New and updated indicators for assessing infant and young child feeding practices Bernadette Daelmans (WHO) on behalf of the Working Group on IYCF indicators Presentation outline The rationale for developing new indicators The process followed Analytical methods used Summary of results Conclusions of the consensus meeting on IYCF indicators, 6-8 November 2007 1
WHO Global consultation on complementary feeding (10-13 th December 2001) Efforts to increase investments in the promotion of improved infant and young child feeding require adequate monitoring and evaluation. Although a global set of indicators to measure breastfeeding practices was agreed on a decade ago and has since been used successfully to assess progress, indicators for measuring complementary feeding practices are scant. There is need to develop a set of indicators that cover the entire range of infant and young child feeding practices, including appropriate complementary feeding. Food and Nutr Bull 2003 Moving forward with complementary feeding: indicators and research priorities (Ruel, Brown, Caulfield) http://www.ifpri.org/divs/fcnd/dp /papers/fcndp146.pdf 2
What do we need population-based indicators for? 1. Assessment 2. Screening and targeting interventions 3. Monitoring and evaluating progress 4. Global reporting, international comparisons, to look at trends Indicators must be: 1. Valid (reflect the truth; free of systematic error) 2. Reliable (replicable; free of day-to-day variability) 3. Responsive 4. Non reactive or non subject to recall bias 5. Easy to measure & standardize 3
Measuring Infant and Young Child Feeding Practices in children > 6 months of age is complex.. Feeding practices are multidimensional Number of inter-related practices Change rapidly within short age intervals Guiding principles for feeding of the breastfed child (2003) Standards for multiple dimensions of appropriate feeding in children 6-24 months 4
Guiding principles for feeding non-breastfed children (2005) Examples of modified recommendations: increased feeding frequency, importance of animal-source foods, fortified foods Informal meeting to review and develop indicators for complementary feeding (2002) breastfeeding practices among children 6 23 months of age group- or community-level energy density of main complementary foods frequency of feeding complementary foods nutrient adequacy of complementary foods and supplements among children 6 23 months of age hygiene during preparation and storage of complementary foods feeding behaviours or style psychosocial care during feeding 5
Study design and data analysis 2003: UC Davis and IFPRI developed protocol and analyzed IYCF data from breastfed children 6-12 months of age in 4 sites (Bangladesh, Ghana, Honduras and Peru) 2004: results discussed with external experts in FAO, Rome. Protocol strengthened, 6 new sites identified (Brazil, India, Madagascar, Malawi, Peru, Philippines), children 6-23 mo and non breastfed children included 2006: results from 10 sites reviewed and consensus among stakeholders on how to complete the analysis 2007: updating of breastfeeding indicators 2007: consensus meeting on complete set of IYCF indicators with participation of multiple stakeholders The steering team and principal investigators Steering team: Mary Arimond, Marie Ruel, Kathryn Dewey, Bernadette Daelmans, Jose Martines, Chessa Lutter, Eunyong Chung, Anne Swindale Principal investigators: Cecile Acuin, Nita Bhandari, Hilary Creed, Mourad Moursi, Helena Panchon 6
Main research questions 1) How well can indicators of dietary diversity or sentinel food groups predict dietary quality* for infants and young children in different populations with varying dietary patterns? 2) How well does the frequency of feeding of foods and nutritive liquids other than breast milk predict energy intake - from foods alone or total - in different populations with varying dietary patterns? * Definitions: Dietary diversity: sum of food groups Sentinel food groups: selected nutrient-dense food groups Dietary quality: adequate micronutrient density of foods and liquids other than breast milk". Data sets Breastfed: Africa: Ghana (6-11 mo), Madagascar (6-23 mo), Malawi (6-23 mo) Asia: Bangladesh (6-11 mo), India (12-23 mo), Philippines (6-11 mo) Latin America: Honduras (6-8 mo), Peru-Huascar (6-11 mo), Peru- Trujillo (6-24 mo) Non breastfed: Africa: Madagascar (6-23 mo) Asia: India (12-23 mo), Philippines (6-11 mo) Latin America: Brazil (12-23 mo), Peru-Trujillo (6-24 mo) 7
Number of child-days Total Breastfed Nonbreastfed 6-8 mo 4,015 3,291 724 9-11 mo 2,733 1,953 780 12-23 mo 4,244 3,266 978 All ages 10,992 8,510 2,482 Major food groups 1. Grains, roots and tubers 2. Legumes 3. Dairy products 4. Flesh foods 5. Eggs 6. Vitamin A rich (> 130 RE/100 g) fruits and vegetables (and juices) 7. Other fruits and vegetables (and juices) 8. Fats and oils 8
Dietary diversity Food Group Index-8 (FGI8): consumption (1=yes, 0=no) of foods from each of the 8 food groups Food Group Index-7 (FGI7): consumption of foods from 7 food groups, excluding fats & oils FGI8R and FGI7R: as above, but restricted to food groups from which > 10 g consumed (except for fats and oils) Dietary quality Dietary quality was based on nutrient density (amount per 100 kcal), rather than absolute nutrient intake Nutrients included: For BF, 6-11 mo: 9 problem nutrients identified previously (Dewey & Brown, 2003): vitamin A, thiamin, riboflavin, vitamin B6, folate, vitamin C, calcium, iron and zinc For BF, 12-23 mo & non-bf: 9 nutrients above + vitamin B12 9
