Development of a complementary feeding manual for Bangladesh Principal Investigator

1. Development of a complementary feeding manual for Bangladesh Principal Investigator Dr. A.K.M. Iqbal Kabir,MBBS, MD,PhD, Vice - Chairperson, BBF Co- Principal Investigators Dr. S. K. Roy MBBS (Dhaka), M.ScNutr, Ph.D (London), FRCP (Edin), Chairperson, BBF Prof. SoofiaKhatoon MBBS, FCPS (Ped),MHPED (Australia),Fellow in Neonatology (U.K), Secretary, BBF Bangladesh Breastfeeding Foundation (BBF)

2. Contents of presentation • Context of the study • Objectives • Methodology • Findings of the Baseline survey • Development of Recipes • TIPs • Laboratory analysis • Conclusion and Recommendations

3. Context of the study • The exclusive breastfeeding rate is 64% and minimum acceptable diet is only 21%. (using the stricter definition as per global guidelines, BDHS-2011) • National guidelines and strategy on CF have been developed (IPHN 2009) • Absence of policy /advocacy tools, particularly a manual on CF recipes using local ingredients and preparation/processing methods).

4. ObjectivesTo provide nutrition practitioners and care providers in Bangladesh with necessary guidelines and a recipe manual for improving complementary feeding practices.

6. Technical committee consultations Developmentof recipes Trials of Improved Practices (TIPs) methods (Recipe trials in selected areas) Acceptability analysis of the recipes (Children’s and mothers’ preferences) Laboratory analysis of 30 recipes Development of a manual of CF recipes and guidelines for CF practices in Bangladesh Final reportwriting The study used multiple methods, such as Literature review, Focus group discussion, In-depth interview, Technical committee consultations, Nutrient analysis (Laboratory) and TIPs (Recipe trial). Methodology Sample frame and Sample Size Training of staff Recruitment of staff Qualitative methods • Baseline survey – • Focus group discussions • In-depth interview Analysis of Data Gap identification

7. Areas selected for qualitative study

8. Results: In depth Interview (Mothers) Complementary feeding • One third of the mothers started complementary food after completion of six months of age of their child with continuation of breast milk. • Two third of the mothers started Complementary feeding between 7 and 8 months. • They fed their child liquid, semi liquid, semi solid foods like khichuri, semolina (suji), sago, potatoes with pulse and family foods. • One third of them added eggs, chicken, liver, small fish in cooked khichuri. The children were fed 3 to 4 times a day. In Khulna division (Dacop), one mother said, “Bartikhabarkhelepustihobe, barbe. Bukerdudherpasapasiborohowarjonno, shaksobji die khichuridei, akhonamaderkhabarkhay.’’(I feed khichuri and vegetables along with breast milk to my child for appropriate growth, so that baby will be well nourished and healthy, now my child eats our casual family foods).

9. Focus Group Discussion (Mothers) • Two third of the mothers had little/lack of knowledge on complementary foods, how to prepare and how much should be given to the children. • Half of them thought they gave appropriate diets to their children. • One third of mothers said that they heard about complementary food from their Didi (health worker) or other elder persons like mothers and sisters . • Half of them heard about complementary food from health care centre but did not get any advice on the type of food, frequency of feeding and/or amount needed daily .

10. Assessing dietary diversity and adequacy of CF foods • To identify the nutrient adequacy, we analyzed some recipes from the field during in-depth interview and FGD. • The assessment showed that energy density was low and did not have required nutritive value and proportion of nutrients. • Such foods fill the child’s stomach and do not provide required amount of energy and nutrients. • The assessment showed that feeding practices and dietary diversity were generally inadequate. For example:

11. Steps for Development of Recipes • Principles • The formulation of recipes was based on foods used by mothers in 7 Divisions and the assessment of nutrient gaps was carried out with the help of baseline study. • Factors for assessing nutrient adequacy of recipes considered energy density, nutrient density, protein content, use of micro nutrient rich foods, animal foods, serving size, number of times fed, age of the child, consistency, cost, feasibility, accessibility and seasonality following standard guidelines. (WHO/UNICEF - 2003)

12. Recipedevelopment • Selection of potential foods Based on field experience selected criteria were followed in developing recipes for children aged 6 to 23 months : Availability, feasibility, nutritive value, cost, acceptability. 2. Recipe development considering potential food combinations (adapted from FAO, 2002)

15. Trials of improved practice (Tips) • Demonstration experience trials • The Complementary foods, recipe options, guidelines, key nutrition education messages and recommendations were based on Trials of Improved Practices (TIPs) carried out in Bangladesh. • For the recipe trials, cooking sessions and sensory evaluations were conducted with mothers. • The recipes were tested for acceptability by young children by observing intake .

