Complementary feeding patterns in India

Nutrition, Metabolism & Cardiovascular Diseases (2012) 22, 799e805

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REVIEW

Complementary feeding patterns in India* R. Kuriyan*, A.V. Kurpad Division of Nutrition, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore 560034, India Received 17 November 2011; received in revised form 14 February 2012; accepted 12 March 2012

KEYWORDS Complementary feeding; India; Non communicable disease; Catch up growth; Obesity; Adult disease

Abstract There are far too many children in the world who suffer from under-nutrition and growth faltering, with life time consequences such as reduced work capacity, increased infections, impaired intellectual performance and an increased risk of non communicable diseases later in life. These changes occur early in life, and consequently, complementary feeding has been receiving increased attention in the international nutrition community. In India, common problems relate not only to insufficient breastfeeding, but also to detrimental feeding practices. Only about 20% of children aged 6e23 months were fed according to the three recommended Infant and Child Feeding practices [1]. The most common types of solid or semisolid foods fed to both breastfeeding and non-breastfeeding children under 3 years of age were foods made from grains and roots. These complementary feeding practices were found to be significantly associated with poor socioeconomic status, undesirable socio-cultural beliefs, maternal illiteracy, and ignorance. Although many initiatives have been carried out in India to promote Infant and Young Child Feeding, the progress in reducing the number of undernourished children in India over the last decade has been slow and modest. Equally, with the growing evidence and interest in the role of infant nutrition in the development of over nutrition and non-communicable disease, it is important to plan appropriate complementary feeding interventions that result in optimal growth. Contact opportunities with parents, specifically mothers, must be used for counseling through multiple communication channels such as local media, in order to constantly educate the population with consistent and simple messages on child feeding. ª 2012 Elsevier B.V. All rights reserved.

* The paper was presented at the Joint WHO/Regional Government of Puglia Workshop on Complementary Feeding and development of NCDs held between 14 and 17th June 2011 at Brindisi, Italy. * Corresponding author. Tel./fax: þ91 80 25532037. E-mail address: [email protected] (R. Kuriyan).

0939-4753/$ - see front matter ª 2012 Elsevier B.V. All rights reserved. doi:10.1016/j.numecd.2012.03.012

800

R. Kuriyan, A.V. Kurpad

Introduction Adequate nutrition during infancy and early childhood is fundamental to the development of a child’s full human potential. The period from birth to two years of age is the “critical window” for the promotion of optimal growth, health, and cognitive development. Insufficient quantities and inadequate quality of complementary foods, poor child feeding practices have a detrimental impact on health and growth in these important years. Therefore, the introduction of the right complementary foods at the right time during infancy is necessary for both nutritional and developmental reasons. The link between malnutrition and infant feeding practices has been well established [2]. Complementary feeding is associated with major changes in both macronutrient and micronutrient intake and is a nutritionally turbulent time for the infant. Yet, in contrast to the large literature on breast and formula feeding, relatively little attention has been paid to the complementary feeding period, the nature of the foods given, or to whether this period of significant dietary change influences later health and development. The limited scientific evidence base is reflected in considerable variation in complementary feeding recommendations between countries. In India, stunting still persists, with the proportion of stunted children rising sharply from 0 to 20 months, peaking at nearly 60% [1]. Equally, aggressive feeding by mothers and the family, to make the child grow “taller”, could result in unnecessary extra weight gain. While the early origins of adult diseases had focused on nutrition and growth during the intrauterine and early postnatal period, there is increasing evidence that nutrition during the complementary feeding period also has long term effects. For example, children who showed catch up growth between 0 and 2 years were fatter and had more central fat distribution at 5 years [3] although less is known about the specific role of diet as a potential mediator of these effects. In India, the role of complementary feeding in the development of adult chronic diseases has not been studied extensively. The Indian dietary energy recommendation for infants, recently revised [4], is based on the energy expenditure of infants measured using doubly labeled water [5]. According to these recommendations, the energy

