Development of a Complementary Feeding Manual for...

Development of a Complementary

Feeding Manual for Bangladesh

The study conducted by:

Bangladesh Breastfeeding Foundation (BBF)

Principal Investigator:

Dr. A.K.M. Iqbal Kabir Vice Chairperson


Co-Investigators:

Dr. S. K. Roy Chairperson


Prof. Soofia Khatoon Secretary


This study was carried out with the support of the

National Food Policy Capacity Strengthening Programme

June 2013 [Type

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This study was financed under the Research Grants Scheme (RGS) of the

National Food Policy Capacity Strengthening Programme (NFPCSP) Phase

II. The purpose of the RGS is to support studies that directly address the

policy research needs identified by the Food Planning and Monitoring Unit

of the Ministry of Food. The NFPCSP is being implemented by the Food and

Agriculture Organization of the United Nations (FAO) and the Food

Planning and Monitoring Unit (FPMU), Ministry of Food with the financial

support of EU and USAID.

The designation and presentation of material in this publication do not imply

the expression of any opinion whatsoever on the part of FAO nor of the

NFPCSP, Government of Bangladesh, EU or USAID and reflects the sole

opinions and views of the authors who are fully responsible for the contents,

findings and recommendations of this report.

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Acknowledgements

This study was carried out by Bangladesh Breastfeeding Foundation with the technical support of National Food Policy Capacity Strengthening Programme (NFPCSP) of Food and Agriculture Organization (FAO) of the United Nations. The study provided a documentation and analytical update of complementary feeding in 7 divisions of Bangladesh. This was followed by assessment of the dietary adequacy of complementary feeding. And finally, a manual of complementary food recipes and complementary feeding guide have been developed drawing upon the documented practices in the divisions including regional food habits and cultural patterns that have influenced Complementary Feeding (CF). Trials of improved practices (TIPs) have been carried out to provide the rationale for developing CF recipes drawing upon field and science based information and complying with international manual and indicators. The nutrient content of the recipes have been analyzed in an accredited laboratory to demonstrate a high level of accuracy and harmonization with calculated values. The field testing of TIPs in all divisions showed high level of acceptability. This report and manual provide practical knowledge and serve as a training tool for nutrition practitioners, academicians and mothers. We are thankful to Mr. Naser Farid, Director General, FPMU and Mr. Mostafa Faruq Al Banna, Associate Research Director, Food Consumption and Nutrition Wing, FPMU for their insights and cooperation. We are grateful to Mr. Mike Robson, FAO Representative in Bangladesh and Dr. Ciro Fiorillo, Chief Technical Advisor, NFPCSP – FAO for their encouragement and support. We also thank Dr. Nur Ahammed Khondaker for his overall guidance on the research process and logistics. We are particularly indebted to the Technical Assistance Team of NFPCSP –FAO, Dr. Lalita Bhattacharjee, Nutritionist, Dr. Mohammad Abdul Mannan, National Nutrition Advisor for their technical support throughout the study. Their valuable advice, suggestions, direction, guidance and careful review of the manual are gratefully acknowledged. Our deepest thanks go to the mothers and caregivers of children who generously shared their knowledge, views, experience and actively participated in preparing and tasting the complementary foods. Our gratitude goes to the Government authorities (Civil surgeon, UNO, TNO, UHFPO, THFPO) in seven divisions of Bangladesh who facilitated introductions and supported the field work. Special thanks are due to the HI, HW, HA who were involved in the Trials of Improved Practices (TIPS) on Infant and Young Child Feeding, who helped to test thirty five recipes and provided valuable comments and inputs. My special thanks are due to the technical committee members of this project (Development of a complementary feeding manual for Bangladesh) FAO, IPHN,

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UNICEF, A & T, HKI, DFID, USAID, INFS, BRAC, ICDDR, B for their valuable information, suggestions and advice. I express my sincere thanks and gratitude to Khurshid Jahan, Director BBF, Nigar Sultana, Program Manager BBF and the team and all the members of BBF for their contributions, valuable suggestions, keen interest and extended support toward finalizing this manual in time. Finally, I hope that the technical report of “Development of a complementary feeding manual for Bangladesh” will be useful to the health and nutrition practitioners in improvement of infant and young child feeding and health and nutritional status of the children of 6 to 23 months of age.

Dr.SK Roy Chairperson Bangladesh Breastfeeding Foundation

Table of contents

Contents Page number

Acknowledgements……………………………………………………………………………….…… i

Abbreviations……………………………………………………………………………………… …iii

Executive summary…………………………………………………………………………………….v

1. Context of the Study ...................................................................................................................... 1

2. Key outputs and research ............................................................................................................... 3

3. Objective ....................................................................................................................................... 4

4. Literature review ........................................................................................................................... 4

4.1 Complementary Feeding .......................................................................................................... 4

4.2 Association between complementary feeding and malnutrition……………………………... .7

4.3 Complementary Feeding in Bangladesh ................................................................................... 7

4.4 Complementary Feeding in South Asia .................................................................................. 11

4.5 Effectiveness of Complementary Feeding Intervention……………………………………….13

4.6 Trials of improved practices (TIPs) ........................................................................................ 15

5. Methodology ............................................................................................................................... 16

5.1 Sampling frame and size ........................................................................................................ 17

5.2 Staff recruitment and training ................................................................................................. 19

5.3 In-depth interview .................................................................................................................. 19

5.4 Focus Group Discussions (FGDs) .......................................................................................... 20

6. Preliminary findings and discussion from baseline study ............................................................ 21

6.1 In-depth Interview ................................................................................................................ 21

6.2 Focus Group Discussions (FGD) .......................................................................................... 24

6.3 Assessing Dietary Diversity and Adequacy of CF foods ......................................................... 29

7. Steps for Development of Recipes ............................................................................................... 29

7.1 Selection of potential foods .................................................................................................... 29

7.2 Identification of the potential food combinations .................................................................... 29

7.3 Development of recipes .......................................................................................................... 30

8. Trials of Improved Practices (TIPs) ............................................................................................. 32

8.1 Demonstration experience trials ............................................................................................. 32

8.2 Findings of TIPs..................................................................................................................... 32

8.2.1 Children’s acceptability ................................................................................................... 32

8.2.2 Mothers’ acceptability ..................................................................................................... 37

9. Laboratory analysis of improved recipes ...................................................................................... 42

9.1 Report of the laboratory analysis of 30 recipes ....................................................................... 43

9.2 Comparison between calculated value and analyzed value for 30 recipes ............................... 44

10. Manual of CF recipes and CF guidelines ................................................................................... 50

11. Conclusion ................................................................................................................................ 50

12. Policy Recommendations........................................................................................................... 50

References…………………………………………………………………………………………….51

Annexure......................................................................................................................................... 58

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Abbreviations

ACF = Action Against Hunger

A & T = Alive and Thrive.

BBF=Bangladesh Breastfeeding Foundation

BDHS= Bangladesh Demographic and Health Survey

BMI= Body Mass Index

BMS= Breastmilk substitute

BRAC= Bangladesh Rural Advancement Committee

CF= Complementary Feeding

CHT = Chittagong Hill Tract

CIP= Country Investment Plan

DAE= Department of Agricultural Extension

DFID= Department for International Development

EU= European Union

FAO= Food and Agriculture Organization

FCT= Food Composition Table

FGD= Focus Group Discussion

FPMU= Food Planning and Monitoring Unit

HAZ= Height for Age z score

HKI= Helen Keller International

HPNSDP= Health Population and Nutrition Sector Development Program

ICDDR’B= International Centre for Diarrhoeal Disease Research, Bangladesh

IHNDP = Integrated Horticulture and Nutrition Development Project

IMR= Infant Mortality Rate

INE= Intensive Nutrition Education

INFS= Institute of Nutrition and Food Science

IPHN= Institute of Public Health Nutrition

IYCF= Infant and Young Child Feeding

Kcal= Kilo calorie

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MoA= Ministry of Agriculture

NFPCSP= National Food Policy Capacity Strengthening Programme

NNP= National Nutrition Programme

OABPF = One Asia Breastfeeding Partners Forum

RNI= Recommended Nutrient Intake

SAIFRN = South Asia Infant Feeding Research Network

SES= Socio-economic status

SF = Supplementary Feeding

TIPs= Trials of Improved Practices

TNO= Thana Nirbahi Officer

THFPO= Thana Health and Family Planning Officer

UNO= Upazila Nirbahi Officer

UHFPO= Upazila Health and Family Planning Officer

USAID= United States Agency for International Development

WAZ= Weight for Age z score

WHO = World Health Organization

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Executive summary Inappropriate infant and young child feeding practice is a major cause of the onset of malnutrition in young children1. Children who are not breast fed appropriately have repeated infections, grow less well, and are almost six times more likely to die by the age of one month than children who receive at least some breast milk. From six months until 23 months of age, when breastfeeding alone is no longer sufficient to meet all nutritional requirements, infants require appropriate complementary feeding, during which they gradually move to consuming family foods. During this period, the incidence of malnutrition, the effects of which are seldom reversed in later childhood and adolescence2 rises sharply, mainly due to poor quantity and quality of complementary foods and faulty feeding practices. According to the BDHS 20114, in Bangladesh, 62 percent children are introduced to complementary foods at an appropriate age. The quality of diets is also poor, 37 percent consume vitamin A rich fruits and vegetables, 43 percent have meat, fish or poultry and 25 percent consume eggs. One in five children (21 percent ) complies with the IYCF recommendations of consuming breastmilk or other milk products, having the minimum dietary diversity and having the minimum meal frequency .Feeding according to IYCF recommendations is quite low during ages 6-8 month (6 percent)., with an increase to 31 percent among 18-23 months old children. The prevalence of stunting among under five children in Bangladesh decreased from 51% in 2004 and 43% in 20073 to 41% in 20114. The pattern and change in wasting has been small and inconsistent. It increased from 15% in 2004 to 17% in 2007 and declined to 16% of children in 2011. Moreover, the level of underweight has been declining to from 43 in 2004, to 41% in 2007, and to 36% in 2011.Data from recent 2011 BDHS showed that under–five mortality, IMR and Neonatal death rate are decreased to 53, 43, and 32 per 1,000 live births respectively. The exclusive breastfeeding rate is increased to 64% but correct complementary feeding practice (6-23 months of child) rate is only 21%. The HPNSDP 2011-2016 target of 52% of children 6-23 months to be given appropriate IYCF may need to be revisited 4. Bangladesh is still one of the 24 countries with the highest burden of stunting in the world 5,6. Over the years, the country has adopted legislation, curriculum on Infant and Young Child Feeding, including a National Strategy for Infant and Young Child Feeding and an accompanying Plan of Action. Similarly, the National Food Policy Plan of Action (2008- 2015)7 clearly includes a key area of intervention for promoting and protecting breast feeding and complementary feeding. The Country Investment Plan (CIP) also outlined the importance of promotion and protection of breastfeeding and complementary feeding in programs. 8 One important constraint to implement these policies is the absence of adequate policy tools, guidelines and manual on complementary feeding that can be used for guiding policy implementers and educates the trainers at various levels of implementation. The “Training curriculum on complementary feeding”, developed by the Bangladesh Breastfeeding Foundation in 2007, serves as a general guide for national and sub national

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level health professionals who provide training to health and nutrition workers in IYCF. It includes some recipes, complementary feeding messages and general instructions on how to overcome common feeding problems. While this is useful, science-based guidance targeted at mothers and care givers on the types and quantities of foods, recipes, the preparation and processing methods, details on nutrient composition and adequacy and for further diversifying complementary foods is needed. Objective To provide nutrition practitioners in Bangladesh with the necessary guidance material for improving complementary feeding practices. Methodology This was a qualitative study which included a baseline survey and Trials of Improved Practices (TIPs). Baseline study: Multi stage random selection method (for In-depth interviews and Focus group discussions) used to select the population (6-23 months children, child bearing mother/father/mother-in-law) from both urban and rural areas of seven divisions of Bangladesh for the study. Staff recruitment has been done by BBF. One research officer and six research fellows with an educational background in nutrition, social science, economics and child development were engaged. At base line survey a total 15 in-depth interviews were held with mothers and fathers who served as key informants in both rural and urban areas for complementary feeding practices at the household and community level. After selection of the subjects from similar socio - economic characteristics, Focus Group Discussions (FGDs) were conducted on three groups from each selected population in a convenient place. The three groups included (1) mothers, caregivers and grandmother; (2) fathers; (3) health workers. Each group consisted of 6-8 persons, of which one of the participants was a critique to get more insights. Analysis of base line study was done manually and consistencies of data were ensured by re-checking. Development of recipes: The formulations of recipes were based on foods used by mothers and assessment of nutrient gap from baseline study. Thirty five recipes were developed, prepared and standardized using locally available ingredients. The key issues considered here are the “WHO indicators to assess adequacy of CF practices”, including a minimum list of food groups (≥ 4 food groups) from 7 recommended food groups, minimum age-appropriate meal frequency, energy density, nutrient density, protein content, micro nutrient rich foods. At the same time serving number and size according to different age group, cost, feasibility, accessibility and seasonal availability were also considered. Nutrient composition was calculated using available national (INFS FCT) tables for the energy, moisture, available carbohydrate, fibre, protein, fat and ash. TIPs: Based on Trials of Improved Practices (TIPs) carried out in Bangladesh, complementary foods, recipe options, guidelines, key nutrition education messages and recommendations had been developed. Cooking sessions were carried out in selected

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districts of seven divisions in Bangladesh. Thereafter acceptability of the recipes by both mother and children were evaluated using a standard acceptability score card. Mothers were asked if they could prepare the food in their home. At the same time the facilitators also measured the amount of food consumed by the children. Thereafter 30 selected recipes were analyzed in laboratory for energy and specific nutrients (energy, moisture, carbohydrate, protein, fat, ash, vitamin A, calcium, iron and zinc). Results Breast feeding: About 3/4th of the mothers’ breastfed and 2/3rd of them fed colostrum. Two third of the children (6-8 months of age) suckled mother’s milk 7 to 12 times a day , one third of the children (9 to 11 months) had fed breast milk 3 to 5 times a day. Most of the health workers advised them to feed colostrum within one hour of birth and continue breast feeding. Among the participants, half of them gave pre-lacteal foods such as honey, sugar water, sugar candy’s water within 1 hour after birth. Complementary feeding: One third of the mothers started complementary food after completion of six months of their child with continuation of breast milk. One third of the mother started complementary foods before six months as they had the misconception that starting complementary food earlier is good for their children. Half of the mothers said that the child does not get enough milk so they started complementary feeding. Two third of the mothers were started Complementary feeding between 7 to 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. Health workers also advised them to feed complementary foods. A large number did not advise how to prepare the complementary feeding and the types of food for cooking.

Responsive feeding: About half of the mothers’ said they faced difficulty while feeding their children and they said that their children refused to take foods. Two third of the mothers’ said that their children are given foods but sometimes later they refused to take food. This was due to sickness; also they did not like same type of food every time, sometimes they bothered the mother so much that the mother went to beat or scold the child. However, no one force fed the child because if they forced them, the children started vomiting. One third of the mothers’ said that sometimes they walk the child, sing song and lullabies, rhymes, show them birds, the moon, and cows or even play the ring tone of the mobile to motivate and help feed their children.

Food availability: In all divisions, many kinds of vegetables and fruits like egg plant, Green Papaya, Cucumber, amaranth, Indian spinach, Radish leaves , sweet pumpkin, Gourd (Bottle), Orange, Apple, Banana, Papaya, Grapes, Guava and many other seasonal fruits are available to buy. Besides Egg, puffed rice are also available. But children are often given Biscuits, Chips, Chocolate, Cake, Mojo, Cow’s milk etc. In Khulna division,

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different fruits and vegetables are seasonally available e.g. jack fruit, mango, lichi, black berry, sweet pumpkin, potato, green papaya, ladies finger, gourd (Green), egg plant, gourd (Ridge), drumstick, amaranth (red and data), Indian spinach, helencha leaves (thanchi shak) but they did not consider giving these to their children. They felt that fruits such as apple and orange are more nutritious for children. In Rangpur division, a mothers’ group said that they gave cow’s milk, chanachur, biscuits, bread, cake, fruits like- banana, apple, orange, grapes, mango juice, mango, water melon and vegetables like-potatoes, bottle gourd, bitter gourd, folwal, ladies finger, brinjal, bean, tomato, cow pea, Indian spinach, spinach, amaranth, bottle gourd leaves, arum leaves, kolmee leaves, Malva verticillata (Napa shak), taro leaves and so on. However, dry fish (shutki), small fish (keski), banana, potato, tomatoes are easily available and affordable in Chittagong division but these are rarely given to the children. Sometimes mothers fed tinned foods like lactogen, cerelac, bio milk and aldo milk. Knowledge about nutrition: Two third of mothers did not have enough knowledge about nutrition. But 1/3rd of them thought that vegetables, fish, egg, meat, water melon, banana, khichuri, seasonal fruits contain a lot of vitamins. But they did not know which type of foods contain nutrients like minerals, vitamins, protein and energy. Some of them also had misconceptions about nutrition. They said that “they have no idea about nutrition, they think that oranges, apples have more nutrients, but they could not buy it. Two third of them said that if the food is affordable then they could buy nutritious foods easily. Cost: About 2/5th of fathers said that they spend 250 to 400 ($3 - 5.0) taka for their children’s food, whereas, about one third said they spend 450 to 800 ($5-10) taka for their children’s food monthly. One father said he spends 1000 to 2000 ($12-25) taka monthly for their child. If they do not have enough money to buy foods for their children they borrow money from others. Hygiene practices: 2/3rd number of the mothers’ said that, they cover the food after cooking, if the foods were stale; they throw it out and cook again. 2/3rd of them said that they wash hands before and after feeding their child. 1/3 of them said that after defecation, they wash hands with soap but not always. All of them said that they wash hands but could not say appropriately, how and why they need to wash their hands. Assessing dietary diversity and adequacy of CF foods: The assessment showed that energy density of commonly given complementary foods was low and did not meet the nutritional requirements for the child nor did it have the adequate proportion of nutrients. Such foods often fill the child’s stomach, provide less energy and nutrients and are known to contribute to growth faltering. It was also noted that the complementary foods habitually given to the children did not provide the required amount of energy and nutrients. The result is that many infants and young children 6-23 months of age do not receive enough of the right kind of foods to grow and develop well. The assessment showed that feeding practices and dietary diversity were inadequate.

