Translating guidelines into practice: Complementary feeding in Indonesia SEAMEO-TROPMED Regional Center for Community Nutrition University of Indonesia Dr. Umi Fahmida SEAMEO RECFON ILSI-SEA Region Seminar on Maternal, Infant and Young Child Nutrition in Indonesia August 13th, 2014 Jakarta - Indonesia 1
Outline Complementary feeding in Indonesia: situation and challenges Evaluation and formulation of population-specific complementary feeding recommendation (CFR) using linear/goal programming Results of previous CFR studies Putting guidelines into practice: Examples from rural Indonesia (Lombok) Conclusions and recommendations 2
Complementary feeding indicators 1. Introduction of solid, semi-solid or soft foods: %infants 6 8mo who received solid, semi-solid or soft foods. 2. Minimum dietary diversity: %children 6 23mo who received 4food groups. 3. Minimum meal frequency: the percentage of breastfed and non-breast-fed infants 6 23mo who received solid, semi-solid or soft foods the minimum number of times or more Breasfed: 2 times/day for 6-8mo, 3 times/day for 9-23mo Non-breast-fed infant: 4 times/day s aged 6 23mo 4. Minimum acceptable diet: %children 6 23mo who fulfill criteria #2 and #3. WHO, UNICEF, USAID, AED, UC Davis and IFPRI (2008). Indicators for Assessing Infant and Young Child Feeding Practices (Part 1 Definitions): Conclusions of a Consensus Meeting held 6 8 November 2007 in Washington D.C., USA. Geneva: WHO
Percentage of Indonesian children who did not reach minimum criteria for CF indicator (secondary analysis of DHS 2007 data) 6-11mo 12-23mo 100 90 80.314 80 70 62.3 60 51.700 50 47.7 47.676 40 35.4 30 20 10 0 Min.dietary diversity Min.meal frequency Min.acceptable diet Source: Dibley et al (2012). Publ Health Nutr 15(5): 827-39 4
Risk factors Risk factors for not meeting criteria of CF indicators Minimum Dietary diversity Minimum meal frequency Minimum acceptable diet Poor households 1.76 (1.16-2.68) ns ns No education (mothers) 1.92 (1.09-3.38) ns 3.84 (2.07-7.12) Younger age (child) 6.36 (4.73-8.56) 2.30 (1.79-2.96) 2.27 (1.67-3.09) Exposure to TV 1x/wk 1.36 (1.06-1.74) Exposure to mags/ newspaper 1x/wk 1.53 (1.10-2.11) 1.36 (1.05-1.75) ns Exposure to radio 1x/wk ns 1.27 (1.01-1.60) ns Place of delivery: health facility ns 1.25 (1.00-1.56) ns Rural 1.34 (1.00-1.78) ns 1.46 (1.13-1.89) Source: Dibley et al (2012). Publ Health Nutr 15(5): 827-39 5
Nutrient density Nutrient densities of the complementary food diets, in 12-23mo children in Lombok Nutrient (unit) Desired Actual Calcium (mg/100 kcal) 63 20 Iron (mg/100 kcal) 1.0 0.5 Zinc (mg/100 kcal) 0.6 0.4 Folate (µg/100 kcal) 21 10 Niacin (mg/100 kcal) 0.9 0.6 Source: Fahmida et al, submitted for publication 6
Formulation and evaluation of population-specific complementary feeding recommendation (CFR) using linear/goal programming SEAMEO-TROPMED Regional Center for Community Nutrition University of Indonesia Source: Fahmida et al, to be published in Food and Nutrition Bulletin (2013) 7
Why locally available foods? Global Strategy for Infant and Young Child Feeding (WHO/ UNICEF) gives guidance on appropriate complementary feeding puts emphasis on use of suitable locally available foods. Affordable, locally contextual complementary feeding recommendations (CFR) takes into account cultural diversity and differences in food availability is more likely to result in long-term improvements in complementary feeding practices than general recommendations 8
Development of CFR using LP analysis J Nutr 2006;136: 2399-2404. Phase I Development of draft CFR (optimal diet) Phase II Test the robustness of draft CFR for ensuring a nutritionally adequate diet (Identifying worst & best scenarios for each nutrient and diet cost) If there is (are) nutrient (s) falls below 70% of RNI Phase III Finding nutrient dense food to fill the nutrient gap for problem nutrient Phase IV Comparison of alternative CFRs to incorporate into draft CFR Final Complementary Feeding Recommendation (CFR) 9
