PLoS ONE
Public Library of Science
Maternal dietary practices, dietary diversity, and nutrient composition of diets of lactating mothers in Jimma Zone, Southwest Ethiopia
DOI 10.1371/journal.pone.0254259 , Volume: 16 , Issue: 7 , Pages: 0-0
Article Type: research-article, Article History

Abstract

### Background

Optimal nutrition during lactation is essential for the well-being of the mother and the infant. Studies have shown that access to nutrient-rich foods during lactation is critical as minimal stores of nutrients can have adverse effects. This study aimed to investigate the diversity, composition, and nutrient adequacy of diets of lactating mothers in Southwest Ethiopia.

### Methods

A community-based cross-sectional survey was carried out in three districts of Jimma Zone, Southwest Ethiopia, in February 2014. A stratified multistage sampling technique was used to select 558 lactating mothers. Data were collected using a pre-tested and structured interviewer-administered questionnaire. Minimum dietary diversity for women (MDD-W) was computed from a single 24-h recall. A cut off value of 5 was used to classify the dietary diversity into achieving MDD-W or not. The proximate, mineral and anti-nutritional compositions of 12 commonly consumed foods were analysed using standard methods. Nutrient adequacy ratio (NAR) and Mean adequacy ratio (MAR) of these foods were estimated.

### Results

The mean (±SD) dietary diversity score (DDS) of the study participants was 3.73±1.03. Meeting MDD-W was positively associated with agricultural production diversity (P = 0.001) and educational level of the women (P = 0.04). Conversely, district of the study (P = 0.003) and place of residence (P = 0.019) were negatively associated with meeting MDD-W. The proximate composition (g/100g) of the sampled foods ranged between 24.8–65.6 for moisture, 7.6–19.8 for protein, 2.1–23.1 for crude fat, 2.0–27 for crude fibre, 1.0–21.2 for total ash, and 0.9–45.8 for total carbohydrate content. The calorific value ranged between 124.5–299.6 Kcal/100g. The mineral contents (mg/100g) ranged between 9.5–52.5 for iron, 2.2–4.2 for zinc, 42.6–318.2 for calcium, and 150.7–379.9 for phosphorus. The content of anti-nutritional factors (mg/100g) ranged between 11.1–178.9 for phytate and 3.7–315.9 for tannin. All the commonly consumed maternal foods were not sufficient to meet the energy, fat and protein requirements, (NAR<1). However, all diets provided adequate iron and most of the cereal-based foods provided adequate carbohydrate and minerals. The overall nutrient adequacy was below the cut-off point for all food types.

### Conclusions

The diets of lactating mothers in Southwest Ethiopia lack diversity and nutrient adequacy. A community-based nutrition education program on the importance of diet diversity and nutrient intake during lactation based on a multi-sectoral approach is needed.

## Introduction

Maternal undernutrition is a significant cause of morbidity and mortality in low- and middle-income countries throughout the world and is estimated to affect 22% of the mothers of Ethiopia. Ethiopia is still among countries with a high burden of maternal malnutrition [1]. Mothers from low-income settings are amongst the most vulnerable to undernutrition because their body’s nutrient reserve is severely affected due to frequent pregnancies and lactation [2]. Lactating women who do not get enough energy and nutrients in their diets risk maternal depletion [35].

According to the United Nations Children’s Fund (UNICEF) conceptual framework of undernutrition, inadequate dietary intake is an immediate cause of maternal and child undernutrition [6]. Based on nutrition recommendations, energy needs are 25% higher during lactation, and protein needs are 54% higher during lactation compared to a non-lactating woman [7, 8]. However, lactating women from low-income settings are considered as a nutritionally vulnerable group because their dietary practices may not be optimal. Ethiopia experiences one of the highest incidences of child and maternal nutritional deficiencies which contribute to increased morbidity and mortality [9]. A malnourished mother will give birth to a low birth weight baby; the low birth weight baby will grow as a malnourished child, then to a malnourished teenager, then to a malnourished pregnant woman, and so the cycle continues [10].

One of the available tools for measuring dietary adequacy among lactating mothers is dietary diversity [11]. However, literature evidenced that dietary diversity among lactating mothers is very low in low-income settings [12]. Several demographic, socio-economic, and other factors, which could vary from setting to setting, could contribute to reduced dietary diversity [13].

Another gap that is noticed regarding maternal diets in low-income settings like Ethiopia is the composition of the foods customarily consumed is not exhaustively documented in the food composition tables. This information is fundamental for programmes which operate in the agriculture-nutrition-health interface. Inadequate food composition data may lead to a failure in understanding the relationship between nutrient intake and health or result in inappropriate, inefficient interventions to improve micronutrient status [14].

Information on dietary practices, dietary diversity and associated factors, and composition of foods of lactating mothers are urgently needed for prioritizing, designing and initiating intervention programs aiming at improving maternal and child nutrition. However, little is documented on maternal dietary practices, dietary diversity and the associated factors and composition of maternal foods in the study area. The objective of this study was therefore to assess the dietary practices, diversity, composition, and nutrient adequacy of diets of lactating mothers in Jimma zone, Southwest Ethiopia.

## Methods

### Setting and study design

The study was conducted in Southwest Ethiopia, Jimma zone. Three districts were purposively selected based on their agricultural production. Omo Nada, Dedo and Mana are cereal, vegetable and coffee producing areas, respectively. The survey was a community-based cross-sectional study.

### Participants, sample size and sampling technique

The study population included all lactating mothers in the study area. From these, 558 mothers were sampled following a stratified multistage sampling procedure [15]. On the first stage, the districts were stratified into lowland, midland and highland agroecology. Out of the 19 districts in the zone, three (1 Lowland, 1 Midland and 1 Highland) were selected purposively. The total kebeles (the smallest administrative unit of Ethiopia) in each district/woreda (the third level of the administrative division of Ethiopia—after zones and the regional states) were initially stratified into rural and urban areas. Then, three (two rural and one urban) were selected from the existing kebeles based on probability non-proportional to size sampling technique. A total of six rural and three urban kebeles were sampled from the three districts. In these selected kebeles, households with lactating mothers were systematically identified using the registration at the health posts (January 2014, post-harvest season which is dry). The calculated sample (558) was non-proportionally allocated to the selected districts (186 for each) then to the selected kebeles (62 for each kebele). A simple random sampling of the households was employed to recruit the study subjects. Sick mothers were excluded from the sample. Participants were recruited in February 2014.

### Variables

The variables involved in the analysis include socio-economic and demographic factors. These factors included family composition, age, household size, educational status of the mothers and fathers (formal vs. informal), the primary occupation of mothers and fathers, the wealth of the household and source of income, source of drinking water and availability of toilet facility, availability of health centres and education or training given on health and nutrition. Additionally, maternal dietary practices, maternal dietary diversity, nutrient compositions of maternal diets and nutrient adequacy of maternal diets were also involved in the analysis.

### Measurements

#### Socio-economic information

A wealth index was determined using principal component analyses based on data on assets encompassing land for agriculture, production of crops, ownership of animals and properties [16]. The index was rank divided into tertiles and used for further analyses.

#### Maternal practice of essential nutrition actions

The guideline on essential nutrition actions for healthy maternal nutrition during breastfeeding was followed to assess dietary practices of the mothers. Maternal knowledge and practice in use of insecticide-treated net, consumption of two additional meals in a day, consumption of a variety of food groups, daily use of iodized salt and family planning were assessed [17]. Semi-structured interviews were used to collect data on demographic, socio-economic and dietary practices.

#### Dietary diversity

A single 24-h dietary recall was used to obtain data on dietary diversity. Dietary diversity was assessed with the ten MDD-W food groups namely (1) Grains, white roots and tubers, and plantains, (2) Pulses (beans, peas and lentils), (3) Nuts and seeds (4) Dairy, (5) Meat, poultry and fish, (6) Eggs, (7) Dark green leafy vegetables, (8) Other vitamin A-rich fruits and vegetables, (9) Other vegetables and (10) Other fruits. One point was awarded for the consumption of each food group with a total possible score being 10. MDD-W was achieved if a mother consumed five or more food groups per day and respondents with mean of less than 5 food groups were considered as not achieving the MDD-W [18].

#### Nutrient composition of maternal diets

Based on the responses on maternal dietary practices, twelve customary foods consumed by the mothers were selected for composition analysis. Composite samples (a mixture of individual samples) were collected, dried, ground and packaged [19]. These samples were analysed for proximate composition (protein, fat, carbohydrate, moisture, ash and fibre), energy content, mineral (iron, zinc, calcium and phosphorous) and anti-nutritional factors (phytate and tannin) following the respective official methods of analysis [20].

#### Nutrient adequacy of maternal diets

According to Public Health Department of Georgia and World Health Organization, the average recommended portion per day is 550g/day, 450g/day and 175g/day for cereal, vegetable and legume food types, respectively for a healthy life [21]. Nutrient intake was calculated as a multiple of recommended portion per day and composition (proximate and mineral) of the food as indicated in the equation below.

 N u t r i e n t i n t a k e ( g d a y ) = R e c o m m e n d e d p o r t i o n ( g d a y ) * N u t r i e n t c o m p o s i t i o n ( g 100 g )

Nutrient adequacy ratio (NAR) was calculated as the ratio of a subject’s nutrient intake to the estimated average requirement calculated using the Food and Agriculture Organization/ World Health Organization recommended nutrient intakes for mothers [35]. The mean adequacy ratio (MAR) was calculated as the sum of NARs for all evaluated nutrients divided by the number of assessed nutrients, expressed as a percentage [22] as indicated in the equations below.

 N A R = A c t u a l i n t a k e o f a n u t r i e n t p e r d a y R e c o m m e n d e d D a i l y A l l o w a n c e o f t h e n u t r i e n t
 M A R = N A R ( e a c h t r u n c a t e d a t 1 ) N u m b e r o f n u t r i e n t s

### Statistical analysis

Data were entered, cleaned and then analyzed using SPSS version 20. Descriptive summaries using frequencies and proportions were used to present the study results. In this study, the dependent variable was dietary diversity coded one as lower dietary diversity and 0 as moderate or high dietary diversity. Descriptive statistics such as mean, median, range and percentages were calculated. Bivariate and multivariable logistic regression statistical analysis was carried out to determine the factors associated with diet diversity in lactating mothers. For all statistical analyses, a P value < 0.05 was considered for statistical significance.

### Ethics approval and consent to participate

Ethical clearance was obtained from the Research and Ethical Review Board of Jimma University. Permission to undertake the study was obtained from every relevant authority in Jimma Zone. Each study participant was briefed about the research and offered the opportunity to ask questions. Then oral informed consent was obtained from each participant before participation in the study, and data were kept confidential. The Ethical Review Board agreed to verbal consent as the study was not intervention. The data collection and consent process were randomly checked by the Ethical Review Board to ensure the ethical undertaking of the research.

## Results

### Characteristics of the sample

A total of 558 mothers who had children aged 0–24 months were interviewed, and all agreed to participate in the study, which made the response rate of 100%. The majority 372 (66.7) of the participants were from the rural part of the survey area, Muslims in religion 516 (92.5%), Oromo in ethnicity 486 (87.1%), married and living together 501 (89.8%) and 336 (60.2%) were uneducated. A large proportion of the families belong to lower middle class or socio-economic status because most of them were engaged in small business, and many 436 (78.1%) were housewives (Table 1).

