Conference place:

By: MOTUMA ADIMASU ABESHU1/15/2016 1

Content

• Introduction

• Objectives

• Methodology

• Result and Discussion

• Limitation of the study

• Conclusion and Recommendation

• Acknowledgement

1/15/2016 2

Introduction

• Complementary feeding:

– covers the sensitive time period of 6 – 23 months in infants & young children

life span; it continues to challenge good nutrition.

• Child malnutrition is unacceptably high in Ethiopia (DHS, 2011), takes its

peak during complementary feeding period

– contributing factors – nutritionally inferior diets, improper feeding

practices (UNICEF, 2011)

• Most of complementary foods consumed in Ethiopia are:

– Homemade, extension of family foods, based primarily/exclusively on

plant derived products (Baye et al, 2012; Temesgen, 2013; Gibson et al,

1998).

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Introduction, ctd …• Challenges:

– Family foods are insufficient even when based on improved recipes (Allen, 2012; Dewey, 2013).

– Unfortified plant-based complementary foods are known for inadequacy of key nutrients, Ca, Fe & Zn

(WHO/UNICEF, 1998; Gibson et al, 1998; Dewey & Brown, 2003).

– The nutrient composition of homemade CFs & adequacy of intake is not well studied.

• For available literatures

– Conflicting reports (e.g., energy composition):

• Rural villages of Sidama zone – low energy density (49 - 53kcal/100g) (Abebe et al, 2006)

• Gibson et al (1998) – high energy density of 123 kcal/100g

– Missing the critical age of 6 – 8 months

• 9 – 11 mo – Gibson et al (1998); 12 – 23 mo – Baye et al (2012)

– Don’t target the food insecure segment of the population

– Methods used - mostly 24 hr recall (e.g. DHS series), estimated food record (e.g. Gibson et al, 1998)

• For this study, therefore, a Weighed Food Record Method was used

1/15/2016 4

Objectives

To assess the nutritional composition of homemade

complementary foods and evaluate adequacy of daily intakes

of energy & key micronutrients for children of age between 6

– 23 months in food insecure woredas of

Wolayita zone, Southern Ethiopia.

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Study Area and Period

• The study was conducted on two selected food insecure woredas of Wolayita

Zone, Southern Ethiopia, between October 2014 to April 2015.

Study Design

• Cross-sectional Weighed Food Record Method

Samples and Sampling Design

Sample Size:

• 68 HHs, after reviewing other literatures

– Abebe et al (2006) – 58; Baye et al (2012) – 76, & Owino (2008) – 20;

Sampling Design:

• Multi-Stage Cluster Sampling method

1/15/2016 6

Methodology

Figure 1: Sampling frames and sampling procedure used

Wolayita Zone

13 Administrative Woredas

5 CBN Woredas

2 Very hot spot woredas:

Kindo Koysha &

Dugna Fango, were selected

Kindo Koysha Woreda:

(40 Households)

14 – Rural Kebeles

9 – Semi-urban kebele;

Woreda Selection Convenience

Sampling

Dugna Fango Woreda:

(28 Households)

12 – Rural Kebeles

8 – Semi-urban kebeles;

Kebele Selection:

1 – Rural Kebele

1 – Semi-urban kebele

Kebele Selection:

1 – Rural Kebele

1 – Semi-urban kebele

Allocation of Sample Sizes Proportionate

Sampling

Number of HH per Kebele:

29 HHs – from Sorto

11 HHs – from Fechena

Number of HH per Kebele:

12 HHs – from Dugna Sore

8 HHs – from Kercheche

Kebele Selection Stratified Sampling

Technique

No. of HHs per Kebele Proportionate Sampling

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Data collection tools & procedures

Tools:

– Questionnaire – Customized into semi-structured from:

• FAO. (2011). Guidelines for measuring household and individual dietary diversity, &

• WHO. (2008). Indicators for assessing infants and young child feeding practices.

– Food sample collection – SF-400 digital balances with high precision.

Procedure:

– One investigator was assigned per household.

– mothers/caregivers were visited/communicated the day before

– Visits started in the morning (7:00 EAT) & ended during evening (20:00 EAT).

