Table 1 Characteristics of studies included in the systematic review and meta-analysis

Khanal (2024) [38]

Kathmandu, Nepal,

2014–2016

n 602

10 to 19 years

(100% F)

24 h recall

DDS ≥ 5 food groups vs. DDS < 5 food groups

Anemia risk: 13.8 (4.20, 22.6)

245

High bias

Kumar (2023) [39]

data of a collaborative project of the Ministry of Health and Family Welfare India,

2016–2018

n 14,669

10 to 19 years

(49.9% M, 50.1% F)

Not reported

DDS ≥ 4 food groups vs. DDS < 4 food group

Anemia risk: 1·06 (0.95, 1.19)

5126

Very high bias

Zavala (2023) [54]

SMART surveys, Chad,

2016 to 2019 and 2021

n 2170

n 2349

Under 5 years

(mixed)

7 day recall

DDS ≥ 5 food groups vs. DDS < 5 food groups

Anemia risk: 1.53 (1.08, 2.17)

Anemia risk: 1.53 (1.16, 2)

846

Some concerns

Sodde (2023) [49]

Atnago, Ethiopia, 10 to June 25, 2022

n 309

2 to 5 years

(48.3% M, 51.7% F)

24 h recall

DDS ≥ 5 food groups vs. DDS < 5 food groups

Anemia risk: 1.70 (1.02, 3.07)

134

High bias

Fentaw (2023) [31]

Kombolcha town, Ethiopia, February 15 to May 14, 2020

n 395

Under 5 years

(53.9% M, 46.1% F)

24 h recall

DDS ≥ 4 food groups vs. DDS < 4 food group

Anemia risk: 2.61 (1.55, 4.38)

178

High bias

Kathuria (2023) [37]

Rohtak town, India, 2018,2019

n 166

Under 5 years

(41.7% M, 58.3% F)

Not reported

DDS ≥ 5 food groups vs. DDS < 5 food groups

Anemia risk: 1.70 (1.01, 3.01)

53

High bias

Mank (2022) [43]

Ouagadougou, Burkina Faso, 2021

n 1059

11 to 15 years

(43% M, 57% F)

24 h recall

DDS ≥ 5 food groups vs. DDS < 5 food groups

Anemia risk: 0.91 (0.76, 1·09)

312

Some concerns

Lweno (2022) [40]

Dar es Salaam, Tanzania,

2004–2005

n 2522

n 1177

Under 2 years

(51% M, 49% F)

24 h recall

DDS ≥ 5 food groups vs. DDS < 5 food groups

IDA: 0.99 (0.84, 1.19)

IDA: 1.21 (0.76, 1.53)

732

Very high bias

Tegegne (2022) [50]

Bale zone, Ethiopia,

1 to 30 June 2021

n 770

Under 2 years

(50.5% M, 49.5% F)

24 h recall

DDS ≥ 4 food groups vs. DDS < 4 food group

Anemia risk: 2.74 (1.97,2.08)

369

High bias

Hiruy (2021) [36]

three Ethiopia Demographic and Health Surveys,

2005, 2011,2016

n 5638

Under 2 years

(mixed)

24 h recall

DDS ≥ 5 food groups vs. DDS < 5 food groups

Anemia risk: 1.49 (0.96, 2.32)

2762

High bias

Said (2021) [48]

Three Tanzania Demographic and Health Surveys, 2005,2010,2015

n 1173

Under 5 years

(mixed)

Not reported

Not reported

Anemia risk: 0.61 (0.37, 0.98)

382

High bias

Orsango (2021) [10]

Southern Ethiopia, 2018

n 107

2 to 5 years

(48% M, 52% F)

24 h and 7 days child food frequency recall

DDS ≥ 6 food groups vs. DDS ≤ 3 food group

IDA risk: 0.5 (0.17, 1.75)

49

High bias

Alamneh (2021) [28]

Ethiopia, 2018–2020,

n 310

Under 5 years

(52.3% M, 47.3% F)

FFQ + 24 h recall

DDS ≥ 4 food groups vs. DDS < 4 food group

Anemia risk: 2.30 (1.12, 5.14)

167

High bias

Molla (2020) [44]

Debre Berhan Town, Ethiopia, 1 February to 2 March, 2018

n 531

Under 2 years

(49% M, 51% F)

24 h recall

DDS ≥ 4 food groups vs. DDS < 4 food group

Anemia risk: 2.5 (1.40, 4.3)

219

High bias

Tura (2020) [52]