Table 1
Maternal and household characteristics (Jimma Zone, Southwest Ethiopia 2014).
Characteristics N %
Maternal Age (Years)
15–19 26 4.7
20–29 360 64.5
30–39 161 28.9
40–49 11 2
Maternal education
Informal education 338 60.6
Formal education 220 39.4
Maternal Occupation
Housewife 436 78.1
Merchant 83 14.9
Other§ 39 7
Maternal Marital status
Single 33 5.9
Married 501 89.8
Separated 16 2.9
Widowed 5 0.9
Divorced 3 0.5
Religion
Muslim 516 92.5
Orthodox 33 5.9
Protestant 9 1.6
Residence
Rural 372 66.7
Urban 186 33.3
Number of children per mother
1–2 children 252 45.2
3 and above children 306 54.8
District
Coffee producing 186 33.3
Cereal producing 186 33.3
Vegetable producing 186 33.3
Family Size
2–4 Members 201 36
5–7 Members 254 45.5
8–9 Members 81 14.5
10 and Above Members 22 3.9
Socio-economic Status
Low 186 33.3
Medium 189 33.9
High 183 32.8
Husband’s education
Informal education 214 41.4
Formal education 303 58.6
Husband’s Occupation
Farmer 318 63.5
Daily Laborer 63 12.6
Merchant 59 11.8
Other$61 12.2 Primary source of household income Farming 347 62.2 Wage/Salary 111 19.9 Business 90 16.1 Salary 44 7.9 Other¥ 10 1.8 §Farmer, government employee, NGO employee, daily labourer$Government Employee, NGO Employee, daily labourer.
¥Pension, remittance, commission.

### Maternal practice of essential nutrition actions

The majority of the lactating mothers reported that they received the following health information: have two additional meals a day (84.1%), consume a variety of food groups (82.8%), use insecticide-treated net (94.4%), and family planning (97.5%). On the contrary, only 39.1% of the participants reported receiving information to take iodized salt daily. In practice, only 22.2% of the respondents consume two additional meals per day, 14.5% reported consumption of a variety of food groups during lactation, and 36% reported use of iodized salt daily. Two-third of the mothers (65.6%) used bed net to protect themselves from malaria, and 61.5% of the mothers reported practising family planning (Table 2).

Table 2
Maternal practice of essential nutrition actions during lactation in three districts of Jimma Zone, Southwest Ethiopia.
Variables Educated Practised
n % n %
Use insecticide-treated net 527 94.4 366 65.6
Consume two additional meals a day 469 84.1 124 22.2
Consume a variety of food groups 462 82.8 81 14.5
Daily use of iodized salt 218 39.1 201 36.0
Family planning 544 97.5 343 61.5

### Dietary diversity

Table 3 summarises the DDS and percentage of women consuming each of the ten food groups. Among the ten food groups, the mean ± SD DDS of the study participants was 3. 73±1.03: with a maximum score of 8 and a minimum score of 0. The majority of the participants (80.1%) did not achieve MDD-W whereas 19.9% have achieved MDD. Results of the 24-hour recall showed that almost all of the mothers consume starchy staples (99.1%) and nearly three-fourth (77.2%) of the mothers consume pulses. Only 13.4% of the participants consumed dairy products in the 24 hours before the survey, and only 2.3% of them consumed nuts and seeds while only 3.2% consumed other meat, poultry and fish and only 1.3% consumed eggs. Half (53.6%) of the respondents reported consumption of dark green leafy vegetables. The use of vitamin A-rich fruits and vegetables was low (3.4%). However, most of the respondents (89.4%) reported consumption of other vegetables.

Table 3
Dietary diversity score and percentage of women consuming each of the 10 food groups.
DDS
Mean 3.73
Median 4.0
SD 1.03
Minimum 0
Maximum 8
MDD-W N (%)
<5 food groups 447 (80.1)
≥5 food groups 111 (19.9)
Consumption N (%)
Grains, white roots and tubers, and plantains 553 (99.1)
Pulses (beans, peas and lentils) 431 (77.2)
Nuts and seeds 13 (2.3)
Dairy 75 (13.4)
Meat, poultry and Fish 18 (3.2)
Eggs 7 (1.3)
Dark green leafy vegetables 299 (53.6)
Other vitamin A-rich vegetables and fruits 58 (10.4)
Other vegetables 499 (89.4)
Other fruits 129 (23.1)

Table 4 shows the association between socio-demographic variables and maternal dietary diversity. Accordingly, dietary diversity score was significantly (P<0.01) affected by districts, residence area, ethnicity, husband’s educational level and the socio-economic situation of the household. Oromo mothers who live in cereal producing districts, living in poor households and whose husbands attended lower-level education were more likely not to achieve MDD-W as compared with their respective counterparts.

Table 4
Distribution of maternal dietary diversity by different variables in Jimma Zone, Southwest Ethiopia.
Variables  Did not achieve MDD-W Achieved MDD-W
n (%) n (%) P
Districts
Coffee producing 146 (78.5) 40 (21.5) 0.019*
Cereal producing 161 (86.6) 25 (13.4)
Vegetable producing 140 (75.3) 46 (24.7)
Ethnicity
Oromo 397 (81.7) 89 (18.3) 0.005*
Amhara 16 (80.0) 4 (20.0)
Guraghe 6 (75.0) 2 (25.0)
Yem 6 (40.0) 9 (60.0)
Other 22 (75.9) 7 (24.1)
Educational status of the woman
1 to 4 76 (78.4) 21 (21.6) 0.134
5 to 8 65 (76.5) 20 (23.5)
9 to 10 19 (65.5) 10 (34.5)
Preparatory/TVET 4 (44.4) 5 (55.6)
Diploma 1 (50.0) 1 (50.0)
Husband’s educational level
1 to 4 73 (83.9) 14 (16.1) 0.004*
5 to 8 132 (78.6) 36 (21.4)
9 to 10 26 (57.8) 19 (42.2)
Preparatory/TVET 17 (89.5) 2 (10.5)
Diploma 2 (50) 2 (50)
Place of residence
Rural 297 (79.8) 75 (20.2) 0.822
Urban 150 (80.6) 36 (19.4)
Socio-economic status
Poor 155 (83.3) 31 (16.7) 0.046*
Medium 154 (82.8) 32 (17.2)
Rich 138 (74.2) 111 (19.9)
* = Significant at the 0.05 level.

Multivariable logistic regression analyses are presented in Table 5. After adjusting for different variables, meeting MDD-W was positively associated with agricultural production diversity(P = 0.001) and educational level of the women (P = 0.04). For a unit increase in agricultural production diversity of the household, the likelihood of achieving MDD-W was 1.4 times higher (AOR: 1.394, 95%CI: 1.142, 1.701). Similar, for one level increase in the educational status of women the odds of achieving MDD-W were 1.5 times higher (AOR: 1.485, 95%CI: 1.018, 2.168).

Table 5
Multivariable logistic regression model predicting the likelihood of having MDD-W in Jimma Zone, Southwest Ethiopia.
Model B P AOR 95% C.I.
Lower Upper
District
Coffee producing (Mana) -0.211 0.599 0.810 0.369 1.779
Cereal producing (Omo Nada) -1.444 0.003 0.236 0.090 0.616
Vegetable producing (Dedo) 1.000
Food production diversity 0.332 0.001 1.394 1.142 1.701
Educational level of the women 0.396 0.040 1.485 1.018 2.168
Wealth tertile
Poor -0.732 0.154 0.481 0.176 1.317
Medium -1.013 0.062 0.363 0.125 1.052
Rich 1.000
Age of the woman (yrs) -0.065 0.135 0.937 0.861 1.020
Household has alternative income source -0.175 0.639 0.839 0.404 1.744
Place of residence,
Rural -1.263 0.019 0.283 0.099 0.810
Urban 1.00
Educational status of the husband 0.894 0.085 2.446 0.883 6.776
Household size 0.150 0.171 1.162 0.937 1.441
Production diversity: a score generated by summing the number of animal and plant source food that the household reported to produce.
Maximum Standard error: 0.543, Hosmer Lemeshow Test for Model Fitness (P = 0.052).
AOR: Adjusted Odds Ratio.
CI: Confidence Interval.

Conversely, district of the study (P = 0.003) and place of residence (P = 0.019) were negatively associated with meeting MDD-W. Women living in cereal producing (Omo Nada) District were 86% less likely to meet the MDD-W as compared to those who live in vegetable producing (Dedo) District (AOR: 0.236, 95%CI” 0.090, 0.616). Likewise, women who live in the rural areas were 72% less likely to meet the MDD-W as compared to those who live in the urban areas (AOR: 0.283, 95%CI: 0.099, 0.810).

### Nutrient composition of maternal diets

The proximate composition and calorific value of the sampled maternal foods ranged between 24.8–65.6g/100g for moisture, 7.6–19.8 g/100g for protein, 2.1–23.1 g/100g for crude fat, 2.0–27 g/100g crude fibre, 1.0–21.2 g/100g for total ash, 0.9–45.8 g/100g for total carbohydrate and 124.5–299.6Kcal/100g for energy content (Table 6). The mineral contents ranged between 9.5–52.5mg/100g for iron, 2.2–4.2mg/100g for zinc, 42.6–318.2mg/100g for calcium, and 150.7–379.9mg/100g for phosphorus. The content of anti-nutritional factors ranged between 11.1–178.9mg/100g for phytate and 3.7–315.9mg/100g for tannin (Table 7).

Table 6
The proximate and energy composition (dry weight basis) of sampled maternal foods in three districts of Jimma Zone, Southwest Ethiopia from March-May 2014.
Food types Protein Fat Carbohydrate Fibre Ash Energy
g/100g g/100g g/100g g/100g g/100g Kcal/100g
Lentil sauce 18.2 23.1 4.8 5.2 11.9 299.6
Bean sauce 19.8 17.5 10 5.3 11 276.5
Pea powder sauce 16.8 19. 8 2.2 4.3 16.9 254.2
Kale-bean sauce 19.6 6.5 0.9 27 21.2 140.5
Injera (T) 10.1 2.6 45.6 2.5 1.5 246
Injera (T+S) 10.7 2.8 43.8 2.2 1.8 243.5
Injera (T+M) 9.6 7.5 34.8 7.6 2.6 245.1
Injera (T+M+S) 9 3.3 39.2 12.2 2 222.3
Injera (T+S+R) 9.9 5.5 8.9 8 2.1 124.5
Unleavened bread (W+M) 10.8 2.1 45.8 2 1.2 245.2
Unleavened bread (M) 7.6 3.5 42.8 2 1 233.1
Unleavened bread (W) 11.5 3.5 33.3 2.1 1.5 210.5
RDA (g/day) § 65 69.1 210 21–25 NA 2750$T = Teff; S = Sorghum; M = Maize; R = Rice; W = Wheat; RDA = Recommended Daily Allowance. § [4]$ [23]; Unit for energy it is Kcal/day.
Table 7
The content of minerals and anti-nutritional factors (dry weight basis) of sampled maternal foods in three districts of Jimma Zone, Southwest Ethiopia.
Food types Iron Zinc Calcium Phosphorous Phytate Tannin
mg/100g mg/100g mg/100g mg/100g mg/100g mg/100g
Lentil sauce 20 3.4 0.2 0.3 92 14.17
Bean sauce 20.5 3.4 0.2 0.4 BDL 27.06
Pea powder sauce 27.6 4.2 0.3 0.3 11.06 65.26
Kale-bean sauce 24.8 2.8 0.1 0.3 47.65 205.05
Injera (T) 21.8 3.4 0.3 0.3 120.45 BDL
Injera (T+S) 39.7 3.2 0.2 0.4 145.01 81.64
Injera (T+M) 52.5 3.1 0.3 0.3 178.89 6.64
Injera (T+M+S) 39.4 2.7 0.2 0.4 121.61 315.85
Injera (T+S+R) 22 2.2 0.2 0.2 150.82 13.71
Unleavened bread (W+M) 9.5 2.2 0.1 0.3 80.21 3.71
Unleavened bread (M) 12.5 2.5 0.3 0.3 BDL 8.36
Unleavened bread (W) 20.7 3.8 0.2 0.3 55.17 5.46
RDA (mg/day) 10 12 1000 1000 NA NA
T = Teff; S = Sorghum; M = Maize; R = Rice; W = Wheat; BDL = Below Detectable Level.