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Trials of Improved Practices (TIPs) In total, 35 recipes had been trialed in 7 divisions of Bangladesh. Analysis of the acceptability (by mothers and children) shows a wide variation among different divisions. In total, 12 recipes namely fruit firni, buter halwa, carrot ladoo, fruit pitha, vegetable chop, sujir malpoa, fish cutlet, soya chop, kachki macher chop, vegetable roll, egg suji, chicken chop were fully accepted by all the mothers and children in 7 divisions of Bangladesh. Other recipes also had moderate acceptability score. This is possibly due to the regional availability and food consumption patterns. Laboratory analysis of 30 selected recipes After completion of the recipe trials in 7 divisions, out of 35 improved recipes 30 recipes were cooked using standard methods the recipes were then sent to an accredited laboratory for nutrient analysis: energy, protein, fat, carbohydrate, vitamin A, calcium, iron, zinc, moisture, ash (phosphorus, magnesium, copper) .Analysis of these ten nutrients was carried out following standard methods and the result was composed per 100 gram basis. Manual of CF recipes and CF guidelines

A manual of a set of improved complementary foods has been prepared with calculation of dietary diversity scores, energy, protein, fat, carbohydrate (available), fiber, moisture and ash content. Cost on a per serving basis, appropriate for low, middle and high income groups have been calculated. Cooking and standardization of these improved complementary food recipes have been defined based on a variety of locally available foods using appropriate preparation and processing methods and technologies and standard portion sizes. At the same time, acceptability of the recipes in urban and rural locations has also been included. A complementary feeding guide outlining the appropriate feeding practices has been prepared. Key recommendations for using home based preparation methods and appropriate technologies to enhance the nutrient density and bioavailability of the micronutrients from local foods has been discussed. The guidelines also include hygiene for preparation of complementary foods as well as during infant and young child feeding. Conclusions This manual of complementary food recipes and complementary feeding guide has been developed based on the Trials of Improved Practices (TIPs) with scientific formulations following international standards and guidelines. The nutrient content for the recipes has been analyzed in an accredited laboratory. Recipes were developed according to regional food habits and culture. The field testing of TIPs in all divisions showed a high level of acceptability. The manual and guidelines have been developed to provide practical knowledge and as a training tool for nutrition practitioners, academician and mothers.

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Policy Recommendations

1. This practical manual can be utilized by the government and non-government organizations in the programs that promote infants and young child feeding (IYCF).

2. The evaluation of the recipes on biological outcome will be helpful for assessing efficiency of growth of the children.

3. The health system can consider adapting the recipes and guidelines for scaling up through BBF and MOHFW and led the development of recipes and manual for complementary food.

4. The complementary feeding recipes can provide guideline for improving the diversity of the infant and young child’s diet and to improve the nutrient needs.

5. There is a need for integrated program addressing micronutrient deficiencies while simultaneously combating larger issues of food insecurity and malnutrition in the community through appropriate complementary feeding practices.

1. Context of the Study Inappropriate infant and young child feeding practice is a major cause of the onset of malnutrition in young children1. Children who are not breastfed appropriately have repeated infections, grow less well and are almost six times more likely to die by the age of one month than children who receive at least some breast milk. From six months until 23 months of age, when breastfeeding alone is no longer sufficient to meet all nutritional requirements, infants require appropriate complementary feeding, during which they gradually move to consuming family foods. During this period, the incidence of malnutrition, the effects of which are seldom reversed in later childhood and adolescence2 rises sharply, mainly due to poor quantity and quality of complementary foods and faulty feeding practices. According to the BDHS 20073, in Bangladesh, complementary foods are introduced among infants (36%) as early as 1 month of age and by the age of 6 to 7 months only 68% of breast fed children received semi solid or solid foods as per the complementary feeding recommendations. The quality of diets is also poor, with only 25% of infants being fed vitamin A rich foods and as little as 10% receiving animal foods. The prevalence of stunting among under five children in Bangladesh decreased from 51% in 2004 and 43% in 20073 to 41% in 20114. The pattern and change in wasting has been small and inconsistent. It increased from 15% in 2004 to 17% in 2007 and declined to 16% of children in 2011. Moreover, the level of underweight has been declining to from 43 in 2004, to 41% in 2007, and to 36% in 2011.Data from recent 2011 BDHS showed that under–five mortality, IMR and Neonatal death rate are decreased to 53, 43, and 32 per 1,000 live births respectively. The exclusive breastfeeding rate is increased to 64% but correct complementary feeding practice (6-23 months of child) rate is only 21%. The HPNSDP 2011-2016 target of 52% of children 6-23 months to be given appropriate IYCF may need to be revisited 4. Bangladesh is still one of the 24 countries with the highest burden of stunting in the world 5,6. Over the years, the country has adopted legislation, curriculum on Infant and Young Child Feeding, including a National Strategy for Infant and Young Child Feeding and an accompanying Plan of Action. Similarly, the National Food Policy Plan of Action (2008- 2015)7 clearly includes a key area of intervention for promoting and protecting breast feeding and complementary feeding. The Country Investment Plan (CIP) also outlined the importance of promotion and protection of breastfeeding and complementary feeding in programme 10 8 One important constraint to implement these policies is the absence of adequate policy tools, guidelines and manual on complementary feeding that can be used for guiding policy implementers and educates the trainers at various levels of implementation. The “Training curriculum on complementary feeding”, developed by the Bangladesh Breastfeeding Foundation in 2007, serves as a general guide for national and sub national level health professionals who provide training to health and nutrition workers in IYCF. It includes some recipes, complementary feeding messages and general instructions on how to overcome common feeding problems. While this is useful, science-based guidance targeted at mothers and care givers on the types and quantities of foods, recipes, the preparation and processing methods, details on nutrient composition and adequacy and for further diversifying complementary foods is needed.

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This project has developed guidance material targeted at mothers and care providers. This has been build on the above-mentioned “Training curriculum on complementary feeding” and also included a wider range of recipe options; indications on basic foods/ groups; right food combinations; correct food handling methods; appropriate preparation methods and simple processing technologies as well as the schedule and frequency of complementary feeding. Activities are as follows:

• This project involved reviewing documentation and current knowledge, studies on existing practices and constraints to appropriate child feeding practices which have been carried out among 6 to 23 months old children and their mothers. Documents have been reviewed from Bangladesh and South Asia – including those undertaken by ICDDR’B, Alive and Thrive, the National Nutrition Programme (NNP), the Integrated Horticulture and Nutrition Development Programme and Action Against Hunger (ACF)9,10(Action Contre La Faim) .

• Then Identification of current complementary feeding practices was done in the community by in-depth interviews and focus group discussions.

• At the same time through the In-depth interviews and Focus Group Discussions, selection of the recipes from rural and urban areas of seven divisions in Bangladesh including Chittagong Hill Tract (CHT) was done.

• Data was analyzed to identify the gaps and then improved complementary feeding recipes were developed considering nutritional stand point, availability of foods (identified in baseline) and feasibility of the recipes. Related preparation and processing methods were initially standardized in a kitchen laboratory, bearing in mind field realities.

• Developed recipes were then trialed in field for trials of Improved Practices (Demonstration experience trials) for the acceptability of 6-23 months children and their mothers. Acceptability was evaluated using a standard score card.

• Selected 30 recipes were analyzed in the laboratory for its nutrient value. • A Manual of complementary food recipes and guidelines for appropriate complementary

feeding practices in Bangladesh were developed.

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2. Key outputs and research

Objectives 2.1 Research questions Output

To develop a CF guideline to find appropriate feeding practices.

Research Question 1: Is there any documentation and update of complementary feeding practices in Bangladesh?

Literature review was done by consulting articles on complementary feeding by pub med, Icddr,b library and scientific journal.

Documentation of knowledge and practices on complementary feeding, preparation and processing methods, and types of local home based complementary foods used in Bangladesh and in South Asia.

To assess the dietary and food diversity and adequacy of foods

Research Question 2: Is there any assessment of dietary and nutrient adequacy of complementary foods?

There is very limited data on dietary and nutrient adequacy or nutrient gaps of complementary foods in Bangladesh. Adequacy of complementary foods has been studied in seven divisions of Bangladesh.

Determination of dietary and nutrient adequacy of complementary foods has been done through calculation of selected nutrient values (energy, moisture, protein, fat, carbohydrate, fiber and ash) using published FCT (INFS FCT) for Bangladesh.

Determination of nutrient adequacy of the complementary foods in relation to nutrient requirements and recommended dietary intakes/allowances.

3. To prepare a manual of complementary food recipes and complementary feeding guide.

Research Questions 3: Is there any manual of complementary food recipes and complementary feeding guide?

Recipe manual has been developed including 35 recipes using nationally available data (INFS FCT).

35 recipes were tested in the community for acceptability by mothers and their children.

Out of 35 recipes 30 recipes were analyzed in an accredited laboratory.

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3. Objective To provide nutrition practitioners in Bangladesh with the necessary guidance material for improving complementary feeding practices.

4. Literature review The literature review has helped to provide updated knowledge of complementary feeding in Bangladesh and South Asian region. A systematic literature review was conducted to identify the relevant issues of complementary feeding, sources of information on child nutrition problems, complementary feeding practices, preparation and processing methods and the types of locally available and home based complementary foods being used. The cultural beliefs, motivation, dietary intake, hygiene practices and lessons learned in Bangladesh and the South Asia region were also included. For this purpose we have used different search engine like Google, Pub med, and Bing. We also reviewed the work carried out by ICDDR, B, Alive and Thrive (A&T), Institute of Public Health and Nutrition (IPHN), National Nutrition Project (NNP), The Integrated Horticulture and Nutrition Development Project under the Department of Agricultural Extension (IHNDP of DAE), Ministry of Agriculture (MoA) and Action Against Hunger (ACF) as well as South Asia Infant Feeding Research Network (SAIFRN) and One Asia Breastfeeding Partners Forum (OABPF). Review also included the documents of World Health Organization (WHO), United Nations Children’s Fund (UNICEF) and Food and Agriculture Organization (FAO) of the United Nations.

4.1 Complementary Feeding Adequate nutrition during infancy and early childhood is fundamental to the development of each child’s full human potential. It is well documented that first two years of life is a “critical window” for the promotion of optimal growth and behavioral development. Longitudinal studies have consistently shown that this is the peak age for growth faltering, deficiencies of certain micronutrients, and common childhood illnesses such as diarrhea.11 After a child reaches 2 years of age, it is very difficult to reverse stunting that has occurred earlier.12 Poor nutrition during these years significantly associate with morbidity and mortality and delayed mental and motor development. In the long-term, early nutritional deficits are linked to impairments in intellectual performance; work capacity, reproductive outcomes and overall health during adolescence and adulthood. The intergenerational cycle of malnutrition continues, as the malnourished girl child faces greater odds of giving birth to a malnourished, low birth weight infant when she grows up. Poor breastfeeding and complementary feeding practices, with high rates of infectious diseases, are approximately the principal causes of malnutrition during the first two years of life. For this reason, it is essential to ensure adequate nutrition that caregivers are provided with appropriate guidance regarding optimal feeding of infants and young children.11

After 6 months of age when infant’s growth and activities increase, complementary foods should be added to the diet of the child as breast milk is no longer enough to meet the nutritional needs of the infant. Complementary feeding means giving other foods in addition to breast milk. During the

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period of complementary feeding the young child becomes accustomed to eating family food.13

Transition from exclusive breastfeeding to family foods, referred to as complementary feeding, usually covers the period from 6 to 23 months of age. It is the time when malnutrition starts in many infants, contributing significantly to the high prevalence of malnutrition in children under five years of age world-wide. WHO estimates that 2 out of 5 children are stunted in low-income countries.11

Hence complementary food must be nutritious, safe and adequate in amount so the children’s growth and development can be continued.

According to the WHO recommendation, complementary feeding should be started timely, meaning that all infants should start receiving semi solid and soft foods in addition to breast milk from 6 months onwards. It should be adequate, meaning that the complementary foods should be given in amounts, frequency, and consistency and using a variety of foods to cover the nutritional needs of the growing child while maintaining breastfeeding. Foods should be prepared and given in a safe manner, meaning that measures are taken to minimize the risk of contamination with pathogens and they should be given in a way that is appropriate, meaning that foods are of appropriate texture for the age of the child and applying responsive feeding following the principles of psycho-social care.11

Responsive Feeding: The adequacy of complementary feeding not only depends on the availability of a variety of foods in the household, but also on the feeding practices of the caregivers. Feeding young infants requires active care and stimulation. The caregiver is responsive to the child’s signs for hunger and also encourages the child to eat. Providing complementary foods in an “Active” way means to feed responsively. Responsive Feeding is especially important for the children who have been ill or who are recovering from malnutrition.14

Several intervention studies that include feeding behaviors as part of the recommended practices have reported positive effects on child growth. 15,16 In India, it was found that community-based educational interventions on complementary and responsive feeding can improve dietary intake, body length and mental development for children under 2 years.17

Feeding During and After Illness: During illness fluid requirement is often higher than normal. Sick children appear to prefer breast milk to other foods.18 Even though appetite may be reduced, continued consumption of complementary foods is recommended to maintain nutrient intake and enhance recovery.19 WHO recommends increasing fluid intake during illness, including more frequent breastfeeding, and encourage the child to eat soft, varied, appetizing, and favorite foods. After illness, the child needs greater nutrient intake to make up for nutrient losses during the illness and allow for catch-up growth. Therefore, child should be given more food than usual and encourage to eat more. Extra food is needed until the child has recovered weight loss and is growing well.11

Food processing and preparation method: Food processing and preparation method is important to enhance the bioavailability of the nutrients of the food. Some ingredients and beneficial methods of food processing include germination, malting and fermentation. These enhance iron absorption by increasing vitamin C content or by lowering the tannin or phytic acid content, or both.20 Typical household practices of soaking of grains and legumes, help to remove anti-nutrients such as saponins

6

and polyphenols, which are robust inhibitors of non-haem Fe absorption.21 Micronutrient bioavailability is enhanced by some food preparation methods like steaming and stir frying. While preparing the foods containing provitamin A, adequate quantities of fat or oil should be used to promote absorption. To enhance the vitamin A of the meals, foods should be prepared with appropriate combinations of vegetables like green leafy vegetables, sweet potatoes, papaya, carrot and other vegetables in which the levels and bioavailability of carotenoids is very high, along with staple grains and/or preformed vitamin A sources such as liver or fish. Sun-drying, canning and pickling of fruit and vegetables, preparation of fruit squashes are some typical home level technologies that can serve as low cost and effective methods of preserving micronutrient-rich foods.22-24 Another study showed that roasted cereals, legumes and nuts not only give aroma but also destroy contaminated organisms, reduce the moisture content and increase the shelf–life. Fresh spices and herbs (coriander leaves, mint, green chili, etc.) which contain provitamin A can be dried and used as dietary adjuncts to improve the taste of meals while providing dietary provitamin A at the same time.25

Hygienic practices during food preparation and feeding are also important for prevention of gastrointestinal diseases. Usually incidence of diarrheal diseases rises during the second half year of infancy while the intake of complementary foods increases.26One of the major cause of childhood diarrhea is microbial contamination of foods.11

WHO recommends practising good hygiene and proper food handling by - (a) Washing caregiver’s and children’s hands before food preparation and eating. (b) Storing foods safely and serving foods immediately after preparation. (c) Using clean utensils to prepare and serve food. (d) Using clean cups and bowls when feeding children. (e) Avoiding the use of feeding bottles, which are difficult to keep clean. 27

7

4.2 Association between complementary feeding and malnutrition

The majority of young children in developing countries of Asia suffer from malnutrition, especially protein energy malnutrition, stunting, wasting, anemia, vitamin A deficiency and Iodine deficiency.28-31 Bangladesh Demographic and Health Survey (BDHS), 2011 showed that percentage of stunting and wasting increasing after 6 months of age (figure 1).4

Figure 1: Prevalence of stunting, wasting and underweight among under 2 years children, BDHS 2011.

