Outline. Complementary Feeding: Cultural practices vs Scientific evidence. Definition

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1 TM Complementary Feeding: Cultural practices vs Scientific evidence Pattanee Winichagoon, PhD Institute of Nutrition, Mahidol University (INMU) Thailand ILSI SEA Seminar n Maternal Infant and Young Child Nutrition, Updates for Cambodia, Laos PDR and Myanmar Phnom Penh, Cambodia, August 11, 2016 Outline 1. Definition 2. Complementary Feeding (CF): Cultural practices in SEA 3. Scientific evidence: 1. Global recommendations/guidelines 2. CF and short- & Long-term consequences on growth, development and health Definition 1. WHO: Any food or liquid other than breast milk added to meet nutritional requirements 2. Reason for CF: BM no longer adequate to meet nutritional and needs Child developmental ability to chew & interest in other foods

2 Growth faltering by HAZ by WHO region Growth faltering by WHZ by WHO region Victora, et al, Pediatrics, 2010 Victora, et al, Pediatrics, 2010 Key issues in Complementary Feeding 1. Timely introduction of CF: a) Practice of giving solid, semi-solid foods in SEA b) WHO indicators 2. Quality and quantity of CF: a) Nutrient adequacy based on DRI/EAR b) WHO indicators: Minimum meal frequency (MMF), Minimum dietary diversity (MDD), Minimum adequacy (MAD) 3. Impact on growth, development and obesity/ NCDs IYCF Cultural practices in outskirt of Vientiane, Laos PDR Interviewed mothers of <6 mo babies Maternal practices postpartum: Exposure to hot beds of embers, traditional herb tea, restricted diets ( phit kam ), 83% returned by 3 rd mo High % of mothers had insufficient intakes of energy, iron, Ca, vit A, B1, vit C Infants: 54% received chewed glutinous rice early (ave 34.6 d), rice soup (5%) Barennes, et al, EJCN 2009

3 IYCF Cultural practices in Vietnam Early introduction of semi-solid, soft foods 30% at 0-1 mo, 51% at 2-3 mo, 68% at 4-5 mo (2002 DHS); 38.7% at 0-1 mo (2004 NIN) Boiled rice water with sugar or condensed milk at < 2 mo Rice-based, a little meat, but no fish and oil Baby fed at scheduled family meal time (less frequency) Reasons: BM contains only water, baby gets hungry after urinating, so needs to have solid food/rice powder to satisfy the baby s need Concerns that BM is inadequate Lack of knowledge on CF Phoung, et al APJCN 2011 Mothers return to work (Ho Chimin city) Fish and oil cause diarrhea; Meat is expensive IYCF Cultural practices in northern Thailand Prospective study, birth till 2 y Rice, banana: given early (13% by first 7 d, 81% by aged 6 wks); mean age 4 wks, most common foods till 3 mo old Glutinous rice pounding or masticated, alternate with rice+ meat porridge; ~30% received rice meat at 3 mo Upto 3 mo, CF contributed 7-14% daily energy (11, 18, 21% at 2 wks, 6 wks, 3 mo) By 6 mo, CF contributed 33% energy (median) Snacks (e.g., rice w/ coconut milk, cake, biscuit, soy milk) given at 9-12 mo Early introduction of solid foods: rural residents, large HH, maternal employment; girls & LBW infants given CF earlier than boys Jackson, et al, Brit J Nutr 1992 Longitudinal study: pregnancy to child 0-3 y, 4 geographical areas, Thailland 1. Banana, rice, egg yolk were introduced by 3 mo. 2. More than 1/3 children already given fish, meat, whole egg by 6 mo 3. Two peaks of age introduction of meat, eggs: NE was late, while central was early. Mosuwan, et al, pers com IYCF Cultural practices in other SEA countries 1. Different parts of Malaysia: Paste of corn flour + water given in first few days of life Sarawak: Salt + premasticated rice in the first 4 d, first mo: condensed milk + water, then sago, wheat or rice flour gruel N. Sabah: premasticated rice before 3 rd wk 2. Myanmar: chewed rice given 1-2 wk after birth 3. Indonesia: immediately after birth: prelactal foods, rice flour porridge, palm sugar, meat of young coconut Dixon, APJCN 1992

4 IYCF in selected countries in Asia: national data (DHS, MICS) EBF for 6 mo was high in Cambodia (60%); low in others (Laos [22%], Myanmar [11%], Vietnam [15%]; Indonesia & Philippines 30 + % Predominant BF (BM+ water): high in Myanmar (66%), Laos (58%) Timely introduction of CF by WHO definition: Low in Laos (10.3%) and Myanmar (5.5%) Summary: Cultural practices on CF in SEA 1. Early or late introduction of solid foods 2. Reasons for CF Influenced by social cultural factors Adequacy of breast milk Child s satisfactory (sleep well and long) 3. Quality of CF Rice-based: gruel, mashed, pre-masticated Little or no other ingredients (meat, vegetables) 4. Quantity of CF Portion (bulkiness) and feeding frequency Dibley, et al, PHN, 2010 Timely introduction of foods other than BM 1. Meaning? 1. No any solid foods prior to 6 mo 2. Ensure 6-8 mo child receive CF (WHO) 2. Infant feeding guidelines: 1. Different recommendations: e.g., WHO (>6 mo), ESPGHAN (EBF 6 mo desirable, CF given not before 17 wks or later than 26 wks) 2. changed over time: to begin at 3 mo, to 4-6 mo, to >6 mo 3. Specific recommendations, e.g., when to give eggs, milk; documented data is limited in developing countries 3. Evidence of CF impacts 1. Replacement of BM intakes when <6 mo 2. Early introduction of solid foods vs infant growth Quality and quantity of CF practices in SEA

