This is the first time a study has assessed feeding practices and nutritional status of 6–23-month-old children of fasting and non-fasting mothers during the Ethiopian Orthodox lent fasting and non-fasting periods in rural Tigray, Ethiopia. Socio-economic factors, which are possibly associated with stunting, underweight and wasting, were also determined.
4.1. Food Consumption Pattern of 6–23-Month-Old Children
According to the UNICEF conceptual framework of malnutrition, inadequate dietary intake is one of the immediate causes of child malnutrition [
14]. In our study, cereals, roots and tubers, and pulses and nuts are the food groups majorly prepared for the 6–23-month-old children in the rural Tigray in Ethiopia, regardless of fasting period. This result is consistent with previous studies in Ethiopia [
11,
15,
16,
17,
18,
19,
20]. A similar finding was reported on the consumption of grains, roots and tubers for children from Vietnam, Bangladesh, Pakistan, Indian and the U.S. [
21,
22,
23,
24,
25]. According to Demissie and his colleagues [
21], consumption of fruits and vegetables is sub-optimal in the Tigray region and Ethiopia in general [
26]. Supporting this evidence, we also found that only 1% of children consumed vitamin A-rich fruits and vegetables. The result is also comparable with a previous study in rural Tigray [
27]. However, our finding was lower than findings of two national surveys (14.8, 27.7%) in Ethiopia and Pakistan (18.7%) [
22,
28,
29]. This could be related to the fact that cultivation on the farm and availability in the markets are rare in the study area, probably resulting in a less diverse diet. Another explanation could be a difference in feeding practices [
26]. However, the consumption of other fruits and vegetables food group was between 27.0–37.6% in the present study. This result is higher than national figures, which are 3.3% and 10.1% [
28,
29].
Animal source foods are both energy and nutrient dense, and an excellent source of high quality and easily digestible protein, in addition to being an efficient and easily absorbable source of micronutrients like iron, zinc, vitamin A, vitamin B12, riboflavin and calcium [
30]. In the present study, the consumption of a diet composed of flesh foods was 0.5% and 1.6% in fasting and non-fasting periods, respectively. These results are comparable with a previous study during the Ethiopian Orthodox fasting period in the Dejen district (0.0%), and studies conducted in Gobalafto district in North Wollo (0–5%), Wolaita district (1.6%), and findings of the Ethiopian national food consumption survey for all regions in the country (0.1–0.6%) [
11,
15,
31,
32]. However, our finding was lower than a study conducted in the Arsi-Negele district of Oromia region, in Ethiopia (11.3%) and Mongolia (4–14%) [
33,
34]. This might be due to the fact that the area of the later studies has animal husbandry potential and cultural and eating habit differences. In the current study, consumption of dairy products was between 8.5% and 9.9% in fasting and non-fasting periods, respectively. An almost comparable proportion of 6–23-month-old children (7.5%) of the Dejen district consumed dairy products in the fasting period in North-west Ethiopia [
11]. However, the findings in the present study were lower than in studies conducted in Amhara (about 20.0%) and Oromia (52.4%) regions, and Addis Ababa City (70.4%) in Ethiopia and Pakistan (50.5%) [
17,
20,
22,
34]. An explanation for this could be that the studies were conducted in different periods, and dairy products were the second most common foods groups consumed by the Pakistan children. In the present study, the proportions of children who consumed egg in the days before the surveys of fasting and non-fasting periods were 18.5% and 24.8%. However, these were lower than in similar studies in the Amhara region, which was 98.0%, where fasting of Ethiopian Orthodox religion is routine in the fasting days of the year. This could be due to more chickens in the households included in the later study, which may result in availability of eggs for children during the fasting period and household consumption in general. The consumption of egg in our finding was higher than the national findings of the last two Ethiopian demographic and health survey (DHS) studies (8.3%, 17%) and study in Amhara region (<10.0%) in Ethiopia [
15,
28,
29]. However, it was consistent with a study conducted in the Arsi-Negele district (22.3%) of Oromia region, in Ethiopia [
34].