Several studies recognized positive association between growth faltering and inappropriate complementary feeding practices. The WHO Global Database on Child Growth and Malnutrition includes the results of 39 nationally representative datasets from the surveys in developing countries, found that mean weights start to falter at about 3 months of age and decline rapidly until about 12 months, with a markedly slower decline until about 18 to 19 months.28 In Malawi, another study recognized weight faltering occurred mainly between 3 and 12 months of age for frequently attributed to poor complementary feeding.29 Significant associations were found between almost all positive CF practices and nutritional status (HAZ and WAZ) of the children in India.30 Another study observed significant associations between nutritional status (WAZ and HAZ) and the meal-frequency and the dietary diversity of the complementary feeding of infants aged 6-8 months and 9-12 months.31 In China, HAZ and WAZ of children under 2 years positively correlated with the appearance of animal foods, vegetables and fruits in the complementary food, but there was no significant correlation with starchy foods.32

4.3 Complementary Feeding in Bangladesh Inappropriate infant and young child feeding practices have been identified as a major cause of malnutrition. According to the BDHS 2011, about 21 percent of children ages 6-23 months are fed appropriately according to recommended IYCF practices. Feeding practice according to IYCF recommendations is 31 percent among 18-23 months old children, which is quite low (only 6 percent) among the children of 6-8 moths age. About twenty four percent of breastfed children of 6-23 months of age are given four or more food groups and sixty-four percent of the breastfed children are fed at least the minimum number of times (figure 2).4

0

10

20

30

40

50

60

Stunting Wasting Underweight

0-6 mo6-8 mo9-11 mo

12-17mo18-23 mo

8

Figure 2: IYCF practice in Bangladesh, BDHS 2011.

IYCF practices in Bangladesh were positively associated with education levels and wealth score. It was also reported that recommended IYCF practices was better in urban areas (28%) than in rural areas (19%).4

Initiation of complementary food: It is well documented that exclusive breastfeeding for six months confers several benefits on the infant and the mother. Protective effect of exclusive breastfeeding for 6 months, against infant’s gastrointestinal infections has been observed not only in developing countries but also in industrialized countries.33 There is some evidence regarding exclusive breastfeeding for six months play important role to enhance motor development.34 In case of normal birth weight generally infant’s nutrient needs can be met by mother’s milk alone for the first 6 months, if the mother is well nourished. Furthermore; most infants are fully developed for other foods at about six months.35 After six months of age as it becomes increasingly difficult for breastfed infants to meet their nutrient needs from human milk alone36 WHO recommended introducing complementary foods at 6 months of age (180 days) while continuing to breastfeed.11

Initiation of complementary food among infants aged 6-9 months was 76% according to BDHS 2007.3 Result from a prospective study showed that complementary feeding was started much before 6 months of age.37 The mothers reported that they give complementary food when they perceived that their breastmilk supply was inadequate for their baby.37,38 Complementary foods were introduced as early as the first days of life “when the milk did not come in” or at about 2 to 3 months “when the baby cried due to hunger.”37

Commonly used complementary foods in Bangladesh: Inappropriate infant and young child feeding practices are among the most serious obstacles to maintain adequate nutritional status and contribute to malnutrition. Infants can eat pureed, mashed and semi-solid foods beginning at six months. By 8 months most infants can also eat “finger foods” and most children can eat family food by 12 months. WHO recommended increasing food consistency and variety gradually as the infant gets older, adapting to the infant’s requirements and abilities.11 WHO also recommended feeding a variety of foods to ensure that nutrient needs are met from foods like meat, poultry, fish or eggs daily or as often as possible and to feed vitamin A-rich fruits and vegetables daily.

0

20

40

60

80

100

120

Breastfeed Non-breastfeed

All 6-23months

Not feed with IYCFpractices

Feed with all 3 IYCFpractices

2016 Aim: 52%

9

Recommendations have also been made to provide diets with adequate fat content and avoiding giving drinks with low nutrient value, such as tea, coffee and sugary drinks such as soda and limiting the amount of juice to avoid displacing more nutrient rich foods.11 A diet that contains a variety of foods has two advantages: it increases the chances of satisfying requirements for nutrients, especially for vitamins and minerals and increasing the diversity that stimulates the appetite.39

BDHS 2011 reported only 25.2% infants feed 4 or more food groups.4 In rural Bangladesh the complementary foods that are commonly included are rice, wheat, legumes, vegetables (numerous local varieties of tubers, melons, and greens), fruits (guava, banana, mango, coconut), milk, eggs, and fish.40 Community perspectives study on complementary feeding practices in Bangladesh reported that liquid foods (tola khabar) were thought to be suitable for infants below 6 months of age and included fruit juice, infant formula, thin gruel made of suji (semolina), or rice powder cooked in water and sweetened milk or powdered milk. Some mothers tried to slightly thicken the gruel instead of thin gruel or watered animal milk and few mothers tried a more solid food called khichuri (a mixture of rice, lentil, vegetables, and sometimes animal-source foods).37 Another study reported that rice was the major contributor of energy of complementary food and was included in 53% of meals (either alone or mixed with water, milk, dhal, or vegetable or fish curry, or ground to make “luta,” a porridge); wheat products represented 28% of meals and were usually served as suji (wheat porridge), flat bread, or crackers in rural Bangladesh. Fruit accounted for 11% of meals and 15% of all meals contained an animal source food, which was usually cow’s milk.40 The NSP collected data in 2000 to explore how often children fed certain key foods such as fish, egg, dal, green leafy vegetables, or fruit reported that 20% of infants aged 6 months were given family food as the main component of their diet, a percentage which rises to 56% among infants aged 9 months and reaches 87% among infants aged 12 months.39 Ii is well documented that infants and young children need complementary foods with a high micronutrient density, especially at 6–12 months for optimal growth.41-43 However, findings from the NSP indicated the complementary meals given to infants aged 6 to 11 months old rarely contain fish, pulse (dal) and eggs. 39

Meal Frequency: WHO recommended providing complementary food 2-3 times per day at 6-8 months of age and 3-4 times per day at 9-11 and 12-24 months of age. Additional nutritious snacks may be offered 1-2 times per day, as desired.11 BDHS 2011 reported about two-thirds of the breastfed children (64 percent) are fed at least the minimum number of times.4 A community perspective study on complementary feeding practices in Bangladesh recognized that 60% of the children’s frequency of feeding followed global recommendations. Sometimes snacks were offered when the child refused to eat regular meals and at other times as a show of affection.44 Another study found 2.9±1.8 and 3.9±2.1 feeding episode for the infant of 6-8 months and 9-12 months of age respectively in rural Bangladesh.40 Semi-structured interviews and observations recognized that complementary feeding frequency is determined by family mealtimes and the child’s perceived demand rather than nutritional needs or the target number of meals.45

Perception of mothers and care giver: Results from a community based study showed mothers have lack of knowledge about the quantities of foods that should be given to children 6 to 23 months

10

of age. Many mothers mentioned that their children do not want to eat. Mothers complained that children would rather eat biscuits, candy, juice, and chips than a rice-based meal. Many mothers did not modify home foods to make them suitable for small children in terms of spiciness, texture, or consistency. Mothers mentioned that common complementary foods such as khichuri and suji were often rejected by children after they were offered a few times.37 Study on perception of mothers and use of breast milk substitute in Dhaka in 2002 reported that the use of BMS was higher among the mothers of middle SES than the mothers of low SES. About 90% of the mothers of low SES and 70% of the mothers of middle SES could not differentiate infant formula and milk powder; moreover some middle-class mothers thought that infant formula was the best food for their infants.41

Nutrient Content of Complementary Foods: After six months of age’s the nutrient and energy requirements increase breast milk production declines and the needs from complementary foods increase. The total daily average energy requirements for healthy children are 615 kcal at 6–8 months, 686 kcal at 9–11 months and 894 kcal at 12–23 months of age.46 In developing countries, the average expected energy intake from complementary foods is approximately 200 kcal at 6–8 months, 300 kcal at 9–11 months and 550 kcal to 12–23 months. These values represent 33%, 45% and 61% of total energy needs respectively. A study reported that breastfed infants of 6-8 and 9-12 months ages had an intake of 88% and 86% of absolute energy requirements (kJ/d) in rural Bangladesh. Complementary foods supplied 22 and 25% of total energy intake at 6–8 and 9–12 months, respectively. Energy intake (kJ/d) from complementary foods increased only slightly with age. Total daily energy intake from complementary foods ranged from 0 to 500 kcal/d while 47% of infants consuming 100 kcal/d. The energy intake from complementary foods was positively correlated with the number of feeding episodes in 24 h, the amount (g) consumed per 24 h and the amount (g) served per meal. It was also reported that total energy intake positively correlated with meal frequency, quantity consumed per meal and energy intake from breast milk. Energy intake from complementary foods was inversely related to energy intake from breast milk. The median energy density of the complementary food was 4.79 kJ/g (1.2 kcal/g); Energy density was inversely correlated with the amount of complementary food consumed (g/d) and with total daily energy intake from complementary foods.40

Protein is the most important nutrient for the growth of infant and children. The amount of protein needed from complementary foods increases from about 2 g/day at 6–8 months to 5–6 g/day at 12–23 months, with the percentage from complementary foods increasing from 21% to about 50%.11 The average protein intake from complementary food was 0.4g/kg body weight/day and 0.5g/kg body weight/day and among the infant of 6-8 months and 9-12 months of age respectively in rural Bangladesh.40

Breast milk is usually rich in fat (approximately 30–50% of energy), hence little additional fat from complementary foods is needed. However, the fat content of complementary foods becomes more important as breast milk intake declines with age. To achieve at least 30% of energy from fat in the total diet, the amount of fat needed from complementary foods approximately 3 g/day at 9–11 months and 9–13 g/day at 12–23 months respectively.47 Infants and young children need good

11

sources of essential fatty acids in their diet, such as fish, egg, liver, nut pastes and vegetable oils.48 Micronutrient needs are also high during the first 2 years of life to support the rapid rate of growth and development. Depending on the nutrient concentration of breastmilk, the percentage of the recommended nutrient intake needed from complementary foods varies widely. To meet requirements of micronutrients complementary foods needed to include animal-source foods which are rich in iron, Zinc and vitamin B6.49 Findings from the NSP indicated that the complementary meals given to infants aged 6 to 11 months old rarely contain commonly eaten Bangladeshi foods such as fish, pulse (dal) and eggs which are rich in micronutrients and protein.39 Research recognized lower intake of folate, pantothenic acid, riboflavin, thiamin, vitamin B-6, vitamin D, calcium, iron, magnesium, phosphorus, potassium, and zinc than the Recommended Nutrient Intake (RNI) among the infants of 6-12 months in rural Bangladesh. The adequacy of vitamin A intake depends on which assumptions are used for breast milk concentrations. Using an estimate of 226 g/L, mean vitamin A intakes were only 44–48% of the RNI.40

Caregivers and their time: Study showed that the mothers from extremely poor families have financial and time constraints on child care as well as the preparation of complementary food.50 Mothers’ reported that neighbors, family members and friends spend up to 10 to 20 taka (69 taka = US$1) a day on snacks for children under 2 years of age, but very few mothers spend their time making specific food for their children. 37

Hygiene Practices: Practising food safety and personal hygiene is important for preparing safe and healthy complementary foods and feeding children, helps to prevent childhood diarrhea.49

Observation and cross-sectional survey was conducted in rural Bangladesh suggested that hand washing before preparing food is a particularly important opportunity to prevent childhood diarrhea, and that hand washing with water alone can significantly reduce childhood diarrhea. In households where residents washed at least one hand with soap after defecation, children had less diarrhea.51

Factors associated with Complementary Feeding practice: Studies have shown that mothers who had no education had a higher risk for not introducing timely complementary feeds, not meeting the minimum dietary diversity; not giving a minimum acceptable diet and minimum meal frequency than the mothers who had secondary or higher education. 4 In a perspective study, mothers reported lack of appetite, dislike of specific foods and vomiting as barriers to feeding animal-source foods. Eggs and large fish were considered suitable for infants after the age of 6 months.37 Another study reported that the mean amount of complementary foods consumed was inversely related to energy density and positively related to the number of meals/day. Energy intakes from foods were positively related to both factors.52

4.4 Complementary Feeding in South Asia South Asia has the highest global burden of child under nutrition, with almost 41% of children stunted, 16% wasted and 33% underweight. More than 60% of children living in South Asia are malnourished.53 Malnutrition increases the risk of child mortality and is associated with greater than 50% of child deaths54 as well as impaired child development.55 Infants and young children bear the

12

brunt of chronic malnutrition and suffer the greatest consequences, that is, the highest risks of morbidity and mortality.56-58 The incidence of malnutrition rises sharply between 6-18 months of age and the deficits acquired are difficult to compensate for later in the survivors.59 The proportion of micronutrient deficient children (Iron, Vitamin A and Iodine) is very high in South Asia.60 According to the Global Report 2004, the proportion of iron deficient under five children ranged between 55% and 81% in Bhutan, India, Nepal and Bangladesh.61 More than 50 percent child mortality and twenty percent burden of diseases can be reduced in developing countries by eliminating malnutrition.62-67

Inappropriate practices such as delayed introduction of complementary foods, offering low energy and nutrient dense foods, reduced foods from animal sources, feeding with small portion size at meals, and food restrictions due to cultural beliefs are common, even in those parts of Southeast Asia where income and food availability have improved steadily over the last decade.67

Types of Complementary food in South Asia region: Though IYCF practice is better than any other south Asian countries in Sri Lanka, the proportion of infants aged 6–8 months who consumed eggs (7.5%), fruits and vegetables other than those rich in vitamin A (29.6%) and flesh foods (35.2%) was low.68 In Nepal the complementary feeding index showed that cereals and diluted animal milk were the major food-groups fed to the infants.69 A study showed that 42% of children under 2 years got complementary food containing animal food, 30.5% consume milk, 57.8% consume starchy foods, and 48.6% consume vegetables and fruits in the rural areas of China in 2000. The coverage of complementary food containing animal food, vegetables/fruits was only half of that in the urban areas.32

Initiation of complementary food: According to the Bangladesh Demographic Health Survey 2006-2007, the rate of introduction of complementary food at 6–8 months of age was 84% in Sri Lanka.68 This rate was 70% in Nepal69 and 76% in Bangladesh.70 In India only half (55%) of the children aged between 6 and 8 months were introduced to solid foods71 but this rate was 39% in Pakistan. 72 More than half (60.8%) of Pakistani infants do not receive complementary foods at the recommended time72 while another analysis showed 11% infant aged 3-5 months received solid and semisolid or soft food which indicated too early introduction of complementary feeding.73

Minimum meal frequency and Dietary diversity: The Sri Lankan Demographic Health Survey68 showed that minimum meal frequency of complementary food was 88%. This rate was 82% in both Nepal69 and Bangladesh66 while only 42% in India.74 The rate of minimum dietary diversity among children aged 6–23 months ranged in complementary food was also highest (71%) in Sri Lanka among the south Asian countries.67 The rate of minimum dietary diversity was 42% in Bangladesh70 and 34% in Nepal,69 but very low (15%) in India compared to other south Asian countries.74 In India, a community-based cross-sectional study identified that infant’s poor dietary diversity, with only 31% and 18% of the infants reportedly being fed the recommended number of food-groups during 6-8 and 9-12 months respectively. The food-frequency scores of the complementary feeding Index showed that cereals and diluted animal milk were the major food-groups fed to the infants.48

Minimum acceptable diet: Minimum acceptable diet for the breastfed children remained low among children 6-23 month’s was 40% in Bangladesh70 and in Nepal.69 It was alarmingly low in

13

India (9%). Though the rate of dietary diversity (71%) and minimum acceptable diet (68%) for the breastfed children was highest in Sri Lanka but those rates were lower among those children who lived in tea estate sector than children in urban and rural areas.68

Factors associated with poor complementary feeding: The most consistent determinants of inappropriate complementary feeding practices were the lack of maternal education and poverty or lower household wealth in most of the south Asian countries.68-70,72,74 Limited exposure to media, inadequate antenatal care and lack of post-natal contacts by health workers were among predictors of inappropriate complementary feeding. The factors that consistently significantly associated with inappropriate feeding indicators in India were poverty, low level of maternal education, lower frequency of antenatal visits and no exposure to media in India. The children in northern and western geographical regions of India comprise higher odds for inappropriate complementary feeding indicators than in other geographical regions.74 Determinants of not meeting minimum dietary diversity and minimum acceptable diet were lower maternal BMI (<18.5 kg/m2), lower wealth index, no maternal education, less frequent (<7) antenatal clinic visits, lack of post-natal visits and poor exposure to media in most of the South Asian Countries.73

Perception of feeding during illness: Findings from a cross-sectional study on beliefs regarding diet during childhood illness in India found that caregivers believed a child must be fed less during illness. Calorie intake was also significantly lower during illness. Educational status did not play a role in maintaining beliefs, but elders and religion did. Doctors too were responsible for unwanted dietary restrictions. Media did not have an impact in spreading nutrition messages.45

4.5 Effectiveness of Complementary Feeding Intervention

Complementary feeding interventions are usually targeted at the age range of 6–24 months, which is the time of peak incidence of growth faltering, micronutrient deficiencies and infectious illnesses in developing countries. Improved feeding of children less than 2 years of age is particularly important because they experience rapid growth and development and are vulnerable to illnesses such as acute respiratory infections and diarrhoeal diseases. After 2 years of age, it is much more difficult to reverse the effects of malnutrition on stunting and some of the functional deficits may be permanent. Complementary feeding interventions cover a wide variety of approaches, including education/counseling about child feeding, food supplementation, fortification or home fortification of complementary foods, and food processing techniques to increase energy density or enhance nutrient quality of prepared complementary foods.48 Since there is no single, universal package of components in such interventions, it is difficult to generalize about the impact of efforts to improve complementary feeding.