16. Acceptability of recipes (Divisionwise)

17. Laboratory analysis of nutrients • Analysis of 30 CF has been carried out in an accredited laboratory. • Analysis of energy, protein, fat, carbohydrate, vitamin A, calcium, iron, zinc, moisture, ash (phosphorus, magnessium, copper) • Out of 35 recipes 30 most commonly used ones were sent for lab analysis.

18. Laboratory analysis report of improved recipes

19. Energy value (kcal) per serving of selected recipes • Recommended energy intake from CF: 200 kcal for 6-8 mo, 300 kcal from 9-11 mo and 550 kcal for 12-23 mo. (WHO)

20. Comparison between calculated value and analyzed value for 30 recipes

22. Content of “Improved Recipes for Complementary feeding of children aged 6 to 23 months” Part 1:Purpose of this book Part 2:Introduction 2.1 Background 2.2 What is complementary feeding? 2.3 Dietary quality and nutrient adequacy 2.4 Combination of food groups 2.5 Guidance on feeding frequency Part 3:Development of recipes 3.1 Trials of Improved Practices (TIPs) 3.2 Key features of the recipe book 3.3 Menu options

23. Con. Part 4:Improved recipes for complementary feeding . • Menu option 1: Main meals • Menu option 2: Side dishes • Menu option 3: Snacks • Menu option 4: Soups • Menu option 5: Desserts

24. Examples of the most acceptable recipes

25. Fruit firni (folerpayesh) Egg suji (dimersuji) Sujir (semolina)Malpoa Chicken Chop (Murgir chop) Small fish chop (Kachki macher chop) Buter halwa

26. Fruit Pitha (folerpitha) Soya Chop Fish Cutlet (Macher chop) Vegetable chop (sobji chop) Carrot laddo (gajorerladdo) Vegetable roll (Sobji roll)

28. Content of “Guidelines for Complementary feeding” children of different age groups (6 to 23 months) Part -1 Current Status of Infant and Young Child feeding 1.1 Current Strategy for Infant and Young Child Feeding in Bangladesh 1.2 Country policy and practices 1.3 Review of training manual and tools on CF 1.4 Guiding principles for Complementary feeding for breastfed child -(WHO-UNICEF) Part -2 Complementary Feeding 2.1Definitions 2.2 Why complementary foods are important? 2.3Why it is necessary to start complementary food at the appropriate time? 2.4Why a mixture of foods from different food groups is necessary to fill that gap ?

29. Part-3Complementary feeding Guidelines for children of different age groups (6 to 23 months) 3.1 Why improve complementary feeding? 3.2 Common feeding problems A. Dietary Diversity B. Energy (%) from different nutrients C. Energy Density D. Nutrient density E. Frequency F. Portion size G. Acceptability H. Feasibility

30. Cont. I. Preparation Time and Cooking Process J. Cost of food K. Safety, Hygiene and Storage of CF • Responsive feeding • Trials of Improved Practices in Bangladesh N. Household weights and measures O. Geographical areas and feeding pattern • Recommended practices for breastfed children 6-23 months

31. Conclusion • The study addressed documentation and update of complementary feeding in 7 divisions of Bangladesh. • A manual of complementary food recipes has been developed with divisional practices including regional food habits and culture of Complementary Feeding (CF). • A dietary guidelines on CF has been devloped to ease the practices by all level.

32. Policy Recommendations • The recipes and guidelines should be promoted for use in Bangladesh in all areas to prevent malnutrition and subsequent impact studied. • Evaluation of these recipes on biological outcome would be helpful for assessing nutritional improvement in children. • The health systems of MOHFW should consider adopting the recipes and guidelines for use in NNS in collaboration with BBF to promote IYCF activities. This would be a follow up of the Honorable Prime Ministers’ directive (2009) on IYCF, which had in fact led the development of recipes and manual for complementary feeding. • This manual should be used to sensitize food and agriculture Ministries to promote nutrition oriented food production.

33. Field Visits in Baseline

34. Field Visits in TIPs

35. Thank You