### Nutrient adequacy of maternal diets for achieving maternal nutritional goals

Out of the twelve foods assessed in this study, most of the maternal diets do not provide the recommended daily allowances for protein, fat and energy (NAR<1). Most of the cereal-based foods contain sufficient minerals (NAR>1). The overall adequacy is less than 1 for all diets (MAR<1) (Table 8) which indicates the requirements for all the nutrients were not met.

Table 8
Adequacy of the maternal foods in nutrients for meeting dietary recommendations.
Food types P F CHO Fi Energy Fe Zn Ca P MAR
Lentil sauce 0.5 0.6 0.0 0.3 0.2 3.5 0.5 0.4 0.5 0.44
Bean sauce 0.5 0.4 0.1 0.3 0.2 3.6 0.5 0.4 0.7 0.45
Pea powder sauce 0.5 0.5 0.0 0.3 0.2 4.8 0.6 0.5 0.5 0.45
Kale-bean sauce 1.4 0.4 0.0 4.1 0.2 11.2 1.1 0.2 1.3 0.65
Injera (T) 0.9 0.2 1.2 0.5 0.5 12.0 1.5 1.8 1.9 0.78
Injera (T+S) 0.9 0.2 1.2 0.4 0.5 21.9 1.5 1.3 2.1 0.78
Injera (T+M) 0.8 0.6 0.9 1.4 0.5 28.9 1.4 1.7 1.8 0.86
Injera (T+M+S) 0.8 0.3 1.0 2.2 0.4 21.7 1.2 1.0 2.1 0.82
Injera (T+S+R) 0.8 0.4 0.2 1.5 0.3 12.1 1.0 1.0 0.8 0.73
Unleavened bread (W+M) 0.9 0.2 1.2 0.4 0.5 5.2 1.0 0.5 1.5 0.71
Unleavened bread (M) 0.6 0.3 1.1 0.4 0.5 6.9 1.2 1.5 1.5 0.75
Unleavened bread (W) 1.0 0.3 0.9 0.4 0.4 11.4 1.7 0.8 1.9 0.75
P = Protein; Fat = Fat; CHO = Carbohydrate; Fi = Fibre; Cal = Energy Content; Fe = Iron; Zn = Zinc; Ca = Calcium; P = Phosphorous. T = Teff; S = Sorghum; M = Maize; R = Rice; W = Wheat.

## Discussion

### Maternal practice of essential nutrition actions

The majority of the study participants did not change their previous food intake habit (quantity, quality and diversity) during lactation, which is in contrast to the recommendations in the essential nutrition actions to improve maternal health and nutrition [17]. It is known that a lactating mother should produce about 700 to 800ml of milk per day and this requires an additional energy need of about 550 calories (two extra meals) per day [2, 4, 24]. Our finding on the practice of consumption of iodized salt daily (36%) was lower than 76.3% reported in the capital city, Addis Ababa [25]. This might be due to the lesser accessibility of different media (FM radios and television) nearby for the target group in the study area.

### Dietary diversity

The women’s DDS was similar to those previously reported in Bangladeshi women as well as in women in Burkina Faso, Mali, Mozambique, Bangladesh, and the Philippines using the same definition of dietary diversity [26]. Mothers who live in the cereal producing district and rural villages, who are in 25–29 years age group, illiterate and poor mothers had lower DDS as compared with their respective counterparts. These results are in agreement with previous reports which indicated that there is a positive relationship between dietary diversity and diversified agricultural production and income from the agricultural product [27], and formal education to the mother [28]. Regarding the association between maternal age and DDS, a contradicting report has been documented from Nigeria where being young age was positively associated with dietary diversity [24]. In the coffee producing district, mothers could have enough money for household expenditure to buy various food commodities. They might have a diverse diet compared to mothers living in cereal producing regions. Therefore, the study participants highly rely on a few staple foods and often include little or no animal products and few fresh fruits and vegetables as compared to Dedo and Mana districts. This finding is consistent with previous reports [2729] who stated that diversified agricultural production and income from agricultural product market even in a more impoverished household has a positive relationship with dietary diversity. The variation in dietary diversity between vegetable and cereal producing districts indicates that households tend to consume what they have produced; perishables (vegetables) are more likely to be consumed by the producers than durables (cereals) as they spoil fast if not sold. Therefore, increasing the diversity of farm should be encouraged as one key strategy to improve diet diversity and quality [30].

Similarly, DDS was significantly different among lactating mothers living in urban and rural residences. A large proportion (59.1%) of mothers in the rural area showed a low DDS than an urban residential area. Previous findings by Ruel (2003) also indicated urban households had a consistently higher dietary diversity than rural households. Considering the fact that rural areas are hubs for agricultural production, one can assume rural women could be better in dietary diversity than urban counterparts. However, production diversification may not always mean dietary diversity. For example, a study in rural Nigeria found out that production diversification has no statistically significant effect on the dietary diversity of households [30]. Other researchers also argue that despite theoretical basis for the correlation between production diversity and dietary diversity, “there is a need for a deeper empirical understanding of how, under what circumstances, and through what pathways own-production of nutritious foods improves diets [31]”. Although in contrast, higher DDS was reported in the rural sector [28].

According to Ajani, educational status and household wealth were interrelated and had a positive association with dietary diversity [28]. Higher education attainment is likely to be associated with a higher income and thereby money to buy different food commodity for household food preparation.

### Composition of maternal diets

Considering the average recommended gram of portion per day, 550g/day, 450g/day and 175g/day for cereal, vegetable and legume food types, respectively, only kale sauce can fulfil the RDA for protein (17.33g/day) [4, 23]. Kale sauce is prepared by cooking onion and oil 4 to 5 minutes and adding chopped and cooked-until-soft kale, and stirring once or twice, for 10 minutes. During collection of food samples, we have observed that most households add protein rich ingredients like beans when making kale sauce, and the name kale sauce could be a misnomer. Only unleavened bread made of a blend of wheat and corn and Injera (Ethiopian traditional cereal-based pancake, prepared from fermented cereal sour dough) made of teff can fulfil the RDA for carbohydrate (250 g/day) [4]. Concerning the fibre content, four out of twelve food types fulfil the RDA. These are kale sauce, Injera made of teff, maize and sorghum, Injera made of teff, maize and rice and, Injera made of teff and maize [4, 23]. Even though there is no recommendation of ash for lactating mothers, it is known that as ash content (a measure of the total amount of minerals present within a food) is correlated with micronutrient content in that particular food type. Therefore, from the 12 food types analysed, kale sauce could provide relatively healthy micronutrients to the lactating mothers. Based on the recommended gram of portion for adults none of the 12 food types fulfils the RDA for fat (69.1 g/day) [4], and energy (2750 kcal/day) [23].

Among the mineral forms analysed, iron was predominantly found in all tested foods above the recommended amount (10mg/day). Except for lentil, bean and pea powder sauces, all the food types can fulfil the recommended daily allowance for zinc (12mg/day). All Injera types and the unleavened bread made of maize can fulfil the RDA for calcium (Ca). Except for lentil, bean and pea powder sauces and Injera made of blends of teff, sorghum, and rice, all the food types can fulfil the recommended daily allowance for P (1000mg/day) [4].

High phytate intakes and low fruit consumption may compromise iron, zinc, and to a lesser extent calcium status in these mothers [32]. Tannins had been reported to affect protein digestibility, adversely influencing the bioavailability of non-haem iron leading to poor iron and calcium absorption [33]. There is no recommendation or cut-off points for the availability of anti-nutritional factors in foods while reducing the anti-nutrition levels (e.g. dephytinization) to the best minimum using different strategies is advised [34] combined with enrichment with animal-source foods and/or fortification with appropriate levels and forms of mineral fortificants [35].

### Nutrient adequacy of maternal diets for achieving maternal nutritional goals

The ideal cut-off for nutrient adequacy should be 1, which would mean that all the nutrients were consumed in a sufficient amount [36]. In another way, the NAR for protein and calorific value/energy throughout the whole sampled food types were found to be below 1, which means that all the commonly eaten foods by lactating mothers were not sufficient to meet the protein and energy requirements. Protein from cereals is usually with relatively low digestibility and quality [37]. The consequences of low energy in the diets is the women suffer from chronic energy deficiency and will have poor nutritional status [2]. Lack of dietary diversification and the foods lack vegetables, fruits, and animal source food types [29]. The overall nutrient adequacy was different for the twelve types of food types. MAR was below the cut-off point for all food types.

As presented in Table 8, most of the food types had sufficient mineral content which had NAR above 1. These could be, from the supply side, because of Ethiopian foods, especially Injera , had a significantly high amount of minerals [2]. The other reason, from a demand side, could be since breastfeeding usually suppresses menstruation for a few months, lactating mothers iron requirement is decreased to 10 mg/day RDA [36]. Care should be taken in interpreting these results as bioaccessibility and bioavailability of minerals from plant-based foods is impaired [38].

### Limitations and strengths of the study

#### Limitation of the study

Recall bias might have occurred as information on maternal dietary practices were collected retrospectively. The 24-hour recall is prone to over and under-reporting of maternal dietary intakes. Dietary intakes of the mothers were not directly measured by using portion sizes as family members in Ethiopia consume food from a common plate. Ethiopia does not have a food guide; therefore we used the amount of recommended portions per day (in grams) for Georgia. Vitamin contents of the meals were not analysed. Ethiopia is a very diverse country in terms of food production and consumption culture, and this study may not be representative of the rest of the country. Additionally, the dietary data alone does not refer to bioavailability of the nutrients, which are influenced by the overall health of the mothers.

#### Strength of the study

Rigorous sampling methodology was used. An official food analysis methodology was employed to analyze the composition of undocumented maternal diets.

## Conclusions

Our study shows that lactating women in Southwest Ethiopia consume diets that lack sufficient nutrient-dense foods to achieve micronutrient adequacy. The dietary diversity of lactating mothers in the study area was not satisfactory. Kale sauce, which is traditionally popular in South and Southwest part of rural Ethiopia, tend to provide relatively healthy macro and micronutrients to the lactating mothers. A community-based nutritional education on food diversification and local processing techniques based on a multi-sectoral approach is needed to curb the problem of malnutrition among lactating mothers in the study area.

## Acknowledgements

We are grateful to the mothers for their participation and the health extension workers for their assistance. The authors also thank Ethiopian Public Health Institute for assisting in the nutrient analysis.