Impact of Complementary feeding Intervention on Growth and development: Several complementary feeding intervention programmes observed positive impact on growth providing complementary foods or without nutrition education in Africa and South Asia region. Greatest impact of education intervention was found on both weight and length gain in Peru75 and China .42 Both studies recommended providing an animal source food to the infant regularly. In India, an

14

education intervention study recommended milk products and a significant effect was found on length gain among the males, who had a significantly greater increase in milk intake than the females.76 Large impact on nutritional status of the moderately malnourished children was observed in Bangladesh where one group received intensive nutrition education (INE) and the other group received same nutrition education plus home preparation of a complementary food mixture (Khichuri) including egg, meat or fish [INE+SF]. After six months of observation, the nutritional status of children in the intervention group improved further from moderate to mild or normal nutrition (59% in INE and 86% in INE+SF group) compared to the control group (30%). Body-weight gain was positively associated with age, length-for-age, and weight-for-length, frequency of feeding of khichuri (mixture of rice, lentil, vegetable, oil and animal food), egg, and potato. 41

During 2000-2002, Roy et al observed higher weight gain among the intervention group than the control group (1.81kg vs. 1.39 kg), where mothers of the intervention group received weekly nutrition education based on the nutrition triangle concept of UNICEF and preparation of energy- and protein-rich local complementary foods rich in micronutrients (khichuri) were demonstrated. 50 Another food plus education intervention study in India found that intervention group gained 250g more weight and 0.4cm more height than the control group during the 8-month intervention, while only education group gained 90g weight.76 Both these settings demonstrated that inclusion of a food supplement is more effective than education alone.41,76 In several studies, the impact of providing a complementary food, in combination with nutrition education, was evident only in the younger children. Positive effect of food plus education programme was observed on linear growth only in children who were 6 months old at baseline in Mexico 77 and the effect of intervention was seen only among the children aged less than 15 months in Vietnam.78 There is some evidence that milk products can have a growth-promoting effect76,79 although further research on their importance for complementary feeding is needed. The effect on weight was partially explained by greater energy intake from complementary foods in Ghana.80 The interventions which content only micronutrient fortification generally had little or no effect on growth.81, 82

A few numbers of studies include assessments of behavioral development in evaluations of complementary feeding interventions observed positive impact on either gross motor development80 or mental development of the children83 by providing complementary food supplement.

Impact of complementary feeding interventions on morbidity: The milk fortification study in India demonstrated significant effects on both diarrhea and acute lower respiratory illness84 and the Sprinkles study in Pakistan85 showed beneficial effects on diarrhea and fever. Adverse effects on morbidity of food supplementation programm41,76 and increased energy density82 have been observed due to excessive displacement of breastmilk and/or unhygienic preparation and storage of complementary foods. Complementary feeding interventions should be provided with counseling regarding continued breastfeeding, responsive feeding and hygienic practices to reduce the morbidity rate.48

15

4.6 Trials of improved practices (TIPs) To improve complementary feeding practices, a nutrition education and food security intervention project was piloted in Cambodia. Based on household assessment, 15 nutritionally improved rice based, sweet potatoes/taro based CF recipes were developed consisting of starchy food + (Fish or egg or peanut or meat) + green leafy vegetables + small quantity of oil. The recipes were induced to the household through community based cooking sessions and were subsequently tested for acceptability and feasibility in home settings for two months. Caregivers were strongly encouraged to complement the recipes with fruit/ vegetables daily and to give CF with foods of animal origin at least 2-3 times per week. 86

After implementation of TIPs approximately 70% of households achieved better dietary diversity using locally available foods 3-5 times a week and items in the child’s diet increased from 2-3 food items to 10 or more. Notable achievement included acquisition of knowledge and skill by mothers’ and caregivers and increased the number of caregivers adding other food items to borbor.86

In Bangladesh, another study by Roy et al. provided nutrition intervention in two group where the mothers of first intervention group received intensive nutrition education (INE group) and the second intervention group received the same nutrition education and their children received additional supplementary feeding (INE+SF group).The procedures for preparing was a nutritionally sound complementary food (Khichuri) containing inexpensive and locally-available foods (rice + lentil+ egg/fish/meat + potato/ sweet pumpkin + green-leafy vegetables + oil) was demonstrated. After 6 months of observation cooking of additional complementary food for children was improved in intervention groups (1% to 76% in INE and 9% to 92% in INE+SF group) while there was no change occurred in control group. Feeding frequency increased was also increased in INE (3% to 97%) and INE+SF group (13% to 100%) while control groups improved only (15 to 58%).41

A community-based, randomized, controlled trial was carried out among normal and mildly malnourished children in Bangladesh from 2000 to 2002 where preparation of nutritious complementary food using common local ingredients to preparations, Khichuri was demonstrated. After six months of observation, significant increase in the frequency of complementary feeding was observed in the intervention group as compared with the control group.50

Complementary feeding interventions using home based complementary food are still relatively very low. Some food plus educational interventions have demonstrated significant effect on improved complementary feeding practices, child’s growth, development and morbidity. But still there are many unanswered questions that deserve further research. To design and implement most effective programmes in a large scale still remaining a great challenge.

16

5. Methodology

The purpose of the project is to develop a complementary feeding manual for Bangladesh. Multiple methods, such as literature review, focus group discussion, in depth interview, nutrient analysis (Lab), TIPS were adopted.

Final report writing

Analysis of Data

Sample frame and Sample

Size Qualitative methods

Baseline survey • Focus group discussions • In-depth interview • ws

Methodology

Technical committee consultations

Development of recipes

Trials of Improved Practices (TIPs) methods (Recipe trials

in selected areas)

Development of a manual of CF recipes and guidelines for CF practices in Bangladesh

Training of

Gap identification

Acceptability analysis of the recipes (Children’s and mother’s preferences)

Laboratory analysis of 30 recipes

Recruitment of staff

17

5.1 Sampling frame and size: Multi stage random selection method (for In-depth Interviews, and Focus Group Discussions) used to select the population (6-23 months child bearing mother/father/mother-in-law) for the study. Population selected from urban and rural areas of seven divisions to cover all the geographical areas with cultural variation in Bangladesh. The following areas were selected for the study

18

Table- 1: Areas selected for the qualitative baseline study Division District Upazilla Union Qualitative methods Dhaka

Munshi ganj

Lowhoa jang

Bejgoan and Kumarbhog

Respondents

Focus Group Discussion

In-depth interview Recipe trial (TIPs)

Number of the session

Participants

Number of the session

Participants

Number of improved recipe

Mother 2 14 1 1

5 Father 1 6 1 1 Health Worker

1 6

Total number of participants (FGD+IDI)=28 4 26 2 2 Sylhet

Habiganj

Chunarughat

Sadar and Raniganj

Mother 2 13 1 1


1 8

Total number of participants (FGD+IDI)=30 4 28 2 2 Rangpur

Gaibandha

Gobindaganj

Fulbariand Saatmara

Mother 2 13 1 1

8

Father 1 8 1 1 Health Worker

1 7

Total number of participants (FGD+IDI)=30 4 28 2 2 Khulna

Khulna

Dacop

Paankhali and Bajua

Mother 2 15 1 1


1 6

Total number of participants (FGD+IDI)=29 4 27 2 2 Division District Upazilla Union Qualitative methods Chittagong

Cox’sbazar Rangamati

Ramu Sadar

Jowarianala Rangapani & Tobolchori

Mother

2

13

2

2


1 6

Total number of participants (FGD+IDI)=29 4 26 3 3 Barisal

Pirojpur

Nazirpur

Sreeram kathi and 6 no Nazir pur

Mother 2 15 1 1

7

Father 1 6 1 1 Health Worker

1 7

Total number of participants (FGD+IDI)=30 4 28 2 2 Rajshahi

Shirajganj

Belcuchi

Bhangabari and Rajapur

Mother 2 12 1 1


1 8

Total number of participants (FGD+IDI)=29 4 27 2 2

19

5.2 Staff recruitment and training: Staff recruitment has been done by BBF. One research officer and six research fellows were engaged. Their educational background was in nutrition, social science, economics and child development. They were selected by competitive examination. The Research Assistants and Research Fellows were trained for In-depth interviewing, FGDs and Recipe trials. 5.3 In-depth interview: It was conducted in rural and urban areas covering seven divisions of Bangladesh including CHT. The mothers of 6-23 months children, grand mothers/care givers and fathers were the participants. The duration of the interview ranges between 1 hour to 2 hours. The research fellows and the research assistants conducted the In-depth interview. The Principal investigator or Co-principal investigators supervised the process. The In-depth interviews are useful qualitative data collection technique that was used for a variety of purpose including needs assessment, issue identification and strategic planning. A total 15 in-depth interviews were held with mothers and fathers who served as key informants in both rural and urban areas for complementary feeding practices at the household and community level. Before starting the interview, informed consent was obtained from the respondents. The research assistant and research fellow conducted the interviews and an interview guide was used to facilitate the interview process and the research officers supervised the interview through observation. These responses were audio-recorded and complemented with written notes by the assistants. Suitable key informants as opponent were chosen to the purposes that have a good understanding of the issues to explore. Interviews took place formally or informally-preferably in a setting familiar to the informant. Guidelines for the in-depth interview

1. Do you ever breastfed your child? 2. What types of food do you give to your child? Does your child like your food which you

feed? 3. Is your child satisfied with the food that you give him/her? 4. Does your child ask for more? 5. What type of preparation methods you use to feed your child? How do you cook? Briefly

describe the process and frequency of foods? 6. Do you have any idea about Complementary food (barti khabar)? 7. What types of food are available in your locality for the feeding of your children? 8. Do you wash your hands, when and how? Do you use boiled water, mineral water/tube-

well water to prepare your children's food 9. How many times did you visit the health centre for your child after six months of his age?

Why? Did you get any information about complementary feeding? Please tell me in details.

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5.4 Focus Group Discussions (FGDs): The Focus Group Discussions (FGDs) were conducted in rural and urban areas covering seven divisions including CHT. The three groups from each selected population included (1) mothers, caregivers and grandmother; (2) fathers; (3) health workers. Each group consisted of 6-8 persons, of which one of the participants was a critique to get more insights. They were similar in socio-economic characteristics.

Two FGDs for mother /grandmother group +1 for father group + 1 (grass root level health worker group) were conducted in each division. Thus a total of 28 FGDs were conducted in seven divisions. The research fellow and research assistant conducted the FGDs.

FGDs were conducted by the research assistant who served as a moderator to guide the group on the right topic by putting them on the track. The research fellow facilitated the discussion. A tape recorder was used to record the discussion. One facilitator asked the questions and another facilitator took the notes and recorded. The tape recorded information was transcribed. Each FGD took 1 to 2 hours duration. Analysis was done manually and consistencies of data were ensured by re-checking. Guidelines for Focus Group Discussion

1. Do you ever breast feed? ( ask about colostrum, frequency etc) 2. What types of food do you give to your children? 3. What is the minimum amount of food you feed your children? Explain in

cups/bowl/spoons/serving size 4. Do you think that the food that you give is adequate for the child? 5. What type of preparation methods do you use in preparing Complementary Food? How

do you cook it? Briefly describe the process how do you feed Complementary Food to your child/children?

6. What types of foods are available in your locality for the feeding of your children? List : Local foods/commercial foods

7. How much money do you expend per month for food of your family? 8. When do you start giving extra food in addition breastfeeding? Does your child like the

food that you feed him/her? 9. Do you wash your hands, plates and glass before feeding your baby? 10. Did you get any information about complementary feeding? (Where and how)Tell me in

details.

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6. Preliminary findings and discussion from baseline study

6.1 In-depth Interview In-depth interview was conducted to investigate the current status of understanding about breastfeeding, complementary feeding, responsive feeding, food cost, availability of food, knowledge about nutrition, hygiene practices, etc. The findings of the in-depth interview of the key informants are described briefly below.

Breast feeding: About 3/4th of the mother gave breastfeeding and about 2/3rd of them fed colostrum.

In Khulna division (Dacope), a mother stated that, “After birth, my child was fed colostrum within 2 hours as it helps to develop child’s brain and it works as a vaccine”. While in Barisal division (Pirojpur), another mother said, “Ma, sasuri boleche oi dudhta valo bachchar jonno, tai dichi.”( She said, my mother and mother in law said colostrum is good for child’s health and that’s why I fed it.)

In Dhaka (Munshiganj), one of the participant mothers said that, “mone hoy shal dudh khawaini, sizar hoeachilo, Baby Care aktana khawaichi. Pasapasi buker dudho dichi, dudh painato, kannakati korto, ai jonno koutar dudh khwaichi.” (I am not sure if colostrum was given to my child. I had cesarean section; therefore `Baby care’ was given on a regular basis. I also gave breastmilk but it was insufficient, for that reason I had to feed tinned milk). A father said “prothome or mukhe modhu diachilam, murubbira dite bolechilo tai deachilam.”(I gave honey to my child just after birth, as adults said so).

In Chittagong division (Cox’s Bazar), a mother said, “Buker dudh akhono khay, shal dudh dichi, shal dudh dile bachchar valo hoy, shorir, haddi pusto oi, brain valo oi, shastho valo oi.” (I still breastfeed my child, I also fed colostrum, colostrum is good for health and also for bone and brain development)

Discussion: Among the participants, half of them gave pre-lacteal foods such as honey, sugar water, and sugar candy’s water within 1 hour after birth. They thought that the child will talk sweetly if they give sweet things after birth. Two third of the children (6-8 months of age) suckled mother’s milk 7 to 12 times a day, one third of the children (9 to 11 months) had fed breast milk 3 to 5 times a day. They said that they didn’t count how many times their child usually breast feed.

Complementary feeding: One third of the mothers started complementary food after completion six months of age of their child with continuation of breast milk. One third of the mother had some misconception about complementary feedings. They thought that if they started complementary foods earlier, it is good for their children. Half of the mothers said that the child does not get enough milk so they started complementary feeding. Two third of the mothers were started complementary feeding between 7 to 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, and small fish in cooked khichuri. The children were fed 3 to 4 times a day.

In Khulna division (Dacop), one mother said, “pusti hobe, barbe, buker dudher pasapasi boro howar jonno, shak sobji die khichuri dei, akhon amader khabar khay.’’(I feed khichuri and vegetables along

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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).

In Barisal division (Pirojpur), one of them said “buker dudh kom pai, kande, pet vorena, khuda pay, tai khawai.” (My baby doesn’t get enough breast milk, remains hungry and keeps crying, that’s why I fed Complementary food).

In Dhaka division (Munshiganj), a mother stated, “dudh paina, sobai bole, suzi jal kore khawao. Bacha onek kanna kati korto tai suji khawano suru korechi.’’(Child does not get enough breast milk, every one suggested feed semolina, my baby used to cry a lot, that’s why I started feeding semolina).

In Rajshahi division, a father informed that “thik ek mas por theke bachake khawai, Bachcha dudh kom pay, bachaketo bachano lagbe, bachar pete khida thake, bacha kande, khaile bacha thanda thake.”(I started complementary feeding at one month of age, the baby did not get enough breastmilk, and remains hungry and keeps crying until complementary foods were offered).

Responsive feeding: About half of the mothers said that they faced difficulty while feeding their children. Two third of the mothers said that their children at first took the foods but later they refused. Sometimes children bothered/disturbed so much that the mother went to beat or scold the child. When mothers forced the child to eat, they often started vomiting.

In Khulna division (Khulna), one key informant mother stated that “hete hete khawate hoi, khida lagle khai, moja kore khaina” (I need to walk here and there to feed my child, she eats when she is hungry, but doesn’t eat willingly at al).

In Rajshahi division, a mother said, “mone koren amra jeta khawate chai, hai khaina, sorire kichchu lagena, jathesto hoina, ruchi nai.” (He refuses whatever we offer him, hence remains malnourished, it’s not enough for him).

In Rangpur division, one of the respondent mothers said, “bachcha uki kore fele. Akdom khete chain a, ea iota dekhe khaole bomi kore fele dei.”(My child vomits every time I try to feed and refuses everything. Whenever I try to feed showing something he refuses and vomits).

In Sylhet division, a father said, “Pete khida laagle khay. Pet bhora thakle khay na. Na khete chaile mobile e, cassette e gan sunaya khawai, hatahati kore jor kore khawai, echara ar temon somossa hoi na.”(My child eats whenever he is hungry, if his stomach if full, he refuses, we try to feed him by showing different things or sometimes we force feed him).

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Picture: In-depth interview in Rangamati and Cox’s bazar, Chittagong. Cost of foods: Cost of food is a serious concern for ensuring complementary feeding at the community level. Information about food cost was also collected. In Barisal division, one of the respondent mothers said, “baper bari thaki, taka na thakle, baper kache jai. Ar jokhon kichui thakena, karo kach theke salon to pai, vater sathe khawai”. Ai dhoren 200 taka to lagey, gorib manus, temon kichu kine khwaina.” (I live with my parents, when I don’t have enough money, I borrow from my father but when I don’t have any other way I feed my child whatever I get from others such as rice & curry. It may cost about 200 tk per month. I am poor, I can’t afford buying special foods for my child). In Rajshahi division, a mother said, “mase cerelac lage 1 ta, tai khoroch hoi 1000 theke 1500 takar moto.”(I need a cerelac every month to feed my baby, thus I need to spend around 1000 to 2000 tk.) One father said, “amarto kono taka poysa nai, vagnera, boner jamaira, ar attiora taka poysa dey, tai dea bachhar khabar kini” (I don’t have enough money, I purchase food with whatever I get from my nephew, brother in law and relatives).

