1. Introduction

The concept of optimum feeding is a key determinant of growth and development among infants and young children [1]. According to the United Nations Children’s Fund, the age of 6–23 months is considered the critical period in the first 1000 days of life because infants transition from feeding on breastmilk only to the inclusion of complementary foods [2]. Suboptimal infant feeding practice is a major public health concern among children, particularly in less developed communities [3]. Poor feeding practices among infant and young children are on the rise [4]. According the World Health Organization (2018), only less than 25% of infants between 6–23 months consume the recommended diverse diet [5]. Several studies have reported a poor dietary diversity among infants in developing countries [4]. A high prevalence of minimum dietary diversity has been reported in South Africa (43.9%), Tanzania (26%), and Ethiopia (23.3%) [6]. A study conducted by Frempong and Annim revealed that 47% of children in Ghana met the minimum dietary diversity [7]. Studies show that complementary foods given to young children in Ghana are mostly foods of plant origin and tend to have reduced amounts of nutrients [8]. Majority of infants in sub-Saharan Africa (SSA) are fed with cereal based supplemental feeds which are mostly nutritionally inadequate to support rapid growth [9].

Dietary diversity plays an important role in the health of infants. The World Health Organization recommends the provision of a diverse diet to ensure adequate intake of energy, vitamins, proteins, fats, and minerals through complementary feeding for infants and young children aged 6 months and above [10]. “Minimum dietary diversity is defined as consumption of food from four or more out of seven food groups for higher dietary quality and to meet daily energy and nutrient requirements of the seven recommended food groups namely: grains, roots and tubers; legumes and nuts; dairy products; flesh foods (meat, fish, poultry and organ meat), eggs; vitamin-A rich fruits and vegetables; other fruits and vegetables” Minimum dietary diversity is one of the eight indicators of infant and young child feeding practices as proposed by the World Health Organization [11]. Increased variety of dietary intake is usually proportional to improved diet quality, characterized by more animal-source foods than a less diversified one [12]. Consistent intake of diverse food sources is essential for adequately meeting nutrient demands [13]. The consumption of a diverse diet during infancy is relevant for maintaining proper health, growth and development of infants and children [14].

Inadequate dietary diversity among children leads to deficiencies in micronutrient intake necessary for growth and other cognitive functions [15]. A large population study reported that the majority of children who did not meet the recommended nutrient intake, including folate, vitamin E, zinc, and fiber, performed poorly in a cognitive test [16]. Consumption of inadequate diverse diet among infants may lead to undernutrition, risk of infections and severe illness [17]. Evidence suggests that poor feeding practices, including an insufficient quantity of complementary and poor-quality foods, are linked with childhood malnutrition [14]. According to the UNICEF, 3.1 million children die from undernutrition yearly. Poor feeding practices at the ages of 6–23 months are the leading cause of undernutrition and other infant morbidities in developing countries, including Ghana [18].

Several studies have reported a positive association between dietary diversity and micronutrient intake, employment status, household food security, socioeconomic status and nutrition knowledge [19, 20]. Families with higher income status tend to have consume a diverse diet which results in a positive nutritional status of their infants and young children [20]. Another study which accessed the nutrition knowledge and complementary feeding practices among 1400 mothers in the Northern part of Ghana showed a positive relationship between maternal nutrition knowledge and appropriate feeding practices [21]. According to the study, women who had higher nutrition-related knowledge and attitude were almost twice likely to feed their children with appropriate diet. Poor dietary diversity among infants is reported to be associated with child’s age, geographical region and cultural traditional barriers. Understanding factors associated with food consumption and dietary diversity among a large population of infants is a critical step which will be necessary in designing appropriate interventions. This will help improve the proportion of children who are fed with diversified diet in sub-Saharan Africa. However, in Ghana and other sub-Saharan Africa countries, fewer studies have focused on the dietary diversity and food consumption of infants aged between 6 and 18 months who have transitioned from breastmilk only to include complementary foods. Also, very few studies in Ghana have reported on factors associated with poor diet quality in infants aged 6 and 18 months. In this study, we used a large population and primary data to report on factors associated with food consumption and dietary diversity in infants aged between 6 and 18 months. Due to the various food variations in the different regions of Ghana, conducting such a study in Ashanti Region, the second most populous region in Ghana with diverse ethnicity and socioeconomic status will provide a general representation of food consumption and dietary diversity among infants and further serve as a basis for policy implementation.