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12 Feb 2021

PONE-D-20-19141

Maternal dietary practices, dietary diversity, and nutrient composition of Diets of Lactating Mothers in Jimma Zone, Southwest Ethiopia

PLOS ONE

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Reviewers' comments:

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Partly

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: No

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Reviewer #1: Concerns that the data was collected about 6 years ago ie 2014

There are a few grammatical errors that should be reviewed in the manuscript and corrected - need to improve in certain parts on the English

There is reference in the abstract to "little stores" - I propose this be altered to minimal stores

Would have been good to make reference to the overall maternal mortality rate in Ethiopia including causes - and if any are related to nutritional deficiencies . More data on the general health of the subjects in the study would help

In mentioning the vulnerability of mothers to undernutrition in this context, would help to also mention the possibility of intergenerational cycles of malnutrition

Whilst most of the study participants were Muslim, I wondered the extent to which those who were christian were Orthodox Christians and could have still adhered to fasting regimes even during lactation - a comment on this aspect would be useful

In order to understand the food security, income and poverty dimension, it would help to know how many of the mothers resided in PSNP woredas/ kebelles and therefore may have been enrolled in this social protection scheme which could have influenced dietary diversity.

Whilst there is mention of consumption of iodised salt - at the time the survey data was collected the quality of iodised salt was very poor - with minimal levels

Under limitations I propose to include the fact that the dietary data alone does not refer to bioavailabilty of the nutrients which are influenced by the overall health of the mothers

Reviewer #2: Thank you for the opportunity to review this paper. My comments are as follows:

There are some minor issues with English throughout that need to be addressed. For example:

Line 169 "Majority" should be "The majority.."

Line 172 "When it comes to the practice.." should be "In practice.."

Line 210 "played its role for this" should be "played a role in this"

Line 214 "Majority" should be "The majority.."

Abstract: Line 17 "little stores" should perhaps be "low stores"

Line 27 DDS should be defined

Line 40 should be "nutrition education program"

Abstract is otherwise appropriate.

Introduction: Appropriate.

Methods: Maternal dietary practices section, line 109, what is meant by semi-structured questionnaires? Questionnaires are generally structured in nature - do the authors mean semi-structured interviews?

Line 115 to calculate DDS was 1 point awarded for the consumption of each food group with a total possible score being 9? This should be explained in the text.

Line 116-117 "greater than 3.4 mean food groups" This word is not correct and should be something like "a mean (or average) number of food groups greater than 3.4".

Line 117 "respondents with <3.4 mean food groups" is also not correct and should be "respondents with mean of less than 3.4 food groups..."

Line 121 Please clarify as to what composite samples are. Are they combined samples or just samples of each food individually?

Line 128 "gram of portion per day" is not clear. Should is just be "grams per day"?

Were t-test considered to compare means between groups?

Results:

Line 185 What is "organ" meat?

Line 190-191 sentence beginning "This study.." is not presenting results and should be removed.

Discussion: Line 215-216 is not clear and needs to be reworked.

Line 222 is not clear.

Line 232 could the authors please define what they mean by cash crop

Line 242, incorrect reference format for Ruel

Paragraph 240-244 is not clear e.g. what is "placed in the separate residence"?

Line 245 incorrect reference format for Ajani. Again, this paragraph is not clear.

Line 253, could the authors please describe what injera is. For example, is it like bread?

Line 257 please indicate what is meant by ash.

Line 266 has Ca been previously defined (it is assumed this is calcium?)

Line 251 - kale sauce has been highlighted specifically in the discussion but has not been described previously. It would be of benefit to describe how kale sauce is used, or what part it plays in the diet prior to this.

Limitations - appropriate although how representative is this study of the rest of Ethiopia? Strengths - I am unclear how this is a strength. This is an outcome from the study but the methodology undertaken to achieve this is the strength.

Conclusions:

Line 307-308 this sentence is not clear and should be reworked.

Table 4 - why was 0.01 used as the p value when .05 is the standard and this is stated in line 147.

Other tables appropriate although only descriptive in nature

Reviewer #3: While the topic of the study has public health importance, masurement approaches, the tools and the data analysis is not scientifically sounding. Despite the result section and conclusion attempted to note the variables associated with low dietary diversity there is no a strong method of data analysis to test the hypothesis. The study used simple chi-square which simply allows us to see the precence or absence of any association between two variables at a time. This does not help us to know which variable is cause and which is an effect? In what magnitude? In what direction (favoring or not).

Another concern is, construction of survey questionnaire has not been clearly stated and its reliability and validity are not presented. For example, measuring socioeconomic class, educational status etc was not clear.

Including different agroecological areas in this study could be taken as one of the strengths. However, it is true that dietary diversity could vary seasonally, and the study has not mentioned the season(s) when the study was undertaken.

Reviewer #4: Consideration of the nutrient needs of lactating women is an important topic, particularly as longer periods of lactation are being recommended.

An important reference that the authors will want to consider is: FAO and FHI 360. 2016. Minimum Dietary Diversity for Women: a Guide for Measurement. Rome: FAO. The MDD-W has been utilized and validated by several groups. The MDD-W presented in this publication outlines 10 food groups (which are not the same as those specified in this manuscript. And it specifies a cut-off of ≥5 food groups.

There are several inconsistencies in the manuscript that the authors must address. Some, but not all, of these inconsistencies are included in the following points:

L. 22-23 says the average MDD-W was computed from two 24-h recalls, while L. 112 says a single 24-h dietary recall….

The nine food groups listed on L. 113 -115 are not the same as the FAO publication nor are they identical to the food groups listed in Table 3 of this manuscript.

L. 88-89 says kebeles were sampled from the three selected districts by lottery method. If only by lottery, there could have been 0 to 3 urban kebeles selected from one district. Please clarify the sampling procedure.

L. 127. The document from the Public Health Department of Georgia and World Health Organization (2015) seems to be a report for the general public about healthy eating. Are the recommended grams of portion per day given as dry weight or wet weight. How were these portion sizes adjusted for the calculations in this paper?

L. 135 mentions the FAO/WHO RNI intakes for mothers. L. 139 specifies division by the RDA. The RNI and the RDA typically are not the same. RDA appears also on Table 5&6.

L. 180. Does the Dietary score of zero represent a woman who was fasting??

L. 210 Fermentation is very likely to increase the bioavailability of Zn, Fe, and perhaps Ca, but usual laboratory analyses and food composition tables show total mineral concentration not bioavailable mineral concentrations.

L. 222. What is meant by different media?

While it is clear that diet diversity was poor and food intakes were inadequate, it is not always clear which differences among the three areas were significantly different from each other. On Table 4, overall differences are shown between “low” and “moderate or high” by chi-square. In L. 224-235 which of the differences described are significantly different when there are more than two categories for a variable?

A supplementary table is needed to describe the ingredients (recipe) in lentil sauce, bean sauce, pea powder sauce and kale sauce. Particularly for a sauce based on kale, it is hard to imagine a protein concentration of 19.6 g/100 g.

There has been work published on phytate and bioavailability (Food & Nutrition Bulletin, 2010) that the authors might find useful.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

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7 Apr 2021

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Partly

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: No

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1:

Reviewer 1 comment 1:

Concerns that the data was collected about 6 years ago ie 2014

Authors' response 1:

That is true.

Reviewer 1 comment 2:

There are a few grammatical errors that should be reviewed in the manuscript and corrected - need to improve in certain parts on the English.

Authors' response 2:

Language edition is done using a premium subscription of Grammarly (a digital writing assistance tool based on artificial intelligence and natural language processing). See revised manuscript.

Reviewer 1 comment 3:

There is reference in the abstract to "little stores" - I propose this be altered to minimal stores

Authors' response 3:

Line 24: Corrected as suggested by the reviewer.

Reviewer 1 comment 4:

Would have been good to make reference to the overall maternal mortality rate in Ethiopia including causes - and if any are related to nutritional deficiencies. More data on the general health of the subjects in the study would help

Authors' response 4:

Lines 68-70: The following sentence is added to show the relation between nutritional deficiencies and maternal mortality.

“Ethiopia experiences one of the highest incidences of child and maternal nutritional deficiencies which contribute to increased morbidity and mortality (Central Statistical Agency [Ethiopia] & ICF International, 2012).”

Reviewer 1 comment 5:

In mentioning the vulnerability of mothers to undernutrition in this context, would help to also mention the possibility of intergenerational cycles of malnutrition

Authors' response 5:

Lines 70-72: The following sentence is added:

“A malnourished mother will give birth to a low birth weight baby; the low birth weight baby will grow as a malnourished child, then to a malnourished teenager, then to a malnourished pregnant woman, and so the cycle continues (10).”

Lines 471-473: The following reference was added to the reference list:

“Ramakrishnan U, Martorell R, Schroeder DG, Flores R. Role of intergenerational effects on linear growth. In: Journal of Nutrition [Internet]. American Institute of Nutrition; 1999 [cited 2021 Mar 25]. Available from: https://pubmed.ncbi.nlm.nih.gov/10064328/”

Reviewer 1 comment 6:

Whilst most of the study participants were Muslim, I wondered the extent to which those who were christian were Orthodox Christians and could have still adhered to fasting regimes even during lactation - a comment on this aspect would be useful

Authors' response 6:

Out of 558 participants, there were 42 Christian participants in the study out of which 33 (78.5%) were Orthodox Christians. However, there was neither fasting nor feasting when we undergone the survey.

Reviewer 1 comment 7:

In order to understand the food security, income and poverty dimension, it would help to know how many of the mothers resided in PSNP woredas/ kebelles and therefore may have been enrolled in this social protection scheme which could have influenced dietary diversity.

Authors' response 7:

Only chronically food insecure districts (woredas) are enrolled in PSNP. None of our study districts were in this social protection scheme.

Reviewer 1 comment 8:

Whilst there is mention of consumption of iodised salt - at the time the survey data was collected the quality of iodised salt was very poor - with minimal levels

Authors' response 8:

What we meant by the sentences in lines 312-315 is the consumption of iodized salt in the study area is very low compared to other areas of the country where media coverage (radio and television) coverage is wider.

Reviewer 1 comment 9:

Under limitations I propose to include the fact that the dietary data alone does not refer to bioavailabilty of the nutrients which are influenced by the overall health of the mothers

Authors' response 9:

Lines 400-402: The following sentence was added as suggested by the reviewer:

“Additionally, the dietary data alone does not refer to bioavailability of the nutrients, which are influenced by the overall health of the mothers.”

Reviewer #2:

Thank you for the opportunity to review this paper. My comments are as follows:

Reviewer 2 comment 1:

There are some minor issues with English throughout that need to be addressed. For example:

Line 169 "Majority" should be "The majority.."

Authors' response 1:

Line 191: “Majority…” is changed to “The majority…”

Line 200: “Majority…” is changed to “The majority…”

The English was edited by a premium version of Grammarly.

Reviewer 2 comment 2:

Line 172 "When it comes to the practice.." should be "In practice.."

Authors' response 2:

Lines 203-204: Modified as suggested by the reviewer

Reviewer 2 comment 3:

Line 210 "played its role for this" should be "played a role in this"

Authors' response 3:

Line 297: The phrase “fermentation is believed to have played its role for this” is deleted as it is out of context.

Reviewer 2 comment 4:

Line 214 "Majority" should be "The majority.."

Authors' response 4:

Line 306: “Majority…” is changed to “The majority…”

Reviewer 2 comment 5:

Abstract: Line 17 "little stores" should perhaps be "low stores"

Authors' response 5:

Line 24: "little stores" is changed to "minimal stores"

Reviewer 2 comment 6:

Line 27 DDS should be defined

Authors' response 6:

Line 36: “DDS” was changed to “dietary diversity score (DDS)”

Reviewer 2 comment 7:

Line 40 should be "nutrition education program"

Authors' response 7:

Line 53: Corrected as suggested by the reviewer

Reviewer 2 comment 8:

Abstract is otherwise appropriate.

