- Email: [email protected]
Indicators for feeding practices in children
Comment
number of studies that address this shortage of solid evidence on which to base policy. But evaluations of social programmes need to use a theory-based approach.
3 4
5
Howard White
6
Independent Evaluation Group, World Bank, Washington, DC 20433, USA [email protected] I declare that I have no conflict of interest. 1
2
Ruel M, Menon P, Habicht J-P, et al. Age-based preventive targeting of food assistance and behaviour change and communication for reduction of childhood undernutrition in Haiti: a cluster randomised trial. Lancet 2008; 371: 588–95. Evaluation Gap Working Group, Center for Global Development. When will we ever learn? Improving lives through impact evaluation. May, 2006. http:// www.cgdev.org/content/publications/detail/7973 (accessed Jan 24, 2008).
7 8
Banerjee A. Making aid work. Cambridge, MA: MIT Press, 2007. Alderman H. Improving nutrition through community growth promotion: longitudinal study of the nutrition and early child development program in Uganda. World Dev 2007; 35: 1376–89. Hossain SM, Duffield A, Taylor A. An evaluation of the impact of a US$60 million nutrition program in Bangladesh. Health Policy Plan 2005; 20: 35–40. World Bank Operations Evaluation Department. Maintaining momentum to 2015? An impact evaluation of interventions to improve maternal and child health and nutrition outcomes in Bangladesh. 2005. http://lnweb18. worldbank.org/OED/oeddoclib.nsf/DocUNIDViewForJavaSearch/ CE73E964941BB85585256FF700729B6D/$file/impact_evaluation_ bangladesh_child_health.pdf (accessed Jan 24, 2008). White H, Masset E. The Bangladesh Integrated Nutrition Program: findings from an impact evaluation. J Int Dev 2007; 19: 627–52. World Bank Independent Evaluation Group. Impact evaluation: the experience of the Independent Evaluation Group of the World Bank. 2006. http://lnweb18.worldbank.org/oed/oeddoclib.nsf/DocUNIDViewFor JavaSearch/35BC420995BF58F8852571E00068C6BD/$file/impact_ evaluation.pdf (accessed Jan 24, 2008).
Indicators for feeding practices in children Simple, valid, and reliable indicators are crucial to track progress and guide investment to improve nutrition and health during the first 2 years of life. Indicators that assess breastfeeding are useful to monitor trends, to develop and evaluate programmes, and for advocacy.1 Until now, however, we have lacked indicators for populationbased surveys to measure feeding practices for children 6–24 months of age. Limited knowledge about the scale and distribution of inadequate feeding practices and consequences for childrens’ survival, health, and physical and mental development has hampered investment and action to improve these practices, as argued by Jennifer Bryce and colleagues in last week’s Lancet.2 The development of indicators for child-feeding practices poses conceptual and analytical challenges in that these practices are multidimensional, inter-related, and change rapidly within short age-intervals.3 Unlike exclusive breastfeeding, which can be summarised in a single indicator, the measurement of feeding practices for children aged 6 months and older involves assessing various dimensions simultaneously. These dimensions include continued breastfeeding, appropriate timing of introduction of complementary foods, and optimum quantity and quality (micronutrient density) of the foods consumed. With the scientific rationale for the various dimensions of child feeding defined for breastfed4 and non-breastfed children,5 WHO and partners developed indicators to assess child feeding for the ages 6–24 months and updated the breastfeeding indicators.3,6,7 Partners were the International Food Policy Research Institute, www.thelancet.com Vol 371 February 16, 2008
the Food and Nutrition Technical Assistance Project at the Academy of Educational Development, Macro International, the University of California at Davis, the US Agency for International Development, UNICEF, and a group of collaborating researchers. This 5-year effort resulted in a set of core and optional indicators. The former include new indicators for dietary diversity (a proxy for nutrient-density adequacy), feeding frequency (a proxy for adequate energy intake from food), and consumption of iron-rich or iron-fortified foods in breastfed and non-breastfed children aged 6–24 months. The indicators focus on selected food-related dimensions of child feeding that can be measured in large surveys. Other dimensions of optimum feeding, such as responsive feeding and adequate texture of food, are likely to require more complex measurement approaches. The core list also includes previously used breastfeeding indicators and updated indicators for exclusive breastfeeding in infants aged less than 6 months and appropriate breastfeeding in children aged less than 24 months. Most of the proposed indicators can be derived from questions already in widely implemented population-based surveys, such as the Demographic and Health Surveys and UNICEF Multiple Indicator Cluster Surveys; others will require the addition of simple questions. These same questions can easily be added to other surveys. An earlier version of these indicators showed the gravity of problems with feeding of infants and young children and the scale of the challenges ahead. For example, in 13 of 18 countries with nationally representative data
