Complementary feeding indicators among children aged 6–23 months: a cross-sectional study assessing minimum dietary diversity, minimum acceptable diet and dietary patterns in Njombe Town Council, Tanzania

Abstract

Objectives

This study assessed the minimum dietary diversity (MDD), minimum meal frequency (MMF), minimum acceptable diet (MAD) and dietary patterns among children aged 6–23 months in Njombe Town Council.

Design

Community-based cross-sectional study.

Setting

This study was conducted in the Njombe Town Council, which is located in the Njombe region in the southern part of Tanzania.

Participants

A total of 330 caregivers of children aged 6–23 months were recruited using a multistage probability sampling technique. Data were collected from January to March 2021 using a structured questionnaire adapted from the Process for Promotion of Child Feeding (ProPAN) manual.

Interventions

None.

Primary and secondary outcome measures

The primary outcomes were the prevalence of MDD, MMF and MAD, assessed according to the 2021 WHO infant and young child feeding indicators. Secondary outcomes included food group consumption and dietary patterns identified using principal component analysis.

Results

A total of 330 caregivers of children aged 6–23 months participated in the current study. Nearly half (43.9%; n=145) were aged between 30 and 49 years, with a mean age of 30.28 years and an SD of ±6.119 years. Only 26.36% of children aged 6–23 months achieved MDD, 71.5% achieved MMF and 18.48% met MAD, with a mean dietary diversity score of 3.35±1.6. Predominant foods included grains, roots and tubers (80.91%) and breast milk (90%), while dairy products were the least consumed (7.27%). Three dietary patterns emerged: cereals, roots and tubers; dairy products and eggs; and vitamin A-rich fruits and vegetables.

Conclusion

The MDD and MAD attainment in Njombe Town Council are suboptimal, reflecting reliance on staple foods and limited nutrient-rich options. These findings highlight the need for context-specific interventions, including strengthened nutrition education, promotion of diversified diets and agricultural strategies that improve access to nutrient-dense foods to enhance infant and young child nutrition.

Strengths and limitations of this study.

• The current study provides valuable localised data on infant and young children’s feeding practices in a high-burden rural region, using a community-based design and a validated Process for Promotion of Child Feeding (ProPAN) questionnaire for robust assessment.

• However, the cross-sectional design precludes causal inferences, and reliance on 24-hour recall may introduce recall bias, potentially underestimating dietary diversity.

• Self-reported data could be influenced by social desirability bias, and exclusion of seriously ill children may overlook vulnerable subgroups.

Introduction

Adequate nutritional intake in Infant and Young Children Feeding (IYCF) is critical for optimal growth, cognitive development and long-term health outcomes among children under 5 years of age.¹ Appropriate complementary feeding practices after 6 months of age are particularly important because breast milk alone becomes insufficient to meet the increasing nutritional demands of growing children. Evidence shows that optimal complementary feeding should ensure both minimum dietary diversity (MDD) and minimum meal frequency (MMF) to provide adequate energy and nutrient intake required for healthy growth and development.² Inadequate dietary diversity and insufficient feeding frequency are strongly associated with undernutrition, micronutrient deficiencies, impaired immunity, stunting and increased childhood morbidity and mortality.

Globally, child malnutrition remains a major public health concern, particularly in low-income and middle-income countries. The United Nations International Children’s Emergency Fund/WHO (UNICEF/WHO)/World Bank Joint Child Malnutrition Estimates 2025 report indicates that approximately 150.2 million children under 5 years of age were stunted (23.2%), 42.8 million suffered from wasting (6.6%), including 12.2 million with severe wasting, while 35.5 million children were overweight (5.5%) worldwide.³ The highest burden of stunting was reported in Asia (51%) and Africa (43%), highlighting persistent inequalities in child nutrition and access to adequate diets.³ Sub-Saharan Africa continues to experience a disproportionately high burden of undernutrition due to poverty, food insecurity, poor feeding practices and limited access to nutrition education and healthcare services. In many developing countries, children aged 6–23 months are frequently fed monotonous diets dominated by cereals and starchy foods with inadequate meal frequency, resulting in insufficient nutrient intake to support optimal growth.⁴

