Improving Diet Quality Among Infants and Young Children: Challenges and

Potential Solutions

Purnima Menon International Food Policy Research Institute

Workshop on

The Feed the Future Zone in the South and the Rest of Bangladesh:

A Comparison of Food Security Aspects 16 January 2013

Dhaka 1

Why care about diet quality?

• Diet quality (as measured by proxy indicators such a diversity) is associated with better nutritional outcomes for children

• Diet quality for young children, especially diversity, is known to be a problem in most developing countries

2 Zongrone et al., Public Health Nutrition, 2012

IYCF practices in the FTF zone compared to the rest of the country

3 0 20 40 60 80 100 120

Exclusive breastfeeding under 6 months

Continued breastfeeding at 1 year

Introduction of solid, semi-solid or soft foods

Minimum dietary diversity (4+ food groups)

Minimum meal frequency

Minimum acceptable diet

Consumption of iron-rich or iron-fortified foods

BDHS

BIHS

FTF

Timely introduction of high nutrient-value foods is low (BIHS sample)

Before 6 mo

6-8.9 mo After 9 mo

Complementary food % % %

Water 69.8 29.0 1.2 Other non-breast milk liquids (e.g. sugar/glucose water, tea, fruit juice, etc.)

48.3 49.0 2.8

Cow or goat milk 37.4 49.9 12.7

Sooji, rice gruel, etc. 27.9 65.9 6.3 Semi-solid foods (e.g. soft rice, mashed potato, ripe banana, etc.)

12.5 76.9 10.7

Solid foods (e.g. rice, wheat, puffed or pressed rice, etc.) 7.5 67.5 25.0

Fish 5.9 65.3 28.7

Meat 5.0 60.8 34.2 Eggs 7.2 71.9 20.9

Legumes 6.3 72.5 21.2 Green vegetables 6.0 75.0 19.0 Snack foods (e.g. chips) 3.3 54.2 42.5 4

Diet diversity is especially low for 6-8 mo old infants (BIHS sample; 24-hr food group recall)

Items fed to children aged 6-8 months based upon 24 hour recall % (N = 115)

Liquids

Breast milk 98.2

Water 87.5

Prepared baby formula 16.1

Any other kind of milk (e.g. powder, cow, goat, etc.) 31.8

Fruit juice (homemade) 8.0 Fruit juice (purchased) 1.2

Water-based liquids (e.g. teas, sugar water, coffee, etc.) 42.6

Food groups Grains, roots, and tubers 70.3

Legumes and nuts 8.3 Dairy (e.g. milk, yogurt, cheese) 42.9

Flesh foods (e.g. meat, fish, poultry, and liver/organ meats) 5.3

Eggs 8.3

Vitamin A-rich fruits and vegetables 16.2 Other fruits and vegetables 10.4 5

Types of food fed to children is not different by gender for children 6-23 months old (BIHS sample)

6

0

20

40

60

80

Gra

ins,

ro

ots

,an

d t

ub

ers

Legu

mes

an

dn

uts

Dai

ry (

e.g.

milk

,yo

gurt

, ch

eese

)

Fles

h f

oo

ds

(e.g

. mea

t, f

ish

,p

ou

ltry

, an

d…

Eggs

Vit

amin

A-r

ich

fru

its

and

vege

tab

les

Oth

er f

ruit

s an

dve

geta

ble

s

Pe

rce

nta

ge

Boys Girls TOTAL

% of children 6-23 months old achieving minimum diet diversity, by division and wealth

7

0

10

20

30

40

50

60

70

80

90

100

Division Wealth group %

Use of micronutrient supplements (BIHS)

8

Mother tookiron

tablets/supplements during

recentpregnancy

Mother wasgiven vitamin A

capsule afterdelivery

For childrenaged 6-23

months, childreceived acapsule of

vitamin A in last6 months

Diarrhea: oralrehydration

solution (ORS)that was

purchased.

Diarrhea: zinctablets.

Series1 56.0 23.6 70.7 86.7 21.9

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

%

Maternal nutrition knowledge is variable (BIHS)

9

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Baby should bebreastfed

immediately or <1hour after birth

Baby should bebreastfed colostrum

after birth

Iron deficiency canimpair child growthand development

Handwashing beforefeeding a child.

%

Awareness about micronutrient powders (BIHS) is especially low

10

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

1 (lowest) 2 3 4 5 (highest)

Percentage of mothers under-twos who have heard about MNPs, by SES (BIHS)

What are some solutions?

• Improving diet quality requires investments in: – Behavior change communication

– Shaping social norms

– Addressing food insecurity (often a predictor of diet quality for young children)

• A challenge is implementing interventions to address this issue at scale!

