TOR# 14
Title 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
And
Prof. 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)
Breastfed Children
Non bresatfed Children
All Children
80
Percentage of Children
70
64
69
65
60
50
41
40
30
24
25
21
21
15
20
10
0
Minimum Dietary Diversity
Minimum Meal Frequency
Minimum Acceptable Diet
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
1. To develop a CF
guideline to find
appropriate
feeding
practices.
Research questions
Research Question 1:
Is there any
documentation and
update of
complementary feeding
practices in
Bangladesh?
Research Question 2:
2. To assess the
dietary and food Is there any assessment
of dietary and nutrient
diversity and
adequacy of
adequacy foods
complementary foods?
methodology /output
•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.
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unpublished FCT for Bangladesh as well as Regional FCT.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
Research Questions 3: •Recipe manual including 35 recipes from nutrient
manual of
Is there any manual of content.
complementary food complementary food
•35 recipes were tested in the community
for
recipes and
recipes and
acceptability by mothers and their children.
complementary
complementary feeding •Out of 35 recipes 30 recipes were analyses in a
feeding guide.
guide?
accredited laboratory.
Methodology
The study used multiple
methods, such as
analysis of literature
Sample frame
and Sample Size
Qualitative methods
Training of
staff
Baseline survey ------•Focus group discussions
•In-depth interview
review, focus group
Analysis of Data
discussion, in-depth
interview, technical
committee
consultations, nutrient
analyzing and TIPs
(Recipe trial).
Stakeholder
consultations
Development of
recipes
Recipe trials in seven
divisions (Demonstration
experience)
Manual of CF recipes and CF
guidelines
Final report
Recruitment 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
Result: In depth Interview (Mother)
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 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
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
Fat
Ingredients Dietary
diversity
(Type of
food)
Rice,
3
Lentil, Oil
Milk,
2
Suit,Sugar
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 oil
3. Cereal + nuts/fish/egg +fruit/vegetable + adequate quantity of oil
4. Cereal + pulse + Fruit/vegetable + adequate quantity of oil
5. Cereal + pulse + animal food (egg/ liver/ chicken) + vegetable+ oil
6.Cereal + milk/egg + sugar/ molasses + fruit/vegetable
Category
Name of the recipe
Age group
Category 1
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
Vegetable khichuri
6-8 months
Vegetable chapri,Pusti Gura,Buter Halwa
9-11 months
Sweet potato Halwa
12-23 months
Category 3
Egg suji,
6-8 months
Cereal +nuts/fish/egg+ fruit
/vegetables+ adequate
quantity of oil
Bread toast, Tomato soup,
Fish with vegetable & White sauce
9-11 months
Fruit pitha, pumpkin coconut halwa, Fish
cutlet,
12-23 months
Cereal+ Animal food (fish/
eggs/ meat) + green leafy
vegetables+ adequate
quantity of oil
Category 2
Cereal + pulse +nuts
+vegetables/fruits + adequate
quantity of oil
Category
Name of the recipe
Age group
Category 4
Papaya halwa;
6-8 months
Cereal + pulse +
Fruit/vegetables + adequate
quantity of oil
mixed vegetable pitha, soya
chop
12-23 months
Category 5
chicken khichuri, liver khichuri 6-8 months
Cereal + lentil + Animal food
(chicken/egg )+ fruit /
vegetables + oil
Vegetable chop
9-11 months
Vegetable roll, Egg khichuri
12-23 months
Fruit firni; Mango payesh;;
Fruit faluda; Pumpkin payesh
6-8 months
Sujir halwa; Carrot Laddo
Sujir Malpoa; Pudding
9-11 months
12-23 months
Category 6
Cereal + milk/egg +
sugar/molasses+
fruit/vegetables
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
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)
Acceptability (100%) of different recipes by children
(Division wise)
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,
magnesium, copper)
•Out of 35 recipes 30 most commonly used ones were
sent for lab analysis.