Feeding frequency is a critical but often overlooked component of complementary feeding practices. Children who receive meals less frequently than recommended are at increased risk of inadequate caloric intake even when dietary diversity is relatively acceptable. The WHO recommends that breastfed children aged 6–8 months receive complementary foods at least two times per day, those aged 9–23 months receive at least three meals daily, and non-breastfed children receive at least four meals, including milk feeds.² Evidence from sub-Saharan Africa demonstrates that poor meal frequency and low dietary diversity significantly contribute to persistent rates of stunting and micronutrient deficiencies among children under 5 years of age.⁵ This pervasive malnutrition not only constitutes a significant public health concern but also acts as a profound impediment to poverty reduction, productivity and overall economic growth.⁶

In developing countries, meeting dietary diversity standards remains a significant challenge, directly affecting the nutritional status of young children.⁷ This is particularly true in sub-Saharan Africa, where low-income conditions often impede the attainment of MDD for children under 5 years.⁸ The risk of child mortality before the age of 5 years in Africa is higher, underscoring the urgency of addressing suboptimal feeding practices and nutritional deficiencies.⁵ Suboptimal feeding practices among caregivers are a major contributor to these nutritional challenges, leading to various health problems in children in low-income and middle-income countries such as Tanzania.^{9 10}

For instance, studies have shown that, despite being major food producers, the Southern and Southwestern highland regions of Tanzania, including Njombe, exhibit stunting and underweight rates exceeding the national average.¹¹ The previous study documented that stunting in Njombe children aged 0–59 months is reported to be 53.6%, a 4.6% increase since 2015, despite the region’s agricultural potential.¹² Understanding the specific feeding practices prevalent in Njombe is therefore vital for developing effective strategies to combat undernutrition, which contributes significantly to mortality and morbidity rates in children under 5 years. Such a comprehensive analysis can identify specific gaps in dietary intake and inform targeted interventions, especially considering the influence of local food taboos and preferences that may impact nutritional programme effectiveness.

These suboptimal practices highlight a critical gap in knowledge and resources concerning IYCF guidelines, despite community awareness campaigns aimed at improving maternal and child health services.¹² For instance, the previous study in Dodoma revealed limited information on competencies of caregivers in providing diverse and adequate diets to children under 5 years, with few continuing to attend community-based clinics for feeding practice education.⁹ This knowledge gap contributes to the persistent challenges of undernutrition, with national data indicating high rates of stunting (31%), wasting (6%) and underweight (14%) among children under 5 years in Dodoma City, Tanzania.⁹ This persistent problem underscores the inadequacy of current interventions and highlights the necessity for a detailed examination of IYCF practices as a cornerstone for improving child health outcomes in the region. Also, this alarming trend underscores the critical need for a comprehensive investigation into the factors influencing child feeding practices in these areas.

Despite the critical importance of appropriate feeding, many caregivers in these regions demonstrate unsatisfactory practices regarding dietary diversity and adequacy, often falling below the recommendations set by the WHO. Chronic malnutrition remains a serious concern in regions such as Njombe due to these feeding practices. Addressing this problem, the current study aimed to evaluate the MDD, acceptable diet and feeding patterns among children aged 6–23 months in the Njombe Town Council, Tanzania.

Materials and methods

Study design

A community-based cross-sectional study design was used to collect data from caregivers regarding dietary diversity, meal frequency, acceptable diet and dietary patterns among children aged 6–23 months in the Njombe Town Council. A quantitative research approach was suitable for this study because it enables the measurement of variables and statistical analysis. This cross-sectional study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Study setting

This study was conducted in the Njombe Town Council, which is located in the Njombe region in the southern part of Tanzania. Administratively, Njombe region lies between latitude 8°50’ and 10°30’ south of the equator and between longitude 33°45’ and 35°45’ east of Greenwich. Njombe region has an area of 24 994 km² and is divided into six administrative districts: Makete District Council, Makambako Town Council, Njombe Town Council, Ludewa District Council, Njombe District Council and Wanging’ombe District Council.