Calculating overall mean micronutrient density adequacy (MMDA or MMDA-no iron) Individual micronutrient density adequacy (MDA) calculated for each nutrient as % of desired nutrient density for that age and BF status MMDA is the average of the 9 or 10 individual MDA scores for that day, after each is capped at 100% MMDA-no iron is the average of the 8 or 9 individual MDA scores (excluding iron), after each is capped at 100% CONCLUSIONS Reported in: Working Group on Infant and Young Child Feeding Indicators. Developing and validating simple indicators of dietary quality and energy intake of infants and young children in developing countries: summary of findings from analysis of 10 data sets. August, 2006. http://www.fantaproject.org/downloads/pdfs/iycf_datasets_sep06.pdf Working Group on Infant and Young Child Feeding Indicators. Developing and validating simple indicators of dietary quality of infants and young children in developing countries: additional analysis of 10 data sets. July, 2007. http://www.fantaproject.org/downloads/pdfs/iycf_datasets_sep07.pdf 10
Conclusions Dietary diversity Dietary diversity is a useful indicator of dietary quality except for non-bf infants who receive fortified products FGI7 performed better than FGI8 for predicting micronutrient density Imposing a 10-g minimum for the food group indicator did not yield consistently better results Dietary diversity Dietary diversity performed better and more consistently with MMDA < 50% than with MMDA > 75% - dietary diversity is a better predictor of poor dietary quality than better dietary quality However, with MMDA-no iron > 75%, technical qualities (Se + Sp; % misclassified) were comparable to those for MMDA < 50% Best cutoff point for predicting MMDA-no iron > 75% was > 4 food groups 11
Sentinel food groups In most sites, lack of animal source foods (ASF) was predictive of a poor quality diet The ASF indicator did not work well in all sites (due to either very low or very high proportion of child-days with ASF consumption) Other food groups may function as useful local sentinels of dietary adequacy, but can t be generalized as global indicators of micronutrient density Combinations of sentinel food groups are useful indicators in some settings, but there is insufficient consistency to use as universal indicators Feeding frequency Feeding frequency was associated with energy from non-breast milk foods/fluids in all sites, but correlations with total energy intake of BF infants (breast milk + CFs) were weaker (r = 0.02-0.51) The Se/Sp results did not identify a universal cutoff that could be used across populations with an acceptably low level of misclassification to predict low energy intake from foods However, feeding frequency may still be a useful indicator of the adequacy of feeding practices, given that the published guidelines represent the minimum number of feeding episodes 12
Recommended core indicators Early initiation of breastfeeding: proportion of children born in the last 23.9 mo who were put to the breast within one hour of birth Exclusive breastfeeding under 6 months: proportion of children 0 5.9 months who are fed exclusively on breastmilk Continued breastfeeding at 1 year: Proportion of children 12 15.9 mo who are fed breastmilk Recommended core indicators Introduction of solid, semi-solid or soft foods: Proportion of children 6-8.9 mo who receive solid, semi-solid or soft foods Minimum dietary diversity: Proportion of children 6-23.9 mo who receive foods from 4 or more food groups Minimum meal frequency: Proportion of breastfed and non-breastfed children 6-23.9 mo who receive solid, semi-solid, or soft foods (but also milk feeds for non-breastfed children) the minimum number of times or more 2 times for breastfed infants 6-8.9 mo 3 times for breastfed infants 9-23.9 mo 4 times for non-breastfed children 6-23.9 mo 13
Recommended core indicators Minimum acceptable diet: Proportion of children 6-23.9 months of age who receive a minimum acceptable diet Breastfed children who had at least minimum dietary diversity and minimum meal frequency Non-breastfed children who received at least 2 milk feedings and had minimum dietary diversity and minimum meal frequency Consumption of iron-rich or iron-fortified foods: Proportion of children 6-23.9 mo who receive iron-rich or iron fortified foods Recommended optional indicators Children ever breastfed Continued breastfeeding at 2 years Age-appropriate breastfeeding Predominant breastfeeding under 6 months Duration of breastfeeding Bottle feeding Milk feeding for non-breastfed children 14
Selected results from DHS using a previous version of the diversity and frequency indicators Percentage of Children Fed according to 3 IYCF Practices by Breastfeeding Status of Child Burkina Faso Cameroon Ghana BF NBF Kenya Madagascar Mozambique Nigeria 0 10 20 30 40 50 15
Next steps Address comments solicited through peer review Finalize the document and publish jointly with partners Develop an operational guide on measurement as a companion document Produce country profiles with data on the core indicators using DHS data Integrate new indicators in existing surveys Disseminate the indicators and assist in data collection, interpretation and use 16