Picture: In-depth interview in Rangamati, Chittagong. Foods availability: In Khulna division jack fruit, mango, lichi, black berry, and vegetables are available by seasons and fruits trees of Sapodilla (sofeda) are grown in their house, but they did not consider these for children. They think about apple and orange. They get sweet pumpkin, potato, green papaya, ladies finger, gourd (Green), egg plant, gourd (Ridge), drumstick which are grown in their land. There are many kinds of vegetables like, amaranth (red and data), Indian spinach, helencha leaves (thanchi shak), etc.

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Knowledge about nutrition: Two third of the mothers did not have enough knowledge about nutrition. Half of them thought that oranges, apples have more nutrients, but they could not buy it. Two third of them said that if the food is affordable then they could buy nutritious foods easily. In Khulna division, one of them said“Kola, komola ar holud jatio jinisher moddhe vitamin ache, kacha moriche vitamin C ache, agula shune bachchader khaoai.”(We heard that Banana, orange and yellow color fruits are enriched with different vitamins, green chili contain vitamin C, so we feed these to our children).

In Dhaka division, a mother said, “Pusti somporke amar kono dharona nai. Majhe majhe sunechi, khichuri, dim, mach, vaat , egulo bachcha ke khawano valo.” (I don’t have any idea on nutrition although I heard that a child should be fed khichuri, egg, fish and rice, these are good for child’s health). While in Rajshahi division, one father said,“shaksobji khaile vitamin hoi, mach , mangso, dim khaile shakti hoi.”(Vegetables provide vitamins and fish, meat, egg provide energy).

Hygiene practices: The information on the understanding of hygiene practices was also collected. In Dhaka division (Munshiganj), one mother said that “bachake khawanor somoy hat dhui, saban die dhuina, satya kotha, khali pani dia dhui, bathroom theke asar por chhai, mati, saban, jokhon ja pai, tai dia dhui.”(I wash my hands before feeding my child; its true, I only use water, although I wash my hands with ash, mud or soap whatever is accessible in that time after using bathroom).

In Rajshahi division, one mother stated “paikhana theke ese saban ba chhai dia hat dhui, nije khawar somoy, bachhar khaoanor somoy haat dhui. Haate moyla thakle, santaner khabare gele, dairia hobe, ejonno porisker kori.”(I wash my hands with ash after using bathroom, before eating and also before feeding my child, it may cause diarrhea if I feed my baby with dirty hands).

6.2 Focus Group Discussions (FGD) FGDs were conducted to investigate the current status of understanding about breastfeeding, complementary feeding, responsive feeding, food cost, availability of food, knowledge about nutrition, hygiene practices, etc. The findings of the FGDs are described briefly below.

Breastfeeding: One of the FGD participant mothers from Rangpur informed that “Dudh khelaile bachchar pete shoina, dactarer poramosho nia kouter dudh khaite dai, lactogen.” (My child has problem with milk digestion, therefore I fed tinned milk, Lactogen, as doctor prescribed). While another mother said, ‘Ma koiche, bon a koiche, dadi koiche, shobai koiche’, tai dichi”. (Mother, sister, grandmother, and others told me to feed colostrum, hence I did). One mother from Dhaka division (Munshiganj) informed that “jonmer por prothome modhu tarpore shal dudh dichi. Shal dudh bachchar jonno valo, pustikor, R modhu dite hoi, murobbira boleche.”(I gave honey before feeding colostrum, colostrums is good for child’s health, it nutritious, but honey was given as elders suggested). One mother from Rajshahi division (Belkuchi) informed that“Shaldudhta nijey chipa dichilam, daima amar kole delo, buher dudh dichilam. Pani, misri dewar loichilo, koilam, pani, misri dibamna, buher dudh allah diche, se buher dudh khawaichi.”(I fed my child colostrum, the birth attendant gave my child on my lap, then I fed her, she tried to give water, sugarcandy but I said no, breast milk is God gifted, I fed that to my child). While a mother respondent from Chittagong

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division (Cox’s Bazar) opined that “uker dudh akhono khay, shal dudh dichi, shal dudh dile bachar valo hoi, sharir, haddi pusto oi, brain valo oi, sastho valo oi.” (I still breast feed my child, I also gave colostrums. Colostrum is good for child’s health, it nourishes body, bone, brain as well as health). Among the Tribal people of Rangamati, one of the mother said, “dakter boleche shal dudh dite.”(Doctors suggested to feed colostrum).

Picture: Fathers’ FGD in Cox’s bazar, Chittagong. One FGD participant from mothers group in Sylhet division (Habiganj) informed that “jonmer porpor bachchake a age modhu dichi, tarpar shal dudh dichi, keno dichi seta janina.” (I gave honey to my child before feeding colostrum, but don’t have any idea why I did this.” One father informed that, “buker dudh kisudin khawaise, akhon khaina, modhu disilo, jonmer 2 ghonta por shal dudh diche.”(Breastfeeding was continued for few days, now my child doesn’t take breastmilk, Honey was given 2 hours after birth while colostrums was introduced after 2 hrs). Father : 2/3rd of the fathers said that their wife fed breast milk, but many of them also gave honey, sugar water, sugar candy’s water after birth, because the child will talk sweetly. They did not have any idea why child needed colostrum although they knew it is beneficial for their child. Discussion: 2/3rd of the mother fed breast milk. 1/3rd of them fed colostrum within 1-2 hours therefore, 2/3rd of them gave honey, candy sugar or canned milk. Complementary feeding: One mother of the FGD participants from Rangpur division informed that, “Bachcha kechal kore, barti khabar dile to ar kechal korbe na”(Child remains disturbed, if I give extra food then child remain calm). The other mother said, “Barti khabare shorir bare”(Complementary food improves child’s health). They also said about the Health Worker’s message, “Koiche choy mash pore bachar barti khabar lage, mayer buker dudhe pet vorti hobe na, barti khayen, shastho valo hobe, buddhi hobe, taratari boro hoa jabe”(Health worker said that complementary food is necessary after completion of 6 months of age as Breast milk alone isn’t sufficient to meet the requirements. Complementary food will develop child’s health, brain, and also improve growth rate). They said that “we are poor people; we haven’t got enough money to give our child fish, egg, meat every time.” Though 1/3rd of them gave their child banana, papaya, orange, apple, sometimes seasonal fruits like mango, jack fruit, guava and so on for their child’s health,

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actually they had not enough knowledge or practice about complementary foods how to prepare and what is the amount required by the child. They thought they gave perfect diets for their children. However, a 2/3rd of them said that they heard about complementary feeding from their Didi (health worker) or other elder persons like mother and sisters. When they went to the health care centre for vaccine or others reasons, 2/3rd of them heard about complementary foods but did not take any advice about types of foods, nutrition, or frequency of feeding per day. While conducting FGD with fathers group one of them said, “mayer dudhe posaina , pet vorena, tai barti khabar dite hobe.”(Breastmilk is not sufficient, therefore complementary food is required). They thought complementary food is helpful for the child to prevent diseases. On the other hand, 3/5th of them said that the child does not get enough milk that’s why they started complementary food. Responsive feeding: In Rangpur, one of the mothers said that ‘bachcha uki kore (vomitting) fele. Akdom khete chaina, ata oita dekhe khaole orokom bomi kore fele dei.’(my child vomits on force feeding, doesn’t like to eat at all, if I try to feed showing other objects, he still vomits). While one mother from Rajshahi division (Belkuchi) informed that “amar bachchaketo barti khabar dei kono kichui khaina, ja sotty tai koi, aktuo khaina, mane jodi samanno kichu dai, toi muhe dia falai dibo.”(I offer extra foods to my child, but he doesn’t like to eat at all, I am telling the truth, means if I give something even a little bit he takes but then throws out). One father said, “majhe majhe maja kare khay, rag hole sob fele dey, tarpor bivinno voy dekhai, golpo kore khawai, mobile e gan sunay, khawano lage, boro somossa kore, kande, khaite chaina.”(Sometimes my baby takes food eagerly, but when he is in bad mood, he cries and does not want to eat). About half of the mothers said they faced difficulty to feed their child and they said that their children refused to take foods. 2/3rd of them said that their children at first take the foods but sometimes later they refused to take food. This was due to sickness, also they did not like same type of food every time, sometimes they bothered so much that the mother went to beat or scold the child, but no one forced to feed, because if forced the children started vomiting. 1/3rd of the mothers said that sometimes they walk away, sometimes sing song, lorry, and rhyme, show the bird, moon, cows, and use ringtone of the mobile to feed their children. Foods availability: In Rangpur division, a mothers’ group said that they give cow’s milk, chanachur, biscuits, bread, cake, fruits like- banana, apple, orange, grapes, mango juice, mango, water melon, vegetables like-potatoes, bottle gourd, bitter gourd, folwal, ladies finger, brinjal, bean, tomato, cow pea, Indian spinach, spinach, amaranth, bottle gourd leaves, arum leaves, kolmee leaves, Napa shak (Malva verticillata), taro leaves and so on. While in Khulna division, the respondents added “onek rokom shak pawa jai, pui shak, lal shak, lau shak, kumro shak, helencha shak, kumra, jhinga, lau, machta onek kom pawa jai, borsha kale pawa jai tilapia, pangas mas ache, shol mas ache, taki , koi, agulo pawa jai. Bazare apple, komola,sofeda

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pawa jay. Akhane dim, mangsho khawa nishedh, khaina( they were Hindu )”(Different type of leafy vegetables are available, for example, Indian spinach, Amaranth, Kumra shak, Helencha shak. But Pumpkin, jhinga, gourd, fishes are less available, telapia, pangas, shol, taki, koi fishes are more available in rainy season. Egg and meat are not acceptable here). There are many kinds of vegetables like Brinjal, Green Papaya, Cucumber, amaranth, Indian spinach, Radish leaves, sweet pumpkin, Gourd (Bottle), Egg, puffed rice, Biscuits, Chips, Chocolate, Cake, Mojo, Cow’s milk and Orange, Apple, Banana, Papaya, Grapes, Guava and many other seasonal fruits are available to buy easily in all of divisions. However, dry fish (shutki), small fish (keski), banana, potato; tomatoes are easily available and affordable in Chittagong division. Sometimes mothers fed tin foods like lactogen, cerelac, bio milk, aldo milk. Knowledge about nutrition: In Rangpur division, they said “Hamar gorib manush bujen na, beshi damer jinish hamra kinte pari na,olpo dam hole valo hoy hamar” (We are poor, we can’t afford buying expensive foods, its good if foods are less pricy). While few mothers of Khulna division said “Pustikor khabar hoilo apple, komola. Amra gorib manush, barir jinis shak sobji, aloo, ai somosto,prochur vitaminnai, tobu khwate hoi.” (Apple, oranges are nutritious foods, we are poor, leafy and other vegetables, potato are available in household level. These doesn’t contain high amount of vitamins, but we have no other way). Two-third of them did not have not enough knowledge about nutrition. But 1/3rd of them thought that vegetables, fish, egg, meat, water melon, banana, khichuri, seasonal fruits contain a lot of vitamins. But they don’t know which type of foods contains all nutrients like mineral, protein, vitamin, energy. Some of them have some misconception about nutrition. Some of them opined that “they have no idea about nutrition, they think that oranges, apples have more nutrients, but they could not buy it. “Kola, kamola ar holud jatio jinisher moddhe vitamin ache, kacha moriche vitamin C ache, agula shune bachchader khawai.”(We heard that banana, orange and all other colorful vegetables and chili contains vitamin C, hence we fed these to our children). One of them said that if her children takes banana, her child will be affected by cough and cold, that’s why she didn’t give her child banana. Her mother in law had forbidden to give banana. However, 1/5th of them thought that whatever the cost of nutritious foods, it should be given for good health for their children. But 4/5th of them said that if the food cost is affordable they could buy nutritious foods easily. The fathers had little idea about nutrition. Cost of foods: About 2/5th of fathers said that they spend 250 to 400 ($3 - 5.0) taka for their child’s food cost. Whereas, about one third said that they spend 450 to 800 ($5-10) taka per month for their children’s food. One father said he spends 1000 to 2000 ($12-25) taka monthly for their child. If they do not have enough money to buy foods for their children they borrow money from others. In Rangpur (Gobindoganj), one mother said that “sokal bela akta dim khete dete partam, dupurbela aktu mach dea vaat khawate partam, raater bela aktu dudh vaat khawate partam! kintu shei rokom

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shamortho nai boila parina.” (I could give an egg in morning, at lunch I could feed fish with rice and at dinner I could give her rice along with milk, but I can’t afford it). Hygiene practices: In Rajshahi division a mother of FGD group said “ Bachcha khilanor somoy haat dhui, nijer khawar somoy haat dhui, saban dia duy haat porisker kori, koto somoy saban dia haat dhui, koto somoy saban sara sara dhui”. (I wash my hands before feeding my child, before eating myself, I clean my hands with soap, Sometime I use soap and sometimes do not). Two-thirds of the mothers said that after cooking, they cover the food, if the foods were stale, they throw it out and cook again. 5/7th of them said that they wash hands before and after feeding their child. 2/7th of them said that after defeacation, they wash hands with soap but not always. All of them said that they wash hands but could not say appropriately, how and why need to wash.

Picture: FGD of HW in Hobiganj, Sylhet. Focus Group Discussion with Health Worker During FGD with the Health Workers, one of them informed in the FGD session that ‘Ami dekhije dim sidho dei, keski mach (gura fish) samanno tel dia, morich na dea, peaj, rasun, samanno ada bata dia ranna kori. Jader abostha valo, tara cerelac, ar jara gorib tara khichuri khawai’. (I noticed that they feed boiled egg, small fish cooked with little bit of spices e.g. ginger, garlic, and oil. Children from rich family are fed cerelac while in poor families they usually give Khichuri). In Khulna division, one Health Worker said, ‘Rannar poramorsho khub besi dewa jaina, tobuo dekha jache hojom hoi se dhoroner rannar kotha bole thaki.’(Usually we don’t give cooking advice that much, although we suggest few easily digestible food recipes).

2/3rd of the Health Workers advised people and mothers to give breast feeding, colostrum within 1hr. 2/3rd of them also advised them to feed complementary foods while 3/4th of them did not advise the parents of the children on how to prepare the complementary foods and the types of foods for cooking. On the other hand, 3/4th of them advised the parents that hands should be washed with soap before preparing foods and feeding child and also advised them to wash after using the toilet.

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6.3 Assessing Dietary Diversity and Adequacy of CF foods To identify the nutritional adequacy, analysis of some recipes collected from the field during in-depth interview and FGD were done. The assessment showed that energy density was low and did not have required nutritive value and adequate 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 result is that many infants and young children 6-23 months of age do not receive enough of the right kind of foods to grow and develop well. The assessment showed that feeding practices and dietary diversity were generally inadequate. For example: Table-2: Sample recipes of generally practiced complementary food (collected) from baseline study.

Name of the Recipes

Age group (months)

Total energy (Kcal) Per serving

Weight per serving (g)

Energy density (kcal/g)

Nutrient value (% )

Ingredients Dietary diversity (Type of food)

CHO

Pro Fat

Khichuri 6-8 110 125 0.88 55 9 36 Rice, Lentil, Oil 3

Suzi 12-23 142 125 0.9 92 5 3 Milk, Suji 2

7. Steps for Development of Recipes

Principles: The formulations of recipes were based on foods used by mothers and assessment of nutrient gap from baseline study. The factors considered for recipe were energy density, nutrient density, protein content, micro nutrient rich foods, animals’ foods, and serving size, serving number, age of the child, consistency, cost, feasibility, accessibility and seasonality following standards Guideline. 7.1 Selection of potential foods: Based on field experience selected criteria were followed in developing recipes for children aged 6 to 23 months: Nutritive value, acceptability, availability, cost, and feasibility.

7.2 Identification of the potential food combinations: The 7 food groups used for tabulation of this indicator are: — grains, roots and tubers— legumes and nuts— dairy products (milk, yogurt, and cheese) — flesh foods (meat, fish, poultry and liver/organ meats) — eggs— vitamin-A rich fruits and vegetables— other fruits and vegetables. The cut-off of at least 4 of the above 7 food groups above was selected because it is associated with better quality diets for both breastfed and non-breastfed children. Consumption of foods from at least 4 food groups on the previous day would mean that in most populations the child had a high likelihood of consuming at least one animal-source food and at least one fruit or vegetable that day, in addition to a staple food (grain, root or tuber).40

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Potential food combinations

1. Cereal, roots and tubers+ Flesh foods (poultry /organ meats- liver) or Eggs + Vitamin A rich fruits and vegetables + Other fruits and vegetables + Adequate amount of oil. 2. Cereal, roots and tubers + Legumes and nuts + Vitamin A rich fruits and vegetables or Dairy product-milk + Other fruits and vegetables + Adequate amount of oil. 3. Cereal, roots and tubers + Legumes and nuts or Flesh foods-fish or Eggs + Vitamin A rich fruits and vegetables+ Other fruits and vegetables or Dairy product-milk + Adequate amount of oil. 4. Cereal, roots and tubers + Legumes and nuts + Vitamin A rich fruits and vegetables or Eggs + Other fruits and vegetables + Adequate amount of oil. 5. Cereal, roots and tubers + Legumes and nuts + Flesh foods (poultry / organ meats-liver) or Eggs + Vitamin A rich fruits and vegetables or Other fruits and vegetables (or both) + Adequate amount of oil. 6. Cereal, roots and tubers + Dairy products-milk + Legumes and nuts or Eggs or Other fruits and vegetables + Vitamin A rich fruits and vegetables + Adequate amount of sugar/ molasses and/or oil. Source: adapted from Food–based strategies to meet the challenges of micro nutrient malnutrition in the developing world, FAO, 2002.