Authors' response 8:

Ok

Reviewer 2 comment 9:

Introduction: Appropriate.

Authors' response 9:

Ok

Reviewer 2 comment 10:

Methods: Maternal dietary practices section, line 109, what is meant by semi-structured questionnaires? Questionnaires are generally structured in nature - do the authors mean semi-structured interviews?

Authors' response 10:

Line 130: “questionnaires” is changed to “interviews”

Reviewer 2 comment 11:

Line 115 to calculate DDS was 1 point awarded for the consumption of each food group with a total possible score being 9? This should be explained in the text.

Authors' response 11:

Lines 142 - 143: The following sentence is added as suggested by the reviewer:

“One point was awarded for the consumption of each food group with a total possible score being 10.”

NB. As suggested by another reviewer, the FAO & FHI 360, 2016 methodology, which is based on 10 food groups, was used to recalculate the dietary diversity of the women.

Reviewer 2 comment 12:

Line 116-117 "greater than 3.4 mean food groups" This word is not correct and should be something like "a mean (or average) number of food groups greater than 3.4".

Authors' response 12:

Line 144-: corrected as suggested by the reviewer:

“mean number of food groups greater than 5”

NB. According to the FAO & FHI 360, 2016 methodology, which is based on 10 food groups, the cut-off is >5 food groups.

Reviewer 2 comment 13:

Line 117 "respondents with <3.4 mean food groups" is also not correct and should be "respondents with mean of less than 3.4 food groups..."

Authors' response 13:

Line 145: corrected as suggested by the reviewer:

“respondents with mean of less than 3.4 food groups”

Reviewer 2 comment 14:

Line 121 Please clarify as to what composite samples are. Are they combined samples or just samples of each food individually?

Authors' response 14:

Line 149-150: The following phrase was added to explain what composite samples mean.

“(a mixture of individual samples)”

Reviewer 2 comment 15:

Line 128 "gram of portion per day" is not clear. Should is just be "grams per day"?

Authors' response 15:

Line 156: corrected as follows.

“recommended portion per day”

Line 158: corrected as follows.

“recommended portion per day”

Reviewer 2 comment 16:

Were t-test considered to compare means between groups?

Authors' response 16:

We did not understand this comment. We did not conduct a t-test to compare means between groups.

Reviewer 2 comment 17:

Results:

Line 185 What is "organ" meat?

Authors' response 17:

Line 138; Line 221: organ meat is deleted from the manuscript as it is not included in the FAO & FHI 360 (2016)´s ten food groups.

Reviewer 2 comment 18:

Line 190-191 sentence beginning "This study.." is not presenting results and should be removed.

Authors' response 18:

Line 231-232: The following sentence is deleted:

“This study showed the distribution of dietary diversity over different influencing factors.”

Reviewer 2 comment 19:

Discussion: Line 215-216 is not clear and needs to be reworked.

Authors' response 19:

Lines 306-309: The sentence was revised in order to improve clarity.

“…food intake habit (quantity, quality and diversity) during lactation, which is in contrast to the recommendations in the essential nutrition actions…”

Reviewer 2 comment 20:

Line 222 is not clear.

Authors' response 20:

Line 314: the following phrase is added to explain what media refers to.

“(FM radios and television)”

Reviewer 2 comment 21:

Line 232 could the authors please define what they mean by cash crop

Authors' response 21:

Line 324: The following word is added to explain what cash crop meant in this study’s context:

“(coffee)”

Reviewer 2 comment 22:

Line 242, incorrect reference format for Ruel

Authors' response 22:

Line 334: “(Ruel, 2003)” changed to “Ruel (2003)”

Reviewer 2 comment 23:

Paragraph 240-244 is not clear e.g. what is "placed in the separate residence"?

Authors' response 23:

Line 332-333: "placed in the separate residence" is replaced with “living in urban and rural residences”

Reviewer 2 comment 24:

Line 245 incorrect reference format for Ajani. Again, this paragraph is not clear.

Authors' response 24:

Line 337: “(Ajani, 2010)” is changed to “Ajani (2010)”

Line 337-340: The paragraph is revised as follows:

“According to Ajani (2010) educational status and household wealth were interrelated and had a positive association with dietary diversity. Higher education attainment is likely to be associated with a higher income and thereby money to buy different food commodity for household food preparation.”

Reviewer 2 comment 25:

Line 253, could the authors please describe what injera is. For example, is it like bread?

Authors' response 25:

Line 349-350: The following phrase is added to describe what Injera is.

“(Ethiopian traditional cereal-based pancake, prepared from fermented cereal sour dough)”

Reviewer 2 comment 26:

Line 257 please indicate what is meant by ash.

Authors' response 26:

Lines 354-355: The following phrase is added to explain what ash content means:

“a measure of the total amount of minerals present within a food”

Reviewer 2 comment 27:

Line 266 has Ca been previously defined (it is assumed this is calcium?)

Authors' response 27:

Line 363: corrected as follows:

“calcium (Ca)”

Reviewer 2 comment 28:

Line 251 - kale sauce has been highlighted specifically in the discussion but has not been described previously. It would be of benefit to describe how kale sauce is used, or what part it plays in the diet prior to this.

Authors' response 28:

Line 345-348: the following sentence is added to describe how kale sauce is used:

“Kale sauce is prepared by cooking onion and oil 4 to 5 minutes and adding chopped and cooked-until-soft kale, and stirring once or twice, for 10 minutes. During our survey we have observed that most households add protein rich ingredients like beans when making kale sauce.”

Reviewer 2 comment 29:

Limitations - appropriate although how representative is this study of the rest of Ethiopia?

Authors' response 29:

Lines 399-400: The following limitation statement is added as suggested by the reviewer.

“Ethiopia is a very diverse country in terms of food production and consumption culture, and this study may not be representative of the rest of the country.”

Reviewer 2 comment 30:

Strengths - I am unclear how this is a strength. This is an outcome from the study but the methodology undertaken to achieve this is the strength.

Authors' response 30:

Lines 404-405: The sentence was rewritten as follows:

“An official food analysis methodology was employed to analyze the composition of undocumented maternal diets.”

Reviewer 2 comment 31:

Conclusions:

Line 307-308 this sentence is not clear and should be reworked.

Authors' response 31:

Lines 410-412: The sentence is revised as follows:

“Kale sauce, which is traditionally popular in South and Southwest part of rural Ethiopia, tend to provide relatively healthy macro and micronutrients to the lactating mothers.”

Reviewer 2 comment 32:

Table 4 - why was 0.01 used as the p value when .05 is the standard and this is stated in line 147.

Authors' response 32:

Line 246: corrected as suggested by the reviewer.

Reviewer 2 comment 33:

Other tables appropriate although only descriptive in nature

Authors' response 33:

Lines 257-263: A new table is added:

“Table 5. Multivariable logistic regression model predicting the likelihood of having Minimum Dietary diversity (MDD-W) among women in Jimma Zone, Southwest Ethiopia”

Reviewer #3:

Reviewer 3 comment 1:

While the topic of the study has public health importance, measurement approaches, the tools and the data analysis is not scientifically sounding. Despite the result section and conclusion attempted to note the variables associated with low dietary diversity there is no a strong method of data analysis to test the hypothesis. The study used simple chi-square which simply allows us to see the presence or absence of any association between two variables at a time. This does not help us to know which variable is cause and which is an effect? In what magnitude? In what direction (favoring or not).

Authors' response 1:

Line 174-175:

“Chi-square test was used to see the association between dietary diversity and socio-economic and demographic variables.”

was changed to

“Bivariate and multivariate logistic regression statistical analysis was carried out to determine the factors associated with diet diversity in lactating mothers.”

Lines 249-271: The following results of multivariate logistic regression were added:

“On multivariable logistic regression analyses presented in Table 5, after adjusting for different variables, meeting Minimum dietary diversity (MDDS) of women was positively associated with agricultural production diversity(P=0.001) and grade of the women(P=0.04). For a unit increase in agricultural production diversity of the household, the likelihood of achieving minimum dietary diversity of women was 1.4 times higher (AOR: 1.394, 95%CI: 1.142, 1.701). Similar, for one grade increase in the educational status of women the odds of achieving minimum, dietary diversity was 1.5 times higher( AOR: 1.485, 95%CI: 1.018, 2.168).

Table 5. Multivariable logistic regression model predicting the likelihood of having Minimum Dietary diversity (MDD-W) among women in Jimma Zone, Southwest Ethiopia

Model B P AOR 95% C.I.

Lower Upper

District

Manna -0.211 0.599 0.810 0.369 1.779

Omo-nada -1.444 0.003 0.236 0.090 0.616

Dedo 1.000

Food Production diversity 0.332 0.001 1.394 1.142 1.701

Grade of the women 0.396 0.040 1.485 1.018 2.168

Wealth Tertitle

Poor -0.732 0.154 0.481 0.176 1.317

Medium -1.013 0.062 0.363 0.125 1.052

Rich 1.000

Age of the woman(yrs) -0.065 0.135 0.937 0.861 1.020

Household has alternative income source -0.175 0.639 0.839 0.404 1.744

Place of residence,

Rural -1.263 0.019 0.283 0.099 0.810

Urban 1.00

Educational status of the husband 0.894 0.085 2.446 0.883 6.776

Household size 0.150 0.171 1.162 0.937 1.441

Production diversity: a score generated by summing the number of animal and plant source food that the household reported to produce.

Maximum Standard error: 0.543, Hosmer Lemeshow Test for Model Fitness (P=0.052).

AOR: Adjusted Odds Ratio.

CI: Confidence Interval.

Conversely, district of the study (P=0.003) and place of residence (P= 0.019 ) were negatively associated with meeting minimum dietary diversity. Women living in Omo-Nada District were 86% less likely to meet the minimum dietary diversity as compared to this who live in Dedo District( AOR: 0.236, 95%CI” 0.090, 0.616). Likewise, women who live in the rural areas were 72% less likely to meet the minimum dietary diversity as compared to those who live in the urban areas (AOR: 0.283, 95%CI: 0.099, 0.810).”

Reviewer 3 comment 2:

Another concern is, construction of survey questionnaire has not been clearly stated and its reliability and validity are not presented. For example, measuring socioeconomic class, educational status etc was not clear.

Authors' response 2:

Line 29-30

“pre-tested and”

Line 121-124: the following paragraph was added to describe how the wealth index was calculated:

“Socio-economic information

A wealth index was determined using principal component analyses based on data on assets encompassing land for agriculture, production of crops, ownership of animals and properties (Garenne & Hohmann-Garenne, 2003). The index was rank divided into tertiles and used for further analyses.”

Line 492-493: The following reference is added to the reference list:

Garenne M, Hohmann-Garenne S (2003) A wealth index to screen high-risk families: Application to Morocco. J Heal Popul Nutr 21:235–242

Reviewer 3 comment 3:

Including different agroecological areas in this study could be taken as one of the strengths. However, it is true that dietary diversity could vary seasonally, and the study has not mentioned the season(s) when the study was undertaken.

Authors' response 3:

Line 107: The following phrase is added to indicate the season of the study:

“post-harvest season which is dry”

Reviewer #4:

Reviewer 4 comment 1:

Consideration of the nutrient needs of lactating women is an important topic, particularly as longer periods of lactation are being recommended.

Authors' response 1:

Ok

Reviewer 4 comment 2:

An important reference that the authors will want to consider is: FAO and FHI 360. 2016. Minimum Dietary Diversity for Women: a Guide for Measurement. Rome: FAO. The MDD-W has been utilized and validated by several groups. The MDD-W presented in this publication outlines 10 food groups (which are not the same as those specified in this manuscript. And it specifies a cut-off of ≥5 food groups.

