1. Development of a complementary feeding manual for Bangladesh
Principal Investigator
Dr. A.K.M. Iqbal Kabir, MBBS, MD,PhD,
Vice - Chairperson, BBF
Co- Principal Investigators
Dr. S. K. Roy
MBBS (Dhaka), M.Sc Nutr, Ph.D (London), FRCP (Edin),
Chairperson, BBF
Prof. Soofia Khatoon
MBBS, FCPS (Ped),MHPED (Australia),Fellow in Neonatology (U.K),
Secretary, BBF
Bangladesh Breastfeeding Foundation (BBF)

2. Contents of presentation
Context of the study
Objectives
Methodology
Findings of the Baseline survey
Development of Recipes
TIPs
Laboratory analysis
Conclusion and Recommendations

3. Context of the study
The exclusive breastfeeding rate is 64% and minimum acceptable diet is only 21%. (using the stricter definition as per global guidelines, BDHS-2011)
National guidelines and strategy on CF have been developed (IPHN 2009)
Absence of policy /advocacy tools, particularly a manual on CF recipes using local ingredients and preparation/processing methods).

4. Objectives To provide nutrition practitioners and care providers in Bangladesh with necessary guidelines and a recipe manual for improving complementary feeding practices.

5. Objectives
Research questions
methodology /output
1. To develop a CF guideline to find appropriate feeding practices.
Research Question 1: Is there any documentation and update of complementary feeding practices in Bangladesh?
Literature review.
Documentation of knowledge and practices on complementary feeding, local and regional practices, preparation and processing methods.
2. To assess the dietary and food diversity and adequacy foods
Research Question 2: Is there any assessment of dietary and nutrient adequacy of complementary foods?
Limited data on dietary and nutrient adequacy or nutrient gaps of complementary foods in Bangladesh. Adequacy of complementary foods has been studied in seven divisions of Bangladesh.
Determination of dietary and nutrient adequacy of complementary foods has been done through calculation of selected nutrient values (energy, moisture, protein, fat, carbohydrate, fiber and ash) using published FCT (INFS FCT) for Bangladesh.
Determination of nutrient adequacy of the complementary foods in relation to nutrient requirements and recommended dietary intakes/allowances.
3. To prepare manual of complementary food recipes and complementary feeding guide.
Research Questions 3: Is there any manual of complementary food recipes and complementary feeding guide?
Recipe manual has been developed including 35 recipes using nationally available data (INFS FCT).
35 recipes were tested in the community for acceptability by mothers and their children.
Out of 35 recipes 30 recipes were analyses in a accredited laboratory.

6. The study used multiple methods, such as Literature review, Focus group discussion, In-depth interview, Technical committee consultations, Nutrient analysis (Laboratory) and TIPs (Recipe trial).
Recruitment
of staff
Sample frame and Sample Size
Qualitative methods
Methodology
Training of staff
Baseline survey –
Focus group discussions
In-depth interview
Technical committee consultations
Trials of Improved Practices (TIPs) methods (Recipe trials in selected areas)
Acceptability analysis of the recipes (Children’s and mothers’ preferences)
Development of recipes
Analysis of Data
Gap identification
Final report writing
Development of a manual of CF recipes and guidelines for CF practices in Bangladesh
Laboratory analysis of 30 recipes

7. Areas selected for qualitative study

8. Results: In depth Interview (Mothers)
Complementary feeding
One third of the mothers started complementary food after completion of six months of age of their child with continuation of breast milk.
Two third of the mothers started Complementary feeding between 7 and 8 months.
They fed their child liquid, semi liquid, semi solid foods like khichuri, semolina (suji), sago, potatoes with pulse and family foods.
One third of them added eggs, chicken, liver, small fish in cooked khichuri. The children were fed 3 to 4 times a day.
In Khulna division (Dacop), one mother said, “Barti khabar khele pusti hobe, barbe. Buker dudher pasapasi boro howar jonno, shak sobji die khichuri dei, akhon amader khabar khay.’’(I feed khichuri and vegetables along with breast milk to my child for appropriate growth, so that baby will be well nourished and healthy, now my child eats our casual family foods).