See Series page 608
541
Comment
Panos Pictures
The printed journal includes an image merely for illustration
children must be measured and standard indicators for doing so used globally. Our proposed indicators already enjoy support from key institutions involved in child nutrition, and their revision, on the basis of public comment, will further ensure broad consensus and adoption. Mary Arimond, *Bernadette Daelmans, Kathryn Dewey, for the steering team of the Working Group on Infant and Young Child Feeding Indicators International Food Policy Research Institute, Washington, DC, USA (MA); WHO, 1211 Geneva 27, Switzerland (BD); and University of California, Davis, CA, USA (KD) [email protected] The steering team of the Working Group on Infant and Young Child Feeding Indicators is: MA, Eunyong Chung, BD, KD, Chessa Lutter, José Martines, Marie Ruel, and Anne Swindale. The views in this Comment do not necessarily represent the decisions or the stated policy of WHO. We declare that we have no conflict of interest.
in sub-Saharan Africa, less than 30% of breastfed children were fed solids or semisolids the minimum number of times and fed the minimum number of food groups.8 Non-breastfed children fared worse: in 14 of 18 of the same countries less than 10% received milk products in addition to being fed solids or semisolids the minimum number of times and being fed the minimum number of food groups. The steering team of the Working Group on Infant and Young Child Feeding Indicators invites all stakeholders to share their observations and comments on the draft outline of the proposed indicators9 by Feb 27, 2008. The final set of indicators will be published by WHO and partners in 2008. To further harmonise and standardise assessment across countries, an operational guide on sampling and other measurement issues will be published separately. To advance the public-health agenda to improve child survival, health, and mental and physical development, the key input of feeding practices in infants and young
1
2
3 4
5
6
7
8
9
WHO. Indicators for assessing breastfeeding practices. WHO/CDD/SER/91.14. 1991 http://www.who.int/child_adolescent_health/documents/cdd_ser_91_ 14/en/index.html (accessed Jan 31, 2008). Bryce J, Coitinho D, Darnton-Hill I, for the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: effective action at national level. Lancet 2008; 371: 510–26. Ruel MT, Brown KH, Caulfield LE. Moving forward with complementary feeding: indicators and research priorities. Food Nutr Bull 2003; 24: 289–90. Pan American Health Organization, World Health Organization. Guiding principles for complementary feeding of the breastfed child. 2003. http://www.who.int/child_adolescent_health/documents/a85622/en/index. html (accessed Jan 31, 2008). World Health Organization. Guiding principles for feeding non-breastfed children 6–24 months of age. 2005. http://www.who.int/child_adolescent_ health/documents/9241593431/en/index.html (accessed Jan 31, 2008). 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 (accessed Jan 29, 2008). 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 (accessed Feb 1, 2008). United States Agency for International Development. Infant and young child feeding update. September, 2006. http://www.measuredhs. com/pubs/pdf/NUT1/NUT1.pdf (accessed Jan 29, 2008). WHO. Indicators for assessing infant and young child feeding practices. http://www.who.int/child_adolescent_health/topics/prevention_ care/child/nutrition/indicators/en/index.html (accessed Jan 31, 2008).
Activated vitamin D sterols in kidney disease Activated vitamin D sterols are used to manage secondary hyperparathyroidism. As kidney function declines, the production of activated vitamin D (1,25-dihydroxyvitamin D) and serum calcium concentrations drop, phosphate retention ensues, and the aggregate culminates in secondary hyperparathy542
roidism.1,2 Activated vitamin D directly and indirectly (by increasing serum calcium) suppresses the synthesis and secretion of parathyroid hormone (PTH), and high concentrations of PTH are indicators of osteitis fibrosa, a bone disorder that accompanies renal failure. High serum concentrations of phosphorus and calcium are www.thelancet.com Vol 371 February 16, 2008
number of studies that address this shortage of solid evidence on which to base policy. But evaluations of social programmes need to use a theory-based approach.