Administratively, the Njombe Town Council is divided into two divisions, Njombe Urban and Igominyi, with 13 wards, 45 villages and several streets. The majority of the population lives in rural areas, while a smaller percentage resides in the urban centres. The area is also agriculturally productive, with many households engaged in farming, including the cultivation of maize, potatoes, beans, vegetables and fruit. This makes Njombe Town Council an important setting for assessing whether households meet recommended indicators for young children, such as MDD, MMF and minimum acceptable diet (MAD). Furthermore, Njombe Town Council has a mix of urban and peri-urban communities, allowing researchers to compare feeding patterns across different social and economic groups.

Study population

This study involved all caregivers of children aged 6–23 months in the selected district in the Njombe region in order to identify best practices and evidence-based approaches to enhance nutrition outcomes for infants and children. All caregivers who have children aged 6–23 months and consented to participate in the study were recruited. However, those with seriously ill children, temporary residents and those with any form of disability were excluded from the current study.

Patient and public involvement

None.

Sample size estimation and sampling procedure

The sample size was calculated using the Cochran formulas: N = (Z_1−α/2)² p (1−p)/d². Z_₁−α/2 was 1.96 at an alpha level of 5%, ‘p’ represents the estimated proportion of an attribute present in children, and ‘d’ was set at 0.05, indicating a 95% confidence level. Also, p=proportion of children with stunting was equal to 26.7%.¹³ The sampling process was probability-based and involved several sequential stages. In the initial stage, the Njombe region, out of 31 regions in Tanzania, was selected purposefully. First, Njombe Town Council was selected from the Njombe Region using simple random sampling.

Second, 10 wards were randomly selected from the 14 wards within the council using the lottery method. Third, one street was randomly selected from each selected ward, resulting in a total of 10 streets. Finally, within each selected street, a household list of caregivers with children aged 6–23 months was compiled with the assistance of local leaders, and 33 households were selected using simple random sampling. This resulted in a total sample of 330 households (10 wards×1 street per ward×33 households=330 participants). Moreover, all households per street were randomly selected using prepared identical pieces of paper with the same size, shape and colour, numbered from one to the last. These papers were combined and placed in a box. This method ensured fairness in participant selection.

Data collection tools and procedures

A structured questionnaire was adopted from the ProPAN manual.¹⁴ The questionnaire consisted of five parts; part 1 included socio-demographic characteristics, such as family and child information. Part 2 covered health and other services, part 3 of the questionnaire assessed breastfeeding and complementary feeding practices and part 4 addressed health communication and covered HIV/AIDS (online supplemental file 1). The questionnaire was first prepared in English and then translated into Swahili, which is the national language of Tanzania, following the translation procedures suggested by Tsang et al.¹⁵ The forward translation from English to Swahili was conducted by a bilingual health professional who was fluent in both languages and familiar with public health and nutrition terminology. The Swahili version was then independently back-translated into English by another bilingual translator who had not participated in the initial translation and was not given access to the original English questionnaire.

The research team compared the original English questionnaire with the back-translated version to identify differences in meaning, wording and interpretation. Any inconsistencies or unclear expressions were discussed by the translators and investigators and corrected to ensure that the Swahili version retained the same meaning as the original instrument while remaining culturally appropriate and easy to understand. Before the main data collection, the translated questionnaire was pre-tested among 33 caregivers of children aged 6–23 months from a community with similar characteristics to the study population. Feedback from the pre-test helped improve the clarity, wording, and understanding of the questions. This process enhanced the face validity and content validity of the questionnaire before it was used in the final study.

Data collection took place from January 2021 to March 2021. This was an interviewer-administered questionnaire whereby the first author collected data across all streets in the respective wards in Njombe Town Council. Participants were approached by the first author, who explained their involvement in the study. Those who agreed to participate were given a consent form to read and sign, and then asked to complete a questionnaire. All eligible caregivers who were approached consented to participate and completed the interview. Consequently, the response rate was 100%, and the time taken to fill each questionnaire was about 40 min. The principal investigator supervised the entire data collection process, ensuring that each step was followed.

Validity and reliability

To ensure validity, a questionnaire was given to three nutritionists. Their feedback helped establish coding and revise the tool based on observed difficulties and comments regarding the clarity of the questions to improve understanding. Reliability of the questionnaire’s internal consistency was assessed using Cronbach’s alpha, with values ≥0.70 considered acceptable for this study.