5 Dewey & Brown, FNB 2003 Dewey & Brown, FNB 2003 Adequacy ensured nutrients a using locally available non-fortified foods in serving sizes consumed Age group # nutrients >70% RNI Cambodia Indonesia Laos PDR Thailand Vietnam folate 6-8 m a out of 11 nutrients modelled

6 FBR with and w/o fortified food (Thailand) FBR + Non-fortified foods Fortified Foods 6-8 months breastfed Nutrien %RNI ts Iron Zinc Ca Iron Zinc Ca Max months breastfed Nutrient %RNI Max s Iron Zinc Ca months not breastfed Nutrien ts None Iron None %RN I Ma x Micronutrients and potential bioavailability in commercial CF in selected Asian countries country Mg/ 100 g dry wt Phy:Fe Phy: Fe Zn Ca IP5+IP6 Zn Indonesia (n=14) Philippines (n=7) Thailand (n=7) China (n=1) Mongolia (n=3) Phy: Ca a a < a one sample with 0. Desirable molar ratio (adults): Phy:Fe <1, Phy:Zn 4-18 for mixed plant-based, Phy:Ca<.17 Gibbs, et al, J Fd Comp Anal 2011 WHO global guidelines on IYCF 1. Recommendation: 1. Exclusive breastfeeding (EBF) for 6 mo 2. CF from 6 mo, continue BF till 2 y 2. WHO indicators for monitoring IYCF 1. Early initiation of BF 2. EBF during the past 24 h 3. Continued BF at 1 y 4. For 6-8 mo babies, CF is given 5. Minimum dietary diversity (MDD) 6. Minimum meal frequency (MMF) 7. Minimum acceptable diets (MAD) 8. Consumption of Iron rich or iron-fortified foods

7 Timely introduction of CF (WHO): 6-8 mo old received CF vs growth 6-24 mo old children Using WHO IYCF indicators & DHS 14 countries 66% received solid foods by 6-8 mo, continued BF till 15 mo For infants 6 8 mo, consumption of solid foods associated with significantly lower risk of both stunting & underweight (P < 0.001) Feeding frequency was associated with lower risk of underweight (P < 0.05). Timely solid food introduction with maternal education, dietary diversity and IRF were associated with reduced risk of underweight and stunting and (P < 0.001). Conclusion: Feeding indicators were associated with growth and reinforce importance of maternal education to reduce risk of underweight and stunting in poor countries Mariott, et al, MCN 2012 WHO IYCF indicators vs anthropometry: review of studies using DHS data from 13 LMIC Studies which included WHO IYCF indicators and child anthropometry (9 Africa, 3 Asia (India, B desh, Cambodia), Haiti) At 6-8 mo, solid foods introduced (60-90% of children), MDD, MDF, MAD, IRF all varied across countries For 0-23 mo: Stunting 23-47%; wasting (5-26%) Finding: MDD & MAD +ve associated with HAZ in 4 countries, no relation with WHZ; Lack sensitivity/ specificity may contributes to inconsistent finding Conclusion: WHO indicators useful to monitor trends of CF practices, but how CF relate to growth faltering needs better indicators Jones, et al, MCN 2014 Efficacy/effectiveness of CF interventions in developing countries Dewey & Adu-Afarwuah (MCN 2008): 1. No single best package of CF interventions, context specific and nature of habitual eating patterns and prevalence of MN 2. Child growth/anthropometry may not be a sensitive indicators of benefits 3. Improving energy density where traditional diets are bulky 4. Fortification helps to ensure several micronutrient gaps 5. Education/counseling with key messages on CF along with providing CF - better impact Short- and long-term impacts of CF on growth, development and health CF practices can influence: Food preference, appetite, eating behavior & later health outcomes Evidence on later health impact is limited and from developed countries; suggestive that introducing solid foods before 4 mo may increase the risk of obesity and allergy (Fewtrell, 2016)

8 Conclusion WHO indicators on CF: currently used in many national surveys good for monitoring practices No recent data on early introduction (before 6 mo) of CF, esp. in development transition Benefits of CF practices (using WHO indicators) on child growth and health other outcomes being inconsistent; More rigorous CF/IYCF indicators needed Both under- & over-nutrition should be assessed Other later benefits e.g., food preference, eating behavior, cognition