Development of a complementary feeding manual for Bangladesh

Transcription

1 TERMS OF REFERENCE #14 For the research proposal to be funded under NFPCSP Phase II Development of a complementary feeding manual for Bangladesh 1. Background and Rationale Inappropriate infant and young child feeding practices are a major cause of the onset of malnutrition in young children 1. Children who are not breast fed appropriately have repeated infections, grow less well, and are almost six times more likely to die by the age of one month than children who receive at least some breast milk. From six months until 23 months of age, when breastfeeding alone is no longer sufficient to meet all nutritional requirements, infants enter a particularly vulnerable phase known as complementary feeding - during which they gradually move to eating family foods. During this period, the incidence of malnutrition the effects of which are seldom reversed in later childhood and adolescence 2 - rises sharply, mainly due to poor quantity and quality of complementary foods and faulty feeding practices. According to the BDHS , in Bangladesh complementary foods are introduced among infants (36%) as early as 1 month of age and by the age of 6 to 7 months, only 67% of breast fed children received semi solid or solid foods as per the complementary feeding recommendations. The quality of diets is also poor, with only 25% of infants being fed vitamin A rich foods and as little as 10% receiving animal source foods. Although the prevalence of stunting among children in Bangladesh decreased from 55 % in to 43 % in Bangladesh is still one of the 24 countries with the highest burden of stunting in the world 6 7. Over the years, the country has adopted legislation and curricula on Infant and Young Child Feeding, including a National Strategy for Infant and Young Child Feeding and an accompanying Plan of Action. Similarly, the National Food Policy Plan of Action ( ) 8 recognises the importance of addressing the issue of child malnutrition. The Plan of 1 WHO Collaborative Study Team. Effect of breast feeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet (2000) 355: Shrimpton R, Victoria CG, de Onis M, Lima RC, Blössner M &Clugston G. (2001) Worldwide timing of growth faltering: Implications for nutrition interventions. Pediatrics 107, E75. 3 BDHS (2009). Bangladesh Demographic and Health Survey 2005, NIPORT. 4 Mitra SN, Al-Sabir A, Cross AR & Jamil K. (1997).Bangladesh Demographic and Health Survey, National Institute of Population Research and Training (NIPORT), Mitra and Associates, and Macro International Inc.: Dhaka, Bangladesh and Calverton, USA 5 National Institute of Population and Training (NIPORT), Mitra and Associates & Macro International. (2009) Bangladesh demographic and health survey National Institute of Population Research and Training, Mitra and Associates, Macro International: Dhaka, Bangladesh and Calverton, USA. 6 UNICEF. (2009) Tracking progress on childhood and maternal nutrition. UNICEF: New York. 7 Food Security and Nutrition Surveillance Project, HKI/BBS/BRAC, National Food Policy Plan of Action Food Planning and Monitoring Unit (FPMU), Ministry of Food and Disaster Management, Government of the People s Republic of Bangladesh. P. xiii. 1

2 Action and has accordingly identified and outlined the promotion and protection of breast feeding and complementary feeding as one of the key areas of. One important constraint to implementing these policies is the absence of adequate policy instruments, specifically a manual and recipes for complementary feeding. The Training curriculum on complementary feeding, that was developed by the Bangladesh Breastfeeding Foundation in 2007, is a guide for national and sub national level health professionals who provide training to health and nutrition workers in IYCF. It includes recipes, key CF messages and provides guidance on how to overcome common feeding problems. While this is useful, additional science-based guidance - targeted at mothers and care givers - on the quantities of foods, the preparation and processing methods and for further diversifying complementary foods is needed. This project will develop guidance material targeted at mothers and care providers. This will build on the above-mentioned Training curriculum on complementary feeding but will also include a wider range of recipe options; indications on basic foods/ groups; right food combinations; correct food handling methods; appropriate preparation methods and simple processing technologies as well as the schedule and frequency of complementary feeding. This will involve reviewing existing studies on existing practices and constraints to adopting appropriate child feeding practices in Bangladesh and South Asia - including those undertaken by ICDDR Alive and Thrive, the National Nutrition Programme (NNP), the Integrated Horticulture and Nutrition Development Programme and ACF Recipes and the related preparation and processing methods will initially be standardized in a laboratory, bearing in mind field realities. A selection of the recipes will then be tested in rural areas and urban slum communities through focus group discussions and acceptability trials. Best practices for developing complementary feeding guidance material such as those described in Designing by dialogue: A Program Planners Guide to Consultative Research for Improving Young Child Feeding prepared by the Health and Human Resource Project will be applied. 2. Objectives The objective of this research project is: a. To provide nutrition practitioners in Bangladesh with the necessary guidance material for improving complementary feeding practices. 3. Scope of the study 9 Saha KK, Frongillo EA, Dewan SA, Arifeen SE, Persson LA, Rasmussen KM (2008) Appropriate infant feeding practices result in better growth of infants and young children in rural Bangladesh. AJCN 87: South Asian Infant Feeding Research Network (SAIFRN) Kuntal K Saha, Edward A Frongillo, Dewan S Alam, Shams E Arifeen, Lars Åke Persson, and Kathleen M Rasmussen (2008) Appropriate infant feeding practices result in better growth of infants and young children in rural Bangladesh Am J Clin Nutr, 87:

