Line 235: restructure sentence to read ‘national Demographic and Health surveys in China, …. RESPONSE: Thank you for your suggestion, the sentence have restructured as “The result of this meta-analysis was consistent with the national Demographic and Health surveys in China” Line 237: remove ‘finding from’ RESPONSE: Thank you, noted and deleted Line 238: ‘in low- and middle-income countries… RESPONSE: Comment accepted and well treated Line 234: heterogeneity without capital H RESPONSE: Thank you, accepted Line 256: Correction: higher prevalence of MAD was observed in studies conducted in urban settings compared to studies conducted in rural settings. RESPONSE: Thank you, we have replaced the sentence as indicated Line 265: restructure sentence to read ‘more likely to be fed the MAD standard…’ RESPONSE: Comment accepted and revised as recommended Line 268: delete after the end of the MDGs RESPONSE: We thank you again, we have edited accordingly Line 268-271: This sentence does not add any value to the discussion of IYCF or MAD. Or restructure to say how the new 2019 Nutrition programme is addressing IYCF or MAD. RESPONSE: Thank you for insightful comment. The sentence putted prior to this information was not related with this discussion that is why it was confused. Therefore, the indicated sentence is moved to the preceding paragraph and I hope the information from “line 268-271” add a value as a justification why MAD is higher in the studies published after the year 2020 which might be due to the implementation of new 2019 food and nutrition policy in Ethiopia aimed to achieve optimal nutritional status throughout the life cycle. We also made some restructuring of the sentence. Line 277: 1 in 4 children rather than ‘one fourth of children…’ RESPONSE: Thank you, we have replaced the term as suggested Attachment Submitted filename: Response to reviewer.docx Click here for additional data file. 10.1371/journal.pone.0287247.r003 Decision Letter 1 Pillay Yogan Academic Editor © 2023 Yogan Pillay 2023 Yogan Pillay https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version1 2 Aug 2022 PONE-D-22-14108R1Minimum Acceptable Dietary intake among Children Aged 6-23 Months in Ethiopia: a Systemic Review and Meta-AnalysisPLOS ONE Dear Dr.Kassie Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Sep 16 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript:A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Yogan Pillay, Phd Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. 10.1371/journal.pone.0287247.r004 Author response to Decision Letter 1 Submission Version2 9 Aug 2022 POINT BY POINT RESPONSE TO REVIEWER Well written and methodological sound manuscript. A few minor corrections: RESPONSE: We thank the reviewer for kind work and constructive comments. We have revised our manuscripts based on the reviewer’s comments as below. Line 45: Better to say 1 in 4 children rather than one fourth of children RESPONSE: Thank you, we have replaced the term as suggested Line 81: Sentence needs restructuring to read as follows:- ‘This indicates that feeding of the minimum acceptable diet is a major problem in Ethiopia. You cannot say global problem when you have only presented data for Ethiopia RESPONSE: Agree, we have modified accordingly Line 170: Capital letters for Egger’s and Begg RESPONSE: Thanks for this comment, corrected Line 191: Define cases and Prevalence in your table. What cases and prevalence of what? RESPONSE: Thanks for the this suggestion, we have defined cases in the main document as “children who met Minimum Acceptable Diet (MAD)” and prevalence as “Prevalence of MAD” Line 235: restructure sentence to read ‘national Demographic and Health surveys in China, …. RESPONSE: Thank you for your suggestion, the sentence have restructured as “The result of this meta-analysis was consistent with the national Demographic and Health surveys in China” Line 237: remove ‘finding from’ RESPONSE: Thank you, noted and deleted Line 238: ‘in low- and middle-income countries… RESPONSE: Comment accepted and well treated Line 234: heterogeneity without capital H RESPONSE: Thank you, accepted Line 256: Correction: higher prevalence of MAD was observed in studies conducted in urban settings compared to studies conducted in rural settings. RESPONSE: Thank you, we have replaced the sentence as indicated Line 265: restructure sentence to read ‘more likely to be fed the MAD standard…’ RESPONSE: Comment accepted and revised as recommended Line 268: delete after the end of the MDGs RESPONSE: We thank you again, we have edited accordingly Line 268-271: This sentence does not add any value to the discussion of IYCF or MAD. Or restructure to say how the new 2019 Nutrition programme is addressing IYCF or MAD. RESPONSE: Thank you for insightful comment. The sentence putted prior to this information was not related with this discussion that is why it was confused. Therefore, the indicated sentence is moved to the preceding paragraph and I hope the information from “line 268-271” add a value as a justification why MAD is higher in the studies published after the year 2020 which might be due to the implementation of new 2019 food and nutrition policy in Ethiopia aimed to achieve optimal nutritional status throughout the life cycle. We also made some restructuring of the sentence. Line 277: 1 in 4 children rather than ‘one fourth of children…’ RESPONSE: Thank you, we have replaced the term as suggested 10.1371/journal.pone.0287247.r005 Decision Letter 2 Sahin Yasin Academic Editor © 2023 Yasin Sahin 2023 Yasin Sahin https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version2 23 Nov 2022 PONE-D-22-14108R2Minimum Acceptable Dietary intake among Children Aged 6-23 Months in Ethiopia: a Systemic Review and Meta-AnalysisPLOS ONE Dear Dr. Gizachew Ambaw Kassie, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by 06.12.2022. