TOR# 14Title of the Research Project: Development of a complementary feeding manual for Bangladesh

Principal Investigator: Dr. A.K.M. Iqbal Kabir, MBBS, MD,PhD, Vice - Chairperson, BBF

Co- Principal Investigators: Dr. S. K. Roy, MBBS (Dhaka), M.Sc Nutr, Ph.D (London), FRCP (Edin), Chairperson, BBF

AndProf. Soofia Khatoon, MBBS, FCPS (Ped),MHPED (Australia) ,Fellow in Neonatology (U.K), Secretary, BBF

Institution: Bangladesh Breastfeeding Foundation (BBF)

Context of the study

• The exclusive breastfeeding rate is 64% and appropriate CF practices (6-23 months)rate is only 21%. (using the stricter definition as per global guidelines, BDHS-2011)

• National guidelines and strategy on CF have been developed (IPHN 2009)

• Absence of policy /advocacy tools, particularly a manual on CF recipes using local ingredients and preparation/processing methods).

Complementary Feeding Practices (6-23 months)

Source: BDHS-2011

Objectives To provide nutrition practitioners and care providers

in Bangladesh with necessary guidelines and a

recipe manual for improving complementary

feeding practices.

Objectives Research questions methodology /output1. 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 practices, preparation and processing methods, and types of local home based complementary foods used in Bangladesh and in South Asia.

2. To assess the dietary and food diversity and adequacy foods

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

Limited data on dietary and nutrient adequacy or nutrient gaps of complementary foods in Bangladesh.

•Determination of dietary and nutrient adequacy of complementary foods was done by calculation of selected nutrient values(energy, protein, fat, carbohydrate, vitamin A ,calcium iron, zinc, moisture, ash) using published and unpublished FCT for Bangladesh as well as Regional FCT.

3. To prepare 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 including 35 recipes from nutrient content.•35 recipes were tested in the community for acceptability by mothers and their children.

•Out of 35 recipes 30 recipes were analyses in a accredited laboratory.

The study used multiple

methods, such as

analysis of literature

review, focus group

discussion, in-depth

interview, technical

committee

consultations, nutrient

analyzing and TIPs

(Recipe trial).

The study used multiple

methods, such as

analysis of literature

review, focus group

discussion, in-depth

interview, technical

committee

consultations, nutrient

analyzing and TIPs

(Recipe trial).

Sample frame and Sample SizeSample frame

and Sample Size

Recruitment of staff

Recruitment of staff

Training of staff

Training of staff

Qualitative Research:• In-depth interviews with Mothers and fathers :15

• Focus group discussions (FGDs) with the mothers or caregivers and the fathers and the govt. health service providers : 28

• Each focus group discussion included 6-8 persons .

• Duration : About 2 hrs

• TIPs : Total 35 Recipes were tested for acceptability in seven divisions

Complementary feeding One third of the mothers started complementary food after completion of six months of age of their child with continuation of breast milk.

• Two third of the mothers started Complementary feeding between 7 and 8 months.

• They fed their child liquid, semi liquid, semi solid foods like khichuri, semolina

(suji), sago, potatoes with pulse and family foods.

• One third of them added eggs, chicken, liver, small fish in cooked khichuri. The

children were fed 3 to 4 times a day.

Result: In depth Interview (Mother)

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

Focus Group Discussion (Mother) • Two third of the mothers had little/lack of knowledge on

complementary foods, how to prepare and how much should be given to the children.

• Half of them thought they gave appropriate diets to their

children.

• One third of mothers said that they heard about complementary food from their Didi (health worker) or other elder persons like mothers and sisters .

• Half of them heard about complementary food from health care centre but did not get any advice on the type of food, frequency of feeding and/or amount needed daily .

Assessing dietary diversity and adequacy of CF foods:• To identify the nutrient adequacy, we analyzed some recipes from

the field during in-depth interview and FGD.• The assessment showed that energy density was low and did not

have required nutritive value and proportion of nutrients. • Such foods often fill the child’s stomach but provide less energy

and nutrients , thus contributing to growth faltering. Complementary foods given to children frequently do not provide required amount of energy and nutrients.