9. Focus Group Discussion (Mothers)
Two third of the mothers had little/lack of knowledge on complementary foods, how to prepare and how much should be given to the children.
Half of them thought they gave appropriate diets to their children.
One third of mothers said that they heard about complementary food from their Didi (health worker) or other elder persons like mothers and sisters .
Half of them heard about complementary food from health care centre but did not get any advice on the type of food, frequency of feeding and/or amount needed daily .

10. Assessing dietary diversity and adequacy of CF foods
To identify the nutrient adequacy, we analyzed some recipes from the field during in-depth interview and FGD.
The assessment showed that energy density was low and did not have required nutritive value and proportion of nutrients.
Such foods fill the child’s stomach and do not provide required amount of energy and nutrients.
The assessment showed that feeding practices and dietary diversity were generally inadequate. For example:
Name of the Recipes
Age group (months)
Total energy (Kcal)
Per serving
Weight per serving
(g)
Energy density
(kcal/g)
Nutrient value
(% )
Ingredients
Dietary diversity
CHO
Pro
Fat
Khichuri
6-8
110
125
0.88 55 9 36
Rice, Lentil, Oil 2
Suzi
12-23
142
0.9 92 5 3
Milk, Suji,Sugar

11. Steps for Development of Recipes
Principles
The formulation of recipes was based on foods used by mothers in 7 Divisions and the assessment of nutrient gaps was carried out with the help of baseline study.
Factors for assessing nutrient adequacy of recipes considered energy density, nutrient density, protein content, use of micro nutrient rich foods, animal foods, serving size, number of times fed, age of the child, consistency, cost, feasibility, accessibility and seasonality following standard guidelines. (WHO/UNICEF )

12. Recipe development Selection of potential foods
Based on field experience selected criteria were followed in developing recipes for children aged 6 to 23 months : Availability, feasibility, nutritive value, cost, acceptability.
2. Recipe development considering potential food combinations
(adapted from FAO, 2002)

13. Food Combinations (Category) Name of the recipe Age group
Cereal, roots and tubers+ Flesh foods (poultry / organ meats- liver) or Eggs + Vitamin A rich fruits and vegetables + Other fruits and vegetables + Adequate amount of oil.
Pumpkin soup
6- 8 months
Chirar polao; Chicken chop; Small fish chop(kachki); Liver chop
9-11 months
Sago aloor bora, Vegetable omelet
12-23 months
Category 2
Cereal, roots and tubers + Legumes and nuts + Vitamin A rich fruits and vegetables or Dairy product-milk + Other fruits and vegetables + Adequate amount of oil.
Vegetable khichuri, Pusti gura
6-8 months
Vegetable chapri, Buter halwa
Sweet potato halwa
Category 3
Cereal, roots and tubers + Legumes and nuts or Flesh foods-fish or Eggs + Vitamin A rich fruits and vegetables+ Other fruits and vegetables or Dairy product-milk + Adequate amount of oil.
Egg suji
Bread toast, Tomato soup, Fish cutlet,
Fish with vegetable & white sauce
Fruit pitha, Pumpkin coconut halwa

14. Category Name of the recipe Age group Category 4
Cereal, roots and tubers + Legumes and nuts + Vitamin A rich fruits and vegetables or Eggs + Other fruits and vegetables + Adequate amount of oil.
Papaya halwa,
Mixed vegetable pitha, Soya chop
9-11 months
Category 5
Cereal, roots and tubers + Legumes and nuts + Flesh foods (poultry / organ meats-liver) or Eggs + Vitamin A rich fruits and vegetables or Other fruits and vegetables (or both) + Adequate amount of oil.
Chicken khichuri, Liver khichuri, Egg khichuri
6-8 months
Vegetable chop
Vegetable roll
12-23 months
Category 6
Cereal, roots and tubers + Dairy products-milk + Legumes and nuts or Eggs or Other fruits and vegetables + Vitamin A rich fruits and vegetables + Adequate amount of sugar/ molasses and or Oil.
Fruit firni; Mango payesh; Fruit faluda; Pumpkin payesh
Sujir halwa, Carrot laddo, Sujir Malpoa, Pudding