7.3 Development of recipes

The improved recipes were developed based on a principle of food to food enrichment which includes appropriate food combinations enriched with a variety of readily available local foods. Besides from the literature review, FGDs, in-depth interviews and nutrient gap (assessed from observational data of baseline study) were also considered. Thirty five recipes were developed, prepared and standardized using locally available ingredients. The key issues considered here are the “WHO indicators to assess adequacy of CF practices”, including a minimum list of food groups (≥ 4 food groups), 7 recommended food groups, minimum age-appropriate meal frequency, energy density, nutrient density, protein content, and micro nutrient rich foods. At the same time serving number and size according to different age group, cost, feasibility, accessibility and seasonal availability were also considered. Nutrient composition was calculated using available national food composition tables (INFS FCT 2013) for the energy, moisture, available carbohydrate, protein, fat and ash. Thereafter 30 selected recipes were analyzed in laboratory for energy and 9 specific nutrients (energy, moisture, carbohydrate, protein, fat, ash, vitamin A, calcium, iron and zinc). The nutrient adequacies were assessed against the recommended dietary allowances (RDA) using international and regional norms. Nutrient adequacy of the diets was also considered for the nutrient contribution made by breast milk for children between 6 to 23 months of age.

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Table 3: Name of the recipes of different categories

Category Name of the recipe Age group

Category 1 Cereal, roots and tubers+ Flesh foods (poultry /organ meats- liver) or Eggs + Vitamin A rich fruits and vegetables + Other fruits and vegetables + Adequate amount of oil.

Pumpkin soup 6- 8 months

Chirar polao; Chicken chop; Small fish chop(kachki); Liver Chop

9-11 months

Sago aloor bora, Vegetable omelet 12-23 months

Category 2 Cereal, roots and tubers + Legumes and nuts + Vitamin A rich fruits and vegetables or Dairy product-milk + Other fruits and vegetables + Adequate amount of oil.

Vegetable khichuri, Pusit Gura 6-8 months

Vegetable chapri, Buter Halwa 9-11 months

Sweet potato halwa 12-23 months

Category 3 Cereal, roots and tubers + Legumes and nuts or Flesh foods-fish or Eggs + Vitamin A rich fruits and vegetables+ Other fruits and vegetables or Dairy product-milk + Adequate amount of oil.

Egg suji 6-8 months

Bread toast, Tomato soup, Fish cutlet, Fish with vegetable & white sauce

9-11 months

Fruit pitha, Pumpkin coconut halwa 12-23 months

Category 4 Cereal, roots and tubers + Legumes and nuts + Vitamin A rich fruits and vegetables or Eggs + Other fruits and vegetables + Adequate amount of oil.

Papaya halwa, Mixed vegetable pitha, Soya chop

9-11 months

Category 5 Cereal, roots and tubers + Legumes and nuts + Flesh foods (poultry / organ meats-liver) or Eggs + Vitamin A rich fruits and vegetables or Other fruits and vegetables (or both) + Adequate amount of oil.

Chicken khichuri, Liver khichuri, Egg khichuri

6-8 months

Vegetable chop 9-11 months

Vegetable roll 12-23 months

Category 6 Cereal, roots and tubers + Dairy products-milk + Legumes and nuts or Eggs or Other fruits and vegetables + Vitamin A rich fruits and vegetables + Adequate amount of sugar/ molasses and or Oil.

Fruit firni; Mango payesh; Fruit faluda; Pumpkin payesh

6-8 months

Sujir halwa, Carrot laddo, Sujir Malpoa Pudding

9-11 months 12-23 months

These 35 recipes have been divided into 5 different sections (recipe book) as tabulated below:

1. Main meal (8 recipes) 2. Side dishes (6 recipes) 3. Snacks (6 recipes) 4. Soups (2 recipes) 5. Sweet dishes (13 recipes)

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8. Trials of Improved Practices (TIPs) Based on Trials of Improved Practices (TIPs) 87 carried out in Bangladesh, complementary foods, recipe options, guidelines, key nutrition education messages and recommendations had been developed. 8.1 Demonstration experience trials

Cooking session was carried out in selected districts of seven divisions in Bangladesh.

During cooking session at first research assistants and research fellows welcomed mothers/caregivers and presented the recipe that will be prepared. Necessary equipments and materials needed for the demonstration (e.g. ingredients, utensils, fuel, hand washing facilities and complementary food recipes) were then gathered. Health benefits of these complementary food recipes, preparation methods and key nutrition messages were then discussed among the participant mothers.

The research assistant, research fellow and a volunteer facilitated the cooking session and two mothers/caregivers were invited to prepare the food with the facilitators. Facilitators talked with mothers/caregivers through each of the preparation steps. When the preparation was finished, the consistency of the food was pointed out with a spoon. When the food was prepared, each of the participant mothers tasted and served the foods to her child. The facilitator also discussed serving and feeding methods, availability of ingredients and materials and feasibility issues.

Thereafter acceptability of the recipes by both mother and children were evaluated using a standard acceptability score card. Mothers were asked if they could prepare the food in their home. At the same time the facilitators also measured the amount of food consumed by the children. The format on the children’s acceptability of cooked foods and the score card for evaluation of recipes are shown in Annexure.

The cooking session was concluded by thanking once again the mothers/caregivers for coming and participating. And they were requested to share their new knowledge of preparing these complementary foods with neighbors who has young children.

8.2 Findings of TIPs The outcomes of the TIPs have been discussed as follows:

8.2.1 Children’s acceptability All 35 recipes had been trialed in 7 divisions. Recipes were prepared and then fed to the children in presence of their mother or caregivers. Thereafter total consumed amount was measured to evaluate the acceptability. Acceptability of different recipes trialed in 7 divisions of Bangladesh has been described in following figures.

Cent percent (100%) acceptability of recipes (division wise): From the figure 3, it is seen that in Chittagong division, Egg suzi, Small fish chop (kachki macher chop), sujir malpoa, Vegetable Chop and Fruit pitha were fully accepted by 100% children. Furthermore, Small fish Chop (kachki macher chop), Carrot Ladoo and Buter Halwa were most acceptable (100%) in Rajshahi Division. On the

33

other hand, Chicken chop, Soya chop, Carrot laddo, and Fruit firni were fully accepted by the children in Barisal division.

Fig-3: Acceptability (100%) of different recipes by children (Division wise)

Additionally, in Sylhet division Chicken chop, Egg suji, and Vegetable roll were fully accepted, and in Khulna division Soya chop and Fish cutlet were accepted by 100% children. Small fish chop (Kachki macher chop) was fully accepted in Rangpur division by the children. Dhaka division

0

20

40

60

80

100

120

Eaten fully Eaten ¾ Eaten ½ Eaten ¼ Eaten little Not eaten

(%) o

f chi

ldre

n Sweet potato halwaCarrot chatuLiver chop Mixed Vegetable pitha Pudding

Fig-4: Acceptability by children (Dhaka division)

In Dhaka division, the most favorite recipes were Sweet potato halwa and Liver chop (66.7% of the participant had eaten it fully), Mixed vegetable pitha also got a good response (60% children had eaten completely) whereas Pudding was well accepted by 50% children.

34

Sylhet division

0

20

40

60

80

100

120


(%) o

f chi

ldre

n

Chicken chopBread ToastCarrot chatuPumpkin soupVegetable chopFruit pithaVegetable khichuriLiver khichuriPumpkin coconut halwaButer halwaEgg sujiVegetable roll

Fig-5: Acceptability by children (Sylhet division)

In total, 12 recipes had been trialed in Sylhet division. Among them Chicken chop, Egg suji and Vegetable roll got excellent response (all of the children had completed the served amount). Next favorite recipes were Bread toast, Vegetable omelet and Vegetable khichuri. They got 75-80% full response by children. Where as the least acceptable recipes were Buter halwa and Pusti gura.

Rangpur division

0

20

40

60

80

100

120

Eatenfully

Eaten ¾ Eaten ½ Eaten ¼ Eatenlittle

Not eaten

(%) o

f chi

ldre

n

Faluda

Egg khichuri

Kachki macher chop

Papaya halwa

Fish with vegetable and whitesauceChirara polao

Vegetable chapri

Chicken khichuri

Fig 6: Acceptability by children (Rangpur division)

Children’s acceptability varied widely for different recipes in Rangpur division. In total 8 recipes had been trialed there. Among them only Small fish chop got full response and Egg khichuri was well accepted (66.7% children had it completely). Next favorite recipe was Vegetable chapri. Chirar polao, Fish with vegetable and white sauce and Chicken khichuri showed a mixed response. But both Fruit faluda and Papaya halwa showed least acceptability in that division.

35

Khulna division

0

20

40

60

80

100

120


(%) o

f chi

ldre

n

Tomato soupVegetable egg omlettesoya chopEgg khichuriSujir malpoaPumpkin payesMango payesSagu alur boraPumpkin coconut halwaFish cutlet

Fig 7: Acceptability by children (Khulna division)

In khulna division, 10 recipes were prepared for recipe trial session. Among those recipes, Soya chop and Fish cutlet were most acceptable, Vegetable egg omelet and Sujir malpoa were next favorite recipes (87.5 % children liked it most). Among remaining recipes, Egg khichuri, Pumpkin payesh, Mango payesh and Sago alur bora showed a variety of response. In this division the less acceptable (compared to others) recipes were Tomato soup and Pumpkin coconut halwa.

Chittagong division

0

20

40

60

80

100

120


(%) o

f chi

ldre

n

Tomato soupCarrot laddooChicken chopSujir halwaFruit faludaPumpkin payesKachki macher chopPapaya halwaSujir malpoaCarrot chatuEgg sujiVegetable chapriPumpkin soupVegetable chopMango payesFruit pithaChirar polaoBread toast

Fig 8: Acceptability by children (Chittagong division)

In Chittagong division, recipes were trialed among both tribal population and bangali para. In total 18 recipes were trialed there. Five recipes namely, small fish chop, sujir malpoa, egg suji, vegetable chop and fruit pitha got full acceptability. Children also had good responses to vegetable chapri, pumpkin soup and fruit faluda (they got 75% full acceptability). Besides tomato soup was well accepted too (50% of participant children ate it completely). Next favorite recipes were respectively

36

papaya hawa, mango payesh, chirar polao, chicken chop, sujir halwa and bread toast. The least acceptable recipes in this session were pumpkin payesh, carrot laddo and pusti gura respectively.

Rajshahi division

0

20

40

60

80

100

120


Tomato soup

Carrot laddoo

Chicken chop

Fruit firni

soya chop

Pudding

Faluda

Egg khichuri

Kachki macher chop

Vegetable khichuri

Papaya Halwa

Sagu alur Bora

Vegetable roll

Buter halwa

Fish with vegetable and whitesauceSujir malpoa

Fish cutlet

Fig 9: Acceptability by children (Rajshahi division) In Rajshahi division, among 17 trialed recipes carrot laddo, small fish chop and buter halwa were the most favorite, they got full acceptability. Among remaining, chicken chop, pudding and vegetable roll were moderately acceptable, they got full response by 50% children. Next favorite recipe was egg khichuri. And the other recipes got a mixed response, among them fish with vegetable and white sauce was least acceptable.

Barisal division

0

20

40

60

80

100

120


(%) o

f chi

ldre

n

Tomato soupCarrot laddooChicken chopVegetable egg omletteSujir halwaFruit firnisoya chop

Fig 10: Acceptability by children (Barisal division)

37

In Barisal division 4 recipes out of 7 trialed recipes were fully accepted by children. These were carrot laddo, chicken chop, fruit firni and soya chop. Children also liked the other two recipes (vegetable egg omelet and sujir halwa). The least favorite one here was tomato soup.

8.2.2 Mothers’ acceptability The mothers were very cooperative through out the recipe trial session. They were very enthusiastic and helped in preparation of the recipes. They also gave valuable suggestions to make the recipes more acceptable to the children. After completion of preparation they fed their children with these foods.

Recipes were also served to the participant mothers to taste, thereafter they were asked few questions to evaluate the acceptability (sensory evaluation). In this whole evaluation process a score >75% has been defined as most acceptable, where as 50-75% has been defined as satisfactory and <50% as less acceptable.

All 35 recipes have been tried out in 7 divisions of Bangladesh. Among them in total 28 recipes got higher than 75% score. Few recipes also got ‘most acceptability’ (>75%) in more than one division.

Mothers’ acceptability for all 35 recipes in 7 divisions has been described in following figures.

Barisal Division

Figure 11 illustrates that, in Barisal Division 7 recipes have been trialed. Among them 85% recipes (vegetable omelet, chicken chop, soya chop, fruit firni, sujir halwa and carrot laddo) were most acceptable to all of the participant mothers’.

Barisal division

0

20

40

60

80

100

120

Vegeta

ble om

elet

Tomato

soup

Chicke

n cho

p

Soya c

hop

Fruit fi

rni

Sujir h

alwa

Carrot

laddo

Recipes

Part

icip

ants

(%)

Most acceptale

Satisfactory

Less acceptable

Fig 11: Mothers’ acceptability in Barisal division

38

Khulna Division

Figure 12 exemplify the acceptability of the recipes, trialed in Khulna division. From the following figure it is seen that 100% of the trialed recipes got full acceptability.

In Khulna division a group of vegetarian people were intentionally included in recipe trial session. This was just to demonstrate and teach them how to prepare an appropriate complementary food for their children using locally available and feasible vegetarian diets. It also supported the local feeding practices. All the participant mothers’ liked the ideas of preparing these foods for their children. They commented that these recipes are good; no further edition is required and scored them well.

Fig 12: Mothers’ acceptability in Khulna division

Chittagong division

In Chittagong division recipes have been trialed among ethnic group and bangali para. The following figure shows the acceptability of trialed recipes by mothers in Chittagong division. Even though their feeding practices are different from others, 90% recipes were most acceptable to all participant mothers, and remaining 10% recipes got a score between (50-75%), thus considered as satisfactory to mothers. They said all of the recipes were tasty; ingredients are available in households and market. And these are easily preparable too but also suggested to reduce the volume of pusti gura for children.

39

Chittagong division

0

20

40

60

80

100

120

Tomato

soup

Chirar

polao

Chicke

n cho

p

Small fis

chop

Pumpk

in sou

p

Vegeta

ble ch

apri

Pusti g

ura

Bread t

oast

egg s

uji

Fruit p

itha

Papay

a halw

a

Vegeta

ble ch

op

Fruit fa

luda

Mango

paye

sh

Sujir h

alwa

Carrot

laddo

Pumpk

in pa

yesh

Sujir m

alpoa

Recipes

Part

icip

ant (

%)

Most acceptableSatisfactoryLess acceptable

Fig 13: Mothers’ acceptability in Chittagong division

Rajshahi division

In Rajshahi division a total of 15 recipes were trialed and all of them got a score higher than 75% by all participant mothers. Mothers commented that all ingredients used in these recipes are feasible. Besides the recipes are tasty and easily preparable, thus they can easily prepare them between the household chores.

Acceptability for different recipes in Rajshahi division has been illustrated in figure 14.

020406080

100120

Part

icipa

nt(%

)

Recipes

Rajshahi division

MostacceptableSatisfactory

Fig 14: Mothers’ acceptability in Rajshahi division

40

Sylhet division

A total of 12 recipes were trialed in Sylhet division including tea garden area. Their feeding practices also differed from other divisions. Even though the ingredients used in preparation of the recipes are available and affordable, these were less practiced by the mothers to feed their children. Within the trial session, they appreciated the concept of adding different foods in preparation of complementary foods, for example addition chicken liver in khichuri or egg in suji etc. and scored them well. All of the trialed recipes got full acceptability.

The acceptability of different recipes has been described in Figure 15.

0

20

40

60

80

100

120

Part

icip

ant(%

)

Recipes

Sylhet division

Most acceptable

Satisfactory

Less acceptable

Fig 15: Mothers’ acceptability in Sylhet division

Rangpur division

In Rangpur division, in total 7 recipes were trialed. Among them 86% recipes got most acceptability as shown below in figure 16.

41

0

20

40

60

80

100

120

Part

icip

ant(%

)

Recipes

Rangpur division

MostacceptableSatisfactory

Fig 16: Mothers’ acceptability in Rangpur division

Dhaka division

In Dhaka division, among the trialed recipes 60% were highly preferred by the mothers’ and got most acceptability. And remaining had a mixed acceptability score.

Figure 17 illustrates the acceptability of different recipes in Dhaka division.

Dhaka division

0

20

40

60

80

100

120

Liver chop Pusti gura Sweetpotatohalwa

Mixedvegetable

pitha

Pudding

Recipes

Part

icip

ant(%

)

Most acceptable

Satisfactory

Less acceptable

Fig 17: Mothers’ acceptability in Dhaka division

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9. Laboratory analysis of improved recipes After completion of recipe trials in 7 divisions, out of 35 improved recipes 30 recipes were cooked using standard method and then sent to an accredited laboratory to analyze ten nutrients energy, protein, fat, carbohydrate, vitamin A, calcium, iron, zinc, moisture, ash (phosphorus, magnesium, copper) .Analysis of these ten nutrients were thereafter carried out following standard methods and result was published in per 100 gram basis as shown below:

Test items Method Unit/100g Ash AOAC 18th EDN.2005 g Moisture AOAC 18th EDN.2005 g Protein (N×6.25) as received GAFTA(2003) g Fats and Oil as received AOAC 18th EDN.2005 g Carbohydrate(by difference) Method of analysis for Nutrition

Labeling (1993):106 g

Energy (Calories) Method of analysis for Nutrition Labeling (1993):106

kcal

Zinc (as Zn) as received AOAC 18th EDN.2005 mg Iron (as Fe) as received AOAC 18th EDN.2005 mg Calcium (as Ca) as received AOAC 18th EDN.2005 mg Vitamin A IN HOUSE (Ref. Bull. Dept.