Variable measurement

The variable of MDD was defined as children who had consumed foods from at least five of the eight defined food groups within the preceding 24 hours were classified as having met the MDD criterion. Those eight food groups are: (1) breast milk; (2) cereals, roots and tubers; (3) legumes and nuts; (4) dairy products; (5) flesh foods (meats, fish and poultry); (6) eggs; (7) fruits and vegetables high in vitamin A; and (8) other fruits and vegetables.²

The MMF was defined as the proportion of children aged 6–23 months who received solid, semi-solid or soft foods at least the minimum recommended number of times per day. For non-breastfed children, milk feeds were also included in the assessment of meal frequency.²

According to the WHO guidelines, the minimum recommended feeding frequency is two meals per day for breastfed infants aged 6–8 months, three meals per day for breastfed children aged 9–23 months and four meals per day for non-breastfed children aged 6–23 months.² Children who met the age-specific MMF recommendation were classified as having achieved MMF and were coded as ‘Yes’ (1), while those who did not meet the recommendation were classified as ‘No’ (0).

Additionally, those children who achieved MDD (those having at least five types of food per day) and MMF (those breastfed children having at least two meals, while non-breastfed children having at least three meals in the previous day) were considered to have attained MAD.² Dietary patterns in this study were empirically derived using principal component analysis (PCA) of the eight WHO IYCF food groups consumed during the 24 hours preceding the survey interview. Based on the rotated factor loadings, three dietary patterns were identified and labelled according to their predominant food groups: (1) cereals, roots and tubers, other fruits and vegetables, (2) dairy products and eggs, and (3) vitamin A-rich fruits and vegetables.

Data analysis

Before analysis, the data were screened and cleaned to ensure completeness and consistency. Data were managed and analysed using Statistical Package for the Social Sciences (SPSS) V.27. Descriptive statistics were used to summarise participants’ demographic characteristics and the prevalence of MDD, MMF and MAD. PCA was used to identify and characterise dietary patterns based on the factor loadings of the food groups. PCA with varimax rotation was performed to identify underlying dietary patterns based on the eight WHO IYCF food groups consumed during the 24 hours preceding the survey: breast milk; grains, roots and tubers; legumes and nuts; dairy products; flesh foods; eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables. Each food group was coded as a binary variable (1=consumed; 0=not consumed).

Sampling adequacy was assessed using the Kaiser–Meyer–Olkin (KMO) measure and Bartlett’s test of sphericity. The KMO value was 0.74, indicating good sampling adequacy and Bartlett’s test was statistically significant (χ² = 282.118, p<0.001), confirming the suitability of the data for PCA. Components with eigenvalues >1.0 were retained and confirmed by visual inspection of the scree plot.

Three components were retained, explaining 55.9% of the total variance, with the first, second and third components accounting for 26.0%, 17.4% and 12.5% of the variance, respectively. Item communalities ranged from 0.35 to 0.864, indicating that all food groups contributed adequately to the extracted components. Food groups with an absolute rotated factor loading of >0.40 were considered the defining contributors to each dietary pattern, and the patterns were named according to the food groups with the highest factor loadings. Rotated factor loadings ranged from 0.536 to 0.924, indicating strong relationships between the food groups and the identified dietary patterns. The dietary patterns were used descriptively to characterise complementary feeding practices in the study population. Results are presented using tables and figures showing frequencies and percentages.

Results

Socio-demographic characteristics of respondents

A total of 330 caregivers of children aged 6–23 months participated in the current study. Nearly half, 43.9% (n=145), were aged between 30 and 49 years, with a mean age of 30.28 years and a SD of ±6.119 years. More than half, 52.7% (n=154), of the children were female. Regarding marital status, the majority, 93.9% (n=310), were married or living with a partner. Over three-quarters of the study respondents, 79.4% (n=262), had secondary education. Additionally, 85.2% (n=281) of the study respondents were unemployed. Furthermore, 55.8% (n=184) of respondents had a family size of fewer than 5 children (table 1).

Table 1. Socio-demographic characteristics of respondents (n=330).

