Mother’s Nutrition Literacy and Offspring Anemia: A Comparison Study in a Single Center

Abstract

Objective:

It is known that mother’s knowledge about nutrition is associated with the prevalence of anemia in their children. The aim of this study was to evaluate the frequency of iron deficiency without anemia (ID), iron deficiency anemia (IDA), and anemia in children according to the level of mother’s nutrition literacy (NL).

Materials and Methods:

A cross-sectional study was conducted in a well-child outpatient clinic. The study included healthy children aged between 24 and 59 months and their mothers. Scores of the mothers on the Nutrition Literacy Assessment Tool for Adults and children’s anthropometric z-scores, dietary diversity and Mediterranean Diet Quality Index scores, and children’s hemoglobin and ferritin levels were collected. Two-group comparison analysis was performed.

Results:

Ninety mother–child pairs were included. While 36 mothers (40%) had borderline and 54 (60%) mothers had adequate NL, 15 children (16.7%) had ID, 5 (5.6%) children had IDA, and a total of 18 children (20%) had nutritional anemia. The percentage of wasted children was higher in the group with borderline NL (13.9% vs. 1.9%, P = .036). The percentage of children with ID, IDA, or other nutritional anemia was not different between the borderline and adequate NL groups (30.6% vs. 40.7%, P = .326).

Conclusion:

The frequency of ID, IDA, or other nutritional anemia in children does not differ significantly between mothers with borderline and adequate NL. Increasing NL of mothers could be a step toward reducing the burden of child undernutrition.

What is already known on this topic?

• It has been suggested that mothers’ knowledge about nutrition is associated with the prevalence of anemia in their children. There is still a gap in the literature on whether there is a difference in iron and anemia status of children depending on the level of mother’s nutrition literacy.

What this study adds on this topic?

• Iron deficiency or anemia in children did not differ significantly between mothers with borderline and adequate nutrition literacy. The level of nutrition literacy of the mother may be associated with the nutritional outcomes of the child but not with iron or anemia status.

Introduction

Nutrition literacy (NL) is accepted as a form of “health literacy” that applies to nutrition. It is defined as follows: the level to which people have the ability to obtain, process, and understand the basic nutritional knowledge and the tools necessary to make appropriate nutritional decisions.^1,2 Nutrition literacy involves the dietary habits of the individual and has been shown to influence healthy eating behaviors. The level of NL of parents is not only related to their own health but also to the health of future generations and public health. In particular, NL of mothers (NLM) plays an important role in the development of good nutritional attitudes, behaviors, and habits in children.^2-4

Young children continue to grow and develop by obtaining macro- and micronutrients through the foods they consume on a daily basis. Thus, a child diet that meets optimal standards of diet quality and variety is essential to prevent micronutrient deficiencies and malnutrition.⁵ Previous studies in different countries have shown that high level of mother’s NL has a significant and positive correlation with healthy nutrition and good nutritional outcomes in their offspring.^6-10

Iron deficiency is the most common nutritional deficiency worldwide and is a major public health problem, especially in developing countries. Iron deficiency anemia (IDA), which is the most common and preventable type of anemia, is the most common cause of acquired anemia. Being born to an anemic mother, having a low birth weight, and not drinking iron-fortified milk have been reported as factors associated with iron deficiency, while having illiterate or low-educated parents has also been reported as a factor associated with IDA in children under 5 years of age.^11-13 Familial risk of food insecurity has also been associated with iron deficiency or IDA in young children.¹⁴ Previous studies have shown that maternal nutrition education has a positive impact on the iron status of the child and that higher maternal nutritional knowledge is associated with a lower prevalence of IDA in children.^15,16

As IDA is a major cause of mortality and morbidity for women and children in developing countries, Abu et al¹⁷ suggested that nutrition education to improve iron bioavailability in diet may be promising to reduce iron deficiency and anemia. Increasing the rate of NL for mothers may result in better iron status by providing food-based nutrition information and may increase iron and iron-related nutrient intake and reduce anemia in the population.¹⁷ In Turkey, the prevalence of IDA has been reported to be between 15.2% and 62.5% in various studies in the childhood age group, and between 6.5% and 42% of Turkish children have iron deficiency.^18,19 Current epidemiological data indicate that iron deficiency is more prevalent in infants, preschool children, and adolescents.¹⁹ Despite this significant prevalence, there are no current data on the relationship between NLM and iron deficiency or IDA in preschool children in Turkey. The aim of this study was to comparatively assess the frequency of iron deficiency without anemia (ID) and IDA in children according to the level of NLM.

