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Dietary diversity and its associated factors among adolescent girls in Ethiopia: a systematic review and meta-analysis

樱花视频 volume听24, Article听number:听3438 (2024) Cite this article

Abstract

Background

Even though fragmented and inconsistent findings have been reported in Ethiopia, adolescence is a period of rapid growth following infancy and is severely affected by micronutrient deficiencies, food insecurity, and poor-quality diets. Therefore, the aim of this meta-analysis was to estimate the pooled prevalence of dietary diversity and its associated factors among adolescent girls in Ethiopia.

Methods

International databases such as EMBASE, Hinari, Scopus, PubMed, Google Scholar, and direct Google searches were systematically used to search for articles and reports. The Newcastle-Ottawa Scale, modified as appropriate, was used for cross-sectional studies to assess the quality of the included articles and reports. A Microsoft Excel sheet was used for data extraction and then exported into STATA version 17 for further analysis. The pooled prevalence of dietary diversity was estimated using a random effects meta-analysis approach. Egger鈥檚 and Begg鈥檚 tests were employed to evaluate publication bias.

Results

The pooled prevalence of minimum dietary diversity among adolescent girls in Ethiopia was 43% (95% CI: 30, 56) with significant heterogeneity (I2鈥�=鈥�99.2%, p鈥�=鈥�0.00). Urban residence (OR: 2.46), mother being a government employee (OR: 2.31), attending a private school (OR: 6.24), adolescent having formal maternal education (OR: 4.49), adolescent having formal paternal education (OR: 3.26), father being a government employee (OR: 3.50), father being a merchant employee (OR: 2.51), middle family wealth index (OR: 1.76), household food security (OR: 3.96), receiving nutrition counseling (OR: 2.46), and higher meal frequency (OR: 7.35) were significantly associated with minimum dietary diversity.

Conclusion

The pooled prevalence of dietary diversity among adolescent girls was low. Factors significantly associated with achieving minimum dietary diversity included urban residence, higher parental education and employment in government, private school attendance, household wealth, food security, receiving nutrition counseling, and higher meal frequency. These findings emphasize the need to improve dietary diversity among rural adolescent girls and food insecure households. Establishing nutrition counseling services could enhance understanding and skills related to a varied diet.

Peer Review reports

Background

Dietary diversity is defined as the number of different food groups consumed over the given time period [1]. It indicates nutrient intake and dietary quality as well as a proxy for socioeconomic status [2]. A lack of dietary diversity leads to undernutrition and overnutrition, particularly in the context of the ongoing global food and nutrition crises [3]. Adolescents, like infants, undergo rapid growth and development, which has a long-term impact on their health and well-being [4].

Proper nutrition among adolescents is the foundation for healthy growth and development in the next generation [5]. However, adolescents are one of the most vulnerable groups due to inadequately diversified foods, less nutrient-dense foods, and more processed foods and beverages [6, 7]. The prevalence of an inadequately diverse diet is higher in low- and middle-income countries (LMICs) because starchy staples make up a major component of the diet in all age groups [8].

Globally, about 19% of adolescents live with moderate to severe food insecurity [9], and 32% of adolescents are anaemic [10]. More than two-thirds (69%) of adolescent girls and women suffer from micronutrient deficiencies, particularly those in poor and disadvantaged regions, who bear the brunt of undernutrition and micronutrient deficiencies [11]. About 68% of adolescent girls and women in South Asia and 60% in Sub-Saharan Africa are underweight and anaemic [12]. One in two adolescent girls in Ethiopia is deficient in one or more micronutrients, with folate deficiency being the most prevalent among them [13]. Additionally, the overall prevalence of anemia among adolescent girls is 9% [13].

Due to detrimental cultural and gender norms, adolescent girls have difficulty accessing nutritious diets and prenatal care [14]. As a result, stunted and underweight individuals are at a higher risk of malnutrition and negative health outcomes during pregnancy and childbirth. They are also more likely to have babies who are premature or have low birth weight [15,16,17], because they are still growing, and their nutritional needs may compete with the demands of pregnancy, impacting their growth [18]. Furthermore, pregnant adolescent girls who are overweight have a higher risk of gestational diabetes, pre-eclampsia, and caesarean delivery compared to those of normal weight [18].