Minimum meal frequency is a proxy indicator to determine whether the energy requirement of a child is met and examines the frequency of meals where the children received foods other than breastmilk, considering specific age and breastfeeding status of the child [
29]. In this study, three-fourths of children of fasting and non-fasting mothers had eaten the minimum number of meals in the days preceding the fasting and non-fasting surveys. This result is in line with studies conducted in the Dabat (69.3–75.0%) and Gorche (78.0%) districts of northern and southern Ethiopia, respectively [
35,
36]. However, our finding is higher than studies in Kemba (14.5–33.6%), Bale (44.7%), Arsi-Negele (67.3%), Wolaita (69.3%) districts, elsewhere in Tigray region (66.0%) and findings for the Tigray region (55.6%, 49.4%), and national averages (47.9%, 44.6%) in Ethiopian DHS studies of 2011 and 2016, respectively, and Pakistan (38.2%) [
16,
19,
28,
29,
34,
37,
38]. However, it is lower than findings on children from the South Wollo district, in Ethiopia, which were 91.0–97.0% and Nepal (87.8–98.2%) [
15,
39].
Minimum dietary diversity is one of the indicators to assess the quality of food consumed by 6–23-month-old children. Consumption of at least four different food groups in a day is the minimum requirement [
29,
40]. In this study, the proportion of children who consumed foods prepared from at least four diversified food groups (MDD) was 2.5% and 6.9% in fasting and non-fasting periods, respectively. This finding indicates that children aged 6–23 months in the study area are consuming a poor quality complementary diet. A study conducted in 6–23-month- old children of Orthodox Christian mothers in Gojam indicated that 13.6% had four diversified food groups in the food they consumed preceding the survey during the fasting period [
11]. Similarly, our findings are also lower than findings in children living in the Gorche (10.4%), Kemba (23.3%), Bale (28.5%), and Wollo (23.0–41.0%) districts in Ethiopia, India (38%), Bangladesh (48.4%) and Vietnam (83.2%) [
15,
16,
25,
35,
41,
42]. Generally, these findings indicate that undernutrition specifically stunting and micronutrient deficiencies could be the public health problem in the area. This is supported by studies conducted in children from different parts of the world and ours [
43,
44,
45,
46].
For appropriate growth and development, infants and young children should be fed with at least four diversified food groups from the minimum number of meals (MAD) recommended according to specific to the age and breastfeeding status of the child [
40]. In the present study, the proportion of 6–23-month-old children who met both the minimum diversity and the number of meals (MAD) preceding the surveys was 2.3–6.7% in the study population. The result is consistent with DHS 2011 and 2016 findings for the Tigray region (4.5% and 5.7%, respectively) and the national figure (4.0%) in DHS 2016 for Ethiopia [
28,
29]. However, it is lower than research findings conducted in three districts (17.0%) of the Tigray region, in northern Ethiopia, India (9%), Nepal (32%), Bangladesh (40%) and Sri Lanka (68%) [
31,
38,
47]. Moreover, the proportion of 6–23-month-old children who fulfilled the criteria for MAD was higher for non-fasting mothers (2.0–7.5%) and in non-fasting period (6.7%) compared with their counterparts. This finding suggests that activities which can improve the child feeding practices should include improving maternal feeding behavior, as many scholars evidenced their association, including ours [
9,
21,
48].
4.2. Nutritional Status of 6–23-month-Old Children
In the present study, the prevalence of wasting, underweight and stunting in the 6–23 months old children was between 4.4–4.8%, 11.7–15.7% and 31.6–33.7%, respectively. These results are lower than the findings for the Tigray region and national figures in last two DHS studies in Ethiopia. For example, wasting, underweight, and stunting in under-five aged children were 10.3% and 9.7%, 35.1% and 28.7%, and 51.4% and 44.4% in DHS 2011 (Tigray region and national, respectively). Except for wasting, these figures further decreased to 23.0% and 23.6% for underweight, and 39.3% and 38.4% for stunting in the DHS 2016 study [
28,
29]. This could indicate an improvement in child nutritional status, both regionally, and at the national level.