Med. Sci. Vol. 37, No.1 Jan-Mar 1995)

IU

Detailed methods used in analysis of these nutrients have been depicted in Annexure 3.

43

9.1 Report of the laboratory analysis of 30 recipes Laboratory analyzed value for 10 nutrients of 30 improved recipes have been shown in the following table. Table 4: Laboratory analysis report of improved recipes

Name of the recipe Ash (g)

Moisture (g)

Protein (N X 6.25) (g)

Fats & oil (g)

Energy (calories) (Kcal/100g)

Carbohydrate (g)

Zinc (as Zn) mg/100g

Iron (as Fe) mg/100g

Calcium (as Ca) mg/100g

Vitamin A IU/100g

Chirar polao 1.04 69.22 4.75 4.15 140 20.84 0.74 1.26 27.15 15.86 Small fish chop 1.87 48.97 5.61 7.58 235 35.97 1.53 1.70 202.99 ND(<9) Chicken chop 2.4 62.78 9.26 5.34 166 20.22 0.85 0.94 23.56 ND(<9)

Sago-alur bora 2.09 61.16 5.43 8.38 189 22.94 0.70 2.00 105.83 118.12 Vegetable omelet 1.2 72.15 4.88 7.03 142 14.74 0.60 0.97 48.42 39.22 Liver chop 1.66 67.27 5.04 4.93 149 21.1 0.83 1.72 42.74 64.1 Pumpkin soup 1.17 90.99 3.07 1.14 37 3.63 0.28 0.21 5.50 ND(<9) Sweet potato halwa 1.12 57.75 5.47 6.06 195 29.6 0.93 1.52 132.19 56.43 Vegetable chapri 1.12 61.61 5.36 4.65 172 27.26 0.93 1.16 27.21 ND(<9) Buter halwa 0.75 53.45 6.58 7.64 221 31.58 1.04 2.73 45.39 ND(<9) Vegetable khichuri 1.94 69.3 3.81 5.57 143 19.38 0.70 0.94 46.18 ND(<9) Bread toast 1.21 64.37 8.45 11.66 196 14.31 0.73 1.23 85.97 218.25 Fish cutlet 2.2 53.52 8.09 11.65 235 24.54 0.80 0.90 65.24 ND(<9) Egg suzi 0.39 75.8 3.16 3.53 113 17.12 0.44 1.22 49.66 100.02 Tomato soup 3.33 79.10 1.35 2.88 85 13.34 0.70 1.38 72.77 ND(<9) Fruit pitha 0.78 33.89 7.60 8.60 304 49.13 0.74 1.48 78.30 72.24 Pumpkin coconut halwa

1.27 35.21 5.25 9.83 303 48.44 0.95 2.59 143.84 ND(<9)

Soya chop 1.92 65.19 6.24 4.31 153 22.34 0.88 1.79 69.41 69.31 Mixed vegetable pitha 1.46 72.11 5.30 3.54 123 17.59 0.57 1.30 57.89 ND

(<9) Liver khichuri 2.22 69.64 4.2 5.81 142 18.13 0.59 1.25 25.70 555.72 Vegetable roll 1.2 60.95 6.81 6.17 182 24.87 2.12 3.80 93 78.96 Chicken khichuri 2.27 77.14 3.77 2.62 95 14.20 0.46 0.82 13.79 ND(<9) Egg Khichuri 1.13 78.43 3.42 2.7 95 14.32 0.47 1.10 14.73 73.45 Pudding 0.85 63.12 5.30 5.69 173 25.04 0.63 1.60 31.69 149.85 Pumpkin payesh 1.61 44.72 5.92 7.20 251 40.55 1.08 1.16 321.05 93.38 Suji halwa 0.95 52.52 4.91 7.32 223 34.30 0.56 0.39 172.97 49.09 Carrot laddo 1.61 44.87 5.74 9.65 262 38.13 0.79 0.54 94.66 95.04 Sujir malpoa 0.6 57.12 5.68 10.84 223 25.76 0.67 0.95 90.14 119.69 Fruit firni 1.11 63.23 3.82 4.4 165 27.44 0.56 1.24 73.95 46.02 Fruit faluda 1.10 64.12 4.54 5.90 169 24.34 0.54 0.27 170.11 60.38

44

9.2 Comparison between calculated value and analyzed value for 30 recipes Improved recipes were first calculated using the available national food composition table (INFS FCT, 1986). This was followed by the recipe trial sessions in 7 divisions of Bangladesh to evaluate the acceptability of the improved recipes. Thereafter 30 selected recipes were analyzed in an accredited laboratory. In the mean time the improved recipes were readjusted considering the results from TIPs and the values were recalculated using the updated version of INFS FCT, 2013.

The differences found between analyzed and calculated nutrient composition values in the CF recipes might be explained by the following factors:

(a) real differences in food composition (b) cooking procedures (c) the effect of various food combinations and; (d) food preparation losses.

The differences in the analytical methods used, the processing of the food portion samples and possible inaccuracies when nutrients are present in small concentrations, might have also contributed to the differences. Also the absorption of water or oil, which would dilute the provitamins and decrease their concentrations per unit weight, is a factor that needs to be taken into consideration. Degradation of provitamins A during analysis may also be erroneously attributed to cooking, processing, or storage. It is important that values generated using appropriately procured and processed samples and analyzed with validated methodology should be the basis for assessing the validity of calculated nutrient levels in foods.

The calculated and analyzed values have been depicted in the table (5-10).

45

Table 5: Comparison between laboratory analyzed and calculated value for category 1

Name of the recipe

Nutrient (g/100g) and Energy (kcal/100g)

Calculated value using INFS FCT, 1986

Laboratory analyzed value

Calculated value for adjusted recipes using new INFS, FCT, 2013

Small fish chop Carbohydrate 20.51 35.97 23.08 Protein 5.05 5.61 5.66 Fat 3.47 7.58 7.08 Energy 132 235 183

Chirar polao Carbohydrate 24.47 20.84 22.64 Protein 5.37 4.75 5.46 Fat 5.69 4.15 6.69 Energy 168 140 175

Chicken chop Carbohydrate 25.49 20.22 21.68 Protein 8.82 9.26 5.83 Fat 8.82 5.34 6.09 Energy 217 166 169

Sagu alur bora Carbohydrate 23.65 22.94 22.49 Protein 3.82 5.43 4.36 Fat 4.41 8.38 6.13 Energy 148 189 167

Vegetable omlette Carbohydrate 28.65 14.74 15.96 Protein 9.61 4.88 6.14 Fat 7.69 7.03 4.70 Energy 216 142 135

Liver chop

Carbohydrate 25.78 21.1 21.95 Protein 5.48 5.04 5.50 Fat 6.87 4.93 5.52 Energy 182 149 164

Pumpkin soup Carbohydrate 16.6 3.63 8.97 Protein 3.63 3.07 3.07 Fat 3.63 1.14 5.11 Energy 113 37 97

46


Name of the recipe





Sweet potato halwa

Carbohydrate 26 29.6 29.61 Protein 4.63 5.47 6.57 Fat 4.87 6.06 7.38 Energy 165 195 215

Vegetable chapri


Buter halwa Carbohydrate 41.39 31.58 33.85 Protein 8.09 6.58 7.08 Fat 7.74 7.64 8.09 Energy 265 221 239

Vegetable khichuri


47


Name of the recipe





Bread toast Carbohydrate 20.61 14.31 35.18 Protein 8.26 8.45 9.54 Fat 8.79 11.66 9.77 Energy 195 196 271

Fish cutlet Carbohydrate 25.07 24.54 19.59 Protein 7.54 8.09 5.06 Fat 4.33 11.65 5.62 Energy 164 235 153

Egg suji Carbohydrate 16.15 17.12 20.14 Protein 3.81 3.16 5.97 Fat 4.31 3.53 5.54 Energy 120 113 156

Tomato soup


Fruit pitha Carbohydrate 53.05 49.13 44.55 Protein 9.26 7.60 7.53 Fat 8.95 8.60 11.86 Energy 323 304 320

Pumpkin coconut halwa


48


Name of the recipe





Soya chop Carbohydrate 29.33 22.34 20.52 Protein 6.54 6.24 5.69 Fat 4.75 4.31 5.66 Energy 252 153 160

Mixed vegetable pitha



Name of the recipe





Liver khichuri


Vegetable roll


Chicken khichuri

Carbohydrate 16.31 14.20 16.55

Protein 4.68 3.77 4.39

Fat 4.21 2.62 4.52 Energy 122.63 95 127

Egg khichuri


49


Name of the recipe


Recipe Laboratory analyzed value


Pudding Carbohydrate 27.33 25.04 26.88 Protein 6.10 5.30 9.03 Fat 5.79 5.69 6.89 Energy 183 173 207

Pumpkin payesh


Suji halwa Carbohydrate 28.94 34.30 23.97 Protein 5.93 4.91 5.93 Fat 6.62 7.32 6.52 Energy 195 223 180

Carrot laddoo


Sujir malpoa


Fruit firni Carbohydrate 25.48 27.44 21.34 Protein 4.23 3.82 5.86 Fat 3.51 4.4 4.98 Energy 147 165 155

Fruit faluda Carbohydrate 15.4 24.34 18.70 Protein 3.8 4.54 5.18 Fat 3.7 5.90 4.83 Energy 106 169 140

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10. Manual of CF recipes and CF guidelines A manual of a set of improved complementary foods has been prepared with calculation of dietary diversity scores, energy, protein, fat, carbohydrate (available), fiber, moisture and ash content. Cost on a per serving basis, appropriate for low, middle and high income groups have been calculated. Cooking and standardization of these improved complementary food recipes have been defined based on a variety of locally available foods using appropriate preparation and processing methods and technologies and standard portion sizes. At the same time, acceptability of the recipes in urban and rural locations has also been included.

A complementary feeding guide outlining the appropriate feeding practices has been prepared. Key recommendations for using home based preparation methods and appropriate technologies to enhance the nutrient density and bioavailability of the micronutrient content of local foods has been discussed. This guideline also includes hygiene for preparation of complementary foods as well as during infant and young child feeding.

11. Conclusion The study addressed a documentation and update of complementary feeding in 7 divisions of Bangladesh. This was followed by assessment of the dietary adequacy. And finally, a manual of complementary food recepies and complementary feeding guide have been developed with background of all of these documented divisional practices including regional food habit and culture of Complementary Feeding (CF). TIPs have been carried out with scientific formulations following international standers. The recipes have been analyzed for nutrient content showing high level of accuracy. The field testing of TIPs in all divisions showed good levels of acceptability. Perhaps, this report and manual will provide practical knowledge as well as will act as a training tool for nutrition practitioners, academician and mothers.

12. Policy Recommendations 1. This practical manual could be considered for use by the of government and non-government

organizations in the programs for promoting infants and young child feeding (IYCF). 2. Evaluation of these recipes on biological outcome would be helpful for assessing nutritional

improvement in children. 3. The recipes and guidelines should be promoted for use in malnutrition and poverty stricken

areas with subsequent impact studied. 4. The health system should consider adopt 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), which had in fact led the development of recipes and manual for complementary feeding.

5. There is a need for an integrated program to address micronutrient deficiencies while simultaneously combating larger issues of food insecurity and malnutrition in the community through appropriate complementary feeding.

51

References

1. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortlity. Lancet 2000 Feb 5; 355(9202):451-455.

2. Shrimpton R, Victoria CG, de Onis M, Lima RC, Blossner M and Clugston G. Worldwide timing of growth faltering: Implications for nutrition interventions. Pediatrics. 2001 May; 107(5):E75.

3. Bangladesh Demographic and Health Survey 2007. NIPORT.

4. Bangladesh Demographic and Health Survey (BDHS) 2011. Preliminary report. NIPORT.

5. Tracking progress on childhood and maternal nutrition: UNICEF: New York: 2009.

6. Food Security and Nutrition Surveillance Project. HKI/BBS/BRAC; 2010

7. National Food Policy Plan of Action 2008-2015. Food Planning and Monitoring Unit (FPMU), Ministry of Food and Disaster Management, Government of the People’s Republic of Bangladesh. P. xiii.

8. Ahmed AU, Aberman NL, Jabbar M, Akhtar N, Policy Perspectives of the Country Investment Plan for Food and Nutrition Security in Bangladesh. IFPRI; 2011 Mar 50p.

9. South Asian Infant Feeding Research Network (SAIFRN) 2008.

10. Saha K K, Frongillo E A, Alam D S, Arifeen S E, Persson L A and Rasmussen K M. Appropriate infant feeding practices result in better growth of infants and young children in rural Bangladesh, Am J Clin Nutr, 2008, 87:1852–9.

11. Principles for complementary feeding for Breastfeed child, Washington, D.C. Pan American Health Organization (PAHO)/ World Health Organization (WHO) Guiding, 2003.

12. Martorell R, Khan LK, Schroeder DG. Reversibility of stunting: epidemiological findings in children from developing countries. Eur J Clin Nutr. 1994; S45-S57.

13. Infant and young child feeding Counseling: An integrated course. Trainer’s Guide. Geneva: World health organization; 2006

14. Pelto G, Levitt E, Thairu L. Improving feeding practices: current patterns, common constraints, and the design of interventions. Food Nutr Bull. 2003 Mar; 24(1):45-82.

15. Sternin M, Sternin J, Marsh DL. Rapid, sustained childhood malnutrition alleviation through a positive- deviance approach in rural Vietnam: preliminary findings. In: Wollinka O, et al., eds. Hearth nutrition model: applications in Haiti, Viet Nam and Bangladesh. Arlington, VA: BASICS. 1997: 49-61.

16. Creed de Kanashiro H, Penny M, Robert R, Narro R, Caulfield L, Black R. Improving infant nutrition through an educational intervention in the health services and the community.

52

Presentation at the WHO Global Consultation on Complementary Feeding, Geneva, December 2001.

17. Vazir S, Engle P, Balakrishna N, Griffiths PL, Johnson SL, Creed-Kanashiro H, Fernandez Rao S, Shroff MR, Bentley ME. Cluster-randomized trial on complementary and responsive feeding education to caregivers found improved dietary intake, growth and development among rural Indian toddlers. Matern Child Nutr. 2013 Jan; 9(1):99-117. doi: 10.1111/j.1740-8709.2012.00413.x.

18. Brown KH, Stallings RY, de Kanashiro HC, Lopez de Romaña G, Black RE. Effects of common illnesses on infants’ energy intakes from breast milk and other foods during longitudinal community-based studies in Huascar (Lima), Peru. Am J Clin Nutr. 1990; 52:1005-13.

19. Brown KH. A rational approach to feeding infants and young children with acute diarrhea. In: Lifschitz CH, ed., Pediatric Gastroenterology and Nutrition in Clinical Practice. New York: Marcel Dekker, Inc., 2001

20. De Maeyer EM, Dallman P, Gurney JM, Hallberg L, Sood SK, Srikantia SK, Preventing and Controlling Iron Deficiency Anemia Through Primary Health Care. A Guide for Health Administrators and Programme Managers. Geneva: World Health Organization; 1989

21. Brune M, Rossander L, Hallberg L. Iron absorption and phenolic compounds: importance of different phenolic structures. Eur J Clin Nutr. 1989 Aug; 43(8):547-57.

22. Dikshit SN, Udipi SA, Rao A, Manoharan V. Separation of carotenoids and estimation of beta carotene content of selected Indian food preparations by HPLC. J Food Sci Technol. 1988; 25(1):39-41.

23. Padmavati K, Udipi S A, Rao M. Effect of different cooking methods on carotene content of vegetables. J Food Sci Technol. 1992; 29 (3):137-140.

24. Bhattacharjee LI, Mudambi SR, Bhusan B, Patanakar AV. Provitamin A content of selected Indian foods. J Food Sci Technol. 1994; 31(3):249-251.

25. Tontisirin K, Valaiphatchara U. Development and utilization of rice and legume mixtures in improvement of childhood nutrition. In: Yasumoto K, ltokawa Y. Koishi H. Sanno Y. eds. Proceedings of the fifth Asian Congress of Nutrition. Tokyo: Center for Academic Publications, 1987:347-50.

26. Martinez BC, de Zoysza I, Glass RI. The magnitude of the global problem of diarrhoeal disease: a ten-year update. Bull WHO 1992; 70:705-14.

27. Complementary Feeding: Family foods for breastfed children. World Health Organization: 2000.

28. Shrimpton R, Victora CG, de Onis M, Lima RA, Blössner M, Clugston G: Worldwide timing of growth faltering: implications for nutritional interventions. Pediatrics. 2001;107(5):E75.

29. Maleta K, Virtanen S, Espo M, Kulmala T, Ashorn P: Timing of growth faltering in rural Malawi. Arch Dis Child 2003, 88:574-578.

53

30. Srivastava N, Sandhu A. Index for measuring child feeding practices. Department of Foods and Nutrition, M.S. University of Baroda, Vadodara, Gujarat, India. Indian J Pediatr. 2007 Apr;74(4):363-8.