The Ethiopian government, along with non-governmental organizations, has implemented efforts to improve the health and nutrition of adolescent girls; however, this issue remains a significant public health concern [19, 20]. Additionally, dietary diversity among adolescent girls in Ethiopia varies greatly, ranging from 22.8 to 75.4% across different local studies, indicating prevalent inconsistencies in dietary diversity and its associated factors [21, 22]. This systematic review and meta-analysis aimed to assess the pooled prevalence of minimum dietary diversity and its associated factors among adolescent girls in Ethiopia, where there is a lack of nationwide data and research on the inconsistent prevalence and determinants. The findings will provide evidence to support policymakers and program planners in designing initiatives to promote diverse diets for adolescent girls.

Methods

Searching strategies

A comprehensive search was conducted using various electronic databases, including EMBASE, Scopus, PubMed, Hinari, Google Scholar, and Google, with specific keyword and MeSH term searches. The investigation utilized a variety of MeSH terms and synonyms to conduct the search. These terms included 鈥減revalence,鈥� 鈥渄iet,鈥� 鈥渕inimum dietary diversity,鈥� 鈥渄ietary diversity score,鈥� 鈥渁dequate dietary diversity,鈥� 鈥渄ietary diversity practice,鈥� 鈥渄ietary diversity score among adolescent girls,鈥� 鈥渇actors for dietary diversity,鈥� and 鈥淓thiopia.鈥� These search terms were applied both independently and in conjunction with each other, utilizing operators such as 鈥淥R鈥� and 鈥淎ND.鈥� A comprehensive literature search was conducted across multiple databases and websites from March 15, 2023, to March 25, 2023. Our search method for published and unpublished articles was limited by sex (adolescent girls) and country (the studies were only done in Ethiopia). Articles published up to March 7, 2023, were carefully considered for inclusion in the systematic review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was used during the systematic review [23].

Eligibility criteria

This study included articles published in reputable journals and unpublished reports conducted exclusively in Ethiopia, provided they were reported in English. It focused on original research examining the prevalence of dietary diversity and the associated factors among adolescent girls in Ethiopia. The research utilized observational study designs to assess dietary diversity using 24-hour dietary recall methods among adolescent girls aged 10 to 19 years. Studies were excluded if full-text access was not available, if outcome measurements were not reported, or a 7-day recall period was used.

Outcome of interest

The aim of this study was to estimate the pooled prevalence of dietary diversity and the factors affecting it among adolescent girls in Ethiopia. The primary outcome was the prevalence of dietary diversity, calculated by dividing the number of adolescent girls who received minimum dietary diversity by the total number of participants and multiplying by 100. Odds ratios were calculated based on the binary outcomes reported in the studies. Factors examined included residence, educational attainment of mothers and fathers, mothers and fathers being government employees or merchants, attending a private school, wealth index, household food security, receiving nutrition counseling, and meal frequency.

Data extraction

A total of four authors participated in the data extraction process: Ak and EA independently extracted the data, while DA and ZY resolved any discrepancies that occurred between Ak and EA. The data extraction was performed using the Microsoft Excel tool and included information, such as the primary author, publication year, region, study setting, sample size, quality of articles included, number of adolescent girls who received dietary diversity, prevalence rates, standard error of prevalence, and factors affecting dietary diversity among adolescent girls. Cross tabulation (a, b, c, and d) was used to extract factors with odd ratios. Detailed information, including the adjusted odds ratio along with the lower and upper confidence intervals, was meticulously calculated. Moreover, the logarithm of adjusted ratios, lower and higher confidence intervals, and standard error of adjusted odds ratio were computed on the data extraction sheet for each variable before being imported into STATA 17 for further analysis.