Ambo town, Ethiopia, August 5–29, 2018

n 523

10 to 19 years

(100% F)

24 h recall

DDS > 6 food groups vs. DDS ≤ 3 food group

Anemia risk: 0.96 (0.61, 1.53)

205

Very high bias

Fentie (2020) [32]

Jimma town, Ethiopia, 2019

n 528

14 to 19 years

(100% F)

24 h recall

DDS ≥ 6 food groups vs. DDS ≤ 3 food group

Anemia risk: 3.57 (1.88, 6.76)

312

High bias

Fage (2020) [30]

Haramaya town, Ethiopia, February 1 to 28, 2017

n 493

12 to 19 years

(65.1% M, 34.9% F)

Not reported

DDS ≥ 6 food groups vs. DDS ≤ 3 food group

Anemia risk: 2.33 (1.12, 4.86)

267

High bias

Agustina (2020) [27]

Indonesia, 2016–2018, Iron Folate Supplementation Program

n 335

12 to 19 years

(100% F)

2-day 24 h recall

DDS ≥ 4 food groups vs. DDS < 4 food group

Anemia risk: 1.44 (0.90, 2.29)

173

High bias

Visser (2021) [24]

South Africa, 2009–2012

n 578

5 to 12 years

(51% M, 49% F)

3-day 24 h recall

DDS > 4 food groups vs. DDS ≤ 4 food group

Anemia risk: 1.56 (1.45, 2·67)

IDA risk: 2.79 (1.77, 4.48)

236

High bias

Malako (2019) [41]

Southern Nation Nationalities and Peoples Region, Ethiopia, April 2017

n 477

Under 2 years

(50.9% M, 49.1% F)

FFQ

DDS ≥ 4 food groups vs. DDS < 4 food group

Anemia risk: 2.95 (1.78, 4.91)

283

Some concerns

Alemayehu (2019) [29]

Wolaita Zone, Southern Ethiopia, 2015

n 990

Under 2 years

(56.2% M, 43.8% F)

24 h recall

DDS ≥ 4 food groups vs. DDS < 4 food group

Anemia risk: 1.40 (1.03, 1.92)

312

High bias

Parbey (2019) [47]

Hohoe Municipality, Ghana,

2018–2019

n 210

Under 5 years

(48·3% M, 51·7% F)

24 h recall

DDS ≥ 4 food groups vs. DDS < 4 food group

Anemia risk: 9.15 (3.13, 26.82)

104

High bias

Gonete (2018) [34]

Dembia, Ethiopia, March 1 to April 15/2017

n 462

15 to 19 years

(100% F)

24 h recall

DDS ≥ 5 food groups vs. DDS < 5 food groups

Anemia risk: 2.10 (1.30, 3.50)

215

High bias

Gosdin (2018) [35]

Bihar, India, 2017–2018

n 5664

Under 2 years

(51% M, 49% F)

24 h recall

DDS ≥ 4 food groups vs. DDS < 4 food group

Anemia risk: 1.14 (1.00, 1.33)

1863

High bias

Getaneh (2017) [33]

Gondar town, Ethiopia, February to May, 2017

n 523

6 to 14 years

(51.4% M, 49·6% F)

FFQ + 24 h recall

DDS ≥ 7 food groups vs. DDS ≤ 3 food group

Anemia risk: 1·77 (0·69, 4.55)

219

High bias

Tiku (2018) [49]

Ethiopia, February to March 2016

n 399

Under 5 years

(47.1% M, 52.9% F)

Not reported

DDS ≥ 4 food groups vs. DDS < 4 food group

Anemia risk: 3.24 (1.68, 6.23)

231

High bias

Nair (2016) [45]

Telangana, India, 2013–2015

n 445

Under 2 years

(53.1% M, 46.9% F)

n 347

2 to 5 years

(48.3% M, 51.7% F)

FFQ

FFQ

DDS ≥ 4 food groups vs. DDS < 4 food group

DDS > 7 food groups vs. DDS ≤ 7 food group

Infants anemia risk: 1.51 (0.93, 2.46)

Pre-schoolers anemia: 1.13 (0.56, 2.27)

198

High bias

Woldie (2015) [53]

Northeast Ethiopia, March to May, 2014

n 347

2 to 5 years

(52·5% M, 47·7% F)

24 h recall

DDS ≥ 4 food groups vs. DDS < 4 food group

Odds of anemia: 3.20 (1.35, 7.38)

221

High bias