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript:A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. 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Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Yasin Sahin Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #2: All comments have been addressed Reviewer #3: (No Response) ********** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #2: No Reviewer #3: Partly ********** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: No Reviewer #3: No ********** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #2: (No Response) Reviewer #3: Yes ********** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #2: No Reviewer #3: No ********** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #2: The rationale for the present meta-analysis is rather weak and unclear. The pooled prevalence estimate is not useful or informative given the very substantial heterogeneity (I2 > 99%) among the different studies and contexts being pooled. Specific comments: 1. This is a "systematic review" and not a "Systemic Review". 2. Please change "Even though, many studies" to "Even though many studies". 3. Please change "The Global burden" to "The global burden". 4. As per PRISMA guidelines, please specify in the methods section if the review protocol was prospectively registered. Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address). 5. The reliability and reproducibility of a systematic review cannot be overemphasized. Please also provide the full electronic search strategy used to identify studies, including all search terms and limits for at least one database. The rest can be provided in the supplementary material. 6. Please change "gray literature" to "grey literature". 7. Please change "Homogeneity across studies" to "Heterogeneity across the studies". 8. "Full title articles excluded with reason (n=21)" - please state the exact reasons for exclusion. 9. It was unclear if the samples were drawn from population or clinical samples. This should be stated as clinical samples would be quite different in characteristics. 10. The findings of the result were not well discussed. What minimum dietary intake value do the authors consider to be acceptable, considering the characteristics of the country, the population and the environment? What specific recommendations can be made to address these gaps? 11. The discussion of study limitations was grossly inadequate. How can we account for the very significant heterogeneity in the meta-analysis? Equally if not more important than the point estimate, the distribution of estimates (i.e., how much they are dispersed around the average pooled estimate) is a key aspect in meta-analyses of prevalence. Are the studies truly comparable? 12. "We would like to thank all of the authors of studies participated in this systematic review and meta-analysis" - this does not make sense. Suggest to omit. Reviewer #3: General comments 1. The work lacks nobility. Since there is EDHS 2019 that reported a prevalence of 11% minimum acceptable diet, it is not possible to generate a pooled prevalence that is more valid and reliable than the EDHS 2019 finding. How can your finding be preferred over EDHS 2019 finding. Your pooled prevalence is very far to represent the national prevalence as the included studies are few and obtained from only four regions out of a total of 11 regions in the country. 2. I suggest a systematic review only. You should not pool a prevalence (never conduct a meta-analysis). 3. There is a serious English language editorial problem Specific comments Abstract Introduction: Line 27: remove “an adequate” as “minimum acceptable diet” is by itself enough to convey the intended message. Line 28 and second sentence: It says “Feeding the minimum acceptable…………” Correct as “Not feeding at least the minimum acceptable diet…….’’ Line 30: Your objective was to produce a pooled prevalence as a result of a rationale of inconsistence studies in Ethiopia. The problem you actually observed from your result is a serious consistence across studies as evidenced by your heterogeneity test. So, I recommend you end up with systematic review only rather than pooling a very heterogeneous results, which may be due to small number of studies. Method: Line 35: “Data was” correct as “Data were” Results: What was the source of heterogeneity since you mentioned in the method section above that you did a subgroup analysis to identify the source of heterogeneity? Key words (incorrect), Keyword (correct): Separate the keywords by a semicolon not by a comma. Introduction The introduction content need to be re-structured so as to create a logical follow of the introduction information. As there was 2019 EDHS’s report of 11% minimum acceptable diet proportion, how strong your finding will be in attracting the governments attention as compared to the EDHS 2019 finding? Due to this and other reasons, I suggest you simply conduct systematic review only. Line108 and 109: Published and unpublished reports: There should be consistency. Which one you really did in your review? Only published (in the abstract) or both Published and Unpublished (introduction). Line 116: Which searching terms were combined by "and" which were combined by "or"? Line 127: Exclusion criteria – not published in English was already mention in the inclusion criteria. Line 137: What is that standardized data abstraction sheet you used? Results The nine studies are all from three regions and one city administration. So, meta-analysis is not important. Line 191: Remove meta-analysis in the bracket. Discussion Line 232: Please cite for the global recommendations at the end of “This Indicates that most children aged 6–23 months in Ethiopia were not taking the minimum acceptable diet according to global recommendations”. Line 234-235: You compared your finding with other Countries’ DHS report. So, the Ethiopian Demographic and Health Survey finding is more comparable with those DHS reports than your pooled prevalence. So, I recommend only systematic review. Line 236: You again compared your finding with the EDHS 2019 report and yours was higher. The explanation you gave for the difference was your study was not representative of all regions as EDHS was. So, this shows your study was not important at all. Because the EDHS finding is valid than yours. Limitation and strength Line 271: Why you only included English language articles? Line 272: Since we already the EDHS 2019 report that has not the limitations encountered by your study, EDHS is more important than yours. Conclusion and recommendation “The result of this systemic review and meta- analysis indicated that minimum acceptable diet among children aged 6-23 months was found to be low in Ethiopia; only 1 in 4children met the minimum acceptable diet.” Your study finding (25%) is better than EDHS finding (11%). So, your recommendation is not acceptable since it has serious limitations. References References are not edited and formatted ********** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #2: No Reviewer #3: No ********** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. 10.1371/journal.pone.0287247.r006 Author response to Decision Letter 2 Submission Version3 30 May 2023 Reviewer #2: General comment: The rationale for the present meta-analysis is rather weak and unclear. The pooled prevalence estimate is not useful or informative given the very substantial heterogeneity (I2 > 99%) among the different studies and contexts being pooled. Response: Dear reviewer, we would like to express our gratitude for the tie you have taken to insightful and constructive comments on our manuscript, and we appreciate the effort you have put in to review our paper. Yes, of course high heterogeneity can affect our result. However to address this significant heterogeneity; we have estimated the pooled prevalence by random effect model. As well as we performed subgroup analysis and meta-regression to identify the possible cause of the heterogeneity. In addition, we acknowledge the limitations and uncertainties associated with meta-analyses and to interpret the findings cautiously in light of the available evidence. Specific comments: Comment 1: This is a "systematic review" and not a "Systemic Review". Response: Thank you for pointing out it. We have corrected it in the revised version Comment 2: Please change "Even though, many study" to "Even though many studies". Response: Thank you! Comment accepted and corrected as recommended. Comment 3: Please change "The Global burden" to "The global burden". Response: Thank you, comment accepted and well treated accordingly. Comment 4: As per PRISMA guidelines, please specify in the methods section if the review protocol was prospectively registered. Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address). Response: Thank you again for suggestion and comment. We have stated as “the protocol is was not registered Comment 5: The reliability and reproducibility of a systematic review cannot be overemphasized. Please also provide the full electronic search strategy used to identify studies, including all search terms and limits for at least one database. The rest can be provided in the supplementary material. Response: Thank you again for suggestion and comment. We have included the searching terms for PubMed in the main manuscripts in addition. We have also attached the searching strategy as supplementary files. Comment 6: Please change "gray literature" to "grey literature". Response: Comment accepted and corrected as “grey” Comment 7: Please change "Homogeneity across studies" to "Heterogeneity across the studies". Response: Thank you for pointing out it. Corrected in the revised manuscript Comment 8: "Full title articles excluded with reason (n=21)" - please state the exact reasons for