Complementary Feeding in Indnesia

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
50
47.7
51.700
47.676
35.4
40
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
for not meeting criteria of CF indicators
Risk factors
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
1.34 (1.00-1.78)
ns
1.46 (1.13-1.89)
Rural
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)
Calcium (mg/100 kcal)
Iron (mg/100 kcal)
Zinc (mg/100 kcal)
Folate (µg/100 kcal)
Niacin (mg/100 kcal)
Desired
63
1.0
0.6
Actual
20
0.5
0.4
21
0.9
10
0.6
Source: Fahmida et al, submitted for publication
6
Formulation and evaluation of population-specific
complementary feeding recommendation (CFR)
SEAMEO-TROPMEDprogramming
Regional Center for Community Nutrition
using linear/goal
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
Age groups:
•6-8mo (n=2,768),
•9-11mo (n=3,394),
•12-23mo (n=2,641)
2
Survey in district of Bandung,
urban area, 12-23mo children
Socioeconomic levels:
•Low SES (n=114)
•Middle SES (n=114)
3
Survey in subdistrict levels of Bogor(1) and East
Lombok (2), 9-11mo children, low SES
Area:
•Rural/E.Lombok (n=100)
•Peri-urban/ Bogor
(n=100)
(1) Santika et al, J Nutr 2009
(2) Ferguson et al, J Nutr 2006
4
Intervention study in sub-district of East
Intervention groups:
Lombok, NTB Province, 9-23mo children, low SES •Control (n=108)
•Stimulation (n=117)
•CFR (n=113)
14
•Stimulation+CFR (n=126)
Problem nutrients* by stratum
Iron
Zinc
Calcium
Others
6-8mo
√
√
√
9-11mo
√
√
-
-
12-23mo
-
-
-
-
Rural
√
√
√
B1, niacin
Peri-urban
√
√
√
B1, B2, niacin, B6, folate
Low SES
√
-
√
B1, niacin
Middle SES
-
-
-
B1, niacin, folate
By age groups
B1, niacin
By area
(9-11mo, low SES)
By SES levels
(12-23mo, urban)
*
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
Human milk
Grains and grain products
Bakery and breakfast cereals
Starchy roots and other starchy plant
foods
Composites (mixed food groups)
Legumes, nuts and seeds
Meat, fish, poultry and eggs (MFPE)
Dairy products
Vegetables
Fruits
Sweetened snacks and desserts
Savory snacks
Beverages (non-dairy)
Low SES
FP
No FP
7
6.9
25
21.5
10
10
2
3
1
4
8
12.4
5
5
5
6
2
1
9
15
16
13
9
2
1
3
Middle SES
FP
No FP
7
7
21
21
8.6
14.1
2
3
1
6
21
19
6
5
8
6
1
Nutrient-dense foods to promote: tempe/tofu; MFPE esp. liver, anchovy;
green leafy vegetables; banana; fortified infant cereals/biscuits
2
14
21
19
13
10
0
5
3
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
Thiamin
Low SES
Middle SES
Niacin
naturally occuring
Low SES
Middle SES
Folate
Low SES
Middle SES
Iron
fortified
19
Number and type of nutrients that are
<65% RNI in the worst-case scenario analyses
with optimized CFR and micronutrient powder (MNP)
6-8mo
9-11mo
No. /wk
of MNP1
MNP
alone
MNP +
FBR2
MNP + FBR +
Fortified3-7
MNP
alone
MNP +
FBR
1
5
Ca, B3,
B6, Fe,
Zn
4
Ca, B3,
Fe, Zn
2
Ca, Fe
2
Ca, Fe
1
Ca
2
Fe, Zn
1
Fe
3
Ca, Fe,
Zn
1
Fe
0
0
0
0
0
0
0
5
Ca, B3,
B6, Fe,
Zn
3
Ca, Fe,
Zn
2
Ca, Fe
2
Ca, Fe
1
Ca
2
3
3.5
4
12-23mo
MNP +
FBR +
Fortified
0
1
Ca
0
1
Ca
1
Ca
1
Ca
0
0
0
MNP
alone
MNP +
FBR
5
Ca, B3,
B6, Fe,
Zn
4
Ca, B3,
Fe, Zn
2
Ca, Fe
2
Ca, Fe
1
Ca
2
Ca, B3
MNP +
FBR +
Fortified
0
2
Ca, B3
0
1
Ca
1
Ca
1
Ca
0
0
0
Putting guidelines
into Regional
practice:
SEAMEO-TROPMED
Center for Community Nutrition
University of Indonesia
an example from
rural Indonesia
(Lombok)
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:
–
–
2.
3.
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.
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.
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
[email protected] / [email protected]
30

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