3 More specifically, the study will address the following issues 12 : Documentation and update of complementary feeding in Bangladesh: Review of complementary feeding practices, preparation and processing methods and types of local, home based complementary foods being used in Bangladesh and in the South Asian region 13, over the past 10 years; identify the source and supply of complementary foods, application of home and community based appropriate technologies and, if applicable, hygiene and safety issues; identify specific dietary problems and the range of options available for improvement of complementary feeding along with breast feeding. Assessment of dietary and nutrient adequacy of complementary foods: Determine the nutrient adequacy of complementary foods through calculation of the energy, protein, fat, carbohydrate, vitamin A, calcium, iron, zinc and vitamin C content using available national food composition tables, unpublished but updated food composition tables, and regional food composition; assess the extent to which the complementary foods being used along with breast feeding meet the nutritional requirements of children between 6 to 23 months of age; determine the nutritional adequacy of the recipes in fulfilling the recommended dietary allowances (RDA) 14 along with an identification of suitable local complementary food sources that are produced, readily available and affordable. Manual of complementary food recipes and complementary feeding guide : Define cooking and standardization of a set of improved complementary food recipes 15 based on a variety of locally available foods using appropriate preparation and processing methods and technologies and standard portion sizes; prepare a manual of recipes of improved complementary foods with calculation of dietary diversity scores, energy, protein, fat, carbohydrate, calcium, iron, zinc and vitamin C content and cost on a per serving basis appropriate for low, middle and high income groups, 16 and acceptability of the recipes in rural and urban field locations; develop a complementary feeding guide outlining the appropriate feeding practices with key recommendations for using home based preparation methods and appropriate technologies to enhance the nutrient density and bioavailability of the micronutrient content of local foods and 12 To the extent possible, the research will draw upon the available literature in Bangladesh and in the region for getting an update on the complementary feeding situation. It will use the existing 12 and updated food composition tables for Bangladesh and will also consult the Indian food composition tables 12, as appropriate, and use the WHO 12 and FANTA 12 dietary diversity indicators 12 for assessing the adequacy of complementary foods. 13 Phatak A and Gupta A (2001) Recommended duration of exclusive breast feeding and age of introduction of complementary foods :A review, BPNI and IBFAN, South Asia, New Delhi. 14 Recommended dietary allowances for Indians, NIN, ICMR, (2010), 15 This will feed into the process for using trials of improved practices (TIPs) based on household preferences and capabilities, as well as the obstacles faced in improving their nutrition and motivations in trying new behaviours and practices drawing upon evidence from key references on CF in Bangladesh. 16 HIES, 2005; Categorization of groups will include two for low income, 2 for middle income and 1 for high income quintiles 3

4 hygiene for infant and young child feeding. The Complementary feeding guide and recipes will be validated through focus group discussions with mothers in urban and rural settings. The study will deliver: A draft inception report within 3 weeks from the date of signing of the contract. The inception report will detail the research programme, the literature and data requirements, methodology and expected outputs. A final inception report within 2 months from the date of signing of the contract. The NFPCSP will provide feedback to the draft inception report within 3 weeks of its submission. The research institution will then have 2 additional weeks to finalize and submit the final inception report. A detailed methodological note (draft), within 3 months from the date of signing of the contract, which incorporates tools (e.g. survey questionnaires), approaches (e.g. sampling and areas selection) and a detailed work plan for the fieldwork. The draft note will be circulated and a final version will be submitted within 2 weeks of receiving NFPCSP feedback An interim report, within 5 months from the date of signing of the contract, presenting interim findings. The interim report should include the full literature review and data sources, preliminary findings, annotated table of contents for the final report and revised research program. In particular, the report will include: a thorough review of the complementary feeding practices followed; national, NGO and INGO complementary feeding interventions implemented; nutrition education messages delivered on complementary feeding; household preparation and processing methods used; and types of complementary foods being given in Bangladesh and the South Asian region 17 over the past 10 years. A draft final report, within 10 months from the date of signing of the contract. The draft final report (length between 25,000 and 30,000 words -excluding an executive summary not exceeding 2,500 words, and annexes) should be based on the data analysis and program and literature review and should include: o Description of the purpose, relevance and background of the study and methodology used. o Literature review of secondary sources o Data analysis and statistical tools used 17 National Guidelines on infant and young child feeding (2004) Ministry of Human Resource Development, Department of Women and Child Development, Food and Nutrition Board, Government of India, New Delhi. 4

5 o Descriptive statistics highlighting accumulated evidence analyzed, foods used, processing methods and feeding practices followed, nutritional status trends in children under five years of age o Assessment of dietary and nutrient adequacy of complementary foods using standard dietary diversity, nutrient composition and nutrient adequacy criteria o A manual of recipes with standard portion sizes of complementary foods with analysis of energy and nutrient content on a per serving basis for children from 6 to 23 months of age. The manual will also list the standard weights, measures and volumes used in standardization of the recipes and the costing of the recipes for use by various income categories (classified by income quintile) as well as acceptability scores of recipes o A complementary feeding guide Draft Databases on: improved complementary food recipes using a variety of locally appropriate and available foods; standardization of weights, measures, volumes and portion sizes; data set of the nutrient composition of complementary feeding recipes with calculations of energy, protein, fat, carbohydrate, calcium, iron, vitamin A (RE), zinc and vitamin C on a per serving basis; costing of recipes for different income groups A final report and database, 12 months from the date of signing of the contract. The final report and database will incorporate the feedbacks and adjustments required by the NFPCSP 4. Duration and funding available Maximum duration: 12 months Maximum funding available: US$50,000 5