Quality Assessment

EndNote (version X7.0.2) was used to remove duplicate articles and download full article information. The Newcastle-Ottawa Scale, modified for cross-sectional studies, was used to assess the quality of the published papers and unpublished reports [24]. Two independent reviewers (AK and EA) critically examined each work, and any disagreements among reviewers were resolved through discussion. If the disagreement persists, DA and ZY will be asked to help resolve it among the two independent reviewers. The quality assessment also includes case representativeness, sample size, non-response, screening tool ascertainment, comparability, outcome assessment, and statistical testing. The assessment tool had a maximum score of 9 in three domains. The eligible studies were then categorized based on their scores as follows: 0鈥�4 points (unsatisfactory), 5鈥�6 points (satisfactory), 7鈥�8 points (good), and 9 points (very good quality) [24].

Statistical analysis

STATA version 17 statistical software was used for further analysis after the data were exported from the Microsoft Excel. Heterogeneity among studies was assessed by using the inverse variance (I2) with the Cochran Q statistic, where 25%, 50%, and 75% indicated low, moderate, and considerable heterogeneity, respectively, along with a p-value of less than 0.05 [25]. A random effects meta-analysis model was used to estimate the pooled prevalence of dietary diversity. The pooled prevalence of dietary diversity among adolescent girls was reported using a forest plot. Sensitivity analysis was conducted to assess the effects of individual studies on the pooled prevalence of dietary diversity. The association between the primary outcome and factors was checked by using an odds ratio with a 95% confidence interval. Possible differences between studies were explored by subgroup analyses. A visual funnel plot and the statistical Egger鈥檚 test were done to check for the presence of publication bias [26, 27].

Results

Selection of the studies

After a comprehensive search of databases and websites, a total of 436 relevant articles and reports were identified. Out of this initial pool, 380 studies were excluded due to duplication. After carefully reviewing the titles and abstracts, an additional 39 articles were removed, and one article could not be retrieved. Ultimately, 16 full-text articles were accessed and assessed for eligibility based on the predefined criteria. Following a critical appraisal process, 7 articles were excluded, and the remaining 9 articles were included in the final analysis (Fig.听1).

Fig. 1
figure 1

Flow chart diagram studies included in the systematic review, and meta-analysis using the PRISMA check list

Full size image

Characteristics of included studies

A total of nine articles met the inclusion criteria and were included in this systematic review and meta-analysis. All the included studies were unpublished and published from 2015 to 2023. All included studies used a cross-sectional study design. A total of 4729 adolescent girls participated in these studies, with an estimated sample size range of 284 [28] to 820 [29] used to estimate the pooled prevalence of minimum dietary diversity and its associated factors among adolescent girls in Ethiopia.

Three studies were done in the Amhara regional state [22, 30, 31], three studies in the South Nations, Nationalities, and Peoples of Ethiopia (SNNP) [29, 32, 33], two studies in Addis Ababa [21, 28], and one study in Oromia [34]. Six studies were conducted at the school level [22, 28, 30,31,32, 34], while the remaining three were conducted in the community [21, 29, 33] (Table听1).

Table 1 Characteristics of nine included studies to estimate the pooled prevalence of minimum dietary diversity and its associated factors among adolescent girls in Ethiopia
Full size table

Pooled prevalence of minimum dietary in Ethiopia

The pooled prevalence of minimum dietary diversity among adolescent girls in Ethiopia was 43% (95% CI: 30, 56) (Fig.听2). The heterogeneity across the included studies was high (I2鈥�=鈥�99.0%; P鈥�<鈥�0.00) (Fig.听2). As result, a Der Simonian and Laird random effects model was used to estimate the pooled prevalence of dietary diversity. Therefore, based on the observed results, subgroup analysis, meta-regression, and sensitivity analysis may be needed after testing for publication bias.

Fig. 2
figure 2

Forest plot indicating the pooled prevalence of minimum dietary diveristy among adolescent girls in Ethiopia

Full size image

Publication Bias: Publication bias was investigated using Egger鈥檚 and Begg鈥檚 tests to explore potential sources of heterogeneity (Fig.听3). The analysis indicated a p-value of 0.948, suggesting there was no evidence of publication bias in the study (Table听2).