• The assessment showed that feeding practices and dietary diversity were generally inadequate. For example:

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, Suit,Sugar

2

Steps for Development of Recipes

Principles : •The formulation of recipes was based on foods used by mothers and the assessment of nutrient gap was done from baseline study.

• Factors for assessing nutrient adequacy of recipes considered energy density, nutrient density, protein content, use of micro nutrient rich foods, animal foods, serving size, number of times fed, age of the child, consistency, cost, feasibility, accessibility and seasonality following standard guidelines. (WHO/UNICEF - 2003)

Recipe development:1. Selection of potential foods:

Based on field experience selected criteria were followed in developing recipes for children aged 6 to 23 months : Availability, feasibility, nutritive value, cost, acceptability.

2. Potential food combinations (adapted from F AO, Food –based strategies to meet the challenges of micronutrient malnutrition in the developing world)

1. Cereal+ Animal food (fish/ egg/ meat/ chicken/liver) + vegetables+ adequate quantity of oil

2. Cereal + pulse +nuts +vegetable/fruit + adequate quantity of oil3. Cereal + nuts/fish/egg +fruit/vegetable + adequate quantity of oil4. Cereal + pulse + Fruit/vegetable + adequate quantity of oil5. Cereal + pulse + animal food (egg/ liver/ chicken) + vegetable+ oil6.Cereal + milk/egg + sugar/ molasses + fruit/vegetable

Category Name of the recipe Age group

Category 1

Cereal+ Animal food (fish/ eggs/ meat) + green leafy vegetables+ adequate quantity 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 + pulse +nuts +vegetables/fruits + adequate quantity of oil

Vegetable khichuri 6-8 months

Vegetable chapri,Pusti Gura,Buter Halwa 9-11 months

Sweet potato Halwa 12-23 months

Category 3

Cereal +nuts/fish/egg+ fruit /vegetables+ adequate quantity of oil

Egg suji, 6-8 months

Bread toast, Tomato soup,Fish with vegetable & White sauce

9-11 months

Fruit pitha, pumpkin coconut halwa, Fish cutlet,

12-23 months

Category Name of the recipe Age group

Category 4

Cereal + pulse + Fruit/vegetables + adequate quantity of oil

Papaya halwa;

mixed vegetable pitha, soya chop

6-8 months

12-23 months

Category 5

Cereal + lentil + Animal food (chicken/egg )+ fruit / vegetables + oil

chicken khichuri, liver khichuri 6-8 months

Vegetable chop 9-11 months

Vegetable roll, Egg khichuri 12-23 months

Category 6

Cereal + milk/egg + sugar/molasses+ fruit/vegetables

Fruit firni; Mango payesh;; Fruit faluda; Pumpkin payesh

6-8 months

Sujir halwa; Carrot LaddoSujir Malpoa; Pudding

9-11 months12-23 months

Trials of improved practice(TIPs):Testing improved recipes for use (Demonstration):

•The Complementary foods, recipe options, guidelines, key nutrition education messages and recommendations were based on Trials of Improved Practices (TIPS) carried out in Bangladesh.

•For the recipe trials, cooking sessions and sensory evaluations were conducted with mothers.

•The recipes were tested for acceptability by young children by observing intake .

Examples of the most acceptable recipes

Chicken Chop (Murgir chop)

Small fish chop (Kachki macher chop)

Buter halwa

Egg suji (dimer suji)

Sujir (semolina)Malpoa

Fruit firni(foler payesh)

Fruit Pitha (foler pitha) Fish Cutlet (Macher chop)

Soya Chop

Vegetable roll (Sobji roll)

Vegetable chop (sobji chop)

Carrot laddo (gajorer laddo)

Acceptability (100%) of different recipes by children (Division wise)

Laboratory analysis of nutrients:

•Analysis of 30 CF has been carried out in an accredited laboratory.

•Analysis of energy, protein, fat, carbohydrate, vitamin A, calcium, iron, zinc, moisture, ash (phosphorus, magnesium, copper)

•Out of 35 recipes 30 most commonly used ones were sent for lab analysis.