2. Materials and methods

3. Results

Fig 1 shows the percentage distribution of food consumed by the children in the past 24 hours. Among the food groups, the majority of the children (77.4%) consumed porridge. More than half of the children did not consume foods including vegetables, beans, sugary foods, milk, and oils. Meat consumption was very poor among children, as 26% and 74% did not consume organ meat or any other meat.

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Fig 1. Distribution of food consumption by children in the past 24 hours.

https://doi.org/10.1371/journal.pone.0294864.g001

Fig 2 shows the dietary diversity among the infants. From the figure, dietary diversity was poor among the infants as it can be observed that more than half of the infants (64.7%) did not meet the minimum dietary diversity.

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Fig 2. Dietary diversity among infants between 6–18 months.

https://doi.org/10.1371/journal.pone.0294864.g002

Table 1 shows the relationship between food consumption and the dietary diversity of the children. From the table, children who did not consume some foods did not meet the minimum dietary diversity, and children who consumed most foods the previous day were more likely to meet the minimum dietary diversity. The majority of the children who consumed foods including dark green vegetables, meat, and milk had adequate dietary diversity. A higher proportion of children who did not consume fruits (56.8%, P<0.001) had adequate dietary diversity score compared to those who consumed fruits and did not meet the dietary diversity (43.2%). Similar observations can be seen in children who consumed vegetables (62.5%, P<0.001). S1 and S2 Tables represent food group consumption by age groups and the dietary diversity of children. A higher proportion of 12–18 months old children who consumed bread, rice, or noodles (54.5%) met the DD (p<0.001) compared with 6–11 months old children who consumed bread, rice, noodles (39.0%). Also, children between 12–18 months who consumed porridge (52.5%) the previous day had adequate dietary diversity (p<0.001) as compared to their counterparts between 6–11 months who consumed porridge (31.0%). This can also be seen in the consumption of infant formula, where a higher proportion of older infants who consumed infant formula (63.9%) had adequate dietary diversity compared to the younger adults who consume infant formula (36.9%). A higher proportion of children aged 12–18 months who consumed any meat (76.0%) had adequate dietary diversity as compared to their counterparts who consumed meat (64.3%).

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Table 1. Relationship between food consumption and dietary diversity of children.

https://doi.org/10.1371/journal.pone.0294864.t001

Table 2 shows the relationship between the socio-demographic factors and the recommended dietary diversity score of the participants. The table also shows the means of the child’s age, mother’s age, income, and the mean dietary diversity score. The mean age of the children was 11 months. About 65% of the children did not meet the recommended food group intake. A higher proportion of 6–11 months old children (74.0%) had inadequate DD (p<0.001) compared with 12–18 months old children (52.5%). The majority of the children from rural areas (81.8%) could not meet the DD (p<0.001). A greater proportion of children whose mothers were unemployed had inadequate DD (p<0.001).

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Table 2. Relationship between the socio-demographic factors and dietary diversity score of infants.

https://doi.org/10.1371/journal.pone.0294864.t002

Table 3 shows the relationship between child morbidity in the past seven days and the dietary diversity status of infants. From the table, there was no significant difference between child morbidity and dietary diversity score, although most of the children who had no illness for the past seven days recorded a low recommended dietary diversity score. However, children who had diarrhea in the previous week (66.7%) were more likely to have inadequate DD compared with those who had no diarrhea (64.2%). Similarly, children who vomited continuously in the previous week (63.1%) were not likely to consume diverse diet as compared to their counterparts who did not vomit (64.9%).