Table 1

requirement for an infant aged 6e12 months now is 80 kcal/kg and for children aged 1e3 years is 82 kcal/kg. This is lower, when compared to the earlier recommendations [7] of 98 kcal/kg for infants aged 6e12 months of age and 101 kcal/kg for children aged 1e3 years. Table 1 depicts the energy requirement of the infants calculated based on the earlier [6] and recent [4] recommendations. The difference in the daily energy requirement between these recommendations is 170 kcal/day for children aged 6e12 months and 180 kcal/day for 12e24 months. Although the difference between earlier and recent total energy requirement is about 20%, this difference increases with reference to complementary feeding when one assumes a relatively constant contribution of breast milk to the total energy intake, of about 50% of the energy requirement. However, the guidelines on Infant and Young Child Feeding [7,8], provides suggestions for the amounts of complementary food that should be offered at different ages, based on the earlier recommendations. If the difference in energy requirement is translated into the number of meals of complementary food that should be offered, this aggregated difference represents approximately 1meal/ day (about 125 ml of a 0.8 kcal/ml/feed for ages 9e23 months). Based on these considerations, it is possible that infants are potentially overfed by 20e25%, but further research is critically needed to decide whether this would be appropriate. Nevertheless, these considerations do have implications for the back-of-pack labeling of commercial infant feeds. Additionally, behavioral changes such as comforting a crying child without using food as the first option can be considered; once again more research is needed. If infants and young children are still being fed according to the earlier recommendation, it is possible that the higher energy intake could have resulted in overfeeding of infants, promoting rapid catch up growth with more central fat, which could track into early childhood and adulthood. The guidelines on Infant and Young Child Feeding [7,8], also suggests the addition of sugar or jaggery and oil or ghee to every feed of the infant to increase the energy density of the infant foods. While this is relevant and appropriate for poor families in which a lower energy intake is the problem, it may work adversely in richer, middle class families. Thus, it may be possible in urban India that the higher energy intake and the addition of sugar and fat to every meal could

Energy requirement of infants calculated based on the earlier and recent recommendations.

Age (months)

En Req (earlier) (kcal/d)

En Req (recent) (kcal/d)

Breast milk EI (kcal/d)

En Req from CF (earlier kcal/d)

En Req from CF (recent kcal/d)

6e12 12e24

843 1240

672 1060

396 346

447 894

276 714

En Req e Energy requirement. Breast milk EI e Breast milk energy intake. En Req from CF e Energy requirement from complementary feeding. En Req (earlier) e Energy requirement calculated based on ICMR 1989 [7] @98 kcal/kg for 6e12 months & 101kcal/kg for 1e3 years. En Req (recent) e Energy requirement calculated based on ICMR 2010 [5] @ 80 kcal/kg for 6e12 months & 82 kcal/kg for 1e3 years. Breast milk EI e Breast milk energy intake of breast fed children in developing world (WHO/UNICEF 1998) [36]. En Req from CF e Energy requirement from complementary foods; calculated as difference between energy requirement (earlier/ recent) and breast milk EI.

Complementary feeding patterns in India predispose to rapid catch up growth. There is a need for further longitudinal explorations of postnatal catch up growth linked to complementary feeding patterns.

Complementary feeding pattern in India Timing of introducing complementary feeds The age at which complementary foods are introduced is a sensitive time in infant growth since; breast milk alone is insufficient to meet their nutritional needs. Studies on the timing of introduction of complementary feeds and obesity have shown mixed results. Lower rates of childhood obesity have been reported among those who started complementary food later [9,10]. Individuals who started complementary foods later in infancy were less adipose and overweight in adult life [11]. On the other hand, some other studies have found no association [12,13] or an opposite direction [14]. The timing of weaning is determined by many factors such as maternal characteristics, her food choices, her knowledge and perceptions about child’s health or cultural beliefs. The pattern of complementary feeding in India is probably dichotomous, with poorer rural families delaying the introduction of or giving poor quality complementary foods. In urban India, this pattern is probably opposite [15]. The national data (urban & rural) [1] showed at 6e8 months of age, almost half (44%) the breastfeeding children are not given any solid or semi-solid food, suggesting faulty complementary practices to be a significant problem of public health [1]. Figure 1 shows the trends across the three NFHS Surveys of the timely initiation of complementary feeding. In rural areas and urban slums of India, timely introduction of complementary feeds is not optimal; for example, a recent study conducted in rural UP [16], showed among children aged 6e23 months that only 13% of the children were started on complementary food at 6 months. Aggarwal et al. [17], demonstrated in a tertiary care hospital in Delhi, that only 17.5% of the children received complementary feeds at six months and that the knowledge about the correct timing of complementary feeding significantly correlated to maternal and paternal education. Similarly, in Delhi slums, only 16.6% of the children were

