Measuring Infant and Young Child Complementary Feeding Practices: Indicators, Current Practice and Research Gaps

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Shenggen Fan, April 2015

Measuring Infant and Young Child Complementary

Feeding Practices: Indicators, Current Practice and

Research Gaps

Marie Ruel

Director | Poverty, Health and Nutrition | IFPRI

87th Nestle Nutrition Institute Workshop | Singapore May 8-11, 2016



Key Milestones in Infant and Young Child

Feeding (IYCF) practices

Review of scientific

knowledge on CF (1998)

WHO Guiding Principles

for CF of:

• Breastfed (BF) child (2003)

• Non BF child (2005)

WHO Indicators for

measuring IYCF

practices (2008)



Taking Stock on Indicators of CF

practices

What is the status of CF

indicators?

How have they been

used so far and what

are some of the key

findings?

What are the strengths

and weaknesses of the

indicators?

Suggestions for way forward


Background on IYCF

and related indicators



10 Guiding Principles for Complementary

Feeding of the Breastfed Child

1. Duration of exclusive BF & age of introduction of CF

2. Continued BF

3. Responsive feeding

4. Safe preparation & storage of CF

5. Amount of CF needed

6. Food consistency

7. Meal frequency energy

density

8. Nutrient content of CF

9. Use of supplements or

fortified products

10. Feeding during & after

illness

WHO 2003



The Continuum of Infant and Child Feeding

0-6 mo 6-9 mo 9-12 mo 12-24 mo

•Exclusive BF

•Initiate

breastfeeding

soon after birth

•Feed colostrum

•Avoid prelacteal

feeds

•Avoid bottle-

feeding

•Continue BF

•Introduce variety

of CF, including

animal foods

•Feed CF foods 2-3

times/d + snacks

•Avoid bottle-

feeding

•Continue BF

•Increase amount,

variety, frequency of

CF, including

animal foods

•Feed

complementary

foods 3-4 times/d +

snacks

•Avoid bottle-

feeding

•Continue BF

•Continue to give a

variety of foods,

complete transition

to family diet

•Feed

complementary

foods 3-4 times/d

+ snacks

•Avoid bottle-

feeding



Measuring CF Practices is Complex….

CF practices are multi-

dimensional

Include a number of

inter-related practices

Dynamic, change

rapidly within short age

intervals

Their effects on child

outcomes are likely to

be cumulative

Complement breastmilk

intake (largely variable)



WHO IYCF Indicators for Breastfed

Child

8 core indicators:

• 3 BF practices

• 5 CF practices

7 optional indicators

(all focused on BF

practices)


Shenggen Fan, April 2015WHO 2008

5 WHO CF Indicators for Breastfed

Child

INDICATOR

Timing of introduction of

solid semi-solid and soft

foods

Minimum dietary diversity

(MDD)

Minimum meal frequency

(MMF)

Minimum acceptable diet

(MAD)

Consumption of iron-rich/

iron-fortified foods

MEASURES

Optimal timing of

introduction of CF

foods

Micronutrient

adequacy of diet

Energy adequacy of

diet

Composite indicator

(BF + MDD + MMF)

Adequacy of iron

intake



For use in large surveys for:

• Population-level assessments

• Population targeting

• Monitoring & evaluation

Had to be simple and practical, yet valid and

reliable

This limits dimensions of CF practices that

can be captured

Were meant to be used as a full set to

reflect multi-dimensional nature of IYCF

Purpose of 2008 WHO Indicators



BF

CF

0-5 mo 6-8 mo 9-23 mo

Continued Continued

Timely

introductionQuantity of CF:

- Meal frequency

Quality of CF:- Dietary diversity + iron foods

Hygiene/food safety

Responsive feeding

Feeding during illness

Texture/consistency

Exclusive

CF Indicators versus Guiding Principles


How have the WHO CF indicators

been used so far?



For Population-Level Assessments

and Country Comparisons

Reveals grossly inadequate

CF practices, esp. SS-Africa,

South Asia• < 30% MAD

• Few countries with > 30% MDD

• Poorer practices (younger, rural,

less educated mothers, poorer)

Pooled analysis (46DHS):• < 33% MDD

• ~50% meeting MMF

• 21% MAD

• Africa & Asia fare worst than LA

Indicators have helped unveil the severe problem of

poor IYCF practices globally

WHO 2010 Country Profiles



For Monitoring & Evaluation of

Programs

In the past, programs aimed

at improving IYCF assessed

impact on child anthropometry

• Likely due to lack of standard

IYCF indicators

Indicators helped measure &

document impacts on

practices (often more

achievable outcome)

• E.g. A&T, agriculture-

nutrition programs; social

protection programs0 20 40 60 80 100

Consumption of

iron-rich foods

Minimum

acceptable diet

Minimum meal

frequency

Minimum dietary

diversity

Timely

introduction of

solid, semi-…

%

A&T-I EndlineA&T-NI Endline

Availability of IYCF indicators has led to their

use for M&E and stimulated investments in

programs aimed at improving IYCF

Menon et al. in press



Extensive analysis of association between dietary diversity

and child antropometry• Robust results – strong DD, consistent associations with linear growh, controlling for

energy intake and SES

New studies looking at associations between broader set

of IYCF and child anthropometry• Pooled analysis (14 DHS) – associations between MDD, iron rich foods and

stunting; between MMF and underweight

• Country analyses (8 studies) confirmed association between DD and HAZ (3

countries); MAD and stunting in 4 countries.

New studies look at determinants of CF practices (e.g.

special issue of MCN on patterns and determinants of CF

practices in South Asia)

For Research on Determinants and

Consequences of Poor IYCF Practices

IYCF indicators have been used extensively to

address important gaps in knowledge and

understand patterns, determinants and

consequences of poor IYCF practices


What are the strengths and weaknesses of

the WHO CF Indicators?



Simple, practical, relatively easy to use in

large-scale surveys

Measure some key dimensions of CF

practices

Measure age-specific CF practices

Useful for the purposes for which they were

designed (population-level assessment,

M&E, population targeting)

Strengths of WHO CF Indicators



Most have not been validated against gold standard

(except DD)

For some, unclear if they reflect underlying construct they

are meant to measure

• Esp. MMF, timing of introduction of CF, MAD, iron-rich

foods

Based on 24-h recall – subject to recall error and bias

Do not capture dynamic nature of CF or usual practice

Rely on unverified assumptions related to breast milk

intake and nutrient contribution

Include only a subset of dimensions of CF; do not include

indicators related to prevention of overweight/obesity

Some Weaknesses of WHO CF Indicators


The Way Forward



Need to revisit existing set of indicators and carry out

relevant validation studies

Verify underlying assumptions and adjust indicators:• Energy density (for MMF)

• Differentiation of snacks and meals (for MMF)

• Food consumed in small amounts (for MDD)

Assess magnitude of error/bias due to recall

Revisit missing indicators/dimensions of CF, including

overweight/obesity prevention

Develop simplified, technology-smart 24-h dietary

assessment method to quantify nutrient intake from

CF

Time to Revisit our Set of CF Indicators



Conclusions

WHO CF indicators have

been immensely useful – to

measure, document, raise

awareness, stimulate

investments and action

They have been used

extensively for all the

purposes for which they were

designed and more

Almost 10 years after

their release, it is time

to revisit them, improve

them, develop new

ones and promote their

appropriate use

Education

Measuring Infant and Young Child Complementary Feeding Practices: Indicators, Current Practice and Research Gaps