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Table 3. Child morbidity in the past seven days and dietary diversity status of children.

https://doi.org/10.1371/journal.pone.0294864.t003

Table 4 shows the relationship between nutrition knowledge and the dietary diversity status of the children. The mean nutrition knowledge of the mothers was 7.0 (p<0.001). Children of caregivers who had poor nutrition knowledge (69.9%, P = 0.023) had low dietary diversity scores. Children whose caregivers knew when to provide them with family food (61.9%) had better dietary diversity scores than children whose caregivers did not know when to start giving family food to their children (69.1, p<0.001). Also, caregivers who knew how many times to give complementary food to their children at 9–12 months had their children record better dietary diversity scores (44.1%, 0.00) as compared to their counterparts who did not know (34.1%, p<0.001). However, majority of children of caregivers who knew the quantity of complementary food to give them rather had poor dietary diversity scores (67.9%, p<0.001).

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Table 4. Relationship between maternal nutrition knowledge and dietary diversity status of infants.

https://doi.org/10.1371/journal.pone.0294864.t004

Table 5 indicates the predictive factors associated with Child’s dietary diversity. Children within 6–11 months (adjusted OR = 2.5, p<0.001, 95%CI = 1.4–4.4) had higher odds of having low dietary diversity compared to the children between 12–18 months. Children who lived in rural (unadjusted OR = 3.2, p<0.001, 95%CI = 2.2–4.8) and peri-urban centers (unadjusted OR = 2.8, p<0.001, 95%CI = 2.0–3.9) had higher odds of having a low dietary diversity as compared to children who lived in urban centers. Children whose mothers were unemployed (unadjusted OR = 2.3, p<0.001, 95%CI = 1.7–3.2) had increased odds of having low dietary diversity as compared to their counterparts whose mothers were employed. Children whose mothers had adequate nutrition knowledge had fewer odds of having lower dietary diversity (Adjusted OR = 0.9, p = 0.851, 95%CI = 0.5–1.6).

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Table 5. Predictors of factors associated with child’s dietary diversity.

https://doi.org/10.1371/journal.pone.0294864.t005

4. Discussion

This study identified factors associated with food consumption and dietary diversity among infants in Ghana. Severally implemented policies in Ghana including the National Nutrition Policy has been directed at ensuring the healthy growth and development of infants and young children. However, poor feeding practices are reported among children and young infants in Ghana. From our study, the majority of the children consumed porridge (77.4%) and bread, rice, and noodles (71.6%). A similar study in Ghana reported 81% consumption of bread, noodles, and other grains among children [23]. On the contrary, the intake of milk, vegetables, and meat was very low among the children. Similarly, a study among infants between 6–23 months in rural communities in Ethiopia reported low consumption of animal products including meat and milk [24]. Our study found that more than 6 in 10 (64.7%) children had poor-quality diets. This represents a very low level of dietary diversity among the children. Our findings are in line with a study conducted in Ghana by Bandoh and Kenu, which reported a prevalence of 54% of children not meeting the minimum dietary diversity [25]. A higher prevalence of low dietary diversity was reported among infants between 6–23 months in Tanzania [6]. This indicates that the majority of children in the country are likely to be prone to micronutrient deficiencies. Poor feeding among infants is the cause of infant morbidity and mortality. Therefore, necessary nutrition interventions must be put in place to tackle such issues. A popular approach to curtailing this problem has been the free distribution of nutritionally dense complementary foods or supplements [26].

The findings revealed that some socio-demographic factors were associated with child dietary diversity. Child age was found to be associated with dietary diversity, as 74% of the children who did not meet the minimum dietary diversity were between 6–11 months. According to the study, children in this age group were twice at risk of having a low dietary diversity as compared to their counterparts between 12–18 months. This is consistent with other studies that reported a minimum dietary diversity score among children who were between 6–11 months old in Ghana [27]. The reason is due to the preparedness of older infants to accept food in various forms and their high familiarity with certain foods as compared to younger infants. According to Mura Paroche et al., exposure of an infant to a variety of diets at a young age is efficient in ensuring the liking and consumption of both exposed and new foods [28].