801 started on complementary feeds at the right time [18]. Studies from urban areas and private clinics in India show a slightly different picture. A study conducted in suburban Bombay showed that the timely complementary feeding rate was 48% [19]. In urban Nagpur, it was observed among 217 children, that the timely introduction of complementary was 75% [20]. A private hospital based cross sectional study (n Z 200) in coastal south India, demonstrated that 78% of mothers of children aged 6e24 months had started complementary feeding at the recommended time of six months [21]. It was suggested that the high rates of initiation of complementary feeding of the present study was related to the high literacy rates (96%). Thus, among the limited studies available on complementary feeding patterns in India, there appears to be dichotomy that is based on socioeconomic status and education.

Food composition of the complementary feeds in India Figure 2 depicts the complementary feeding pattern of breast feeding and non- breast feeding children from the NFHS 3 data [1]. The most common type of solid or semisolid foods fed to children under 3 years of age are food made from grains (bread, roti, chapathi, rice, noodles, biscuits and idly). Only a third of breastfeeding children and half of non-breastfeeding children aged 6e23 months consumed fruits and vegetables rich in Vitamin A during the day or night before the survey. Meat, fish, poultry or eggs were consumed only by 10% of breastfeeding children and 20% of non-breast feeding children. Milk products (cheese and yogurt), oil, fat, ghee and butter were not commonly given to the young children. Region wise data also reveals that the complementary foods are predominantly cereal based. In rural UP, it was cereal (85%), fruits and vegetables (45%) and pulses 23%. Milk products were 14% while egg, meat and fish were only 4% of the diet given in the 24 h preceding the interview [16]. Cereal based items predominated the diet of infants in urban slums of Mumbai, with the foods most commonly fed being rice, dhal, milk, glucose biscuit and chapathi [22]. Vegetables were not given to the children, with only 5% of the 13e18 month old children being fed potato as 100

80

Breast feeding Children

89

90

Non breast feeding Children

76

Percentage

%

70 60 47

50 40

32

30 20 20

18

16

14 10

10

10 0 Cereals

Figure 1 Trends across the three NFHS Surveys of the timely initiation of complementary feeding (Ref. [1]).

Fruits & Vegetables

Pulses

Milk Protein Non veg Food

Figure 2 Complementary feeding pattern of breast feeding and non-breast feeding children (NFHS 3-Ref. [1]).

802

R. Kuriyan, A.V. Kurpad

compared to 15e16% of the older children (19e24 months) and fruits were given to less than 2% of the children in both age groups with banana being the main fruit. Milk was the main animal food been given to more than three fourths of children aged 19e24 month and half the children aged 13e18 months. Kapur et al. [23] reported from Delhi that intakes of green leafy vegetables, fruits, sugar, fat and oils were grossly inadequate among urban slum children aged 9e36 months of age. Additionally, only 21% of the Indian children (breastfed and non-breast fed) were fed according to all the three recommended IYCF practices [1]. The percentage of children given food from the appropriate number of food groups and percentage fed with all three IYCF practices increased steadily with age, wealth index, and mother’s education. Maternal educational status was a key determinant of the child receiving optimal complementary feeding patterns according to IYCF guidelines. Figure 3, depicts the relationship of mother’s education and infant feeding practices. Parents play a critical role in the development of food preferences of a child and, prenatal and early postnatal exposure to a flavor enhances the infants’ enjoyment of that flavor in solid foods during feeding. Dietary schedules for the progressive introduction of solids during the complementary feeding in most countries originate from cultural and available food. Therefore, offering complementary foods without adding sugars and salt may be advisable not only for short term health but also, to set the infant’s threshold for sweet and salty tastes at lower levels later in life.