Materials and Methods

Study Design and Participants

This comparative cross-sectional study was conducted at Mersin University Hospital. Healthy children and their literate mothers constituted the sample group of the study. Children between 24 and 59 months of age who were admitted to the well-child outpatient clinic were included in the study. Exclusion criteria included multiple births, prematurity, or postmaturity (<38 or >42 weeks gestational age), low or high birth weight (<2500 or >4000 g birth), use of nutritional supplements or iron supplements, the need for special diets, obesity or overweight, diagnosis of chronic disease, chronic infection, food allergy or food intolerance, and signs of infection and high C-reactive protein (CRP) concentration (>5 mg/L) (Figure 1). Written informed consent was obtained from the mothers and the Ethics Committee of Mersin University has approved this study (MEU; 2023/106).

Figure 1.

Flowchart of the study population selection. CRP, C-reactive protein; NLM, Nutrition literacy of mothers.

Data Collection

Face-to-face interviews were conducted with mothers during well-child visits between February 15 and May 5, 2023. A structured questionnaire was designed to collect data and inquired about sociodemographic characteristics, early nutrition, and dietary patterns.

Sociodemographic variables included child and family characteristics such as the child’s age, gender, method of delivery, birth weight, birth order, primary caregiver, the age and education level of parents, mother’s occupation, number of children in the family, monthly household income, family structure, and place of residence.

Early life nutrition characteristics include breastfeeding and complementary feeding practices. The dietary assessment of children included dietary diversity and diet quality. Dietary diversity was determined using the 24-hour diet recall method. Mothers were asked to recall all foods and beverages consumed by their children on the previous day. The 24-hour recall was performed in standard chronological order (morning to evening), and a list of all foods eaten and beverages consumed was recorded. Following the World Health Organization (WHO) categorization, recalled foods were divided into 7 food groups (grains, roots, and tubers; dairy products; vitamin A-rich fruits and vegetables; other fruits and vegetables; eggs; flesh foods; legumes; and nuts), and the total number of different food groups consumed was calculated (range 0-7). Dietary diversity was defined as appropriate (≥4 food groups/day) and inappropriate (≤3 food groups/day).²⁰ Diet quality was determined using the Mediterranean Diet Quality Index (KIDMED). The KIDMED is a parent-reported measure of diet quality in children and adolescents. The KIDMED uses 16 items to assess adherence to the Mediterranean diet. Four items are assigned a value of −1 for low adherence, while 12 items are assigned a value of +1 for high adherence. The total score (range, 0-12) is created by summing the scores from each item. A total score of ≥8 indicates good diet quality, 4-7 indicates average quality that needs improvement, and ≤3 indicates poor diet quality.²¹ Apaydın Kaya and Temiz²² have adapted the KIDMED into Turkish.

Anthropometric assessment included measurements of weight, height, upper arm circumference, and triceps skinfold thickness. The WHO child growth standards were used to calculate anthropometric z-scores. Weight-for-age, height-for-age, and weight-for-height z-scores not between −2 and +2 SD and upper arm circumference less than 12.5 cm were considered as child malnutrition. Weight-for-age <−2 SD was defines as underweight, height-for-age <−2 SD was defined as stunting, weight-for-height <−2 SD was defined as wasting, and upper arm circumference <12.5 cm were defined as acute malnutrition.^23-25

The Assessment of Nutrition Literacy of Mothers

The NL status of mothers was determined using the Evaluation Instrument of Nutrition Literacy on Adults (EINLA). The EINLA consists of 35 items and 5 sections. The first section includes general nutrition information, the second section includes reading comprehension and interpretation, the third section includes food groups, the fourth section includes portion sizes, and the fifth section includes the ability to read food labels and make simple calculations. Each correct answer receives 1 point, while missed or incorrect answers receive 0 points. When the level of NL is graded, a total score between 0 and 11 is considered as inadequate, between 12 and 23 as borderline, and between 24 and 35 as adequate.¹ Permission was obtained for the use of EINLA in this study.

