PLANNING NUTRIENT DENSE COMPLEMENTARY FOODS

1. PLANNING NUTRIENT DENSE COMPLEMENTARY FOODS Lalita Bhattacharjee Nutritionist NFPCSP, FAO

2. Prevalence of LBW in Selected Asian Countries (weight < 2500 g at birth) 60 50 50 40 33 30 23 30 Prevalence % 20 17 16 20 11 7.2 10 0 BAN NEP IND MMR MAV SRL BHU INO THA Source : WHO/SEARO, 2000

3. Global and regional trends in the estimated prevalence of protein-energy malnutrition in underweight children under five, since 1980 Source : Nutrition for Health and Development, Progress and Prospects on the Eve of the 21st Century (WHO/NHD/1999)

4. 70 60 50 40 30 20 10 0 Prevalence of PEM in children less than 5 years in selected Asian countries. 63 56 54 51 50 50 49 40.1 38 36.1 42 38 30 30.7 31.2 Prevalence % 18 16.1 16 BAN NEP IND MMR MAV SRL BHU INO THA % Prevalence of Underweight children (<2sd NCHS median for weight for age) % Prevalence of Stunted Children (<- 2sd height/age) Source : WHO/SEARO, 2000

5. Issues central to promoting appropriate infant and young child (IYC) feeding • A household food and nutrition security context • Links of maternal and child nutrition • Guidelines for IYC feeding • Adoption of a community based approach

6. Food based dietary guidelines (FBDGs) Basic health services Specific food &nutrition programmes • Prevention & control of malnutrition, GMP & CF, • School meals, etc Consumption Individual / Household & Community as core for development Food quality & processing Utilization Monitoring and Surveillance Food combinations/ Food-to-food enrichment Food production -Rice -Legumes -Fish -Chicken -Eggs -Vegetables -Fruits -Milk & others Agriculture extension Food and Nutrition Security Cycle

7. Maternal and child nutrition links • Malnutrition in pre pregnancy &pregnancy • SE factors, early pregnancy, food taboos, faulty diet,etc. • Anemia –LBW • Lactation performance • Existing practices fail to make up nutrient deficit • Protein –energy malnutrition

8. Fetal development & maternal environment Four relevant factors in fetal life : intrauterine growth retardation (IUGR); premature delivery of a normal growth for gestational age fetus; overnutrition in utero; intergenerational factors Evidence on IUGR associated with increased risk of CHD, stroke,diabetes and raised blood pressure Large size at birth associated with increased risk of diabetes and CV disease

9. Proper feeding in infancy and early childhood • Achieving normal growth • Increasing chances for developing & maturing into well nourished , functionally capable adult • Prevention of malnutrition • Enhance eating behaviour • Identifies a set of feeding and dietary practices to meet nutrient requirements

10. Need for feeding recommendations • Children at greatest risk of nutritional deficiency & growth retardation between 6 & 24 mo (peaks at 12 -24 mo) • Between 1-2 years relative contribution of breast milk declines as it is gradually replaced by appropriate CF • Feeding recommendations to be expanded as CF guidelines

11. Recommended practices for BF children 6-24 months • Continue frequent on-demand BF including night feeding for infants • Introduce CF beginning around 6 months • Increase food quantity as child gets older while maintaining frequent BF (Approx. energy from CF for : 6-8 months 280 kcal; 9-11 months 450 kcal; 12-24 months 750 kcal ); Local research needed to determine best combination of foods and practices to achieve these levels of energy intake

12. Recommended practices for BF children 6-24 months (Contd). Increase feeding frequency as the child gets older, using a combination of foods ( Feed CF : 6-8 month olds 2-3 times/d; 9-11 month olds 3-4 times/d; 12-24 month olds 4-5 times/d) Gradually increase food consistency and variety Diversify diet to improve quality &micronutrient intake Practice active feeding; also during and after illness Practice good hygiene and proper food handling

13. Guidelines for Complementary feeding • Ensure that children reach their proper and full potential for growth and development • Prevent PEM and micronutrient malnutrition • Foster development of desirable eating habits & establish an eating pattern • Need to be accompanied by systematic GMP activities

14. Developing complementary feeding guidelines (CFG) • Appropriate complementary feeding involves a combination of practices to maintain breast-feeding and, at the same time, improve the quantity and quality of foods given to the young child.