31. Garg A, Chadha R. India. Index for measuring the quality of complementary feeding practices in rural India. J Health Popul Nutr. 2009 December; 27(6): 763–771.

32. Wei Sheng Yan Jiu. Relationship between growth of young children and complementary feeding, 2000; 29(5): 279-82.

33. The Optimal Duration of Exclusive Breastfeeding. Report of an Expert Consultation. Geneva, Switzerland: World Health Organization; 2001 Mar.

34. Dewey KG, Roberta J. Cohen, Brown KH, Rivera LL. Effects of Exclusive Breastfeeding for Four versus Six Months on Maternal Nutritional Status and Infant Motor Development: Results of Two Randomized Trials in Honduras; J Nutr. 2001 Feb; 131(2):262-7.

35. Naylor AJ, Morrow AL. Developmental readiness of normal full term infants to progress from exclusive breastfeeding to the introduction of complementary foods. Linkages/ Wellstart International, 2001.

36. World Health Organization, WHO: Complementary feeding of young children in developing countries: a review of current scientific knowledge. Geneva: NUT/98.1, 1998.

37. Rasheed S, Haider S, Hassan N, Pachón H, Islam S, Jalal C S B and Sanghvi T G; Why does nutrition deteriorate rapidly among children under 2 years of age? Using qualitative methods to understand community perspectives on complementary feeding practices in Bangladesh; Food and Nutrition Bulletin, The United Nations University, 2011; 32(3).

38. Rasheed S. Understanding breastfeeding practices in Bangladesh: links between mothers' perception and practice. Ithaca: Cornell University; 2007.

39. Complementary feeding in rural Bangladesh: family food for breast-fed infants. Nutritional Surveillance Project, Bulletin No. 6, Helen Keller Worldwide; 2001 July.

40. Kimmons JE; Dewey KG; Haque E; Chakraborty J; Osendarp SJ; Low nutrient intakes among infants in rural Bangladesh are attributable to low intake and micronutrient density of complementary foods. J Nutr. 2005 Mar; 135(3): 444-51.

41. Roy SK, Fuchs GJ, Mahmud Z, Ara G, Islam S, Shafique S, Akter SS, Chakraborty B. Intensive nutrition education with or without supplementary feeding improves the nutritional status of moderately-malnourished children in Bangladesh. J Health Popul Nutr. 2005 Dec; 23(4):320-30.

42. Guldan GS, Fan HC, Ma X, Ni ZZ, Xiang X, Tang MZ. Culturally appropriate nutrition education improves infant feeding and growth in rural Sichuan, China. J Nutr. 2000 May; 130(5):1204-11.

43. Sharieff W, Bhutta Z, Schauer C, Tomlinson G, Zlotkin S. Micronutrients (including zinc) reduce

diarrhoea in children: the Pakistan Sprinkles Diarrhoea Study. Arch Dis Child. 2006 Jul;

91(7):573-9. Epub 2006 Mar 23.

54

44. Cohen RJ, Brown KH, Canahuati J, Rivera LL, Dewey KG. Effects of age of introduction of complementary foods on infant breast milk intake, total energy intake, and growth: a randomized intervention study in Honduras. Lancet. 1994 Jul 30; 344(8918): 288-93.

45. Benakappa AD, Shivamurthy P. Beliefs regarding diet during childhood illness. Indian J Community Med. 2012; 37(1):20-4. doi: 10.4103/0970-0218.94016.

46. Dewey KG, Brown KH. Update on technical issues concerning complementary feeding of young children in developing countries and implications for intervention programs. Food Nutr Bull. 2003 Mar; 24(1):5-28.

47. Dewey K.G. Complementary feeding. In: Encyclopedia of Human Nutrition (eds B. Caballero, L. Allen, A. Prentice), 2nd Edition. Elsevier Ltd: Amsterdam; 2005: 465–470

48. Dewey KG, Seth A. Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries. Maternal and Child Nutrition, 2008; 4: 24–85.

49. Complementary feeding for children aged 6-23 months, FAO European Union Food Facility Project, sec 2:7

50. Roy SK, Jolly SP, Shafique S, Fuchs GJ, Mahmud Z, Chakraborty B. Prevention of malnutrition among young children in rural Bangladesh by a food-health-care educational intervention: a randomized, controlled trial. Food Nutr Bull. 2007 Dec; 28(4):375-83.

51. Luby SP, Halder AK, Huda T, Unicomb L, Johnston RB. The effect of hand washing at recommended times with water alone and with soap on child diarrhea in rural Bangladesh: an observational study. PLoS Med. 2011 Jun; 8 (6):e1001052. Epub 2011 Jun 28.

52. Islam MM, Khatun M, Peerson JM, Ahmed T, Mollah MA, Dewey KG, Brown KH; Effects of energy density and feeding frequency of complementary foods on total daily energy intakes and consumption of breast milk by healthy breastfed Bangladeshi children. Am J Clin Nutr. 2008; 88(1):84-94.

53. Pelletier, D. L. The relationship between child anthropometry and mortality in developing countries: implication for policy, programs and future research. J. Nutr. 1994, 124:2047S-2081S.

54. A Critical Link. Interventions for Physical Growth and Psychological Development: A Review. Geneva, Switzerland: World Health Organization. 1999; 79p. Ref. WHO/CHS/CAH/99.3 19.

55. Waterlow, J. C. Observations on the natural history of stunting. Linear Growth Retardation in Less Developed Countries 1988:5-8 Nestle Nutrition, 1988, S.A Vevey, Switzerland.

56. Victoria CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, Sachdev HS: Maternal and child under nutrition: consequences for adult health and human capital. Lancet 2008, 371(9609):340-357.

57. Victora CG, de Onis M, Hallal PC, Blossner M, Shrimpton R: Worldwide timing of growth faltering: revisiting implications for interventions. Pediatrics 2010, 125(3):e473-480.

58. World Bank: Repositioning nutrition as central to development: A strategy for large scale action. Washington, DC: The World Bank; 2005.

55

59. Penny ME, Creed-Kanashiro HM, Robert RC, Narro MR, Caulfield LE, Black RE Effectiveness of an educational intervention delivered through the health services to improve nutrition in young children: a cluster-randomized controlled trial. Lancet. 2005; 365(9474):1863-72.

60. South Asia regional development marketplace on nutrition 2009, innovate for nutrition: family and community approaches to improve infant and young child nutrition. Food Nutr Bull. 2009;16( 4):1995.

61. Vitamin and Mineral Deficiency: A Global Progress Report. Unicef and MI. 2004.

62. Grantham-McGregor, S.,1995. “A Review of Studies on the Effect of Severe Malnutrition on Mental Development.” Journal of Nutrition 125(85,Supplement):2233-38S.

63. Brown, J, and Pollit E, 1996. “Malnutrition, Poverty and Intellectual Development.” Scientific American 2:38-43.

64. Tomkins AM., and Watson F. Malnutrition and Infection: A Review. Geneva. ACC/SCN State-of-the-Art Series, Nutrition Policy Discussion1989.

65. International Conference on Nutrition Goals. World Declaration and Plan of Action. Rome FAO and Geneva WHO.1992.

66. Murray, C., and A. Lopez, 1997. “Global Mortality, Disability, and the Contribution of Risk Factors: Global Burden of Diseases Study.” Lancet 349(9063):1436-42.

67. Pelletier DL. The relationship between child anthropometry and mortality in developing countries: implication for policy, programs and future research. J Nutr. 1994 Oct; 124 (Suppl 10):2047S-2081S.

68. Senarath U, Godakandage SSP, Jayawickrama H, Siriwardena I and Dibley MJ, Determinants of inappropriate complementary feeding practices in young children in Sri Lanka: secondary data analysis of Demographic and Health Survey 2006–2007. Maternal & Child Nutrition, 2012; 8(Supp l):60-77

69. Joshi N, Agho K E, Dibley M J, Senarath U and Tiwari K; Determinants of inappropriate complementary feeding practices in young children in Nepal: secondary data analysis of Demographic and Health Survey 2006, Maternal & Child Nutrition 2012; 8 (Suppl). 1:45-59

70. Kabir I, Khanam M, Agho KE, Mihrshahi S, Dibley MJ, Roy SK. Determinants of inappropriate complementary feeding practices in infant and young children in Bangladesh: secondary data analysis of Demographic Health Survey 2007, Matern Child Nutr. 2012 Jan; 8 (Suppl):11-27.

56

71. National Family Health Survey (NFHS-3). Mumbai: Ministry of Health and Family Welfare Government of India; 2007 Sept. 540p.

72. Hazir T, Senarath U, Agho K, Akram DS, Kazmi N, Abbasi S, Dibley MJ. Determinants of inappropriate timing of introducing solid, semi-solid or soft food to infants in Pakistan:secondary data analysis of Demographic and Health Survey 2006-2007. Matern Child Nutr. 2012 Jan; 8 (Suppl 1):78-88.

73. Senarath U and Dibley MJ; Complementary feeding practices in South Asia: analyses of recent national survey data by the South Asia Infant Feeding Research Network; Matern Child Nutr. 2012 Jan;8 Suppl 1:5-10.

74. Patel A, Pusdekar Y, Badhoniya N, Borkar J, Agho KE, Dibley MJ. Determinants of inappropriate complementary feeding practices in young children in India: secondary analysis of National Family Health Survey 2005-2006.Matern Child Nutr. 2012 Jan; 8 Suppl 1: 28-44.

75. Penny ME, Creed-Kanashiro HM, Robert RC, Narro MR, Caulfield LE, Black RE. Effectiveness of an educational intervention delivered through the health services to improve nutrition in young children: a cluster randomized controlled trial. Lancet. 2005 May 28-Jun 3; 365(9474):1863-72.

76. Bhandari N, Mazumder S, Bahl R, Martines J, Black RE, Bhan MK; Infant Feeding Study Group. An educational intervention to promote appropriate complementary feeding practices and physical growth in infants and young children in rural Haryana, India. J Nutr. 2004 Sep; 134(9):2342-8.

77. Rivera JA, Sotres-Alvarez D, Habicht JP, Shamah T, Villalpando S. Impact of the Mexican program for education, health, and nutrition (Progresa) on rates of growth and anemia in infants and young children: a randomized effectiveness study. JAMA. 2004 Jun 2; 291(21):2563-70.

78. Schroeder DG, Pachón H, Dearden KA, Kwon CB, Ha TT, Lang TT, Marsh DR. An integrated child nutrition intervention improved growth of younger, more malnourished children in northern Viet Nam. Food Nutr Bull. 2002; 23( 4):50-58.

79. Hoppe C, Andersen G, Jacobsen S, Mølgaard C, Friis H, Sangild P, et al. The use of whey or skimmed milk powder in fortified blended foods for vulnerable groups. J Nutr. 2008 Feb; 27:145-61

80. Adu-Afarwuah S, Lartey A, Brown KH, Zlotkin S, Briend A, Dewey KG. Randomized comparison of 3 types of micronutrient supplements for home fortification of complementary foods in Ghana: effects on growth and motor development. Am J Clin Nutr. 2007 Aug; 86(2):412-20.

81. Dhingra P, Menon V.P, Sazawal S, Dhingra U, Marwah D, Sarkar A. et al. Effect of fortification of milk with zinc and iron along with vitamins C, E,A and selenium on growth, iron status and development in preschool children – a community-based double-masked randomized trial. Report

57

from the 2nd World Congress of Pediatric Gastroenterology, Hepatology and Nutrition. Paris: 2004 July: p. 3–7.

82. Moursi M, Mbemba F, Trèche S.Does the consumption of amylase-containing gruels impact on the energy intake and growth of Congolese infants? Public Health Nutr. 2003 May;6 (3):249-58.

83. Pollitt E, Jahari A, Husaini M, Kariger P, Saco-Pollitt C. Developmental trajectories of poorly nourished toddlers that received a micronutrient supplementwith and without energy. J Nutr. 2002 Sep;132(9):2617-25.

84. Sazawal S, Dhingra U, Dhingra P, Hiremath G., Kumar J, Sarkar A, Menon V, Black R. Effects of fortified milk on morbidity in young children in north India: community based, randomised, double masked placebo controlled trial. BMJ 2007; 334:140

85. Sharieff W, Bhutta Z, Schauer C, Tomlinson G. & Zlotkin S. Micronutrients (including zinc) reduce diarrhoea in children: the Pakistan Sprinkles Diarrhoea Study. Arch Dis Child. 2006 July; 91(7): 573–9.

86. Dirorimwe C, Wijesinha-Bettoni R, Muehlhoff E; Nutrition education and food security intervention to improve Complementary Feeding Practices in Cambodia.

87. Muehlhoff E, Dirorimwe C, Huang S, Mengkheang K, Ry K L. Trials of Improved Practices (TIPs) Reference Notes and Tools, FAO EU FFP-N 03. 2011 July. P- 19 to 23.

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Annexure

59

Annexure 1: Photos from baseline study

FGD with Father Group IDI with mother

FGD with HW FGD with mother group

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Photos from Recipe Trial in seven Divisions

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Annexure 2: Score card for acceptability analysis of the improved recipes (by both mothers and children)

Score card used for evaluation of mothers’ acceptability

1. Name of Recipe: ------------------------- 2.Date : ……………..

3. Participant’s code: ----------------------- 4. Age of the Child: ---------- 5. Name of Participant: ---------------------- Attribute Score

5 4 3 2 1 0

Appearance

Flavor

Consistency

Mouth feel

Taste

Overall acceptability

Score scale: 5 = excellent; 4 = good; 3 = satisfactory; 2= average; 1= poor/needs

Improvement; 0 = not acceptable; (Total score=25)

Overall acceptability (%): ………………

Is it possible to prepare it at home (Yes/ No):

Why?

: -------------------------------------------------------------------------------------------------

Remarks/Suggestions: …………………………………………………………………..

-------------------------------------

Signature & date of the participant

--------------------------------------

Signature & date of the Supervisor

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Score card used to evaluate children’s acceptability Children’s acceptability of cooked food

1. Amount served and consumed by Children (observation) 2. Name of place ------------------- 3. Name of food: --------------------------------------------------------- 4. Date: ___ ___ /___ ___/________ 5. Name of the Surveyor: ………………………………………….

Age groups: 1=6-8 month, 2= 9-11 month, 3= 12-23 month.

Acceptability: 5 = Eaten fully; 4 = Eaten ¾ portion; 3= Eaten ½ portion; 2 = Eaten ¼ portion; 1= Eaten little; 0 = Not eaten

a b c=b-a d E f=b-e

Child Name of

Child

Age of

Child (Code)

Wt of

container (g)

Food wt

With Container

(g)

Net wt

Food (g)

Household measure

Wt of the left-over food

with container

(g)

Total amount

consumed (g)

Acceptability proportion

eaten (Code)

Acceptability (Percentage

of Food eaten)

Negative Response to

Food (Vomiting /Nausea)

Comments

1

2

3

4

5

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Annexure 3: Methods used in analysis of different nutrients of improved recipes in the laboratory.

Ash In Food & Feeding Stuff

Principle: This method is for the determination of the ash content of food &feeding stuffs. The sample is ashed constant temperature; the residues are weighed.

Reference: AOAC (2005) Method 923.03, 930.30, 940.26, 920.153, 920.155, 950.14, 930.05, 940.25 & 938.08

Moisture In Food & Feeding Stuff

Principle: This method is for the determination of the moisture content in food. The sample is dried in constant temperature in air oven or vacuum oven.

Reference: AOAC (2005) 927.05, 925.10, 934.06, 950.46

Protein In Food & Feeding Stuff

Principle: This method is for the determination of crude protein in feeding stuffs by Kjeldahl method for nitrogen. The sample is digested by sulphuric acid in the presence of a catalyst. The acidic solution is made alkaline by a sodium hydroxide solution. The ammonia released is distilled and collected in a measured quantity of sulphuric acid, the excess of which is titrated with a standard solution of sodium hydroxide.

Reference: Gafta (2005) Method 4:0

Fats and Oil in Food and Feeding Stuff

Principle: This method is for the determination of the content of crude oils and fats in flour and food by acid hydrolysis method. The sample is extracted with light alcohol and petroleum ether. The solvent is evaporated & the residue dried & weighed.

Reference: AOAC (2005) 922.06

Carbohydrate in Food and Feeding Stuff

Principle: Total carbohydrate is calculated by subtracting the sum of the crude protein, total fat, ash and moisture from the total weight of the food. The term “other carbohydrate” is defined as the different as the difference between total carbohydrate and the sum of dietary fiber, sugar and sugar alcohol (if measured).

Reference: Method of analysis for Nutrition Labeling (2005) 922.06

Energy (Calories) in Food & Feeding Stuff

Principle: The calorie value for nutrition labeling can be determined of % of protein, % of carbohydrate, % of fat with multiplied by their individual factors.

Reference: Method of Analysis for Nutrition Labeling (2005): 106

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Heavy Metals In Food and Feeding Stuff

Principle: Products are digested with HNO3, HCl and HNO2 under pressure in a closed vessel microwave digester. Solutions are analyzed by ICP-OES (Inductively Coupled Optical Emission Spectrometry).

Reference: AOAC (2005), 999.10, 968.08

Vitamin A In Food and Feeding Stuff

Principle: Vitamin A extract with n-hexane & finally it dissolved in methanol then analysis by HPLC.

Reference: IN HOUSE (Ref. Bull. Dept. Med. Sci. Vol. 37. No. 1 Jan-Mar 1995)

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