Data required 1. A list of foods a target population typically consumes 2. For each food: its nutrient content per 100 grams, a realistic portion size per eating occasion, a maximum frequency of consumption per week, its cost per edible 100 grams (optional) 3. The food consumption patterns of the target population (low, average and high level) 4. The target population s breastfeeding status 5. The estimated average energy requirements of the target population 6. The desired nutrient content (e.g. FAO/WHO nutrient requirements) 7. The highest price the target population would be willing to spend on their infants diet (optional) Italic = optional
Market Observation Local market / food sellers Observe and document: Food availability (including seasonal availability) Price per 100gr edible portion Others: food choice, food preference,
Linear/Goal Programming Methods J Nutr 2006;136: 2399-2404. Sight and Life Magazine 2008; 3: 13-18. 13
Study descriptions Studies Study characteristics Sample size & stratum 1 National Basic Health survey 2010, 6-23mo children 2 Survey in district of Bandung, urban area, 12-23mo children 3 Survey in subdistrict levels of Bogor(1) and East Lombok (2), 9-11mo children, low SES (1) Santika et al, J Nutr 2009 (2) Ferguson et al, J Nutr 2006 4 Intervention study in sub-district of East Lombok, NTB Province, 9-23mo children, low SES Age groups: 6-8mo (n=2,768), 9-11mo (n=3,394), 12-23mo (n=2,641) Socioeconomic levels: Low SES (n=114) Middle SES (n=114) Area: Rural/E.Lombok (n=100) Peri-urban/ Bogor (n=100) Intervention groups: Control (n=108) Stimulation (n=117) CFR (n=113) 14 Stimulation+CFR (n=126)
Problem nutrients* by stratum By age groups Iron Zinc Calcium Others 6-8mo B1, niacin 9-11mo - - 12-23mo - - - - By area (9-11mo, low SES) Rural B1, niacin Peri-urban B1, B2, niacin, B6, folate By SES levels (12-23mo, urban) Low SES - B1, niacin Middle SES - - - B1, niacin, folate * Problem nutrients are nutrients whose requirements (WHO/FAO, 004) cannot be achieved using locally available foods in the amounts and patterns habitually consumed by the target group 15
Comparison of the food patterns (frequency/week) in the two best diets of 12-23mo: with food pattern goal (FP) and with no food pattern goal (no FP), by socioeconomic (SES) levels Low SES Middle SES FP No FP FP No FP Human milk 7 6.9 7 7 Grains and grain products 25 21.5 21 21 Bakery and breakfast cereals 10 10 8.6 14.1 Starchy roots and other starchy plant 2 3 2 3 foods Composites (mixed food groups) 1 1 1 2 Legumes, nuts and seeds 4 9 6 14 Meat, fish, poultry and eggs (MFPE) 8 15 21 21 Dairy products 12.4 16 19 19 Vegetables 5 13 6 13 Fruits 5 9 5 10 Sweetened snacks and desserts 5 2 8 0 Savory snacks 6 1 6 5 Beverages (non-dairy) 2 3 1 3 Nutrient-dense foods to promote: tempe/tofu; MFPE esp. liver, anchovy; green leafy vegetables; banana; fortified infant cereals/biscuits 16
Example: Final CFR formulated for 9-11mo children living in Bogor Selatan, West Java nutrient-dense foods portion Source: Santika et al (2009). J Nutr 139: 135-141 17
Simulation: Intakes of problem nutrients as percentage of estimated nutrient needs Fahmida U (2013). Use of fortified foods for Indonesian infants. In: Preedy VR (ed). Handbook of Food Fortification and Health: From Concepts to Public Health Applications, Volume 2, Nutrition and Health, pp. 383-93. Springer Science+Business Media, New York Animal source foods Fortified foods NDF=nutrient-dense foods, FF=fortified foods, Fe-rice= rice fortified with iron and other nutrients (zinc, vitamin A, B2, B3, folate).