Variable	Frequency (%)
Age (years) mean (SD)=30.28 (±6.119)
20–24	66 (20.0)
25–29	119 (36.1)
30–49 years	145 (43.9)
Educational level
No formal education	27 (8.2)
Primary education	41 (12.4)
Secondary education	262 (79.4)
Occupational status of the caregiver
Unemployed	281 (85.2)
Vendors	31 (9.3)
Office worker	18 (5.5)
Marital status of the caregiver
Single/divorced	20 (6.1)
Live with partner/married	310 (93.9)
Family size
<5	184 (55.8)
>5	146 (44.2)
Sex of the child
Male	156 (47.3)
Female	174 (52.7)
Age of the child (months)
0–5 months	63 (19.1)
6–11 months	113 (34.2)
12–23 months	154 (46.7)
The child lives with
Grandparents	66 (20.0)
Biological mother only	118 (35.8)
Both biological parents	146 (44.2)

Food groups consumed by children aged 6–23 months

The findings revealed that most children were fed grains, roots and tubers (80.91%) in addition to breast milk (90%), whereas vitamin A-rich fruits and vegetables were consumed by 35.15% of children, and dairy products were the least commonly consumed food group (7.27%). Other information is summarised in figure 1.

Figure 1. Food groups consumed by children aged 6–23 months (n=330).

Uptake of diversified diets and minimum acceptable diet among children aged 6–23 months

Overall, 26.36% (n=87) of children achieved MDD, whereas an estimated 71.5% (n=236) met the MMF recommendation. However, only 18.48% (n=61) achieved the MAD, reflecting the combined requirement of meeting both MDD and MMF. The overall MDD score was 2.45±1.6, with scores ranging from 0.0 to 6.0. These findings indicate that although many children received meals at the recommended frequency, relatively few consumed sufficiently diverse diets, suggesting inadequate dietary intake (table 2).

Table 2. Uptake of diversified diets and minimum acceptable diet among children aged 6–23 months.

IYCF indicator	Frequency (Yes)	Percentage (%)
Minimum dietary diversity for children aged 6–23 months
Grain, roots and tubers	267	80.9
Legumes and nuts	115	34.8
Dairy products	24	7.30
Flesh foods	101	30.6
Eggs	56	17.0
Vitamin A-rich fruits and vegetables	116	35.2
Other fruits and vegetables	129	39.1
Range of minimum dietary diversity score
Minimum score (0)	54	16.4
Maximum score (7)	2	0.60
Mean score of minimum dietary diversity	3.35±1.6
Overall minimum dietary diversity
High dietary diversity (≥5 food groups)	87	26.36
Low dietary diversity (<5 food groups)	243	73.64
Overall minimum meal frequency
Achieved minimum meal frequency	236	71.5
Not achieved minimum meal frequency	94	28.5
Overall minimum acceptable diet 6–23 months
Attained a minimum acceptable diet	61	18.48
Not attained a minimum acceptable diet	269	81.52

IYCF, Infant and Young Children Feeding.

Dietary patterns of children aged 6–23 months based on the principal component analysis

The dietary patterns were empirically derived from the PCA and represent combinations of food groups that tended to be consumed together rather than mutually exclusive or predefined dietary categories. The naming approach was made through team consensus, which was primarily descriptive in nature because food groups were categorised directly according to the highest factor loadings. The patterns were named as follows: cereals, roots and tubers; dairy products; and vitamin A-rich fruits and vegetables. The named patterns should not be interpreted as indicating that children consumed predominantly or exclusively those food groups.

Specifically, the cereals, roots and tubers pattern reflects a tendency towards frequent consumption of staple foods; the dairy products and eggs pattern reflects the co-consumption of these animal-source foods with other foods in the diet; and the vitamin A-rich fruits and vegetables pattern reflects relatively greater consumption of vitamin A-rich plant foods alongside other food groups (table 3).

Table 3. Dietary patterns of children aged 6–23 months based on the principal component analysis.