Result on laboratory analysis of some recipesName of the recipe

ASH Moisture

Protein (N X 6.25)

Fats & oil

Energy (calories)

Carbohydrate

Zinc (as Zn)

Iron (as Fe)

Calcium(as Ca)

Vitamin A

Liver chop

1.66% 67.27% 5.04% 4.93% 149Kcal/100g

21.1% 0.83 mg/100g

1.72 mg/100g

42.74 mg/100g

64.1 IU/100g

Vegetable khichuri

1.94% 69.3% 3.81% 5.57% 143Kcal/100g

19.38% 0.70mg/100g

0.94mg/100g

46.18mg/100g

ND<9 IU/ml

Egg suzi 0.39% 75.8% 3.16% 3.53% 113Kcal/100g

17.12% 0.44mg/100g

1.22mg/100g

49.66mg/100g

100.02IU/100g

Mixed vegetable pitha

1.46% 72.11% 5.30% 3.54% 123Kcal/100g

17.59% 0.57mg/100g

1.30mg/100g

57.89mg/100g

ND<9 IU/ml

Egg Khichuri

1.13% 78.43% 3.42% 2.7% 95Kcal/100g

14.32% 0.47mg/100g

1.10mg/100g

14.73mg/100g

73.45IU/100g

Fruit firni

1.11% 63.23% 3.82% 4.4% 165Kcal/100g

27.44% 0.56mg/100g

1.24mg/100g

73.95mg/100g

46.02IU/100g

Recipe Age group Amount(g)

Frequency Total Kcal

% of energy from different nutrients

CHO Pro Fat

Liver Khichuri

6-8 170 2-3 202 60 15 25

9-11 258 3-4 307

12-23 460 4-5 547

Egg khichuri 6-8 183 2-3 202 51 12 37

9-11 279 3-4 307

12-23 497 4-5 547

Vegetable khichuri

6-8 198 2-3 202 63 12 25

9-11 304 3-4 307

12-23 542 4-5 547

Recipe composition for different age group

Recipe Age group

Amount(g)

Frequency Total Kcal

% of energy from different nutrients

CHO Pro Fat

Egg suji 6-8 171 2-3 202 54 13 33

9-11 260 3-4 307

12-23 463 4-5 547

Fruit firni 6-8 167 2-3 202 69 11 20

9-11 126 2 154

12-23 271 3 328

Small fish (Kachki)

chop

9-11 100 2 204 62 15 23

12-23 160 3 328

Cont.

Comparison between lab result and improved developed recipes

Name of the recipe Nutrient Lab result Calculation by composition table

Difference%

Chirar polao Carbohydrate 59.66 58 1.66Protein 13.6 13 0.6Fat 26.73 29 -2.27Energy density 1.4 1.77 -0.37

Vegetable chapri Carbohydrate 63.27 63 0.27Protein 12.44 11 1.44Fat 24.28 26 -1.72Energy density 1.72 2 -0.28

Fruit pitha Carbohydrate 64.58 65 -0.42Protein 9.99 11 -1.01Fat 25.43 24 1.43Energy density 3.04 3.57 -0.53

Soya chop Carbohydrate 58.36 63 -4.64Protein 16.3 14 2.3Fat 25.33 23 2.33Energy density 1.53 1.87 -0.34

Chicken khichuri Carbohydrate 59.5 53 6.5Protein 15.8 16 -0.2Fat 24.7 31 -6.3Energy density 0.95 1.23 -0.28

Pumpkin payesh Carbohydrate 64.7 68 -3.3Protein 9.45 10 -0.55Fat 25.85 22 3.85Energy density 2.5 1.2 1.3

Policy Recommendations • The manual and guidelines would serve as a tool for

practical knowledge and training for nutrition practitioners, academicians and mothers.

• The manual should receive careful attention of government and non-government partners for use/adapting in programs concerned with infant and young child feeding (IYCF).

• Formulation of recipes was built on existing practices covering 7 divisions of Bangladesh.

• Evaluation of these recipes on biological outcome will be helpful.

• There is need for well linked community based programs to build a true multi-sectoral approach.

Field Visits in Baseline

Field Visits in TIPs