exclusion. Response: Thank you, comment accepted and well treated accordingly. Comment 10: The findings of the result were not well discussed. What minimum dietary intake value do the authors consider to be acceptable, considering the characteristics of the country, the population and the environment? What specific recommendations can be made to address these gaps? Response: Thank you! We have added limitation regarding heterogeneity Comment 11: The discussion of study limitations was grossly inadequate. How can we account for the very significant heterogeneity in the meta-analysis? Equally if not more important than the point estimate, the distribution of estimates (i.e., how much they are dispersed around the average pooled estimate) is a key aspect in meta-analyses of prevalence. Are the studies truly comparable? Response: Thank you, we have made extensive revision Comment 12: "We would like to thank all of the authors of studies participated in this systematic review and meta-analysis" - this does not make sense. Suggest to omit. Response: Thank you pointing out this error. We have omit it based on the comment Reviewer #3: General comments Comment 1: The work lacks nobility. Since there is EDHS 2019 that reported a prevalence of 11% minimum acceptable diet, it is not possible to generate a pooled prevalence that is more valid and reliable than the EDHS 2019 finding. How can your finding be preferred over EDHS 2019 findings? Your pooled prevalence is very far to represent the national prevalence as the included studies are few and obtained from only four regions out of a total of 11 regions in the country. Response: Thank you reviewer for devoting your time to review our manuscript and your comments and suggestions. We have corrected it in the revised version of the manuscript. We have stated this issue as a limitation. Comment 2: I suggest a systematic review only. You should not pool prevalence (never conduct a meta-analysis). Response: Thank you very much for you suggestions. Even though, some limitation of this meta-analysis, we believe that our finding has a greatest implication for policy maker because meta-analysis increase the power of the study Comment 3: there is a serious English language editorial problem Response: Thank you, we have checked grammatically errors, writing style and typos; and made extensive revisions in the revised manuscript. Specific comments Abstract Introduction: Comment: Line 27: remove “an adequate” as “minimum acceptable diet” is by itself enough to convey the intended message. Response: Thank you for pointing out this comment. We have revised it accordingly in the revised manuscript Comment: Line 28 and second sentence: It says “Feeding the minimum acceptable…………” Correct as “Not feeding at least the minimum acceptable diet…….’’ Response: Thank you for pointing out it. Corrected based on the comment Comment: Line 30: Your objective was to produce a pooled prevalence as a result of a rationale of inconsistence studies in Ethiopia. The problem you actually observed from your result is a serious consistence across studies as evidenced by your heterogeneity test. So, I recommend you end up with systematic review only rather than pooling a very heterogeneous results which may be due to small number of studies. Response: Thank you for bringing this issue. To address these limitations, we carefully assess the sources of heterogeneity, conduct subgroup analyses, use appropriate statistical methods, and report the results transparently and comprehensively. We have acknowledge the limitations and uncertainties associated with meta-analyses and to interpret the findings cautiously in light of the available evidence Method: Comment: Line 35: “Data was” correct as “Data were” Response: Thank you pointing out the error. We have corrected it Results: Comment: What was the source of heterogeneity since you mentioned in the method section above that you did a subgroup analysis to identify the source of heterogeneity? Response: Thank you for your question. The observed high heterogeneity might be due to the difference in the study area, study period, residence and other unspecified variations. Comment: Key words (incorrect), Keyword (correct): Separate the keywords by a semicolon not by a comma. Response: thank you we have revised it Comment: As there was 2019 EDHS’s report of 11% minimum acceptable diet proportion, how strong your finding will be in attracting the governments attention as compared to the EDHS 2019 finding? Due to this and other reasons, I suggest you simply conduct systematic review only. Response: Dear reviewer, we would like to thank you for your suggestions. However, despite searching different databases, we were unable to find systematic reviews or meta-analyses on the minimum acceptable diet. Therefore, the papers reviewed were discussed with those of the national studies Comment: Line108 and 109: Published and unpublished reports: There should be consistency. Which one you really did in your review? Only published (in the abstract) or both Published and Unpublished (introduction). Response: we apologize for the inconvenience. We have corrected it based on your comment Comment: Line 116: Which searching terms were combined by "and" which were combined by "or"? Response: Comment accepted, we have revised it in the revised draft Comment: Line 127: Exclusion criteria – not published in English was already mention in the inclusion criteria. Response: Thank you for the comment. We included articles published only in English language for the sake of clarity, understandability, and simplicity of interpretations. In addition, we have stated as a limitation Comment: Line 137: What is that standardized data abstraction sheet you used? Response: We used excel spreadsheet to extract the data Results Comment: The nine studies are all from three regions and one city administration. So, meta-analysis is not important. Response: Thank you for your suggestion. Comment: Line 191: Remove meta-analysis in the bracket. Response: Thank you, we have removed it Discussion Comment: Line 232: Please cite for the global recommendations at the end of “This Indicates that most children aged 6–23 months in Ethiopia were not taking the minimum acceptable diet according to global recommendations” Response: than you we have cited appropriately. Comment: Line 234-235: You compared your finding with other Countries’ DHS report. So, the Ethiopian Demographic and Health Survey finding is more comparable with those DHS reports than your pooled prevalence. So, I recommend only systematic review. Response: Despite searching different databases, we were unable to find systematic reviews or meta-analyses on the minimum acceptable diet. Therefore, the papers reviewed were discussed with those of the national studies Comment: Line 236: You again compared your finding with the EDHS 2019 report and yours was higher. The explanation you gave for the difference was your study was not representative of all regions as EDHS was. So, this shows your study was not important at all. Because, the EDHS finding is valid than yours Response: Thank you very much for your interesting comments and suggestions. One important thing for a research is creating a question for other researchers in order to conduct further research on that specific problem. To the best of my knowledge, it is the first meta-analysis and the finding too. Hence, we give a justification about its discrepancy. In addition, we have mention the problem in the limitation. Limitation and strength Comment: Line 271: Why you only included English language articles? Response: Thank you for the comment. We included articles published only in English language for the sake of clarity, understandability, and simplicity of interpretations. Comment: Line 272: Since us already the EDHS 2019 report that has not the limitations encountered by your study, EDHS is more important than yours. Response: dear reviewer thank you for your comment. As we know one of the key characteristics of research is a single study cannot stand alone. We need to have different research finding with different approaches in order to implement appropriate intervention mechanisms Conclusion and recommendation Comment: “The result of this systemic review and meta- analysis indicated that minimum acceptable diet among children aged 6-23 months was found to be low in Ethiopia; only 1 in 4children met the minimum acceptable diet.” Your study finding (25%) is better than EDHS finding (11%). So, your recommendation is not acceptable since it has serious limitations. Response: Thank you. We compare our finding based on the WHO and other guideline recommendation. The World Health Organization (WHO) recommends ensuring a minimum acceptable diet (MAD) for all children, particularly in the early years, to promote healthy growth and development References Comment: References are not edited and formatted Response: Thank you, we have edited and we have corrected the formats based on your comment Attachment Submitted filename: Reviewer to reviewers.docx Click here for additional data file. 10.1371/journal.pone.0287247.r007 Decision Letter 3 Sahin Yasin Academic Editor © 2023 Yasin Sahin 2023 Yasin Sahin https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version3 2 Jun 2023 Minimum Acceptable Dietary intake among Children Aged 6-23 Months in Ethiopia: a Systematic Review and Meta-Analysis PONE-D-22-14108R3 Dear Dr. Gizachew Ambaw Kassie, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. 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Reviewers' comments: 10.1371/journal.pone.0287247.r008 Acceptance letter Sahin Yasin Academic Editor © 2023 Yasin Sahin 2023 Yasin Sahin https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 7 Jun 2023 PONE-D-22-14108R3 Minimum acceptable dietary intake among children aged 6-23 months in Ethiopia: a Systematic review and meta-analysis Dear Dr. Kassie: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Yasin Sahin Academic Editor PLOS ONE ==== Refs References 1 Black RE , Allen LH , Bhutta ZA , Caulfield LE , De Onis M , Ezzati M , et al . Maternal and child undernutrition: global and regional exposures and health consequences. The lancet. 2008;371 (9608 ):243–60. doi: 10.1016/S0140-6736(07)61690-0 18207566 2 World Health Organization. Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals: World Health Organization; 2009. 3 Dewey K. 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