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
Prof. Soofia Khatoon
MBBS, FCPS (Ped),MHPED (Australia),Fellow in Neonatology (U.K),
Secretary, BBF
Bangladesh Breastfeeding Foundation (BBF)
Contents of presentation
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Context of the study
Objectives
Methodology
Findings of the Baseline survey
Development of Recipes
TIPs
Laboratory analysis
Conclusion and Recommendations
Context of the study
• The exclusive breastfeeding rate is 64% and minimum
acceptable diet 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).
Objectives
To provide nutrition practitioners and care providers in
Bangladesh with necessary guidelines and a recipe manual
for improving complementary feeding practices.
Objectives
1. To develop a CF
guideline to find
appropriate
feeding
practices.
Research questions
methodology /output
Research Question 1: Is
there any documentation
and update of
complementary feeding
practices in Bangladesh?
• Literature review.
• Documentation of knowledge and practices on
complementary feeding, local and regional practices,
preparation and processing methods.
Research Question 2: Is
•
2. To assess the
dietary and food there any assessment of
dietary and nutrient
diversity and
adequacy of complementary
adequacy foods
foods?
•
•
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?
•
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.
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 analyses in a
accredited laboratory.
Methodology
The study used multiple
methods, such as
Literature review, Focus
group discussion, In-depth
interview, Technical
committee consultations,
Nutrient analysis
(Laboratory) and TIPs
(Recipe trial).
Sample
frame and
Sample
Size
Qualitative methods
Training
of staff
Baseline survey –
•Focus group discussions
• In-depth interview
Analysis of Data
Gap identification
Technical committee consultations
Development of recipes
Trials of Improved Practices (TIPs)
methods (Recipe trials in selected areas)
Acceptability analysis of the recipes
(Children’s and mothers’ preferences)
Laboratory analysis of 30 recipes
Development of a manual of CF recipes and
guidelines for CF practices in Bangladesh
Final report writing
Recruitment
of staff
Areas selected for qualitative study
Results: In depth Interview (Mothers)
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.
In Khulna division (Dacop), one mother said, “Barti khabar khele pusti hobe, barbe. Buker
dudher pasapasi boro howar jonno, shak sobji die khichuri dei, akhon amader khabar khay.’’(I
feed khichuri and vegetables along 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).
Focus Group Discussion (Mothers)
• 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 fill the child’s stomach and 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
Khichuri
Suzi
Age group
(months)
Weight per
serving
(g)
6-8
Total
energy
(Kcal)
Per serving
110
Energy
density
(kcal/g)
Nutrient value
125
0.88
55
9
36
12-23
142
125
0.9
92
5
3
CHO
(% )
Pro
Ingredients Dietary
diversity
Fat
Rice,
Lentil, Oil
Milk,
Suji,Sugar
2
2
Steps for Development of Recipes
Principles
•The formulation of recipes was based on foods used by
mothers in 7 Divisions and the assessment of nutrient gaps
was carried out with the help of 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. Recipe development considering potential food
combinations
(adapted from FAO, 2002)
Food Combinations (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, Pusti 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
Name of the recipe
Age group
Category 4
Papaya halwa,
Cereal, roots and tubers + Legumes and nuts + Mixed vegetable pitha, Soya chop
Vitamin A rich fruits and vegetables or Eggs +
Other fruits and vegetables + Adequate
amount of oil.
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 productsmilk + 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
Trials of improved practice (Tips)
Demonstration experience trials
•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 .
Acceptability of recipes (Divisionwise)
Fruit firni
Buter halwa
Carrot laddo
Fruit pitha
Vegetable
chop
Sujir malpoa
Fish cutlet
Soya chop
Kachki
macher chop
Vegetable
roll
Egg suit
Chicken
chop
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,
magnessium, copper)
•Out of 35 recipes 30 most commonly used ones were sent
for lab analysis.