Use of industrial commercial feed in India There are many industrial commercial feeds available in India, but the data on the consumption patterns is limited. The national data [1] showed that among breast fed children aged 6e23 months, the consumption of infant formula was 9.1%, while 15% consumed fortified baby foods, with 1% of infants being given infant formula and fortified foods at a very early age of less than 2 months. Among the nonbreast feeding children, 12.7% consumed infant formula, while 21.7% consumed fortified baby food and 4% infants were started on infant formulas and fortified foods, below the age of 2 months. The commonly consumed fortified

Figure 3

foods were Cerelac and Farex. This consumption is suggesting an upward trend, since a study published in 1994, in the urban slums of Mumbai [19], showed that the usage of commercial infant food formula was 8.5%. In urban Bangalore (n Z 150), it was observed among young children aged 9e24 months, (Dwarakanath et al, unpublished data), that body weight was significantly higher in children who consumed industrial complementary feed as compared to home- made complementary feed (9.7  0.2 kg vs. 9.2  0.1 kg; p Z 0.02). Increased consumption of industrialized complementary feeds could predispose the child to increased body weight and obesity, since industrialized complementary feeds are energy dense with higher protein and fat content. In 50 infantemother pairs, who were studied using deuterium dilution technique at months 1, 3 and 6, it was observed that non-breast milk intake correlated positively with body weight for age at 6 months of age [15]. Commonly introduced complementary foods at 3 months of age were commercial cereal formula, cow’s milk and malted finger millet preparations, while at 6 months of age it was mainly commercial milk formula, commercial cereal formula, cow’s milk, biscuits, mixed grain porridges and typical Indian breakfast foods such as steamed rice and lentil cakes. Some of the reasons stated by the mothers for the early introduction of complementary feeding were a crying baby, which was perceived as insufficient breast milk, having to report back to her job, advice by elders and family and her own perceptions [15]. Additionally, aggressive marketing and advertising by the industries lure mothers to use these products. The main influencers for the consumption of commercial semi-solid food for the infant have shown to be the private doctor and the mother herself [24]. Although the exact role of industrialized complementary feeds in weight gain is not clear, it is possible that the high energy and fat content could cause rapid weight gain.

Influencers and barriers for optimal infant and young child feeding in India The high rates of malnutrition in India are not primarily caused by poverty, but also by behaviors of delayed initiation of breast feeding, early introduction of water and liquids and delay in complementary feeding resulting in

Relationship of mother’s education and infant feeding practices (NFHS 3-Ref. [1]).

Complementary feeding patterns in India a period of “perpetual hunger for the child” [25]. Several issues such as delayed introduction, low energy and nutrient densities, feeding in small amounts as well as restriction due to beliefs and taboos play a role in poor complementary feeding practice. Mothers and grandmothers reported not feeding until, the child showed hunger, suggesting that the perception of a child’s hunger can play a major role [26]. While it is possible that the perceived manifestation of hunger in a child could simply be the presence of crying, this belief could however prove to be a useful behavioral change in avoiding excessive feeding and thereby unwanted weight gain, by devising alternate methods of comforting a crying child instead of immediately offering food. Other beliefs that are regionally held, can affect all aspects of feeding such as food taboos, beliefs about when and how one can introduce complementary foods. These beliefs have to be recognized and incorporated into communication strategies in order to build on traditional practices, some of which are positive [27]. Providing good complementary feeding by the caregivers require knowledge, skills, time, economic resources and the control of decision-making. Families and mothers need the ability to make decisions about caring for their children [27]. Further, mothers may need to be counseled regarding gender equality. In urban slums of Mumbai, boys were fed more nutrient and/or energy dense foods as compared to girls, although the difference was not statistically significant [22]. Similarly, among tribal children in Bihar (aged 0e6 years), consumption of milk products, fats and oils were higher in boys compared to girls [28]. Mothers also need to be educated on nutrient density, since dilution of infant foods may be a problem in complementary feeding. Mothers may dilute foods because viscous foods are difficult for the children to consume [29] or, in order to stretch expensive foods such as lentils for the entire family. In addition to poverty and social marginalization, the status of women may be an underlying factor in Asia; children are better nourished in most African countries when compared to South Asian countries, even though family incomes are similar [30]. The lower status of women affects not only their care practices, but also their ability to provide care, as they may have less autonomy in decision-making, as well as less control over their time and resources. In addition, in most Indian families, the key decision maker may be the parents-in-law; therefore targeting the mothers alone for behavior change may be ineffective [27]. Cross sectional data from 600 mother infant pairs in Andhra Pradesh showed that mothers with higher participation in decision-making in households had infants that were less underweight and wasted, suggesting that improved maternal financial and decision-making autonomy could have a positive effect in infant feeding and growth outcomes [31]. Additionally, evaluation of the nutrition status of Indian children emphasize the need for child care or day care for the young children of working mothers [27,32] and for improving family care for women and girls.