The Evaluation of Child Iron and Anemia Status

After the interviews with the mothers, venous blood samples were collected from each child, and the blood samples were analyzed at the local biochemistry laboratory. Routine hemogram analysis was performed, and the levels of serum ferritin, vitamin B12, folate, and CRP were measured. A CRP concentration >5 mg/L was considered to be high.¹¹ A hemoglobin level of <11.0 g/dL was defined as anemia. Hemoglobin <11 g/dL and ferritin <12 μg/L were used to define IDA, while ID was defined as ferritin <12 μg/L. Deficiencies were defined if serum folate was <4 ng/mL or vitamin B12 was <200 pg/mL.^26,27 Detailed medical history and physical examination, examination of peripheral blood smear and evaluation of mean corpuscular volume (MCV), red blood cell (RBC) count, and Mentzer index (MCV/RBC) values provided guidance to identify and exclude other causes of hypochromic microcytic anemia.¹⁹

Sample Size Calculation and Statistical Analyses

In 2 recent studies, Turkish adults were found to have adequate or borderline NL, but no adults with inadequate NL were reported in these studies.^28,29 Another recent study reported that only 2% of Turkish adults have inadequate NL levels.³⁰ A 1-way hypothesis was formulated assuming that iron status would be worse in the borderline (± insufficient) NL group. Considering the minimum sample size, 95% CI, and 80% power of testing, we calculated 36 individuals for the borderline (± inadequate) NL group and 36 for the adequate NL group, comparing the prevalence of IDA in children with average maternal nutrition knowledge and high maternal nutrition knowledge reported by Ismail and Fatima¹⁶ (86.8% vs. 58.5%).

The Statistical Package for the Social Sciences software program (IBM Corp., version 21.0. Armonk, NY, USA) was used for statistical analysis. Data were analyzed for normality using histograms and the Kolmogorov–Smirnov test. Median (interquartile range, 25th-75th percentile), mean ± SD, and percentages are reported. Groups determined according to the level of mother’s NL were compared. The Student’s t test was used to compare 2 parametric values and the Mann–Whitney U test was used to compare 2 nonparametric values. Categorical variables were tested with the chi-square test. All statistical tests were 2-sided, and P < .05 was considered statistically significant.

Results

General Characteristics

The sample consisted of 90 mother–child pairs. The mean age of the children was 42.5 ± 10.2 months and 53.3% were male. The median age of the mothers was 31 years (28-36). The median (minimum–maximum) total score of the mothers on the EINLA was 25 (23-27). Thirty-six mothers (40%) had borderline level of NL, while 54 mothers (60%) had adequate level of NL. There were no mothers with inadequate level of NL.

No statistical difference was found between the borderline and adequate NL groups in terms of sociodemographic characteristics except birth order and number of children in the family. The index child being the first child was more common in mothers with adequate NL (61.1% vs. 36.1%, P = .020). The median number of children in the family was 1.5 (1-2) in the adequate NL group and 2 (2-2.5) in the borderline NL group (P = .002) (Table 1).

Table 1.

Comparison of Child Sociodemographic and Early Life Nutrition Characteristics by Mother’s Nutrition Literacy