3 4
5
Howard White
6
Independent Evaluation Group, World Bank, Washington, DC 20433, USA [email protected] I declare that I have no conflict of interest. 1
2
Ruel M, Menon P, Habicht J-P, et al. Age-based preventive targeting of food assistance and behaviour change and communication for reduction of childhood undernutrition in Haiti: a cluster randomised trial. Lancet 2008; 371: 588–95. Evaluation Gap Working Group, Center for Global Development. When will we ever learn? Improving lives through impact evaluation. May, 2006. http:// www.cgdev.org/content/publications/detail/7973 (accessed Jan 24, 2008).
7 8
Banerjee A. Making aid work. Cambridge, MA: MIT Press, 2007. Alderman H. Improving nutrition through community growth promotion: longitudinal study of the nutrition and early child development program in Uganda. World Dev 2007; 35: 1376–89. Hossain SM, Duffield A, Taylor A. An evaluation of the impact of a US$60 million nutrition program in Bangladesh. Health Policy Plan 2005; 20: 35–40. World Bank Operations Evaluation Department. Maintaining momentum to 2015? An impact evaluation of interventions to improve maternal and child health and nutrition outcomes in Bangladesh. 2005. http://lnweb18. worldbank.org/OED/oeddoclib.nsf/DocUNIDViewForJavaSearch/ CE73E964941BB85585256FF700729B6D/$file/impact_evaluation_ bangladesh_child_health.pdf (accessed Jan 24, 2008). White H, Masset E. The Bangladesh Integrated Nutrition Program: findings from an impact evaluation. J Int Dev 2007; 19: 627–52. World Bank Independent Evaluation Group. Impact evaluation: the experience of the Independent Evaluation Group of the World Bank. 2006. http://lnweb18.worldbank.org/oed/oeddoclib.nsf/DocUNIDViewFor JavaSearch/35BC420995BF58F8852571E00068C6BD/$file/impact_ evaluation.pdf (accessed Jan 24, 2008).
Indicators for feeding practices in children Simple, valid, and reliable indicators are crucial to track progress and guide investment to improve nutrition and health during the first 2 years of life. Indicators that assess breastfeeding are useful to monitor trends, to develop and evaluate programmes, and for advocacy.1 Until now, however, we have lacked indicators for populationbased surveys to measure feeding practices for children 6–24 months of age. Limited knowledge about the scale and distribution of inadequate feeding practices and consequences for childrens’ survival, health, and physical and mental development has hampered investment and action to improve these practices, as argued by Jennifer Bryce and colleagues in last week’s Lancet.2 The development of indicators for child-feeding practices poses conceptual and analytical challenges in that these practices are multidimensional, inter-related, and change rapidly within short age-intervals.3 Unlike exclusive breastfeeding, which can be summarised in a single indicator, the measurement of feeding practices for children aged 6 months and older involves assessing various dimensions simultaneously. These dimensions include continued breastfeeding, appropriate timing of introduction of complementary foods, and optimum quantity and quality (micronutrient density) of the foods consumed. With the scientific rationale for the various dimensions of child feeding defined for breastfed4 and non-breastfed children,5 WHO and partners developed indicators to assess child feeding for the ages 6–24 months and updated the breastfeeding indicators.3,6,7 Partners were the International Food Policy Research Institute, www.thelancet.com Vol 371 February 16, 2008
the Food and Nutrition Technical Assistance Project at the Academy of Educational Development, Macro International, the University of California at Davis, the US Agency for International Development, UNICEF, and a group of collaborating researchers. This 5-year effort resulted in a set of core and optional indicators. The former include new indicators for dietary diversity (a proxy for nutrient-density adequacy), feeding frequency (a proxy for adequate energy intake from food), and consumption of iron-rich or iron-fortified foods in breastfed and non-breastfed children aged 6–24 months. The indicators focus on selected food-related dimensions of child feeding that can be measured in large surveys. Other dimensions of optimum feeding, such as responsive feeding and adequate texture of food, are likely to require more complex measurement approaches. The core list also includes previously used breastfeeding indicators and updated indicators for exclusive breastfeeding in infants aged less than 6 months and appropriate breastfeeding in children aged less than 24 months. Most of the proposed indicators can be derived from questions already in widely implemented population-based surveys, such as the Demographic and Health Surveys and UNICEF Multiple Indicator Cluster Surveys; others will require the addition of simple questions. These same questions can easily be added to other surveys. An earlier version of these indicators showed the gravity of problems with feeding of infants and young children and the scale of the challenges ahead. For example, in 13 of 18 countries with nationally representative data