Our study also reported how child residence was a predictor of dietary diversity. About 41% of the children who met the minimum dietary diversity were living in urban centers. Children in rural areas had three times the odds of having a lower dietary diversity than their counterparts in urban centers. Similar findings were seen in a study conducted by [29] among Ghanaian adolescents, where rural dwellers had higher odds of inadequate dietary diversity compared to those in urban centers. A study in Nepal reported a higher prevalence of inadequate dietary diversity among children living in developed areas compared to less developed areas [30]. This can also be seen in other studies that reported a more diversified food intake among urban residents as compared to rural residents [31, 32]. Urban centers are characterized by food access and high economic status, which may explain the decreased risk of having low dietary diversity as compared to rural areas [33]. Majority of rural areas in Ghana are noted for farming of foodstuffs, fruits and vegetables, however, such cultivation is usually meant for commercial purposes to generate income for the family. Though was not found in the study, certain cultural practices prominent in the rural areas might account for the poor dietary diversity among the children. About 37% of pregnant women in a study reported one or more food practices influenced by local beliefs and cultural taboos [34]. Such poor cultural beliefs should not be encouraged since it could hinder the consumption of some micronutrients among infants.

According to our study, maternal employment status is also a predictor of infant dietary diversity. Unemployed women had twice the odds of having a lower dietary diversity score for their children as compared to the other women who were employed. Similar issues were seen in a study conducted by Tampah-Naah, where mothers in Ghana who had challenges accessing complementary food items was due to a lack of income or insufficient financial endowment [35]. In a similar study which reported a low dietary diversity among infants, a higher proportion of mothers could not afford a diverse diet because they had difficulty obtaining a decent income [36]. Interventional policies to engage women in livelihood support, as well as other financial support, are critical to addressing this issue. In 2008, the Livelihood Empowerment Against Poverty was initiated to established in Ghana to improve basic household consumption and nutrition, and increase access to welfare services. Strengthening this policy will provide women access to better livelihood where pregnant women can afford nutrient-dense foods.

According to the study, child morbidity was not a predictor of dietary diversity; however, other studies have reported the contrary. Findings from a study by [37] found that child morbidity was a contributing factor to low dietary diversity. Their study also reported low dietary diversity among children suffering from diarrhea. This is, however, consistent with our study, where children who had diarrhea in the previous week (66.7%) were more likely not to meet the DD compared with those who had no diarrhea (64.2%).

Though certain studies have identified a positive association between maternal education level and child dietary diversity [19, 38] our study found no association between maternal educational level and dietary diversity. Similarly, level of education among breastfeeding mothers in India was not associated with breastfeeding practices [39]. However, from our findings, children from mothers who had relatively adequate nutrition knowledge had higher chances of meeting the minimum dietary diversity as compared to the other group. Maternal nutrition knowledge has been established as a predictor of infant feeding practices and nutritional status. A similar observation is seen in a study in Ghana by [40], where households with caregivers who had adequate nutrition knowledge and attitude scores had more diverse diets compared to those with little or no nutrition knowledge. Proper maternal nutrition education interventions are therefore critical to solving such situations. Currently, the Ghana Health Service recommends the intake of a four-star diet for a healthy nutrition. Through the health care systems, pregnant and breastfeeding mothers as part of the antenatal and post-natal services are educated on the consumption of the four-star diet. Empowering pregnant women with nutrition knowledge will help them make better choices which will eventually ensure a healthy nutrition outcome.

5. Conclusions

The study found that infants had poor-quality diet. The majority of the infants also consumed fewer food groups from the 18-food group list. Our study has shown that the factors associated with poor dietary diversity among the infants were multifactorial ranging from age-specific, occupation, nutritional knowledge of mother and residence of infants. Based on the findings in this study, we suggest that proper maternal nutrition education and feeding practices targeting age-specific needs and community livelihood support systems are necessary to improve dietary diversity of infants.

Supporting information

Acknowledgments

We thank the directors of health and health workers in the health centers where the study took place and most of all the mothers and infants who participated in the study.