	Borderline Nutrition Literacy (n = 36)	Adequate Nutrition Literacy (n = 54)	P
Age, months	43.2 ± 10.5	42.0 ± 10.1	.570
Gender, male	21 (58.3)	27 (50.0)	.438
Gestational age, weeks	39 (38-39)	38 (38-39)	.218
Birth weight, g	3205 ± 396	3309 ± 414	.236
Delivery, cesarean	18 (50.0)	35 (64.8)	.162
Birth order
First	13 (36.1)	33 (61.1)	.020
≥Second	23 (63.9)	21 (38.9)
Primary caregiver
Mother	33 (91.7)	47 (87.0)	.734
Grandmother, babysitter, or kindergarten	3 (8.3)	7 (13.0)
Exclusive breastfeeding within 6 months	7 (19.4)	11 (20.4)	.403
Duration of breastfeeding, months	12 (10-18)	12 (10-18)	.492
≤12 months	22 (61.1)	29 (53.7)
13-18 months	10 (27.8)	14 (25.9)	.510
>18 months	4 (11.1)	11 (20.4)
Initiation of complementary foods*
At ≥4-< 6 months of age	26 (72.2)	41 (75.9)	.693
At 6 months of age	10 (27.8)	13 (24.1)
Maternal age, years	31.5 (29-37)	31 (27-34)	.263
Paternal age, years	37.5 (32-42)	34 (30-40)	.202
Maternal educational level
Primary school	14 (38.9)	18 (33.3)	.590
High school/college	22 (61.1)	36 (66.7)
Paternal educational level
Primary school	14 (38.9)	13 (24.1)	.133
High school/college	22 (61.1)	41 (75.9)
Maternal occupation, employed	2 (5.6)	7 (13.0)	.306
Number of children in the family	2 (2-2.5)	1.5 (1-2)	.002
Family structure, nuclear	33 (91.7)	51 (94.4)	.680
Monthly income, US$	410 (357-424)	370 (318-424)	.510
Settlement, urban/semi-urban	36 (100.0)	54 (100.0)

Results are expressed as mean ± SD, median (25th-75th percentile), and number (percentage).

^*Solids and liquids other than breast milk or infant formula.

All children were breastfed (exclusive and mixed) within the first 6 months. Breastfeeding and complementary feeding practices were not statistically different between the borderline and adequate NL groups (P > .05) (Table 1).

Anthropometric Characteristics

Mean values of child anthropometric z-scores and median values of child upper arm circumference and triceps skinfold thickness were not statistically different between the borderline and adequate NL groups (P > .05). The percentage of wasted children was higher in the borderline NL group (13.9% vs. 1.9%, P = .036) (Table 2).

Table 2.

Comparison of Child Anthropometric Characteristics by Mother’s Nutrition Literacy

	Borderline Nutrition Literacy (n = 36)	Adequate Nutrition Literacy (n = 54)	P
z-Scores
Weight for age	0.06 ± 1.36	0.11 ± 1.19	.859
Height for age	0.40 ± 1.09	0.32 ± 1.26	.765
Weight for height	−0.30 ± 1.61	−0.12 ± 1.31	.559
Weight for age*
(−2)-(+2) SD	34 (94.4)	53 (98.1)	.561
< −2 SD	2 (5.6)	1 (1.9)
Height for age*
(−2) to (+2) SD	36 (100.0)	53 (98.1)	1.00
< −2 SD	0 (0)	1 (1.9)
Weight for height*
(−2) to (+2) SD	31 (86.1)	53 (98.1)	.036
< −2 SD	5 (13.9)	1 (1.9)
Upper-arm circumference, cm	13 (12-14)	13 (12.5-14)	.414
<12.5 cm*	5 (13.9)	3 (5.6)	.258
Triceps skinfold thickness, mm	10 (9-11)	10 (9-11)	.746

Results are expressed as mean ± SD, median (25th-75th percentile), and number (percentage).

*Weight-for-age <-2 SD underweight, height-for-age <-2 SD stunting, weight-for-height <-2 SD wasting, and upper-arm circumference <12.5 cm acute malnutrition.

Feeding and Dietary Characteristics

In general, the most frequently consumed group of food was grains, roots, and tubers. This high frequency is due to the fact that 85 children (94.4%) had consumed bread on the previous day. The food groups consumed by the child on the previous day and the child dietary diversity and diet quality scores did not differ significantly between the borderline and adequate NL groups (P > .05) (Table 3).

Table 3.

Comparison of Child Dietary Characteristics by Mother’s Nutrition Literacy

	Borderline Nutrition Literacy (n = 36)	Adequate Nutrition Literacy (n = 54)	P
Food groups consumed in the previous 24 hours
Grains, roots, and tubers	34 (94.4)	51 (94.4)	1.00
Dairy products	31 (86.1)	45 (83.3)	.722
Eggs	27 (75.0)	39 (72.2)	.770
Flesh foods	13 (36.1)	20 (37.0)	.929
Other fruits and vegetables	13 (36.1)	19 (35.2)	.928
Legumes and nuts	8 (22.2)	20 (37.0)	.137
Vitamin A-rich fruits and vegetables	2 (5.6)	4 (7.4)	1.00
Number of food groups consumed in the previous 24 hours	3.5 (3-4)	4 (3-4)	.763
Dietary diversity
Inappropriate	18 (50.0)	26 (48.1)	.863
Appropriate	18 (50.0)	28 (51.9)
The KIDMED score	5 (4-6)	5 (4-6)	.109
Diet quality
Good	2 (5.6)	5 (9.3)
Average	27 (75.0)	44 (81.5)	-
Poor	7 (19.4)	5 (9.3)