Laboratory analysis report of improved recipes
Name of
the recipe
Ash
%
Moistur Protein Fats
e%
(N X
& oil
6.25)%
Energy
(calories)
Kcal/100g
Liver chop
1.66
67.27
5.04
4.93
149
Carboh Zinc (as
ydrate Zn)
%
mg/100
g
21.1
0.83
Iron (as
Fe)
mg/100
g
1.72
Calcium
(as Ca)
mg/100
g
42.74
Vitamin A
Vegetable
khichuri
1.94
69.3
3.81
5.57
143
19.38
0.70
0.94
46.18
ND
(<2.7)
Egg suzi
0.39
75.8
3.16
3.53
113
17.12
0.44
1.22
49.66
30
Mixed
vegetable
pitha
Egg
Khichuri
1.46
72.11
5.30
3.54
123
17.59
0.57
1.30
57.89
ND
(<2.7)
1.13
78.43
3.42
2.7
95
14.32
0.47
1.10
14.73
22.03
Fruit firni
1.11
63.23
3.82
4.4
165
27.44
0.56
1.24
73.95
13.81
mcg
/100g
19.23
Energy value (kcal) per serving of selected
recipes
Recipes
Serving size
(g)
Energy per
serving
(kcal)
Cost per
serving
(tk)
Recommended age group
of the children
(months)
Egg khichuri
115
136
5
6-8 mo+ 9-11 mo+ 12-23 mo
Vegetable
khichuri
93
117
4
6-8 mo+ 9-11 mo+ 12-23 mo
Liver khichuri
70
92
5
6-8 mo+ 9-11 mo+ 12-23 mo
Egg suji
60
94
6
6-8 mo+ 9-11 mo+ 12-23 mo
Fruit firni
63
98
7
6-8 mo+ 9-11 mo+ 12-23 mo
Small fish chop
55
100
5
9-11 mo+ 12-23 mo
•Recommended energy intake from CF: 200 kcal for 6-8 mo, 300 kcal from 9-11
mo and 550 kcal for 12-23 mo. (WHO)
Comparison between calculated value and analyzed value for 30 recipes
Name of the
recipes
Small fish chop
Chirar polao
Chicken chop
Sagu alur bora
Vegetable omlette
Liver chop
Nutrient (g/100g)
and
Energy (kcal/100g)
Carbohydrate
Protein
Fat
Energy
Carbohydrate
Protein
Fat
Energy
Carbohydrate
Protein
Fat
Energy
Carbohydrate
Protein
Fat
Energy
Carbohydrate
Protein
Fat
Energy
Carbohydrate
Protein
Fat
Energy
Calculated value
using INFS FCT,
1986
20.51
5.05
3.47
132
24.47
5.37
5.69
168
25.49
8.82
8.82
217
23.65
3.82
4.41
148
28.65
9.61
7.69
216
25.78
5.48
6.87
182
Laboratory analyzed
value
35.97
5.61
7.58
235
20.84
4.75
4.15
140
20.22
9.26
5.34
166
22.94
5.43
8.38
189
14.74
4.88
7.03
142
21.1
5.04
4.93
149
Calculated value for
adjusted recipes using new
INFS, FCT, 2013
23.08
5.66
7.08
183
22.64
5.46
6.69
175
21.68
5.83
6.09
169
22.49
4.36
6.13
167
15.96
6.14
4.70
135
21.95
5.50
5.52
164
Content of “Improved Recipes for Complementary
feeding of children aged 6 to 23 months”
Part 1: Purpose of this book
Part 2: Introduction
2.1 Background
2.2 What is complementary feeding?
2.3 Dietary quality and nutrient adequacy
2.4 Combination of food groups
2.5 Guidance on feeding frequency
Part 3: Development of recipes
3.1 Trials of Improved Practices (TIPs)
3.2 Key features of the recipe book
3.3 Menu options
Con.
Part 4: Improved recipes for complementary feeding .
• Menu option 1: Main meals
• Menu option 2: Side dishes
• Menu option 3: Snacks
• Menu option 4: Soups
• Menu option 5: Desserts
Examples of the most acceptable
recipes
Fruit firni
(foler payesh)
Buter halwa
Egg suji
(dimer suji)
Chicken Chop
(Murgir chop)
Sujir
(semolina)Malpoa
Small fish chop
(Kachki macher chop)
Fruit Pitha (foler pitha)
Vegetable roll
(Sobji roll)
Soya Chop
Vegetable chop
(sobji chop)
Fish Cutlet
(Macher chop)
Carrot laddo
(gajorer laddo)
Content of “Guidelines for Complementary feeding”
children of different age groups (6 to 23 months)
Part -1
Current Status of Infant and Young Child feeding
1.1 Current Strategy for Infant and Young Child Feeding in Bangladesh
1.2 Country policy and practices
1.3 Review of training manual and tools on CF
1.4 Guiding principles for Complementary feeding for breastfed child (WHO-UNICEF)
Part -2
Complementary Feeding
2.1 Definitions
2.2 Why complementary foods are important?
2.3 Why it is necessary to start complementary food at the appropriate
time?
2.4 Why a mixture of foods from different food groups is necessary to fill
that gap ?
Part-3
Complementary feeding Guidelines for children of different age
groups (6 to 23 months)
3.1 Why improve complementary feeding?
3.2 Common feeding problems
A. Dietary Diversity
B. Energy (%) from different nutrients
C. Energy Density
D. Nutrient density
E. Frequency
F. Portion size
G. Acceptability
H. Feasibility
Cont.
I. Preparation Time and Cooking Process
J. Cost of food
K. Safety, Hygiene and Storage of CF
L. Responsive feeding
M. Trials of Improved Practices in Bangladesh
N. Household weights and measures
O. Geographical areas and feeding pattern
P. Recommended practices for breastfed children 6-23
months
Conclusion
• The study addressed documentation and update of
complementary feeding in 7 divisions of
Bangladesh.
• A manual of complementary food recipes has been
developed with divisional practices including
regional food habits and culture of Complementary
Feeding (CF).
• A dietary guidelines on CF has been devloped to
ease the practices by all level.
Policy Recommendations
1.
The recipes and guidelines should be promoted for use in
Bangladesh in all areas to prevent malnutrition and
subsequent impact studied.
2.
Evaluation of these recipes on biological outcome would be
helpful for assessing nutritional improvement in children.
3.
The health systems of MOHFW should consider adopting
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) on IYCF, which had in fact led the development of
recipes and manual for complementary feeding.
4.
This manual should be used to sensitize food and
agriculture Ministries to promote nutrition oriented food
production.
Field Visits in Baseline
Field Visits in TIPs