See Series page 608
541
Comment
Panos Pictures
The printed journal includes an image merely for illustration
children must be measured and standard indicators for doing so used globally. Our proposed indicators already enjoy support from key institutions involved in child nutrition, and their revision, on the basis of public comment, will further ensure broad consensus and adoption. Mary Arimond, *Bernadette Daelmans, Kathryn Dewey, for the steering team of the Working Group on Infant and Young Child Feeding Indicators International Food Policy Research Institute, Washington, DC, USA (MA); WHO, 1211 Geneva 27, Switzerland (BD); and University of California, Davis, CA, USA (KD) [email protected] The steering team of the Working Group on Infant and Young Child Feeding Indicators is: MA, Eunyong Chung, BD, KD, Chessa Lutter, José Martines, Marie Ruel, and Anne Swindale. The views in this Comment do not necessarily represent the decisions or the stated policy of WHO. We declare that we have no conflict of interest.
in sub-Saharan Africa, less than 30% of breastfed children were fed solids or semisolids the minimum number of times and fed the minimum number of food groups.8 Non-breastfed children fared worse: in 14 of 18 of the same countries less than 10% received milk products in addition to being fed solids or semisolids the minimum number of times and being fed the minimum number of food groups. The steering team of the Working Group on Infant and Young Child Feeding Indicators invites all stakeholders to share their observations and comments on the draft outline of the proposed indicators9 by Feb 27, 2008. The final set of indicators will be published by WHO and partners in 2008. To further harmonise and standardise assessment across countries, an operational guide on sampling and other measurement issues will be published separately. To advance the public-health agenda to improve child survival, health, and mental and physical development, the key input of feeding practices in infants and young
1
2
3 4
5
6
7
8
9
WHO. Indicators for assessing breastfeeding practices. WHO/CDD/SER/91.14. 1991 http://www.who.int/child_adolescent_health/documents/cdd_ser_91_ 14/en/index.html (accessed Jan 31, 2008). Bryce J, Coitinho D, Darnton-Hill I, for the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: effective action at national level. Lancet 2008; 371: 510–26. Ruel MT, Brown KH, Caulfield LE. Moving forward with complementary feeding: indicators and research priorities. Food Nutr Bull 2003; 24: 289–90. Pan American Health Organization, World Health Organization. Guiding principles for complementary feeding of the breastfed child. 2003. http://www.who.int/child_adolescent_health/documents/a85622/en/index. html (accessed Jan 31, 2008). World Health Organization. Guiding principles for feeding non-breastfed children 6–24 months of age. 2005. http://www.who.int/child_adolescent_ health/documents/9241593431/en/index.html (accessed Jan 31, 2008). 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 (accessed Jan 29, 2008). 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 (accessed Feb 1, 2008). United States Agency for International Development. Infant and young child feeding update. September, 2006. http://www.measuredhs. com/pubs/pdf/NUT1/NUT1.pdf (accessed Jan 29, 2008). WHO. Indicators for assessing infant and young child feeding practices. http://www.who.int/child_adolescent_health/topics/prevention_ care/child/nutrition/indicators/en/index.html (accessed Jan 31, 2008).
Activated vitamin D sterols in kidney disease Activated vitamin D sterols are used to manage secondary hyperparathyroidism. As kidney function declines, the production of activated vitamin D (1,25-dihydroxyvitamin D) and serum calcium concentrations drop, phosphate retention ensues, and the aggregate culminates in secondary hyperparathy542
roidism.1,2 Activated vitamin D directly and indirectly (by increasing serum calcium) suppresses the synthesis and secretion of parathyroid hormone (PTH), and high concentrations of PTH are indicators of osteitis fibrosa, a bone disorder that accompanies renal failure. High serum concentrations of phosphorus and calcium are www.thelancet.com Vol 371 February 16, 2008