Results are expressed as median (25th-75th percentile) and number (percentage).

KIDMED, The Turkish version of the Mediterranean Diet Quality Index.

Iron and Anemia Status

Fifteen children (16.7%) had ID and 5 children (5.6%) had IDA. The mean value of hemoglobin and median value of ferritin were not statistically different between the borderline and adequate NL groups (P > .05). In addition, the percentages of children with ID or IDA and children with anemia other than IDA were not statistically different between the borderline and adequate NL groups (P > .05). Twelve children (13.3%) had vitamin B12 deficiency anemia and 1 child (1.1%) had folate deficiency anemia (Table 4). The total maternal EINLA score and subscores did not differ between children with ID, IDA, or other nutritional anemia and children with normal iron and hemoglobin status (Table 5).

Table 4.

Comparison of Child Hemogram Parameters, Iron Status, and Anemia Status by Mother’s Nutrition Literacy

	Borderline Nutrition Literacy (n = 36)	Adequate Nutrition Literacy (n = 54)	P
Hemoglobin, g/dL	11.8 ± 0.7	11.7 ± 1.1	.638
Hematocrit, %	34.5 (33-36)	34 (32-36)	.563
MCV, fL	76 (74-77.5)	77 (75-79)	.179
MCH, pg	26 (25-27)	26 (25-27)	.321
RDW, %	13.6 (13-14.2)	13.4 (12.9-13.9)	.674
Ferritin, ng/mL	20.4 (13.4-37.8)	18.7 (12.4-34.6)	.303
Iron status
Ferritin in normal range	29 (80.6)	41 (75.9)
ID	5 (13.8)	10 (18.5)	-
IDA	2 (5.6)	3 (5.6)
ID or IDA	7 (19.4)	13 (24.1)	.605
Anemia	6 (16.7)	12 (22.2)	.519
Anemia other than IDA	4 (11.1)	9 (16.7)	.463
Vitamin B12 deficiency	4 (100.0)	8 (88.9)	-
Folate deficiency	0 (0)	1 (11.1)
ID, IDA, or other nutritional anemia	11 (30.6)	22 (40.7)	.326

Results are expressed as mean ± SD, median (25th-75th percentile) and number (percentage).

ID, iron deficiency without anemia; IDA, iron deficiency anemia; MCH, mean corpuscular hemoglobin; MCV, mean corpuscular volume; RDW, red cell distribution width.

Table 5.

Comparison of Mother’s Nutrition Literacy Assessment Tool for Adults Scores by Child Iron and Anemia Status

	ID, IDA, or Anemia (n = 33)	Normal Iron and Hemoglobin Status (n = 57)	P
Mother’s
Total EINLA score	25.6 ± 2.7	25.0 ± 2.7	.368
General nutrition information score	7.5 ± 1.2	7.5 ± 1.4	.982
Reading comprehension and interpretation score	5.0 ± 0.6	4.9 ± 0.7	.408
Food groups score	8.5 ± 0.7	8.4 ± 0.8	.471
The serving sizes score	1.8 ± 0.7	1.6 ± 0.7	.264
How to read food labels and ability to do simple calculations score	2.8 ± 1.3	2.7 ± 1.1	.645
Child’s
Age, months	41.0 ± 10.4	43.3 ± 10.1	.293
Gender, male	17 (51.5)	31 (54.4)	.792

Results are expressed as mean ± SD and number (percentage).

EINLA, Evaluation Instrument of Nutrition Literacy on Adults; ID, iron deficiency without anemia; IDA, iron deficiency anemia.