15. Developing CFGs • A set of guidelinesfor the addition of nutrient-dense foods to diets of breastfed infants between 6 and 12 months of age serves as a point of reference for appropriate adaptation to varying country contexts • Can be implemented through national FBDGs • Rationale for CFG should stem from traditional food pattern, food availability and food production data

16. Developing CFGs (Contd). • At the household level, FAO in conjunction with WHO &UNICEF facilitates country efforts to develop and promote use of FBDGs for feeding infants &young children • Work in various countries provides illustration of the effectiveness of such guidelines in improving IYC feeding behaviours when the guidelines are part of an overall strategy to increase household food security

17. Some important considerations • Ideal infant and young child feeding comprises exclusive breast feeding for 6 months • Followed by sequential inclusion of semi-solid and solid foods to complement breast milk • Till the child is able to gradually eat the normal household diet by about 2 years.

18. Promotion, protection and support of breast-feeding • Essential that the newborn gets the initial breast milk called colostrum as the first feed, because of its immense immunologic value.

19. Ingredients for CF Rice (4)+pulse(1)+nuts(1)+veg(2)

20. Suggested complementary feeding guidelines • 0-6 months - Exclusive breast feeding • At 6 months - Begin with rice gruel, ripe banana; add egg yolk, chicken liver or legumes, fish and DGLVs/pumpkin/ carrots 7 months - Add ground meat including chicken, whole egg, well cooked soft fish & other fruits( ripe papaya/mango) progressing until child takes 1 full meal 8 - 9 months - Give 2 complete meals • 10 - 12 months- Give 3 complete meals

21. Energy Needed from Complementary Foods to Meet Daily Requirements by Level of Breast milk Intake Level of Breast milk Intake a Kilocalories needed from complementary foods • Source : Brown et al., 1998 • Figures have been rounded • Estimates of average breast milk intake are: 410 kcal for 6-8 month old, 340 kcal for 12-23 months old. These estimates need to be adjusted for the size of the infant.

22. Timing of introduction of complementary foods • To minimize interference with normal pattern of breast-feeding, complementary foods should preferably be given between breast feeds. • Along with introduction of CF, breast-feeding should remain an important component of the infant’s diet & preferably continue into the second year of life.

23. Preparation of locally appropriate complementary mix • An example of a complementary food mix could include : 3 parts of rice + 1 part of beans + 1 part of nuts/oilseeds suitably roasted, ground & cooked to a gruel to be fed to the young child . • Culturally appropriate combinations can be adapted for use.

24. Hygienic preparation and care • Guidelines for hygienic preparation and storage of complementary foods need to be developed to prevent risks of contamination. • Mothers/caregivers should be instructed to wash their hands thoroughly before preparation and feeding.

25. A community based approach • Way of empowering individuals, households and communities to develop human capital • Based on the notion that community needs to obtain some basic understanding on how to improve essential food, nutrition and related indicators • Evokes community participation

26. Service driven programmes - Vertical, many become welfare oriented - Little intra/inter sectoral coordination - Little people /community participation - Dependency creation - Not sustainable - Inadequate coverage Individual Family Community

27. Community-Based Nutrition Programme Components Minimum Basic Services (Health, Education, Agr. Extension) • Support System • Training • Funding • Problem Solving • Supervision Facilitators • Menus of activities) • Food Production • Nutrition education • Food sanitation/safety • Antenatal care • GMP • BF/CF • Other activities • Interface • (service providers and • community leaders) • Plan/goals • Implementation • Monitoring & evaluation Mobilizers (1:10 households) Community Leaders Household Individual Essential Minimum Needs Goals/Indicators

28. Community based programmes to link CF and GMP • Mothers can be mobilized by community mobilizers to participate in processing, preparation & feeding of complementary foods. • Malnourished children can be identified & timely dietary guidance given to mothers. • Serve as practical guidance tools to monitor children’s growth and nutritional status.

29. Community based programmes to improve complementary feeding (cont’d) • One mobilizer can take responsibility for 10 households in a community to promote the mothers’ concerted involvement in nutrition improvement of their children. • A village nutrition development fundcan be created for use of complementary food mixtures; mix can be given freeto children whose growth falters.

30. Conclusions • For infants up to 6 months exclusive breast-feeding should be encouraged & promoted as the most desirable feeding practice. • For older infants & young children, raising community awareness of the critical importance of the timely introduction of adequate quantities of safe nutritious complementary foods is key for improving nutrition.

31. Conclusions (Cont’d) • FBDGs for infants and young children need to be developed and promoted considering local agro-ecological contexts & the potential for increasing production of nutritious foods,processing techniques & capacities.

32. Thank You for Your Attention