Fig. 3
figure 3

Funnel plot presented the visual inspection of publication bias for systematic review and meta-analysis of minimum dietary diversity among adolescent girls in Ethiopia

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Table 2 Egger鈥檚 test result to assess publication bias
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Sensitivity analysis

sensitivity analysis was performed to assess the effect of individual studies on the pooled estimate of minimum dietary diversity among adolescent girls. The results showed that no single study significantly affected the pooled estimate (Fig.听4).

Fig. 4
figure 4

Sensitivity analysis of the pooled prevalence of minimum dietary diversity included studies (n鈥�=鈥�9)

Full size image

Sub group analysis

Subgroup analysis was conducted by study year and study setting to identify the possible source of heterogeneity across the studies (Table听3). The subgroup analysis result indicated that (P鈥�=鈥�0.00) the source of heterogeneity was not due to study year and study setting (Table听3). The prevalence of dietary diversity among adolescent girls was higher in studies conducted before 2020 (47%; CI: 23, 71) compared to those conducted in 2020 and later (Table听3). Additionally, studies in urban settings among adolescent girls revealed higher dietary diversity (50%; CI: 30, 71) (Table听3).

Table 3 Subgroup analysis of the pooled prevalence of minimum dietary diversity among adolescent girls in Ethiopia
Full size table

Factors associated with dietary diversity among adolescent girls in Ethiopia

Among the nine studies, four revealed that living in an urban residence was significantly associated with the minimum dietary diversity score among adolescent girls, with an odds ratio of 2.46 (95% CI: 2.20, 2.76) (Table听4). This indicates that adolescent girls living in urban residences were 2.46 times more likely to be fed a diversified diet compared to those living in rural areas. Additionally, three studies showed that government-employed mothers provide a diversified diet 2.31 times more than their counterparts, with an odds ratio of 1.93 (95% CI: 1.93, 2.76) (Table听4).

Table 4 Determinants factors dietary diversity among adolescent girls included articles for the final systematic review and meta-analysis in Ethiopia
Full size table

According to three studies, adolescents attending private schools were significantly associated with dietary diversity in Ethiopia. Adolescent girls enrolled in private schools were 6.24 times more likely to receive a diversified diet than those attending government schools, with an odds ratio of 6.24 (95% CI: 5.83, 6.68) (Table听4). Based on data from five studies, adolescent girls between the ages of 17 and 19 had an odds ratio of 2.61 (95% CI: 2.33, 2.92), indicating that they were 2.61 times more likely to be served a diversified diet than those at an earlier age (Table听4).

According to five studies, mothers with a formal education level were 4.49 times more likely than their counterparts to feed their adolescent girls a varied diet, as indicated by an odds ratio of 4.49 (95% CI: 4.19, 4.81) (Table听4). Similarly, three studies revealed that girls whose fathers had formal education were 3.26 times more likely than their peers to be provided with a varied diet, with an odds ratio of 3.26 (95% CI: 2.95, 3.60) (Table听4).

Regarding occupation, three studies showed that a father鈥檚 occupation was significantly associated with dietary diversity. Government-employed fathers and merchants were 3.50 and 2.51 times more likely to provide dietary diversity as compared to their counterparts, with odds ratios of 3.50 (95%CI: 3.20, 3.82) and 2.51 (95%CI: 2.16, 2.91), respectively (Table听4). Similarly, five studies found that adolescent girls from middle-wealth index households were 1.51 times more likely (95% CI: 1.29, 1.76) to receive a diversified diet than those from low-wealth index households (Table听4).

According to four studies, adolescent girls who lived in food-secure households were 3.91 times (95% CI: 3.65, 4.19) more likely than their peers to eat a varied diet (Table听4). Comparatively, three studies showed that adolescent girls who received nutritional counseling had 2.46 times (95% CI: 2.19, 2.75) higher odds of achieving the minimum amount of dietary diversity than their peers (Table听4). Finally, two studies affirmed that adolescent girls who received two or more meals per day were 7.35 times (95% CI: 6.80, 7.94) more likely to have a diversified diet compared to their counterparts (Table听4).