Discussion

This study was conducted to compare the frequency of child ID, IDA, and anemia in children under 5 years of age according to the level of mother’s NL. Findings show that the frequencies of child ID, IDA, or anemia did not differ significantly between mothers with borderline and adequate NL. Malnutrition, including wasting, is more prevalent among children whose mothers have borderline NL than among those with mothers who had adequate NL.

In Pakistan, the prevalence of IDA in children was found as 100% in mothers with poor nutritional knowledge, 86.8% in mothers with moderate nutritional knowledge, and 58.5% in mothers with high nutritional knowledge. The relation between maternal nutritional knowledge and children’s hemoglobin level is highly significant.¹⁶ In this study, the prevalence of ID or IDA did not differ between children of mothers with borderline and adequate NL. This inconsistency may be explained by different study settings and hemoglobin measurement techniques. Ismail and Fatima¹⁶ obtained study samples from different areas of Karachi, Pakistan, through personal contacts and determined hemoglobin levels in capillary blood from a finger prick, whereas we obtained study samples from a single well-child outpatient clinic in a tertiary care hospital and measured venous levels of hemoglobin. Furthermore, the different sociodemographic characteristics of the study populations and the various questionnaire tools used may have also affected the results.

A quarter century ago, Gupta et al³¹ evaluated the associated risk factors for childhood anemia and found no differences in nutritional knowledge or dietary practices between mothers of children with low iron and/or anemia and mothers of children with normal iron. Consistently, the overall score and subscores of EINLA of mothers did not differ significantly between children with ID, IDA or anemia and children with normal iron and hemoglobin status, in our study. We also showed that there was no significant difference between mothers with borderline and adequate NL in terms of child ID, IDA, or anemia, but there was a significant difference in child wasting. Thus, it seems reasonable to suggest that low NLM may increase the risk of malnutrition in children but that NLM is not associated with children’s iron status or anemia. Nevertheless, we think that national representative studies including mothers with inadequate NLM are needed to make a definitive recommendation about the association between NLM and child ID, IDA, or anemia.

In Ethiopia, where IDA is a public health problem, a recent study reported that iron-rich food consumption by children aged between 2 and 5 years was associated with maternal education.³² Maternal education has been suggested to be important in reducing the risk of anemia and iron deficiency and increasing consumption of animal food sources by school-age children in Korea.³³ In Ghana, children (6-59 months) of mothers with low literacy were estimated to have inadequate iron intake.¹⁷ Maternal illiteracy is a risk factor for malnutrition and IDA in children under the age of 5 in sub-Saharan Africa.³⁴ In brief, maternal education is a crucial factor in reducing anemia in children under 5 years of age from 6 to 59 months.¹² Another point is that highly educated adults have significantly higher levels of NL.³⁵ However, in this study, maternal education level, child’s consumption of iron sources, and child’s dietary diversity did not differ significantly between mothers with borderline and adequate NL. Studies with larger samples including mothers with insufficient NL should further confirm our findings.

Iron deficiency anemia is commonly seen in children who prefer cow’s milk and do not eat meat, vegetables, and iron-rich foods.¹⁹ In our study, although the rates of dairy and flesh consumption were not different between the groups of borderline and adequate NL mothers, flesh consumption was less common than dairy consumption in both groups with borderline and adequate NL. This may be due to the fact that meat is among the most expensive foods in Türkiye. Counseling Turkish mothers at all NL levels about iron-rich diets may contribute to the prevention of iron deficiency in children.

In low- and middle-income countries, iron supplementation and fortification reduces the risk of anemia in children under 5 years of age.⁵ In addition, within the scope of the “Iron Like Turkey” Project, all children in Turkey aged 4 months are given iron supplements for 5 months and screened for anemia at 9 months of age, and infants with ID or IDA between 4 and 24 months are treated with iron preparations.³⁶ A previous study suggested a complex relationship between health literacy and adherence to medication, as caregivers with limited health literacy were more likely to adhere to a daily multivitamin and iron regimen in infants compared to caregivers with adequate health literacy.³⁷ In this study, adherence to iron supplementation and history of ID or anemia in infancy were not considered.

