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Shenggen Fan, April 2015
Measuring Infant and Young Child Complementary Feeding Practices: Indicators, Current Practice and Research Gaps
Marie RuelDirector | Poverty, Health and Nutrition | IFPRI
87th Nestle Nutrition Institute Workshop | Singapore May 8-11, 2016
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Shenggen Fan, April 2015
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)
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Shenggen Fan, April 2015
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
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Background on IYCF and related indicators
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Shenggen Fan, April 2015
10 Guiding Principles for Complementary Feeding of the Breastfed Child
1. Duration of exclusive BF & age of introduction of CF
2. Continued BF3. Responsive feeding4. Safe preparation &
storage of CF5. Amount of CF needed
6. Food consistency7. Meal frequency energy
density8. Nutrient content of CF9. Use of supplements or
fortified products10. Feeding during & after
illness
WHO 2003
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Shenggen Fan, April 2015
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
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Shenggen Fan, April 2015
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)
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Shenggen Fan, April 2015
WHO IYCF Indicators for Breastfed Child
8 core indicators:
• 3 BF practices• 5 CF practices
7 optional indicators (all focused on BF practices)
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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
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Shenggen Fan, April 2015
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
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Shenggen Fan, April 2015
BF
CF
0-5 mo 6-8 mo 9-23 mo
Continued Continued
Timely introduction
Quantity 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
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How have the WHO CF indicators been used so far?
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Shenggen Fan, April 2015
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
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Shenggen Fan, April 2015
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 programs
Consumption of iron-rich foods
Minimum acceptable diet
Minimum meal frequency
Minimum dietary diversity
Timely introduction of solid, semi-solid
or soft foods
0 20 40 60 80 100
A&T-I 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
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Shenggen Fan, April 2015
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
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What are the strengths and weaknesses of the WHO CF Indicators?
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Shenggen Fan, April 2015
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
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Shenggen Fan, April 2015
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
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The Way Forward
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Shenggen Fan, April 2015
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
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Shenggen Fan, April 2015
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