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TOR# 14 Title of the Research Project: Development of a complementary feeding manual for Bangladesh Principal Investigator: Dr. A.K.M. Iqbal Kabir , MBBS, MD,PhD , Vice - Chairperson, BBF
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TOR# 14 Title of the Research Project: Development of a complementary feeding manual for Bangladesh Principal Investigator: Dr. A.K.M. IqbalKabir, MBBS, MD,PhD, Vice - Chairperson, BBF Co- Principal Investigators: Dr. S. K. Roy, MBBS (Dhaka), M.ScNutr, Ph.D (London), FRCP (Edin), Chairperson, BBF And Prof. SoofiaKhatoon, MBBS, FCPS (Ped),MHPED (Australia) ,Fellow in Neonatology (U.K), Secretary, BBF Institution: Bangladesh Breastfeeding Foundation (BBF)
Context of the study • The exclusive breastfeeding rate is 64% and appropriate CF practices (6-23 months)rate 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).
Complementary Feeding Practices (6-23 months) Source: BDHS-2011
Objectives To provide nutrition practitioners and care providers in Bangladesh with necessary guidelines and a recipe manual for improving complementary feeding practices.
The study used multiple methods, such as analysis of literature review, focus group discussion, in-depth interview, technical committee consultations, nutrient analyzing and TIPs (Recipe trial). Training of staff Recruitment of staff Sample frame and Sample Size
Qualitative Research: • In-depth interviews withMothers and fathers :15 • Focus group discussions (FGDs) with the mothers or caregivers and the fathers and the govt. health service providers: 28 • Each focus group discussion included 6-8 persons . • Duration : About 2 hrs • TIPs : Total 35 Recipes were tested for acceptability in seven divisions
Result: In depth Interview (Mother) 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 Cox’s Bazar, Chittagong division, one mother said, “bukerdudhakhonokhay, shaldudhdichi, shaldudhdilebachcharvalohoy, shorir, haddipustooi, brain valooi, sasthovalooi.” (I still breastfeed my child, I also fed colostrum. Colostrum is good for health and also for bone and brain development )
Focus Group Discussion (Mother) • 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 .
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 often fill the child’s stomach but provide less energy and nutrients , thus contributing to growth faltering. Complementary foods given to children frequently do not provide required amount of energy and nutrients. • The assessment showed that feeding practices and dietary diversity were generally inadequate. For example:
Steps for Development of Recipes • Principles : • The formulation of recipes was based on foods used by mothers and the assessment of nutrient gap was done from 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)
Recipe development: • 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. Potential food combinations (adapted from F AO, Food –based strategies to meet the challenges of micronutrient malnutrition in the developing world) 1. Cereal+ Animal food (fish/ egg/ meat/ chicken/liver) + vegetables+ adequate quantity of oil 2. Cereal + pulse +nuts +vegetable/fruit + adequate quantity of oil 3. Cereal + nuts/fish/egg +fruit/vegetable + adequate quantity of oil 4. Cereal + pulse + Fruit/vegetable + adequate quantity of oil 5. Cereal + pulse + animal food (egg/ liver/ chicken) + vegetable+ oil 6.Cereal + milk/egg + sugar/ molasses + fruit/vegetable
Trials of improved practice(TIPs): • Testing improved recipes for use (Demonstration): • 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 .
Fruit firni (folerpayesh) Egg suji (dimersuji) Sujir (semolina)Malpoa Chicken Chop (Murgir chop) Small fish chop (Kachki macher chop) Buter halwa
Fruit Pitha (folerpitha) Soya Chop Fish Cutlet (Macher chop) Vegetable chop (sobji chop) Carrot laddo (gajorerladdo) Vegetable roll (Sobji roll)
Acceptability (100%) of different recipes by children (Division wise)
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, magnesium, copper) • Out of 35 recipes 30 most commonly used ones were sent for lab analysis.
Comparison between lab result and improved developed recipes
Policy Recommendations • The manual and guidelines would serve as a tool for practical knowledge and training for nutrition practitioners, academicians and mothers. • The manual should receive careful attention of government and non-government partners for use/adapting in programs concerned with infant and young child feeding (IYCF). • Formulation of recipes was built on existing practices covering 7 divisions of Bangladesh. • Evaluation of these recipes on biological outcome will be helpful. • There is need for well linked community based programs to build a true multi-sectoral approach.