15. Trials of improved practice (Tips)
Demonstration experience trials
The Complementary foods, recipe options, guidelines, key nutrition education messages and recommendations were based on Trials of Improved Practices (TIPs) carried out in Bangladesh.
For the recipe trials, cooking sessions and sensory evaluations were conducted with mothers.
The recipes were tested for acceptability by young children by observing intake .

16. Acceptability of recipes (Divisionwise)
this figure it shows that in Chittagong division, Egg suzi, Small fish chop (kachki macher chop),sujir malpoa, Vegetable Chop and Fruit pitha were fully accepted by 100% children, furthermore, Small fish Chop(kachki macher chop), Carrot Ladoo and Buter Halwa were most acceptable(100%) in Rajshahi Division ,Where as in Barisal division Chicken chop, soya chop, carrot laddo, fruit firni were fully accepted by the children.
Additionally, in Sylhet division Chicken chop, Egg suji, Vegetable roll were fully accepted, and In Khlna division Soya chop and Fish cutlet were accepted by 100% children. Small fish chop (Kachki macher chop) was fully accepted in Rangpur division by the children.

17. Laboratory analysis of nutrients
Analysis of 30 CF has been carried out in an accredited laboratory.
Analysis of energy, protein, fat, carbohydrate, vitamin A, calcium, iron, zinc, moisture, ash (phosphorus, magnessium, copper)
Out of 35 recipes 30 most commonly used ones were sent for lab analysis.

18. Laboratory analysis report of improved recipes
Name of the recipe
Ash%
Moisture %
Protein (N X 6.25)%
Fats & oil
Energy (calories) Kcal/100g
Carbohydrate%
Zinc (as Zn) mg/100g
Iron (as Fe) mg/100g
Calcium
(as Ca) mg/100g
Vitamin A mcg /100g
Liver chop
1.66
67.27
5.04
4.93
149
21.1
0.83
1.72
42.74
19.23
Vegetable khichuri
1.94
69.3
3.81
5.57
143
19.38
0.70
0.94
46.18 ND
(<2.7)
Egg suzi
0.39
75.8
3.16
3.53
113
17.12
0.44
1.22
49.66 30
Mixed vegetable pitha
1.46
72.11
5.30
3.54
123
17.59
0.57
1.30
57.89
Egg Khichuri
1.13
78.43
3.42
2.7 95
14.32
0.47
1.10
14.73
22.03
Fruit firni
1.11
63.23
3.82
4.4
165
27.44
0.56
1.24
73.95
13.81

19. Energy value (kcal) per serving of selected recipes
Serving size
(g)
Energy per serving
(kcal)
Cost per serving (tk)
Recommended age group
of the children
(months)
Egg khichuri
115
136 5
6-8 mo mo mo
Vegetable khichuri 93
117 4
Liver khichuri 70 92
Egg suji 60 94 6
Fruit firni 63 98 7
Small fish chop 55
100
9-11 mo mo
Recommended energy intake from CF: 200 kcal for 6-8 mo, 300 kcal from 9-11 mo and 550 kcal for mo. (WHO)

20. Comparison between calculated value and analyzed value for 30 recipes
Name of the recipes
Nutrient (g/100g)
and
Energy (kcal/100g)
Calculated value using INFS FCT, 1986
Laboratory analyzed value
Calculated value for adjusted recipes using new INFS, FCT, 2013
Small fish chop
Carbohydrate
20.51
35.97
23.08
Protein
5.05
5.61
5.66
Fat
3.47
7.58
7.08
Energy
132
235
183
Chirar polao
24.47
20.84
22.64
5.37
4.75
5.46
5.69
4.15
6.69
168
140
175
Chicken chop
25.49
20.22
21.68
8.82
9.26
5.83
5.34
6.09
217
166
169
Sagu alur bora
23.65
22.94
22.49
3.82
5.43
4.36
4.41
8.38
6.13
148
189
167
Vegetable omlette
28.65
14.74
15.96
9.61
4.88
6.14
7.69
7.03
4.70
216
142
135
Liver chop
25.78
21.1
21.95
5.48
5.04
5.50
6.87
4.93
5.52
182
149
164