Previous studies have shown that NLM is related to children’s dietary diversity and diet quality, and that poor dietary diversity and poor diet quality are associated with anemia among children.^3,7 This study found that children’s dietary diversity, diet quality, and iron and anemia status did not differ significantly between mothers with borderline and adequate NLM. Our sample size was not sufficient to measure associations between NLM and children’s dietary practices.

In this study, breastfeeding and complementary feeding practices did not differ between mothers with borderline and adequate NL. In Jordan, most mothers of anemic preschool children were reported to have poor feeding practices in terms of breastfeeding, age of initiation of iron-rich solid foods, and consumption of animal sources of iron. Improvements in maternal nutrition and food literacy may prevent late introduction of iron-source animal foods and the development of anemia in preschool children.¹³ There is an ongoing need to determine breastfeeding and complementary feeding practices of Turkish mothers with inadequate NL.

Anemia is a common problem in pediatric outpatient clinics, and nutritional deficiencies, especially iron, folic acid, and vitamin B12 deficiency, are the main causes of anemia in children.³⁸ We also found that iron, vitamin B12, and folic acid deficiency are the causes of anemia even in well-child controls. The prevalence of anemia in preschool children in Türkiye has been reported to be 20.0%-39.9%.³⁹ To our knowledge, there is no data about the percentage of these anemias that are vitamin B12 deficiency or folate deficiency anemia. In this study, the prevalence of anemia due to vitamin B12 deficiency was 13.3% and the prevalence of anemia due to folate deficiency was 1.1% in children, and the prevalence of nutritional anemia other than IDA did not differ significantly between mothers with borderline and adequate NL.

Several studies conducted in different countries have shown that NLM is particularly influential on nutritional outcomes [malnutrition including undernutrition (wasting or stunting), insufficient vitamins or minerals, overweight, and obesity] of offspring. These previous studies have highlighted that low levels of mother’s NL are significantly associated with child undernutrition.^6,8,10 We also found that wasting was more prevalent in children whose mothers had borderline NL compared to children whose mothers had adequate levels of NL. In addition to dietary factors and parental literacy, several other socioeconomic and maternal characteristics are also associated with child wasting status. Shorter birth interval, maternal undernutrition during pregnancy, late initiation of breastfeeding, and poor psychosocial and socioeconomic status were reported as independent predictors of wasting among children under 5 years of age. Wasting may also be accompanied by diarrheal infection in the 2 weeks prior to data collection and genetics.⁴⁰ However, we did not identify these factors. Although the current study sample consisted of healthy children, the non-medical factors mentioned above may have been associated with malnutrition in the 6 healthy but wasted children who had participated in our study. A higher prevalence of anemia has been found in malnourished children under 5 years of age.⁴¹ Therefore, national programs to combat malnutrition, anemia, and micronutrient deficiency in children should include NLM interventions.

This study showed that mothers with borderline NL had more children than mothers with adequate NL. Thus, there may be a positive association between NL and family planning literacy, with increased rates of NL among mothers resulting in more successful family planning. This finding is important because successful family planning will reduce anemia in mothers and under-5 children.^42,43

This study has some limitations. First, this was a single-center study with a cross-sectional design, so national representativeness may be low. Another important limitation of the study is the lack of a group of mothers with inadequate NL. Since nutritional anemia can be caused by deficiencies in iron, folate, and vitamins A and B12, it is important to measure the association of anemia with all these potential deficiencies.⁴⁴ However, we did not study vitamin A deficiency. In addition to inadequate dietary diversity, food insecurity and deworming have also been reported as factors associated with anemia in children under 5 years of age.⁴⁵ Food insecurity and deworming were not examined in this study. Finally, pica, a condition that usually occurs with ID, was not ascertained.¹⁹

Conclusion

Our findings suggest that child ID, IDA, or nutritional anemia did not differ significantly between mothers with borderline and adequate NL, but wasting was more common in children of mothers with borderline NL than in children of mothers with adequate NL. Thus, we suggest that NLM may play a role in children’s nutritional outcomes but not in iron or anemia status. Further studies in Turkey should include mothers with inadequate NL to assess iron and anemia status of their young children, and community-based case-control studies should assess the association between NLM and child ID, IDA, and anemia. This study can provide data for national health policy makers to design strategies for the prevention and control of child ID, IDA, anemia, and malnutrition.

Funding Statement

This study received no funding.