Discussion

The aims of this systematic review and meta-analysis were to estimate the pooled prevalence of dietary diversity and its associated factors among adolescent girls in Ethiopia. The pooled prevalence of dietary diversity among adolescent girls in Ethiopia was found to be 43% (CI: 30, 56). The pooled prevalence is consistent with reports from Bangladesh (44.6%) [35] and Uganda (54.7%) [36]. However, the pooled result of the current study is higher than reports from other low- and middle-income countries, such as 17% across these countries [37], 26.55% in Iran [38], 15.3% in Ghana [39], and 11.2% in Zimbabwe [38]. Conversely, the pooled prevalence in the current study is lower than reports of 58% in India [40] and 83% in Nigeria [41]. The possible reasons for these differences may include variations in study periods, settings, sociodemographic and economic factors among the study participants, and the countries themselves. Furthermore, discrepancies may also arise from differences in the presence and implementation of nutrition-related intervention programs, strategies, and policies in the various countries.

The subgroup analysis revealed that the pooled prevalence of minimum dietary diversity among adolescent girls varies significantly based on residence. In urban areas, the consumption of diversified diets was higher. A probable explanation is that urban residents have better socioeconomic opportunities to purchase a diverse diet [42]. Furthermore, urban adolescents can benefit from media exposure that enhances their eating practices through nutrition education.

In school-based studies, a higher minimum prevalence of dietary diversity was also observed. This may be because school-age girls gain knowledge about the importance of a varied diet through schoolgirl clubs and health clubs. Additionally, they can obtain nutrition information by reading and watching media, which can help them enhance their nutritional status by consuming a diverse diet.

This study also aimed to determine the variables affecting the level of dietary diversity among Ethiopian adolescent girls. It was found that several factors were significantly associated with dietary diversity, including living in an urban area, the occupations of both the mother and father, the type of school attended, the age of the adolescent, the educational status of the mother and father, the household wealth index, food security, receiving nutrition counseling, and meal frequency.

Adolescent girls living in urban areas were more likely to receive a diversified diet than those living in rural areas. A probable explanation is that urban adolescents have higher educational levels, greater awareness of feeding practices, and a more varied diet [43]. Furthermore, living in urban areas provides better access to a variety of foods, such as fresh fruits, vegetables, and other dietary staples, which can contribute to improved dietary diversity among urban adolescents.

Government-employed mothers provided a more diversified diet than their counterparts. Similarly, government-employed fathers and merchants were more likely to provide dietary diversity compared to their counterparts. A possible reason for this may be that employed parents generally have a higher socioeconomic status, which improves household food security and increases dietary diversity intake [44], as there is a positive relationship between socioeconomic status and dietary diversity.

Adolescent girls attending private schools were more likely to receive a diversified diet than those attending government schools. Most students in private schools come from higher-income households that can afford to provide a range of meals for their children. Additionally, adolescent girls aged 17 to 19 years were more likely than younger girls to receive a diverse diet. This may be because, as people age, they are more likely to choose healthful foods with a wide range of ingredients.

Mothers with formal education were more likely to provide a diversified diet to their adolescent girls compared to their counterparts. Similarly, fathers with the same level of formal education were more likely to offer a diverse diet. This finding is supported by reports from Bangladesh [45]. A possible explanation is that educated parents have a better awareness of appropriate feeding practices for their families. Additionally, parents with higher educational status have greater access to media that promotes a diversified diet for vulnerable groups. Furthermore, mothers with higher education tend to earn better incomes, which enables them to access a variety of food sources.

Adolescent girls from households with a middle wealth index were more likely to receive a diversified diet than those from households with a low wealth index. This finding is supported by a study conducted in Bangladesh [45]. A possible explanation is that households with a higher socioeconomic status tend to consume more animal-sourced foods, fruits, and vegetables, in addition to grains and staple diets [46]. Members of these households may spend their extra money on non-staple foods [45]. Households with additional cash can allocate it toward non-essential foods. Furthermore, the high cost of meat, eggs, milk, and certain fruits restricts the variety available in adolescents鈥� diets.