%RNI of selected (problem) nutrients by socioeconomic (SES) amongst 12-23mo children in Bandung city, Indonesia 100 90 80 70 60 50 40 30 20 10 0 Low SES Middle SES Low SES Middle SES Low SES Middle SES Low SES Middle SES Thiamin Niacin Folate Iron naturally occuring fortified 19
Number and type of nutrients that are <65% RNI in the worst-case scenario analyses with optimized CFR and micronutrient powder (MNP) No. /wk of MNP 1 MNP alone 1 5 Ca, B3, B6, Fe, Zn 2 4 Ca, B3, Fe, Zn 3 2 Ca, Fe 3.5 2 Ca, Fe 4 1 Ca 6-8mo 9-11mo 12-23mo MNP + MNP + FBR + FBR 2 Fortified 3-7 2 Fe, Zn 1 Fe 1 Fe MNP alone 5 Ca, B3, B6, Fe, Zn 0 3 Ca, Fe, Zn 0 0 2 Ca, Fe 0 0 2 Ca, Fe 0 0 1 Ca MNP + FBR 3 Ca, Fe, Zn 1 Ca 1 Ca 1 Ca 1 Ca MNP + FBR + Fortified MNP alone 0 5 Ca, B3, B6, Fe, Zn 0 4 Ca, B3, Fe, Zn 0 2 Ca, Fe 0 2 Ca, Fe 0 1 Ca MNP + FBR MNP + FBR + Fortified 2 0 Ca, B 3 2 0 Ca, B 3 1 Ca 1 Ca 1 Ca 0 0 0
Putting guidelines into practice: an example from rural Indonesia (Lombok) SEAMEO-TROPMED Regional Center for Community Nutrition University of Indonesia 21
Putting guideline into practice Liver, fish, anchovy Fortified biscuits/snacks 22
Nutrient content of complementary food RECIPE WITH NUTRIENT-DENSE FOODS READING FOOD LABEL 23
Nutrient-dense foods and recipes Shredded fish Stir-fired vegetables with animal protein Home-made snacks using shredded liver/fish or anchovy powder 24
Mothers self evaluation 25
Proportions of children consuming diets with high dietary diversity (Child Dietary Diversity Score, CDDS 5) at baseline and endline, by intervention group (Chi-square test, p=0.721 at baseline, p<0.001 at endline) In CFR groups: 10-40% higher RNI for Fe, Zn, Ca and protein Higher MFP protein than in non-cfr groups Control (n=108) Stimulation (n=117) CFR (n=113) Stimulation+CFR (n=126) 26
Conclusions 1. Complementary feeding in Indonesia is characterized by: Low-medium dietary diversity. Risk of inadequate dietary diversity is increased in poor households, mothers with no education, and younger age of children (6-11mo). Inadequate nutrient density especially for calcium, iron, zinc, folate and niacin. The extent of deficiency in these problem nutrients varies across age groups, area (urban/rural) and socioeconomic level. 2. Complementary feeding recommendation (CFR) from locally available foods can be developed using linear/goal programming approach to objectively identify problem nutrient(s), the nutrient-dense foods potential to improve intake of these problem nutrients, and complementary intervention (e.g. Home fortification) if needed. 3. Animal source foods and fortified foods are potential nutrient-dense foods which can improve micronutrient adequacy from the complementary foods 27
Recommendations 1. Optimized complementary feeding recommendations (CFR) which promote locally available nutrient-dense foods both naturally occuring and fortified foods is critical part to improve dietary diversity and nutrient density from complementary feeding diet. 2. Multiple micronutrient powder (MNP) consumption should only be recommended at frequency necessary to fill the nutrient gaps after CF diet is optimized. 3. Adapt CFR to the specific settings (e.g. food resources, education background) and integrate with existing channels (health institutions/professionals, mass media). 28
Acknowledgement EU through SMILING Project Ministry of Education, Government of Indonesia Ministry of Health, Center for Health Research and Development, Government of Indonesia Nestle Foundation Otago University, New Zealand Sari Husada Dr Elaine Ferguson & Otte Santika, MSc Local government and community in Bandung, Bogor and East Lombok districts 29
Thank You ufahmida@seameo-recfon.org / umifahmida@gmail.com 30