22. Content of “Improved Recipes for Complementary feeding of children aged 6 to 23 months”
Part 1: Purpose of this book
Part 2: Introduction
2.1 Background
2.2 What is complementary feeding?
2.3 Dietary quality and nutrient adequacy
2.4 Combination of food groups
2.5 Guidance on feeding frequency
Part 3: Development of recipes
3.1 Trials of Improved Practices (TIPs)
3.2 Key features of the recipe book
3.3 Menu options

23. Con. Part 4: Improved recipes for complementary feeding .
Menu option 1: Main meals
Menu option 2: Side dishes
Menu option 3: Snacks
Menu option 4: Soups
Menu option 5: Desserts

24. Examples of the most acceptable recipes

25. Sujir (semolina)Malpoa
Fruit firni
(foler payesh)
Egg suji (dimer suji)
Sujir (semolina)Malpoa
Chicken Chop
(Murgir chop)
Small fish chop
(Kachki macher chop)
Buter halwa

26. Fruit Pitha (foler pitha) Soya Chop Fish Cutlet (Macher chop)
Vegetable chop (sobji chop)
Carrot laddo
(gajorer laddo)
Vegetable roll (Sobji roll)

28. Content of “Guidelines for Complementary feeding” children of different age groups (6 to 23 months)
Part -1
Current Status of Infant and Young Child feeding
1.1 Current Strategy for Infant and Young Child Feeding in Bangladesh
1.2 Country policy and practices
1.3 Review of training manual and tools on CF
1.4 Guiding principles for Complementary feeding for breastfed child -(WHO-UNICEF)
Part -2
Complementary Feeding
2.1 Definitions
2.2 Why complementary foods are important?
2.3 Why it is necessary to start complementary food at the appropriate time?
2.4 Why a mixture of foods from different food groups is necessary to fill that gap ?

29. Part-3 Complementary feeding Guidelines for children of different age groups (6 to 23 months)
3.1 Why improve complementary feeding?
3.2 Common feeding problems
A. Dietary Diversity
B. Energy (%) from different nutrients
C. Energy Density
D. Nutrient density
E. Frequency
F. Portion size
G. Acceptability
H. Feasibility

30. Cont. I. Preparation Time and Cooking Process J. Cost of food
K. Safety, Hygiene and Storage of CF
Responsive feeding
Trials of Improved Practices in Bangladesh
N. Household weights and measures
O. Geographical areas and feeding pattern
Recommended practices for breastfed children 6-23 months

31. Conclusion
The study addressed documentation and update of complementary feeding in 7 divisions of Bangladesh.
A manual of complementary food recipes has been developed with divisional practices including regional food habits and culture of Complementary Feeding (CF).
A dietary guidelines on CF has been devloped to ease the practices by all level.

32. Policy Recommendations
The recipes and guidelines should be promoted for use in Bangladesh in all areas to prevent malnutrition and subsequent impact studied.
Evaluation of these recipes on biological outcome would be helpful for assessing nutritional improvement in children.
The health systems of MOHFW should consider adopting the recipes and guidelines for use in NNS in collaboration with BBF to promote IYCF activities. This would be a follow up of the Honorable Prime Ministers’ directive (2009) on IYCF, which had in fact led the development of recipes and manual for complementary feeding.
This manual should be used to sensitize food and agriculture Ministries to promote nutrition oriented food production.

33. Field Visits in Baseline

34. Field Visits in TIPs

35. Thank You