Types of foods	Cereals, other fruits and vegetables	Dairy products and eggs	Vitamin A-rich fruits and vegetables
Grain, roots and tubers	0.5179	0.1948	−0.1173
Legumes and nuts	0.4267	−0.2380	−0.3092
Dairy products	0.0507	0.5548	−0.3385
Flesh foods	0.3733	0.2162	0.1456
Eggs	0.0602	0.4399	−0.4392
Vitamin A-rich fruits and vegetables	0.3773	0.2406	0.4801
Other fruits and vegetables	0.4841	−0.3283	0.1739
Ever breastfed	−0.1483	0.4378	0.5489

Discussion

The current study aimed to assess dietary diversity, acceptable diet and dietary patterns among children aged 6–23 months in the Njombe Region. The findings from this community-based cross-sectional study highlight suboptimal IYCF practices among children aged 6–23 months, with only 26.36% achieving MDD and 18.48% meeting MAD criteria. In contrast, a substantially higher proportion of children (71.5%) achieved the MMF recommendation. The relatively higher prevalence of MMF compared with MDD suggests that caregivers were generally able to provide meals at the recommended frequency. However, inadequate dietary diversity remained the principal contributor to the low prevalence of MAD, highlighting that improving the quality of complementary foods should be prioritised alongside maintaining appropriate meal frequency.

The MDD score of 3.35±1.57 underscores a limited variety in complementary foods, primarily reliant on grains, roots and tubers (80.91%), while animal-source foods like dairy products (7.27%) are minimally consumed. PCA revealed three dominant dietary patterns: cereals, roots and tubers; dairy products and eggs; and vitamin A-rich fruits and vegetables. These patterns indicate a heavy dependence on staple carbohydrates and locally available produce, which, despite Njombe’s agricultural productivity, may contribute to micronutrient deficiencies such as iron, zinc and vitamin A, potentially exacerbating risks of stunting and impaired cognitive development.¹⁶ Although the dairy products and eggs pattern and the vitamin A-rich fruits and vegetables pattern suggest relatively greater consumption of nutrient-rich foods, they should not be interpreted as inherently positive dietary patterns because the overall nutritional quality of a child’s diet depends on adequate consumption of all recommended food groups. Likewise, the cereals, roots and tubers pattern should not be interpreted as a negative dietary pattern in isolation; rather, it reflects reliance on staple foods, which may become nutritionally inadequate when not complemented by sufficient animal-source foods, legumes, fruits and vegetables.

The low MDD and MAD prevalence suggest that while breastfeeding continuation is high (90%), complementary feeding fails to bridge the nutritional gap post 6 months, aligning with global evidence that inadequate diversity correlates with poor nutrient adequacy.⁴ The staple-dominant patterns reflect cultural and economic preferences for affordable, energy-dense foods but at the expense of nutrient-rich options, as evidenced by low consumption of flesh foods. This dietary monotony could stem from barriers like seasonal food availability, limited market access and traditional beliefs delaying animal protein introduction, common in rural Tanzanian contexts.¹⁷ While the current data do not allow direct assessment of these factors, this pattern is consistent with prior evidence suggesting that household food insecurity and caregiver knowledge mediate child dietary outcomes independent of regional food availability.^{18 19}

Comparisons with previous studies reveal consistencies and disparities. Nationally, the 2022 Tanzania Demographic and Health Survey (TDHS) reported MDD at 19% and MAD at 8% among children aged 6–23 months,²⁰ lower than in our study. Also, Njombe’s TDHS estimates align closely with our MDD but show lower MAD.²⁰ These differences may be explained by variations in study design, study population and data collection methods. The TDHS is a large national survey designed to provide representative estimates for the entire region, including both rural and urban populations, in contrast to the present study conducted in selected wards of Njombe Town Council.

The findings from the current study may reflect feeding practices specific to the selected study areas rather than the whole Njombe Region. Another possible explanation is the difference in access to health and nutrition services within the study settings. Njombe Town Council may have better access to healthcare facilities, nutrition education, markets and food supplies compared with some rural districts included in the TDHS regional estimates. These factors may have contributed to the relatively higher MDD and MAD observed in the current study.

In addition, seasonal variation may also have influenced the findings. Data collection for this study was conducted between January and March 2021, a period when food availability may have been relatively better due to agricultural harvests in the Njombe Town Council. Since household food availability changes across seasons, dietary diversity and IYCF practices may also vary over time. The low levels of MDD and MAD observed in both studies highlight the continued need for nutrition education, improved caregiver support and interventions aimed at promoting appropriate IYCF practices.