Result on laboratory analysis of some recipes
Name of ASH
the
recipe
Liver
1.66%
chop
Moistur Protei Fats & Energy
e
n (N X oil
(calories)
6.25)
67.27% 5.04% 4.93% 149
Kcal/100g
Carboh Zinc (as
ydrate Zn)
Iron (as
Fe)
Calcium
(as Ca)
Vitamin
A
21.1%
Vegetabl 1.94%
e
khichuri
Egg suzi 0.39%
69.3%
3.81%
5.57%
143
Kcal/100g
19.38%
75.8%
3.16%
3.53%
113
Kcal/100g
17.12%
Mixed
1.46%
vegetabl
e pitha
Egg
1.13%
Khichuri
72.11%
5.30%
3.54%
123
Kcal/100g
17.59%
78.43%
3.42%
2.7%
95
Kcal/100g
14.32%
Fruit
firni
63.23%
3.82%
4.4%
165
Kcal/100g
27.44%
1.72
mg/100
g
0.94
mg/100
g
1.22
mg/100
g
1.30
mg/100
g
1.10
mg/100
g
1.24
mg/100
g
42.74
mg/100
g
46.18
mg/100
g
49.66
mg/100
g
57.89
mg/100
g
14.73
mg/100
g
73.95
mg/100
g
64.1
IU/100
g
ND
<9
IU/ml
100.02
IU/100
g
ND
<9
IU/ml
73.45
IU/100
g
46.02
IU/100
g
1.11%
0.83
mg/100
g
0.70
mg/100
g
0.44
mg/100
g
0.57
mg/100
g
0.47
mg/100
g
0.56
mg/100
g
Recipe composition for different age group
Recipe
Liver
Khichuri
Egg khichuri
Vegetable
khichuri
Age group
Amount
(g)
Frequency
Total
Kcal
6-8
170
2-3
202
9-11
258
3-4
307
12-23
460
4-5
547
6-8
183
2-3
202
9-11
279
3-4
307
12-23
497
4-5
547
6-8
198
2-3
202
9-11
304
3-4
307
12-23
542
4-5
547
% of energy from
different nutrients
CHO
Pro
Fat
60
15
25
51
12
37
63
12
25
Cont.
Recipe
Egg suji
Fruit firni
Small fish
(Kachki)
chop
Age
group
Amount
(g)
Frequency
Total
Kcal
6-8
171
2-3
202
9-11
260
3-4
307
12-23
463
4-5
547
6-8
167
2-3
202
9-11
126
2
154
12-23
271
3
328
9-11
100
2
204
12-23
160
3
328
% of energy from
different
nutrients
CHO
Pro
Fat
54
13
33
69
11
20
62
15
23
Comparison between lab result and improved
developed recipes
Name of the recipe
Chirar polao
Vegetable chapri
Fruit pitha
Soya chop
Chicken khichuri
Pumpkin payesh
Nutrient
Carbohydrate
Protein
Fat
Energy density
Carbohydrate
Protein
Fat
Energy density
Carbohydrate
Protein
Fat
Energy density
Carbohydrate
Protein
Fat
Energy density
Carbohydrate
Protein
Fat
Energy density
Carbohydrate
Protein
Fat
Energy density
Lab result
Calculation by
composition table
Difference
%
59.66
13.6
26.73
1.4
63.27
12.44
24.28
1.72
64.58
9.99
25.43
3.04
58.36
16.3
25.33
1.53
59.5
15.8
24.7
0.95
64.7
9.45
25.85
2.5
58
13
29
1.77
63
11
26
2
65
11
24
3.57
63
14
23
1.87
53
16
31
1.23
68
10
22
1.2
1.66
0.6
-2.27
-0.37
0.27
1.44
-1.72
-0.28
-0.42
-1.01
1.43
-0.53
-4.64
2.3
2.33
-0.34
6.5
-0.2
-6.3
-0.28
-3.3
-0.55
3.85
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