In this study, the median WAZ of children of fasting mothers was lower compared to children of non-fasting mothers, both in fasting and non-fasting periods. The WAZ of children from non-fasting mothers’ sub-group also improved during the non-fasting period. Similarly, the prevalence of underweight children from the fasting sub-group was higher than that of children from the non-fasting sub-group, in both periods. Likewise, the mean standard deviations (SD) of WAZ, WHZ and HAZ of children from the fasting mothers sub-group were lower compared to children from non-fasting mothers during the fasting period. Similarly, the proportion of wasted children was higher in the fasting sub-group compared to those children from non-fasting mothers during the fasting period. Conversely, relatively more children from non-fasting mothers were stunted than from fasting mothers. This could be due to the higher number of older children in the non-fasting group. Similar findings were observed in studies conducted in the Tigray region, northern Ethiopia [
4]. Multivariate logistic regression showed that children of mothers who fasted during the pregnancy and lactation period were more likely to be undernourished (stunting, underweight, and wasting) than those children of mothers who were not fasting in the same periods. These indicate that, maternal fasting during pregnancy, and lactation not only affect the nutritional status of the mother themselves [
9], but also their fetus/breastfed child. To increase the awareness on the effect of fasting practices on the undernutrition, the Ethiopian Orthodox Church (EOTC) with the United States Agency for International Development (USAID) multi-sectoral nutrition project, Empowering New Generations to Improve Nutrition and Economic opportunities (ENGINE) held a consultative meeting with religious leaders and church scholars to clarify fasting practices for children, pregnant and lactating women in line with religious guidelines. This was done after a sermon guide was developed in 2016, based on the church teachings and outlining the laws and regulations related with fasting and nutrition. According to the joint press release by EOTC and USAID/ENGINE, the sermon guide highlighted the exemption of mothers and their babies from fasting during the first 1000 days [
49]. The sermon guide also emphasized the cooking utensils to be used for complementary food preparation during fasting seasons, as many mothers were not happy to prepare complementary food from the animal sources during fasting seasons due to fear of contamination of family food [
10]. Therefore, strengthening the activities started by the Church and the involvement of religious institutions and leaders in the existing national multi-sectoral approach activities would accelerate and sustain the reduction of nutrition-related problems in the country.
Previous studies in Africa and Southeast Asian countries demonstrated that children in the age between 13–23 months were more associated with underweight and stunting compared to those who were aged 6–12 months [
28,
29,
50,
51,
52,
53,
54,
55,
56,
57,
58,
59,
60,
61]. Similar findings were also revealed in our study. This could be related to feeding practices, contamination and poor quality complementary food, which is mainly cereal based [
4]. Similarly, maternal illiteracy was found to be a predictor variable for underweight and wasting. The former result is consistent with previous studies in Ethiopia and other low and middle income countries [
28,
29,
62,
63,
64,
65]. Similarly, findings in Ethiopian DHS also showed that childhood wasting was associated with maternal illiteracy [
28,
29]. This indicates that educating mothers will be an important activity for improving the nutritional status of children in a given community. Likewise, compared to children whose mothers were housewives, children of farmer mothers were more exposed to being underweight. This might be related to less time allocation for child care due to a high work load and absence from the home. Farm work also expends more energy, and mothers may be more frequently exhausted, which could result in poor appetite and might affect the quality and quantity of breast milk. Moreover, children who did not take the first milk (colostrum) after their birth were more stunted than those who did. This could be related to infection emanating from pre-lacteal foods, which is a predictor for child stunting in North-west Ethiopia [
58]. Therefore, activities which improve the colostrum intake (e.g., -antenatal care) should be done in the study area [
66]. Furthermore, children who were living in households without toilets were more exposed to stunting compared to those from households owning toilets. This could be related to poverty in general, a well-known factor for malnutrition. Additionally, contamination of the soil due to open defecation increases the risk for frequent episodes of childhood diarrhea, which has a negative impact on the nutritional status of sub-Saharan African children [
50].
However, this study has the following limitations: This study considered only the lent fasting period, among the seven official fasting periods in Ethiopian Orthodox religion. It also included only children aged between 6–23 months, out of those children below seven years of age, who are exempted from the official fasting in the religion.