Authors' response 2:

We accepted the reviewer's comments and corrected the dietary diversity related information in the manuscript accordingly.

Lines 133-146:

“A single 24-h dietary recall was used to obtain data on dietary diversity. Dietary diversity was assessed with the ten MDD-W food groups namely (1) Grains, white roots and tubers, and plantains, (2) Pulses (beans, peas and lentils), (3) Nuts and seeds (4) Dairy, (5) Meat, poultry and fish, (6) Eggs, (7) Dark green leafy vegetables, (8) Other vitamin A-rich fruits and vegetables, (9) Other vegetables and (10) Other fruits. One point was awarded for the consumption of each food group with a total possible score being 10. Minimum dietary diversity was found to be achieved when a mother consumed mean number of food groups greater than 5 per day and respondents with mean of less than 5 food groups were considered as not achieving the minimum dietary diversity (FAO & FHI 360, 2016).”

Lines 209-263: The dietary diversity results were revised as follows:

Lines 226-227: Table 3 was revised following the FAO & FHI 360, 2016 methodology:

Table 3 Dietary diversity score and percentage of women consuming each of the 9 food groups

DDS

Mean 3.73

Median 4.0

SD 1.03

Minimum 0

Maximum 8

Minimum Dietary Diversity for Women of Reproductive Age N (%)

<5 food groups 447 (80.1)

≥5 food groups 111 (19.9)

Consumption N (%)

Grains, white roots and tubers, and plantains 553 (99.1)

Pulses (beans, peas and lentils) 431 (77.2)

Nuts and seeds 13 (2.3)

Dairy 75 (13.4)

Meat, poultry and Fish 18 (3.2)

Eggs 7 (1.3)

Dark green leafy vegetables 299 (53.6)

Other vitamin A-rich vegetables and fruits 58 (10.4)

Other vegetables 499 (89.4)

Other fruits 129 (23.1)

Lines 230-238: The presence or absence of any association between MDD and socio-economic and demographic variables at a time was revised according to the FAO & FHI 360, 2016 methodology.

“Table 4 shows the association between socio-demographic variables and maternal dietary diversity. Accordingly, dietary diversity score was significantly (P<0.01) affected by districts, residence area, ethnicity, whether the woman is currently attending education or not, husband’s grade and the socio-economic situation of the household. Oromo mothers who live in cereal producing districts, who are not currently attending education, living in poor households and whose husband attended lower grade education were more likely not to achieve MDD as compared with their respective counterparts.”

Lines 244-246: Table 4 was revised accordingly:

Table 4 Distribution of maternal dietary diversity by different variables in Jimma Zone, Southwest Ethiopia

Variables

Did not achieve MDD Achieved MDD

n (%) n (%) P

Districts

Cash crop 146 (78.5) 40 (21.5) 0.019*

Cereal 161 (86.6) 25 (13.4)

Vegetable 140 (75.3) 46 (24.7)

Ethnicity

Oromo 397 (81.7) 89 (18.3) 0.005*

Amhara 16 (80.0) 4 (20.0)

Guraghe 6 (75.0) 2 (25.0)

Tigre 2 (66.7) 1 (33.3)

Yem 6 (40.0) 9 (60.0)

Other 20 (76.9) 6 (23.1)

Educational status of the woman

1 to 4 76 (78.4) 21 (21.6) 0.134

5 to 8 65 (76.5) 20 (23.5)

9 to 10 19 (65.5) 10 (34.5)

Preparatory/TVET 4 (44.4) 5 (55.6)

Diploma 1 (50.0) 1 (50.0)

Currently attending education

No 446 (80.5) 108 (19.5) 0.006*

Yes 1 (25.0) 3 (75.0)

Husband's grade

1 to 4 73 (83.9) 14 (16.1) 0.004*

5 to 8 132 (78.6) 36 (21.4)

9 to 10 26 (57.8) 19 (42.2)

Preparatory/TVET 17 (89.5) 2 (10.5)

diploma 2 (50) 2 (50)

Place of residence

Rural 297 (79.8) 75 (20.2) 0.822*

Urban 150 (80.6) 36 (19.4)

Socio-economic status

Poor 155 (83.3) 31 (16.7) 0.046*

Medium 154 (82.8) 32 (17.2)

Rich 138 (74.2) 111 (19.9)

*=Significant at the 0.05 level

Line 496-498: The following reference was added to the list:

“FAO, FHI 360. Minimum Dietary Diversity for Women: A Guide for Measurement [Internet]. Rome: FAO; 2016 Feb [cited 2021 Mar 15]. Available from: http://www.fao.org/documents/card/en/c/cb3434en”

Reviewer 4 comment 3:

There are several inconsistencies in the manuscript that the authors must address. Some, but not all, of these inconsistencies are included in the following points:

L. 22-23 says the average MDD-W was computed from two 24-h recalls, while L. 112 says a single 24-h dietary recall….

Authors' response 3:

Line 30-31: The reviewer is correct. The sentence was corrected accordingly.

“Minimum diet diversity (MDD-W) was computed from a single 24-h recall.”

Reviewer 4 comment 4:

The nine food groups listed on L. 113 -115 are not the same as the FAO publication nor are they identical to the food groups listed in Table 3 of this manuscript.

Authors' response 4:

Line 134-137: The food groups are revised according to FAO & FHI 360 (201

).

“(1) Grains, white roots and tubers, and plantains, (2) Pulses (beans, peas and lentils), (3) Nuts and seeds (4) Dairy, (5) Meat, poultry and fish, (6) Eggs, (7) Dark green leafy vegetables, (8) Other vitamin A-rich fruits and vegetables, (9) Other vegetables and (10) Other fruits”

Line 226-227: Table 3 is revised according to FAO & FHI 360 (2016).

Reviewer 4 comment 5:

L. 88-89 says kebeles were sampled from the three selected districts by lottery method. If only by lottery, there could have been 0 to 3 urban kebeles selected from one district. Please clarify the sampling procedure.

Authors' response 5:

Lines 100-104: The sampling method of the kebeles is revised as follows:

“The total kebeles in each woreda were initially stratified into rural and urban areas. Then, three (two rural and one urban) were selected from the existing kebeles based on Probability Proportional to Size (PPS) sampling technique. A total of six rural and three urban kebeles were sampled from the three districts.”

Reviewer 4 comment 6:

L. 127. The document from the Public Health Department of Georgia and World Health Organization (2015) seems to be a report for the general public about healthy eating. Are the recommended grams of portion per day given as dry weight or wet weight. How were these portion sizes adjusted for the calculations in this paper?

Authors' response 6:

We acknowledged, as a limitation of our study that the Public Health Department of Georgia and World Health Organization (2015) report is for the general public about healthy eating and may not directly fit to lactating mothers. The grams of portion per day presented in the Georgia report are given on wet basis. While our food composition results are given on dry weight basis. Because nutrients are found in the dry matter portion of foods, the physical quantity of nutrients will NOT change when water is added or removed.

Reviewer 4 comment 7:

L. 135 mentions the FAO/WHO RNI intakes for mothers. L. 139 specifies division by the RDA. The RNI and the RDA typically are not the same. RDA appears also on Table 5&6.

Authors' response 7:

The definition of RNI used in FAO/WHO report is equivalent to that of recommended dietary allowance (RDA) as used by the Food and Nutrition Board of the US National Academy of Sciences#.

#Food and Nutrition Board, Institute of Medicine. 1997. Dietary Reference Intakes: Washington, DC, National Academy Press.

Reviewer 4 comment 8:

L. 180. Does the Dietary score of zero represent a woman who was fasting??

Authors' response 8:

We suspect a recall bias. There was neither fasting nor feasting when we undergone the survey.

Reviewer 4 comment 9:

L. 210 Fermentation is very likely to increase the bioavailability of Zn, Fe, and perhaps Ca, but usual laboratory analyses and food composition tables show total mineral concentration not bioavailable mineral concentrations.

Authors' response 9:

Line 297: deleted the following phrase as does not fit to the context.

“and fermentation is believed to have played a role in this”

Reviewer 4 comment 10:

L. 222. What is meant by different media?

Authors' response 10:

Line 314: the following phrase is added to explain what media refers to.

“(FM radios, television)”

Reviewer 4 comment 11:

While it is clear that diet diversity was poor and food intakes were inadequate, it is not always clear which differences among the three areas were significantly different from each other. On Table 4, overall differences are shown between “low” and “moderate or high” by chi-square. In L. 224-235 which of the differences described are significantly different when there are more than two categories for a variable?

Authors' response 11:

Line 249-271: The following multivariate analysis result is added to the revised manuscript.

“On multivariable logistic regression analyses presented in Table 5, after adjusting for different variables, meeting Minimum dietary diversity (MDDS) of women was positively associated with agricultural production diversity(P=0.001) and grade of the women(P=0.04). For a unit increase in agricultural production diversity of the household, the likelihood of achieving minimum dietary diversity of women was 1.4 times higher (AOR: 1.394, 95%CI: 1.142, 1.701). Similar, for one grade increase in the educational status of women the odds of achieving minimum, dietary diversity was 1.5 times higher( AOR: 1.485, 95%CI: 1.018, 2.168).

Table 5. Multivariable logistic regression model predicting the likelihood of having Minimum Dietary diversity (MDD-W) among women in Jimma Zone, Southwest Ethiopia

Model B P AOR 95% C.I.

Lower Upper

District

Manna -0.211 0.599 0.810 0.369 1.779

Omo-nada -1.444 0.003 0.236 0.090 0.616

Dedo 1.000

Food Production diversity 0.332 0.001 1.394 1.142 1.701

Grade of the women 0.396 0.040 1.485 1.018 2.168

Wealth Tertitle

Poor -0.732 0.154 0.481 0.176 1.317

Medium -1.013 0.062 0.363 0.125 1.052

Rich 1.000

Age of the woman(yrs) -0.065 0.135 0.937 0.861 1.020

Household has alternative income source -0.175 0.639 0.839 0.404 1.744

Place of residence,

Rural -1.263 0.019 0.283 0.099 0.810

Urban 1.00

Educational status of the husband 0.894 0.085 2.446 0.883 6.776

Household size 0.150 0.171 1.162 0.937 1.441

Production diversity: a score generated by summing the number of animal and plant source food that the household reported to produce.

Maximum Standard error: 0.543, Hosmer Lemeshow Test for Model Fitness (P=0.052).

AOR: Adjusted Odds Ratio.

CI: Confidence Interval.

Conversely, district of the study (P=0.003) and place of residence (P= 0.019) were negatively associated with meeting minimum dietary diversity. Women living in Omo-Nada District were 86% less likely to meet the minimum dietary diversity as compared to this who live in Dedo District( AOR: 0.236, 95%CI” 0.090, 0.616). Likewise, women who live in the rural areas were 72% less likely to meet the minimum dietary diversity as compared to those who live in the urban areas (AOR: 0.283, 95%CI: 0.099, 0.810).”

Reviewer 4 comment 12:

A supplementary table is needed to describe the ingredients (recipe) in lentil sauce, bean sauce, pea powder sauce and kale sauce. Particularly for a sauce based on kale, it is hard to imagine a protein concentration of 19.6 g/100 g.

Authors' response 12:

A supplementary file which indicates the type of stews consumed and ingredients of the stews is included. See Supporting information 2.spv.