Interventions by the government, other agencies and its review of evidence India’s largest program in addressing problems of malnutrition and child development, the Integrated Child

803 Development Services (ICDS) [33] was started in 1975 and covers all of the low-income blocks in India. Evaluation of the program showed positive effects on school attendance, age of school entry, immunization and prevalence of severe malnutrition, but evidence on overall nutrition status is limited [27]. The main barrier to good nutrition has been the inability of the program to reach pregnant, lactating women and children below 3 years of age but, new initiatives under governmental leadership and World Bank funding are trying to increase the focus on these age groups. The National Guidelines on Infant and Young Child Feeding was issued in 2004 in India [7], but it has not been able to successfully implement it. The 10th five year planning commission has set up National Nutrition Goals which were to be achieved by 2007, and one of the goals were to enhance the rate of complementary feeding [7]. However these goals were not achieved and the reasons for this included inadequate knowledge of caregivers regarding correct infant and young child feeding, frequent infections, high population pressure, low social and nutritional status of girls and women, suboptimal delivery of social services and lack of more viable guidelines [8]. There have been several positive deviance approach projects implemented in India with the objective of improving child feeding and rearing practices. Some notable projects have been those targeted to assist ICDS projects in Rajasthan, Uttar Pradesh and West Bengal, and UNICEF assisted Dular Project in Jharkhand [34]. Since there have been were a number of interventions, the USAID-funded Vistaar Project facilitated an expert review, to assess if first, there was an evidence based model for complementary feeding that could be recommended to the Government, second, to identify lessons learned about achieving impact in the area of complementary feeding, and third, to identify key evidence gaps where additional knowledge needed to be generated [35]. The summary of this review indicated that while there is information on what needs to be done to improve complementary feeding, data are lacking on “how” to achieve the goal. Additionally, most interventions did not address equity or gender issues and it was not clear whether the interventions were able to reach the most vulnerable sector. The experts also identified a need for the government interventions to be made more publicly accessible in order to be evaluated and used for future program planning.

Future directions There is a need for research which identifies the variations in feeding practices and beliefs supporting the practices in the various part of India. Additionally, there is a need to explore the quality and implementation of existing nutrition programs. Links between individual programs need to be strengthened, so that the multiple government workers in each area are working together to improve the nutritional status of India’s children. Education of mothers is crucial with focus on aspects such as nutrition, health, gender equality, food consistency, frequency, method of preparation and combination of foods. The latter is particularly important, since milk and non vegetarian foods

804 may be expensive; mothers need to be educated about other food sources as well as techniques for improving bioavailability.

Conclusions It is difficult to draw a single conclusion about complementary feeding practices in India. Poor, rural communities have different practices from richer, urban communities. In one group, there is a need to consider education towards timely introduction of feeds and enhancing the nutritive value; in the other group, perhaps considering a rationalization of intake, since there is increasing evidence for the role of complementary feeding in the development of adult disease. However, most current guidelines on complementary feeding are not evidence based. Dietary schedules during the complementary feeding period in most countries originate from cultural factors and available foods. More data is required to clarify the effects of specific foods and nutrients on growth, development, and metabolic status during this period. Parents and health professionals might be more motivated to comply if, weaning recommendations were more evidence based, particularly in relation to longer term health. Appropriate interventions have to be planned at the household level using behavioral change communication strategies and, multiple communication channels to saturate the population with consistent messages on child care and feeding.

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