Undernutrition remains a pressing problem in sub-Saharan Africa: in 2023, 277 million people there were undernourished, with the share higher in East Africa than in West and Southern Africa. Women are doubly vulnerable because of gender inequality and increased nutrient requirements during pregnancy and lactation. Dietary diversity is directly linked to micronutrient adequacy, and micronutrient deficiencies in pregnant women raise the risk of miscarriage, preterm birth and birth defects. Previous studies mostly covered Ethiopia, while data for West and Southern Africa were fragmentary, and comparisons between pregnant and non-pregnant women in the same communities were virtually absent. This work fills that gap by using a single protocol in three countries.
As part of the prospective PRECISE cohort study, dietary data were collected from June 2019 to December 2022 for 7715 women in The Gambia (North Bank), Kenya (Kilifi County) and Mozambique (Manhiça district). Participants reported which of ten food groups they had eaten in the previous 24 hours; portions under 15 grams were not counted. The primary outcome was achieving Minimum Dietary Diversity for Women (MDD-W), that is, consuming at least five groups. Very low diversity (two groups or fewer) was also assessed. Associations with demographic, socioeconomic and household factors were analyzed using multivariable logistic regression adjusted for country, pregnancy status, place of residence, age, parity, marital status, education, employment, poverty index, spending autonomy and household composition.
The median dietary diversity score was 4 out of 10 possible groups. Overall, only 47.8% of women achieved minimum diversity: in The Gambia 65.1%, in Kenya 45.0%, in Mozambique 39.2%. Very low diversity was recorded in 15.3% of participants. Pregnant women more often met the standard than non-pregnant women (48.4% versus 45.6%). The odds of achieving MDD-W were 3.28 times higher among residents of The Gambia compared with Kenyan women. Protective factors were pregnancy (odds ratio 1.65), having children (1.18), being unmarried (1.49), secondary (1.23) and higher education (1.85), entrepreneurial (1.32) and professional employment (1.33), and larger households (1.30). By contrast, living alone or only with children lowered the odds (0.76), and increasing poverty probability produced a dose-dependent decrease. For very low diversity, the risks were living in Mozambique (1.54) and the two upper poverty quintiles (2.08 and 2.41).
This work is the first to directly compare dietary diversity between pregnant and non-pregnant women from the same communities in West, East and Southern Africa using a single methodology. Unlike most earlier studies focused on Ethiopia, it reveals pronounced regional heterogeneity: The Gambia's high scores despite low levels of education and income point to the role of local culinary traditions, not just socioeconomic status. This shifts the emphasis from universal recommendations to the need to take food culture into account when designing interventions.
It would be valuable to study how seasonality and the effects of the COVID-19 pandemic influenced dietary diversity, since the data were collected over three and a half years without adjustment for time of year. It is also worth assessing whether MDD-W can be used as a screening tool in antenatal care to identify women at high risk of micronutrient deficiency and provide targeted support.
The results are directly applicable to public health and food security programs in sub-Saharan Africa, as well as to global initiatives to improve the nutrition of women and girls.
Analyze seasonal fluctuations in dietary diversity in the PRECISE cohort and assess the association between MDD-W and pregnancy outcomes such as birth weight and preterm birth.
The study addresses an unresolved problem in nutrition science: why standard socioeconomic indicators do not always predict diet quality across different cultural contexts. The findings raise the question of whether locally adapted dietary diversity indicators are needed, ones that take traditional cooking practices into account.
In The Gambia, 63% of women had no formal schooling and the probability of poverty was the highest of the three countries, yet it was there that the share of women with sufficient dietary diversity was the greatest: 65.1%.
Not published on arXiv. Here are its page, the PDF and the formalization: you can check it yourself, not only read our account.