Adolescent girls living in food-secure households were more likely to receive a diversified diet compared to their counterparts. Results from Bangladesh reinforced this finding [45]. Adolescents from food-insecure households may have experienced a much cheaper and monotonous diet [44]. Additionally, household dietary diversity reflects the household鈥檚 food security level, which is associated with individual and household food security levels [44, 47]. Furthermore, food security is defined as the combination of availability, access, and utilization, all of which are strongly associated with a diverse diet [48, 49].

Adolescent girls who received nutritional counseling were more likely to achieve adequate dietary diversity compared to their counterparts. Experimental investigations in Bangladesh and Ethiopia support these findings [50, 51]. A probable explanation is that gaining knowledge and skills through dietary counseling and nutrition education can lead to behavioral changes among adolescent girls, resulting in a more diversified diet.

Finally, adolescent girls who had two or more meals per day were more likely to have a diverse diet than their counterparts. This may be because, with an increased meal frequency, there is a greater opportunity to include a wider variety of food items.

Limitations

Some limitations of this study include the fact that it only included articles and reports written in English, that all reports and articles were cross-sectional and quantitative in nature, and that no research was conducted in certain regions of the country.

Conclusion

The pooled prevalence of minimum dietary diversity among adolescent girls was low. Factors such as urban residence, higher educational attainment of mothers and fathers, parents being government employees or merchants, attending a private school, higher household wealth status, household food security, receiving nutrition counseling, and greater meal frequency were found to be significantly associated with achieving minimum dietary diversity in this population. These findings highlight the need to focus on improving dietary diversity among rural adolescent girls and households facing food insecurity. Establishing nutrition counseling services could help increase awareness and skills related to the importance of consuming a varied diet.

Data availability

Data will be available upon request from the corresponding authors.

Abbreviations

AK:

Aysheshim Kassahun

BA:

Belayneh Ayanaw

BM:

Berhanu Mengistu

DA:

Dessie Ababaw

EA:

Esmeal Ali

LD:

Lemelem Daniel

LMICs:

Low- and Middle-Income Countries

OR:

Odd Ratios

MS:

Mekonnen Sisay

MC:

Muluken Chanie

SNNPR:

South Nations Nationalities and Peoples of regional state

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

ZY:

Zufan Yiheyis

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Acknowledgements

We would like to thank you all authors of the current study participated in this systematic review and meta- analysis.

Funding

No fund was obtained for this study.

Author information

Authors and Affiliations

  1. Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Aysheshim Kassahun Belew,听Mekonnen Sisay,听Lemlem Daniel Baffa,听Berhanu Mengistu听&听Esmeal Ali Muhammad

  2. Department of Physiotherapy, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Moges Gasahw

  3. Department of Midwifery, School of Midwifery, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Belayneh Ayanaw Kassie

  4. Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Muluken Chanie Agimas听&听Dessie Ababaw Angaw

  5. Department of Medical Parasitology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Zufan Yiheyis Abriham

Authors
  1. Aysheshim Kassahun Belew

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  2. Mekonnen Sisay

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  3. Lemlem Daniel Baffa

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  4. Moges Gasahw

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  5. Berhanu Mengistu

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  6. Belayneh Ayanaw Kassie

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  7. Muluken Chanie Agimas

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  8. Zufan Yiheyis Abriham

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  9. Dessie Ababaw Angaw

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  10. Esmeal Ali Muhammad

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Contributions

AK, EA, DA, and ZY developed the protocol and were involved in the design, selection of the study, data extraction, statistical analysis, and development of the initial drafts of the manuscript. MG, BM, MS, and LD are involved in quality assessment. AK, BA, DA, MG, BM, MC, MS, ZY, LD, and EA prepared and revised subsequent drafts. AK, EA, DA, BA, MC, and ZY prepared the final draft of the manuscript. All authors read and approved the final draft of the manuscript.

Corresponding author

Correspondence to Aysheshim Kassahun Belew.

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Belew, A.K., Sisay, M., Baffa, L.D. et al. Dietary diversity and its associated factors among adolescent girls in Ethiopia: a systematic review and meta-analysis. 樱花视频 24, 3438 (2024). https://doi.org/10.1186/s12889-024-20918-7

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  • DOI: https://doi.org/10.1186/s12889-024-20918-7

Keywords

樱花视频

ISSN: 1471-2458

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