In broader sub-Saharan Africa, a 2024 pooled analysis of Demographic Health Survey (DHS) data from 31 countries indicated an MDD prevalence of 11%,²¹ markedly lower than Njombe’s, highlighting Tanzania’s relative progress amid regional challenges such as poverty and food insecurity. However, a specific Ethiopian systematic review and meta-analysis study reports MAD rates of 7.9%–22%,²² similar to our findings, with common associations, including maternal education and antenatal care (ANC) use.

In contrast, Ghanaian data from the 2022 DHS showed 26.4% MAD,²³ exceeding Njombe’s, potentially due to stronger urban nutrition programmes. Earlier Tanzanian research, such as Khamis et al,¹⁷ linked higher dietary diversities to reduced stunting, mirroring our patterns’ implications for growth faltering. These comparisons highlight that while Njombe’s practices surpass some sub-Saharan Africa averages, they lag behind achievable benchmarks in comparable low-income and middle-income settings, underscoring the need for localised interventions.

The low MAD prevalence signals heightened risks of undernutrition, with potential long-term effects on child survival and development, as a previous study reported that inadequate dietary diversity is associated with an increased risk of stunting.²⁴ Integrating nutrition education into ANC and community health services could address gaps, given evidence that more than four ANC visits boost MAD.²⁵ Additionally, promoting agricultural diversification, including vitamin A-rich crops and small livestock, could enhance dietary patterns, aligning with Tanzania’s National Multisectoral Nutrition Action Plan.²⁰

Moreover, these findings advocate for equity-focused strategies under sustainable development goals 2, which focuses on zero hunger, emphasising caregiver empowerment to mitigate malnutrition in high-burden regions like Njombe.²⁶ However, longitudinal studies are warranted to explore the causal pathways between patterns and outcomes, building on cross-sectional limitations like recall bias in 24-hour dietary recalls.

Strengths of the study

This study provides important context-specific evidence on the prevalence of MDD among children aged 6–23 months in Njombe Town Council, an area with limited empirical nutritional data. The large sample size of 330 caregivers enhances representativeness within Njombe Town Council, and the application of PCA offers novel insights into dietary patterns. In addition, the study used a multistage sampling procedure and standardised data collection tools adapted from the ProPAN manual, thereby enhancing methodological rigour and comparability with similar studies conducted in low-income and middle-income countries. Furthermore, adherence to STROBE guidelines improved transparency and reporting quality, thereby enhancing the scientific credibility of the study.

Limitations of the study

Several limitations should be considered when interpreting the findings of this study. First, the descriptive cross-sectional study design precludes the establishment of causal relationships between the predictors and MDD. Therefore, the findings should be interpreted as descriptive rather than causal inference. Second, dietary diversity was assessed using a single 24-hour dietary recall, which may not accurately reflect children’s habitual dietary intake. This method is particularly limited in capturing foods that are consumed infrequently or seasonally, potentially resulting in an underestimation of actual dietary diversity, which is a recognised constraint of the dietary pattern analysis.

Third, the reliance on caregiver self-reported dietary information may have introduced social desirability bias and recall bias. Caregivers may have over-reported socially acceptable feeding practices or under-reported unhealthy dietary behaviours, thereby affecting the accuracy of the measured prevalence of MDD. Fourth, the exclusion of caregivers with seriously ill children may have led to under-representation of the most nutritionally vulnerable subgroup of children. Since illness is often closely linked with poor feeding practices and nutritional deficiencies, excluding this population could have resulted in an underestimation of the true burden of inadequate dietary diversity within the community.

Finally, the sampling frame was restricted to Njombe Town Council, which may limit the generalisability of the findings to the broader Njombe region or other rural Tanzanian settings. Njombe Town Council may differ from remote rural districts in terms of healthcare access, food availability, socioeconomic conditions and caregiver education levels. Therefore, caution should be exercised when transferring these findings to populations with different demographic, cultural or agro-ecological characteristics.

Conclusion

This study reveals alarmingly low levels of MDD and MAD among children aged 6–23 months in Njombe Town Council, with staple-dominant feeding patterns that are consistent with a heightened risk of micronutrient deficiencies in this age group. Taken together with existing evidence, these findings suggest that targeted interventions, including community-based nutrition education, promotion of animal-source foods and vitamin-rich produce, and integration of IYCF counselling into antenatal and child health services, warrant evaluation in this context.

Data availability statement

Data are available upon reasonable request.