Improving Diet Quality Among Infants and Young Children: Challenges and Potential Solutions, by Dr. Purnima Menon, IFPRI

1. 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

2. 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
Zongrone et al., Public Health Nutrition, 2012 2

3. IYCF practices in the FTF zone compared to the
rest of the country
Consumption of iron-rich or iron-fortified foods
Minimum acceptable diet
Minimum meal frequency
BDHS
Minimum dietary diversity (4+ food groups)
BIHS
FTF
Introduction of solid, semi-solid or soft foods
Continued breastfeeding at 1 year
Exclusive breastfeeding under 6 months
0 20 40 60 80 100 120
3

4. Timely introduction of high nutrient-value foods is low
(BIHS sample)
Before After
6-8.9 mo
6 mo 9 mo
Complementary food % % %
Water 69.8 29.0 1.2
Other non-breast milk liquids (e.g. sugar/glucose water, 48.3 49.0 2.8
tea, fruit juice, etc.)
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 12.5 76.9 10.7
banana, etc.)
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

5. 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

6. Percentage
0
20
40
80
60
Grains, roots,
and tubers
Legumes and
nuts
Dairy (e.g. milk,
yogurt, cheese)
Boys
Flesh foods
(e.g. meat, fish,
Girls
poultry, and…
Eggs
TOTAL
Vitamin A-rich
fruits and
vegetables
Other fruits and
vegetables
for children 6-23 months old (BIHS sample)
Types of food fed to children is not different by gender
6

7. % of children 6-23 months old achieving minimum
diet diversity, by division and wealth
100
90
80
70
% 60
Division Wealth group
50
40
30
20
10
0
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8. Use of micronutrient supplements (BIHS)
100.0
90.0
80.0
70.0
60.0
50.0
%
40.0
30.0
20.0
10.0
0.0
For children
Mother took
aged 6-23 Diarrhea: oral
iron Mother was
months, child rehydration
tablets/supplem given vitamin A Diarrhea: zinc
received a solution (ORS)
ents during capsule after tablets.
capsule of that was
recent delivery
vitamin A in last purchased.
pregnancy
6 months
8
Series1 56.0 23.6 70.7 86.7 21.9

9. Maternal nutrition knowledge is variable (BIHS)
100.0
90.0
80.0
70.0
60.0
50.0
%
40.0
30.0
20.0
10.0
0.0
Baby should be Baby should be Iron deficiency can Handwashing before
breastfed breastfed colostrum impair child growth feeding a child.
immediately or <1 after birth and development
hour after birth
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10. Awareness about micronutrient powders (BIHS)
is especially low
Percentage of mothers under-twos who have heard about MNPs, by
SES (BIHS)
100.0
90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
1 (lowest) 2 3 4 5 (highest)
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11. 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

12. INSIGHTS FROM ALIVE & THRIVE
EVALUATION RESEARCH BY IFPRI ON
POTENTIAL SOLUTIONS TO
IMPROVING IYCF AND DIET QUALITY
13

13. A&T evaluation design
60 Rural upazilas
(50 + 10)
20 (paired) rural EHC
upazilas
Process
10 upazilas 10 upazilas evaluation
A&T Intensive A&T Non-intensive
Both
qualitative
Baseline Survey (April-July 2010) and
FHW Survey (September-October 2011) quantitative
Process Evaluation Survey (June-July 2012)
A&T HH Survey(April-July 2013)
A&T Endline Survey (April-July 2014) 14

14. Early impacts of Alive & Thrive’s interventions on infant
and young child feeding practices (WHO indicators)
A&T (2012) Non-A&T (2012) Baseline (2010)
Iron food (6-23 mo) ***
Min acceptable diet (6-23 mo) *
Min meal freq (6-23 mo)
Min diet diversity 6-23 mo **
Solid/semi-solids in 6-8.9 mo
Continued BF 12-15 mo
EBF 0-5.9 mo
Early initiation
0 10 20 30 40% 50 60 70 80 90 100
* p < 0.05, ** p < 0.01, *** p < 0.001 15
Non-A&T= Non-intensive

15. More households in A&T areas have heard
complementary feeding and MNP messages
Baseline (2010) A&T Intensive (2012) A&T Non-Intensive (2012)
100
80
Percent
60
40
20
0
Feed mashed family Feeding animal source Cook children's food Add Multiple Nutrient
food to children aged > foods to children aged with oil Powder (MNP) to the
6 months > 6 months These 2 behaviors – use child's food MNPs - are
of oil and
mainly promoted by FHWs, not the media campaign

16. Health worker visits to HH is high in A&T areas
SS/PS SK PK
100
100 100
A&T Area
90
A&T Area 90
Non-A&T Area 90
Non-A&T Area 80 A&T Area
80 80
70 70
70
60 60
60
50 50
50
40 40
40
30 30
30
20 20
20
10 10
10
0 0
Ever had HH Ever had HH 0
Ever had HH visit Ever had HH visit
visit by SS/PS visit by SS/PS Ever had HH Ever had HH
by SK (unaided by SK (aided
(unaided (aided recall) visit by PK visit by PK
recall) recall)
recall) (unaided (aided recall)
Non-A&T= Non-intensive recall)

17. Mass media campaign: recall of TVCs among total sample
in A&T evaluation sample
60
Early initiation of breast
50 feeding
Exclusive breast feeding
40
Percent
30 Animal source food after 6
months
20 Poor appetite
10
Frequency of
0 complementary feeding
A&T Intensive Areas A&T Non-Intensive The house is on fire
Areas
18

18. INSIGHTS FROM THE BANGLADESH
INTEGRATED HOUSEHOLD SURVEY ON
ACCESS TO KEY INTERVENTION
PLATFORMS
19

19. Exposure to counseling by health workers is quite
low
Literate Illiterate
TOTAL mother mother
(n=979) (N = 886) (N = 93)
% % %
Have been visited at home by any health worker 25.8 26.5 19.2
in the last 6 months
Visited by a health worker ≥3 times in the last 6 43.6 43.5 45.5
months (among those visited in the last 6 mo)
Received advice from health worker about 59.2 59.7 52.6
feeding the child during last visit (among those
visited in the last 6 mo)
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20. Exposure and recall of national IYCF communications
campaign (BIHS, all female respondents, N=5503)
Recalled seeing this television advertisement
Correctly recalled any of the message(s)
27.8
22.8 24.5
22.7 21.8
20.7
Percentage
17.3 17.7 16.2
14.3 15.3
11.4
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about a about about a house about cooking about sports about child
newborn baby breastfeeding on fire ("House fish ("Mother ("Tumpa wins feeding ("Baby
("A mother of ("Father brings is on fire") cooking fish") a prize") goes to sleep
a newborn tinned milk for without
baby") baby") eating")
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21. 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
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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
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