Line 586: The following caption is added to describe the supporting information files:

“Supporting information 2: Type of stews consumed and ingredients of the stews”

Line 347-348: The following sentence is added as a possible explanation for the high protein content recorded for kale sauce.

“During our survey we have observed that most households add protein rich ingredients like beans when making kale sauce.”

Reviewer 4 comment 13:

There has been work published on phytate and bioavailability (Food & Nutrition Bulletin, 2010) that the authors might find useful.

Authors' response 13:

Line 370: The following word is added:

“(e.g. dephytinization)”

Lines 371-373: the following text was added from the recommended paper.

“combined with enrichment with animal-source foods and/or fortification with appropriate levels and forms of mineral fortificants (Gibson et al., 2010)”

Lines 541-545: The following reference is added to the reference list.

“Gibson, R. S., Bailey, K. B., Gibbs, M., & Ferguson, E. L. (2010). A review of phytate, iron, zinc, and calcium concentrations in plant-based complementary foods used in low-income countries and implications for bioavailability. In Food and Nutrition Bulletin (Vol. 31, Issue 2 SUPPL.). United Nations University Press. https://doi.org/10.1177/15648265100312s206”

4 May 2021

PONE-D-20-19141R1

Maternal dietary practices, dietary diversity, and nutrient composition of Diets of Lactating Mothers in Jimma Zone, Southwest Ethiopia

PLOS ONE

Dear Dr. Forsido,

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Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

Reviewer #4: (No Response)

**********

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: I Don't Know

Reviewer #4: I Don't Know

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

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Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: - Need to attend to all the comments from the reviewers eg. the reference to cash crop should rather be substituted by the word coffee as it is confusing

Please review the maternal dietary practices paragraph and reword line 119 which is rather deceptive and subject to multiple interpretations.

Reviewer #2: I thank the authors for addressing the previous comments.

Abstract: Some minor issues with English remain (e.g. line 41 "anti-nutritional factors contents" the word factors is probably not required; line 43 should be "the majority").

Introduction: Appropriate.

Methods: Line 92, the reference should perhaps be at the end of the sentence.

Line 95, a brief description of kebele and woreda would be useful to the reader.

Statistical analysis section: univariate and multivariate should be univariable and multivariable

Ethics section: Line 169-170: This should be "The Ethical Review Board agreed to verbal consent as the study was not an intervention"

Line 170, the word "Besides" is not required

Results: Line 197, either dietary diversity score needs (DDS) after it in order to define the abbreviation in the next line or if already defined DDS should be used rather than "dietary diversity score"

Line 220, For clarity "On multivariable logistic regression analyses" should be "Multivariable logistic regression analyses are.." a full stop is required after Table 5 and then the next sentence becomes "After adjusting..

Line 221, if Minimum dietary diversity has been defined, please use the the abbreviation MDD

Discussion: Some minor issues with English remain. e.g. Line 310, "Whereas" is a conjunction and does not start a sentence.

Line 357 "Recall bias. Over and under-reporting of maternal dietary intakes." These are not complete sentences.

Strength of study, while an official food analysis methodology is somewhat of a strength, I think this section does need more consideration. The sampling methodology could also be considered as strength as it was quite rigorous.

Reviewer #3: what does "women in Omo-nada were less likely consuming diversified diet than women in Dedo district" imply? Any policy implication for this finding? Also your analysis showed a year increase in women's age was associated with higher dietary diversity. However, in the discussion you mentioned other studies have found being young age was positively assciated with dietary diversity and this in opposite of your finding.

Reviewer #4: Page Line Comment

3 43-44 This sentence would be much more readable if it said, “ranged between 24.8-65.6 for moisture, 7.6-19.8 for protein,” etc… instead of a long string of numbers followed by a long string of components for the reader to match in order to obtain meaning.

4 46 See above.

6 102 Description of the sampling is improved by adding the urban/rural stratification. Was the “Probability Proportional to Size” technique actually used to select the kebeles?

How does the woreda relate to the district?

8 143-144 Minimum dietary diversity was achieved if a mother consumed five or more food groups per day??

12 199 Consider a different title for this section. Unusual to see insecticide-treated nets and family planning under a heading of dietary practices.

13 208 Table 2 includes more than nutrition

14 226 Table 3 now lists 10 food groups, but the title still says 9 food groups

16 236 Is it statistically valid to compare the 554 women who were not currently in school with the four women who were in school. How large a cell size is required for Chi-Square?

17 Table 4 See question above.

17 Table 4 Add names of districts in parentheses here to make Table 5 meaningful.

17 Table 4 Some ethnicities were merged into other…….Consider if three more are too small for valid chi-square.

18 251 & 254 “grade of the women”……This should be educational level or educational status…..not grade, because individual grade completed is not shown in Table 4.

18 Table 5, L. 252 Food production diversity and agricultural production diversity appear but how they are identified has not been presented in previous tables. How is a unit increase defined? Is it an additional type of crop?

19 274-277 See first comment

20-21 Tables 6 & 7 Clarify if units are /wet_wt or /dry wt somewhere on each of these tables

22 295-298 Unless I missed something in the methodology, proximate analysis of individual foods was conducted. ..most of the foods eaten by women did not contain…

And, …The overall adequacy is less than 1 for each of the food types shown in Table 8.

22 Table 8 MC is in the footnote but not the table.

Table 8 Use Zn in the heading.

25 351 Confirm the RDA for fiber

27 410 The practice of adding beans to kale sauce is mentioned in the paper, but the food product is still referred to as “kale sauce”. To someone who has knowledge of what % protein typically, would be provided by “kale” alone, this is puzzling. Isn’t the addition of beans critical to the protein concentration being reported?

**********

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Reviewer #3: No

Reviewer #4: No

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17 Jun 2021

Dear editor,

We have accepted the critical inputs of the reviewers with great appreciation as it improves our manuscript very much. We have addressed their queries point by point as follows:

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Authors' response:

• We found out that none of the references are retracted.

• For one reference (23) title of the citation is updated.

• Three references (4, 23 & 37) had changed their internet site, which is updated in the current version.

• For nine references (3, 11, 15, 16, 17, 26, 27, 28 and 38) the internet sites where the documents are available.

• Two new references (30, 31) are added to the reference list.

Reviewers' comments:

5. Review Comments to the Author

Reviewer #1:

Reviewer 1 comment 1:

Need to attend to all the comments from the reviewers eg. the reference to cash crop should rather be substituted by the word coffee as it is confusing

Authors' response 1:

The following corrections were made as suggested by the reviewer.

Line 91: “Cash crop” is changed to “coffee”.

Line 190: Inside Table 1, “cash crop” is changed to “coffee”.

Line 225: Inside Table 4, “cash crop” is changed to “coffee”.

Line 304: “cash crop” is deleted.

Reviewer 1 comment 2:

Please review the maternal dietary practices paragraph and reword line 119 which is rather deceptive and subject to multiple interpretations.

Authors' response 2:

Line 124-126: The sentence was revised as follows:

“Maternal knowledge and practice in use of insecticide-treated net, consumption of two additional meals in a day, consumption of a variety of food groups, daily use of iodized salt and family planning were assessed (17).”

Reviewer #2:

Reviewer 2 comment 1:

I thank the authors for addressing the previous comments.

Authors' response 1:

Thank you.

Reviewer 2 comment 2:

Abstract: Some minor issues with English remain (e.g. line 41 "anti-nutritional factors contents" the word factors is probably not required;

Authors' response 2:

The following corrections were made as suggested by the reviewer:

Line 43: Rewritten as “The content of anti-nutritional factors…”

Line 26: Rewritten as “The content of anti-nutritional factors…”

Line 269: Rewritten as “Table 7 The content of minerals and anti-nutritional factors…”

Reviewer 2 comment 3:

line 43 should be "the majority").

Authors' response 3:

Line 46: “majority” is changed to “most”.

Reviewer 2 comment 4:

Introduction: Appropriate.

Authors' response 4:

Ok

Reviewer 2 comment 5:

Methods: Line 92, the reference should perhaps be at the end of the sentence.

Authors' response 5:

Line 95: The reference is moved to the end of the sentence as suggested by the reviewer.

Reviewer 2 comment 6:

Line 95, a brief description of kebele and woreda would be useful to the reader.

Authors' response 6:

Line 98: The following phrase is added to describe kebele:

“(the smallest administrative unit of Ethiopia)”

Line 98-99: The following phrase is added to describe woreda:

“(the third-level of the administrative division of Ethiopia - after zones and the regional states)”

Reviewer 2 comment 7:

Statistical analysis section: univariate and multivariate should be univariable and multivariable

Authors' response 7:

Line 168: “multivariate” is changed to “multivariable” as suggested by the reviewer.

Reviewer 2 comment 8:

Ethics section: Line 169-170: This should be "The Ethical Review Board agreed to verbal consent as the study was not an intervention"

Authors' response 8:

Line 176-177: Corrected as suggested by the reviewer.

Reviewer 2 comment 9:

Line 170, the word "Besides" is not required

Authors' response 9:

Line 177: The word “Besides” is deleted as suggested by the reviewer.

Reviewer 2 comment 10:

Results: Line 197, either dietary diversity score needs (DDS) after it in order to define the abbreviation in the next line or if already defined DDS should be used rather than "dietary diversity score"

Authors' response 10:

Line 204: “dietary diversity score” is changed to “DDS” as it is already defined in the abstract.

Reviewer 2 comment 11:

Line 220, For clarity "On multivariable logistic regression analyses" should be "Multivariable logistic regression analyses are.." a full stop is required after Table 5 and then the next sentence becomes "After adjusting..

Authors' response 11:

Line 228: Corrected as suggested by the reviewer:

“Multivariable logistic regression analyses are presented in Table 5. After adjusting…”

Reviewer 2 comment 12:

Line 221, if Minimum dietary diversity has been defined, please use the abbreviation MDD

Authors' response 12:

As minimum dietary diversity for women (MDD-W) is defined in the abstract (Line 27), the abbreviation MDD-W is used in the following instances:

Line 33, Line 36, Line 137, Line 140, Line 215 (inside table 3), Line 229, Line 232, Line 234, Line 237-238, Line 247, Line 248, Line 251

Reviewer 2 comment 13:

Discussion: Some minor issues with English remain. e.g. Line 310, "Whereas" is a conjunction and does not start a sentence.

Authors' response 13:

Line 341: Deleted “whereas” and the sentence now begins with “Only unleavened…)

Reviewer 2 comment 14:

Line 357 "Recall bias. Over and under-reporting of maternal dietary intakes." These are not complete sentences.

Authors' response 14:

The incomplete sentences were corrected as follows:

Line 388-389:

“Recall bias might have occurred as information on maternal dietary practices were collected retrospectively.”

Lines 389:

“The 24-hour recall is prone to over and under-reporting of maternal dietary intakes.”

Reviewer 2 comment 15:

Strength of study, while an official food analysis methodology is somewhat of a strength, I think this section does need more consideration. The sampling methodology could also be considered as strength as it was quite rigorous.

Authors' response 15:

Line 398: As suggested by the reviewer, the following sentence is added as a strength of the study.

“Rigorous sampling methodology was used.”

Reviewer #3:

Reviewer 3 comment 1:

What does "women in Omo-nada were less likely consuming diversified diet than women in Dedo district" imply? Any policy implication for this finding?

Authors' response 1:

Line 311-316: The following discussion is added to address reviewer’s comments:

“The variation in dietary diversity between vegetable and cereal producing districts indicates that households tend to consume what they have produced; perishables (vegetables) are more likely to be consumed by the producers than durables (cereals) as they spoil fast if not sold. Therefore, increasing the diversity of farm should be encouraged as one key strategy to improve diet diversity and quality (30).”