• IFPRI’s evaluation of Alive & Thrive interventions implemented by BRAC and FHI360 are shedding light on this

12

INSIGHTS FROM ALIVE & THRIVE EVALUATION RESEARCH BY IFPRI ON

POTENTIAL SOLUTIONS TO IMPROVING IYCF AND DIET QUALITY

13

A&T evaluation design

14

60 Rural upazilas (50 + 10)

20 (paired) rural EHC upazilas

10 upazilas A&T Intensive

10 upazilas A&T Non-intensive

Baseline Survey (April-July 2010)

A&T Endline Survey (April-July 2014)

Process Evaluation Survey (June-July 2012)

A&T HH Survey(April-July 2013)

FHW Survey (September-October 2011)

Process evaluation

Both

qualitative and

quantitative

Early impacts of Alive & Thrive’s interventions on infant

and young child feeding practices (WHO indicators)

0 10 20 30 40 50 60 70 80 90 100

Early initiation

EBF 0-5.9 mo

Continued BF 12-15 mo

Solid/semi-solids in 6-8.9 mo

Min diet diversity 6-23 mo

Min meal freq (6-23 mo)

Min acceptable diet (6-23 mo)

Iron food (6-23 mo)

A&T (2012) Non-A&T (2012) Baseline (2010)

*

***

**

* p < 0.05, ** p < 0.01, *** p < 0.001

%

Non-A&T= Non-intensive 15

More households in A&T areas have heard complementary feeding and MNP messages

0

20

40

60

80

100

Feed mashed familyfood to children aged >

6 months

Feeding animal sourcefoods to children aged

> 6 months

Cook children's foodwith oil

Add Multiple NutrientPowder (MNP) to the

child's food

Per

cen

t

Baseline (2010) A&T Intensive (2012) A&T Non-Intensive (2012)

These 2 behaviors – use of oil and MNPs - are mainly promoted by FHWs, not the media campaign

Health worker visits to HH is high in A&T areas

0

10

20

30

40

50

60

70

80

90

100

Ever had HHvisit by SS/PS

(unaidedrecall)

Ever had HHvisit by SS/PS(aided recall)

A&T Area

Non-A&T Area

SS/PS

0

10

20

30

40

50

60

70

80

90

100

Ever had HH visitby SK (unaided

recall)

Ever had HH visitby SK (aided

recall)

A&T Area

Non-A&T Area

SK

0

10

20

30

40

50

60

70

80

90

100

Ever had HHvisit by PK(unaided

recall)

Ever had HHvisit by PK

(aided recall)

A&T Area

PK

Non-A&T= Non-intensive

Mass media campaign: recall of TVCs among total sample in A&T evaluation sample

0

10

20

30

40

50

60

A&T Intensive Areas A&T Non-IntensiveAreas

Perc

ent

Early initiation of breastfeeding

Exclusive breast feeding

Animal source food after 6months

Poor appetite

Frequency ofcomplementary feeding

The house is on fire

18

INSIGHTS FROM THE BANGLADESH INTEGRATED HOUSEHOLD SURVEY ON

ACCESS TO KEY INTERVENTION PLATFORMS

19

Exposure to counseling by health workers is quite low

TOTAL (n=979)

Literate mother

(N = 886)

Illiterate mother (N = 93)

% % %

Have been visited at home by any health worker in the last 6 months

25.8 26.5 19.2

Visited by a health worker ≥3 times in the last 6 months (among those visited in the last 6 mo)

43.6 43.5 45.5

Received advice from health worker about feeding the child during last visit (among those visited in the last 6 mo)

59.2 59.7 52.6

20

Exposure and recall of national IYCF communications campaign (BIHS, all female respondents, N=5503)

21

27.8

22.8

14.3

24.5

17.3 17.7

22.7 20.7

11.4

21.8

15.3 16.2

Advertisementabout a

newborn baby("A mother of

a newbornbaby")

Advertisementabout

breastfeeding("Father bringstinned milk for

baby")

Advertisementabout a houseon fire ("House

is on fire")

Advertisementabout cookingfish ("Mothercooking fish")

Advertisementabout sports

("Tumpa winsa prize")

Advertisementabout child

feeding ("Babygoes to sleep

withouteating")

Pe

rce

nta

ge

Recalled seeing this television advertisement

Correctly recalled any of the message(s)

Summary

• FTF and BIHS data affirm the significant challenge of ensuring nutritionally adequate infant and young child diets

• Poor feeding practices and low use of micronutrient supplements poor nutrient quality of diets, overall

• Early results from evaluation research suggest interventions such as those implemented by Alive & Thrive have potential to improve diet quality through high quality, high coverage interventions

• A significant challenge, seen in the BIHS, is that overall access to interventions (mass media and health worker counseling) that can improve IYCF is currently lower than desirable

22

Next steps

• Further disaggregated descriptive analysis, not just by age, gender and SES, but also other maternal and household characteristics

• Empirical analyses and research papers on: – Predictors of anthropometric outcomes and IYCF

practices

– Links between agriculture and nutritional outcomes

– Other

23