Reviewer 3 comment 2:

Also your analysis showed a year increase in women's age was associated with higher dietary diversity. However, in the discussion you mentioned other studies have found being young age was positively associated with dietary diversity and this in opposite of your finding.

That discussion was presented wrongly in the previous submission. It has been corrected as follows in the current submission:

Line 302-304: “Regarding the association between maternal age and DDS, a contradicting report has been documented from Nigeria where being young age was positively associated with dietary diversity (24).”

Reviewer #4:

Reviewer 4 comment 1:

3 43-44 This sentence would be much more readable if it said, “ranged between 24.8-65.6 for moisture, 7.6-19.8 for protein,” etc… instead of a long string of numbers followed by a long string of components for the reader to match in order to obtain meaning.

Authors' response 1:

Lines 37-40: Corrected as suggested by the reviewer.

Reviewer 4 comment 2:

4 46 See above.

Authors' response 2:

Lines 41-42: corrected as suggested by the reviewer.

Reviewer 4 comment 3:

6 102 Description of the sampling is improved by adding the urban/rural stratification. Was the “Probability Proportional to Size” technique actually used to select the kebeles?

Authors' response 3:

Line 101-102: This was a mistake and is corrected in the revised version as follows:

“probability non-proportional to size”

Reviewer 4 comment 4:

How does the woreda relate to the district?

Authors' response 4:

Line 98: The following text is added to show how woreda is related to district.

“district/woreda”

Reviewer 4 comment 5:

8 143-144 Minimum dietary diversity was achieved if a mother consumed five or more food groups per day??

Authors' response 5:

Lines 137-138: Corrected as indicated by the reviewer.

Reviewer 4 comment 6:

12 199 Consider a different title for this section. Unusual to see insecticide-treated nets and family planning under a heading of dietary practices.

Authors' response 6:

Line 192: As advised by the reviewer, the section title is revised to “Maternal practice of essential nutrition actions”.

Line 122: Similar modification is done for the section title.

Line 285: Similar modification is done for the section title.

Reviewer 4 comment 7:

13 208 Table 2 includes more than nutrition

Authors' response 7:

Line 201-202: The caption is revised as follows:

“Maternal practice of essential nutrition actions during lactation in three districts of Jimma Zone, Southwest Ethiopia”

Reviewer 4 comment 8:

14 226 Table 3 now lists 10 food groups, but the title still says 9 food groups

Authors' response 8:

That was an error. It is corrected.

Reviewer 4 comment 9:

16 236 Is it statistically valid to compare the 554 women who were not currently in school with the four women who were in school. How large a cell size is required for Chi-Square?

Authors' response 9:

The reviewer is correct. “The Chi-square test is invalid if we have fewer than 5 observations in a cell”. Therefore, we have deleted, from Table 4, the finding presenting whether the mother is currently attending education or not.

Line 220: deleted “whether the woman is currently attending education or not,”

Line 222: deleted “who are not currently attending education,”

Reviewer 4 comment 10:

17 Table 4 See question above.

Authors' response 10:

Line 225-226: We have deleted, from Table 4, the finding presenting whether the mother is currently attending education or not.

Reviewer 4 comment 11:

17 Table 4 Add names of districts in parentheses here to make Table 5 meaningful.

Authors' response 11:

Names of the districts were put in a more meaningful fashion as follows.

Coffee producing (Mana)

Cereal producing (Omo Nada)

Vegetable producing (Dedo)

Reviewer 4 comment 12:

17 Table 4 Some ethnicities were merged into other…….Consider if three more are too small for valid chi-square.

Authors' response 12:

As suggested by the reviewer, the fourth ethnicity “Tigre” was added to “Others” because it would be too small for a valid chi-square.

Reviewer 4 comment 13:

18 251 & 254 “grade of the women”……This should be educational level or educational status…..not grade, because individual grade completed is not shown in Table 4.

Authors' response 13:

Line 34, Line 221, Line 223, Line 226 (inside Table 4), Line 230, Line 233, Line 239 (inside table 5): We have changed “grade” with “educational level” for the women as well as their husbands.

Reviewer 4 comment 14:

18 Table 5, L. 252 Food production diversity and agricultural production diversity appear but how they are identified has not been presented in previous tables. How is a unit increase defined? Is it an additional type of crop?

Authors' response 14:

Line 240-241: At the footnote of Table 5, we have indicated how the production diversity score is generated. Production diversity is a score generated by summing the number of animal and plant source food that the household reported to produce. A unit increase in this context can be defined as an additional type of animal or plant source food produced by the household.

Reviewer 4 comment 15:

19 274-277 See first comment

Authors' response 15:

Line 255-260: Corrected as suggested by the reviewer.

Reviewer 4 comment 16:

20-21 Tables 6 & 7 Clarify if units are /wet_wt or /dry wt somewhere on each of these tables

Authors' response 16:

Line 263: The following information is added to the Table 6 caption:

“(dry weight basis)”

Line 269: The following information is added to the Table 7 caption:

“(dry weight basis)”

Reviewer 4 comment 17:

22 295-298 Unless I missed something in the methodology, proximate analysis of individual foods was conducted. ..most of the foods eaten by women did not contain…

And, …The overall adequacy is less than 1 for each of the food types shown in Table 8.

Authors' response 17:

As indicated by the reviewer, proximate, mineral and anti-nutrient contents analysis of individual foods was conducted.

Line 275-276: “…did not contain...” is changed to “…do not provide the recommended daily allowances for…”

Line 278-279: The following phrase is added to elaborate what MAR<1 means:

“…which indicates the requirements for all the nutrients were not met.”

Reviewer 4 comment 18:

22 Table 8 MC is in the footnote but not the table.

Authors' response 18:

MC=Moisture content is deleted from the footnote of Table 8 as it happened to be there by mistake.

Reviewer 4 comment 19:

Table 8 Use Zn in the heading.

Authors' response 19:

Corrected.

Reviewer 4 comment 20:

25 351 Confirm the RDA for fiber

Authors' response 20:

According to the American Heart Association, the daily value for fiber for women under 50 is 21 to 25 grams per day. The value in Table 6 is revised accordingly.

Reviewer 4 comment 21:

27 410 The practice of adding beans to kale sauce is mentioned in the paper, but the food product is still referred to as “kale sauce”. To someone who has knowledge of what % protein typically, would be provided by “kale” alone, this is puzzling. Isn’t the addition of beans critical to the protein concentration being reported?

Authors' response 21:

This is a legitimate concern. To avoid the confusion, we renamed the “kale sauce” to “kale-bean sauce” in Tables 6, 7 and 8.

Reviewer # 5

Reviewer 5 comment 1:

Significant revision were made and the revised manuscript is more appropriate and ready for publication. I have some concerns, which I stated as follows.

1. The two versions of abstract (abstract copied and pasted in the manuscript submission system and abstract in the main manuscript) are not the same.

Authors' response 1:

This is corrected.

Reviewer 5 comment 2:

2. Sample recruitment period in the original manuscript was changed from March to May 2014 to February 2014 (one month back). Why did the authors change on the period of sample recruitment?

Authors' response 2:

March to May 2014 is when we collected the data. The preliminary tasks were completed ahead of the data collection.

Reviewer 5 comment 3:

3. Tools (DD) in the original was 9 but changed to ten. This has to be clarified.

Authors' response 3:

This was suggested by the reviewer during the first revision, and we agreed with the reviewer’s comment. The FAO, FHI 360 (2016) guide for measurement of Minimum Dietary Diversity for Women (MDD-W) is the most applicable technique for the study population.

Reviewer 5 comment 4:

Result

4. Table 5: Model adequacy is marginally significant (p=0.052) suggesting the model does not correctly fit. For which variable does maximum standard error of 0.543 mean?

Authors' response 4:

We expected Hosmer-Lemeshow test to be non-significant (P>0.05) for fitness of the model based on literature. The value we got for Hosmer-Lemeshow test in this analysis was non- significant (P=0.052). Our conclusion therefore is the model is fit.

Large standard error is an indicator of multicollinearity as approximately 95% of the observations should fall within plus/minus 2 standard error of the regression from the regression line. So, we used Standard error of > 2 as an indicator of multicollinearity and checked it for all variables in the multivariable regression output. However, all variables had low standard error with the maximum standard error being. 0.543 (for educational status of the husband) showing the absence of multicollinearity.

Reviewer 5 comment 5:

5. Two important findings need further explanation. The first finding is women who had increased agricultural productivity had better dietary diversity. Another finding is urban women were better in DD than rural women. It may be true to say agriculture activity is more common in rural than urban. Thus, from these statements, one can assume rural women could be better in DD than urban because of increased agricultural productivity. How do authors explain these controversial findings?

Authors' response 5:

Line 319-327: The following explanation is added to explain the urban-rural disparity in DD.

“Considering the fact that rural areas are hubs for agricultural production, one can assume rural women could be better in dietary diversity than urban counterparts. However, production diversification may not always mean dietary diversity. For example, a study in rural Nigeria found out that production diversification has no statistically significant effect on the dietary diversity of households (30). Other researchers also argue that despite theoretical basis for the correlation between production diversity and dietary diversity, “there is a need for a deeper empirical understanding of how, under what circumstances, and through what pathways own-production of nutritious foods improves diets” (31).”

The following new references were added to the reference list:

Line 525-528:

“Ayenew HY, Biadigilign S, Schickramm L, Abate-Kassa G, Sauer J. Production diversification, dietary diversity and consumption seasonality: Panel data evidence from Nigeria. BMC Public Health [Internet]. 2018 Aug 8 [cited 2021 Jun 15];18(1):1–9. Available from: https://doi.org/10.1186/s12889-018-5887-6”

Line 529-531:

“Aberman N-L, Roopnaraine T. To sell or consume? Gendered household decision-making on crop production, consumption, and sale in Malawi. Food Secur [Internet]. 2020;12(2):433–47. Available from: https://doi.org/10.1007/s12571-020-01021-2”

Reviewer 5 comment 6:

Discussion:

6. Line 309 (…we have observed that most households add protein rich ingredients…). Nothing was said in methods section to clarify this study also involved observation.

Authors' response 6:

We didn’t do observational study, but we have collected food samples from several households. We have revised the sentence to this context.

Line 337: “…our survey…” is changed to “…collection of food samples,…”

Reviewer 5 comment 7:

7. Line 338, it is uncommon to write like this (“According to (34) …). Instead, it would be more informative to re-write what was said by another study).

Authors' response 7:

Line 367-368: Corrected as suggested by the reviewer:

“The ideal cut-off for nutrient adequacy should be 1, which would mean that all the nutrients were consumed in a sufficient amount (36).”

Reviewer 5 comment 8:

Strength:

8. It is not clear what does “an official food analysis methodology” mean? This was not described elsewhere.

Authors' response 8:

Line 147: “standard methods” was changed to “official methods”

Thank you

24 Jun 2021

Maternal dietary practices, dietary diversity, and nutrient composition of Diets of Lactating Mothers in Jimma Zone, Southwest Ethiopia

PONE-D-20-19141R2

Dear Dr. Forsido,

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1 Jul 2021

PONE-D-20-19141R2

Maternal Dietary Practices, Dietary Diversity, and Nutrient Composition of Diets of Lactating Mothers in Jimma Zone, Southwest Ethiopia

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https://creativecommons.org/licenses/by/4.0/This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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