• Data items collected:

– HH information; KAP about complementary feeding; Food Items used to

prepare HCFs

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• Food Sample collection:

– Measurement of serving size & amount consumed all day;

– Samples proportionate to individual serving sizes were drawn

Food Sample Handling:

– weighed food sample transferred to sample collection bottles.

– The bottles were tightly closed, labeled and placed in cold

boxes.

– Samples transferred to refrigerators at the end of each day.

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Preparation of Laboratory Samples:

– The primary food samples were sorted by age:

• 6 – 8 months (category 1), 9 – 11 months (category 2), & 12 – 23 months

(category 3).

– Mixing to homogeneity

• samples crushed with mortar & pestle and mixed to form composite samples.

– Laboratory sample weighing 200g was randomly sampled for assay

Procedures for Laboratory Analysis

Laboratory Analysis was performed as per established procedures:

– AOAC Official Method; ES ISO; difference method for CHO

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Data Analysis and Interpretation

• Tool – IBM SPSS Statistics version 20.

• Presentation – tables, charts and graphs.

• Analysis – both descriptive and inferential

• Statistical tests – One – Sample t-test was employed:

– to compare Observed & Desired Nutrient Density - Energy, Protein, and Ca, Fe & Zn.

• True value for desired nutrient density – WHO recommendation (WHO/UNICEF, 1998)

– to evaluate adequacy of observed daily nutrient intakes compared to estimated daily

requirements – for Energy, Protein, and for Ca, Fe & Zn.

• True value for estimated daily requirement – WHO recommendation (WHO/UNICEF,

1998; PAHO/WHO, 2001).

– t – test was used to test significance of the differences.

– Observed differences were considered significant at p < 0.05.

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Background characteristics

• Two food insecure woredas, 4 Kebeles (2 rural & 2 semi-urban) selected &

data is collected from 68 households:

– Dugna Fango woreda (28) - Dugna sore (12) & Kercheche kebeles (16)

– Kindo Koysha woreda (40) – Sorto (29) & Fechena kebeles (11)

• Household size – average, 5.2

• Age distribution

– Under the age of 49 years – 98.8% of the total populations

– Children between 6 – 23 months of age – 19.89% of the total population

• Literacy rate - very low,

– literate (47.4%)

1/15/2016 12

Result and Discussion

6 - 8 months 9 - 11 months 12 - 23 months

Age category of child selected

10 (14.71%)

12 (17.65%)

11 (16.18%)

10 (14.71%)

11 (16.18%)

14 (20.59%)

Female

Male

Figure: Age distribution & gender composition of the children selected for the study

1/15/2016 13

Background Variable

Woreda

Total Dugna Fango Woreda

(%)

Kindo Koysha Woreda

(%) Dugna Sore Kerchecha Sorto Fechena

N % N % % N % N % % N %

Gender

Male 36 56.25 43 51.81 53.74 65 45.45 32 51.61 47.32 176 50.00

Female 28 43.75 40 48.19 46.26 78 54.55 30 48.39 52.68 176 50.00

Total 64 83 100.00 100.00 143 100.00 62 100.00 100.00 352 100.00

Age

Ranges

< 6 mo. 0 0.00 0 0.00 0.00 1 0.70 0 0.00 0.49 1 0.28

6 - 23 mo. 12 18.75 17 20.48 19.73 29 20.28 12 19.35 20.00 70 19.89

24 - 59 mo. 6 9.38 4 4.82 6.80 15 10.49 0 0.00 7.32 25 7.10

5 - 14 yrs 17 26.56 27 32.53 29.93 35 24.48 21 33.87 27.32 100 28.41

15 - 49 yrs 26 40.63 35 42.17 41.50 62 43.36 28 45.16 43.90 151 42.90

50 - 64 yrs 3 4.69 0 0.00 2.04 1 0.70 1 1.61 0.98 5 1.42

> 65 yrs 0 0.00 0 0.00 0.00 0 0.00 0 0.00 0.00 0 0.00

Total 64 100.00 83 100.00 100.00 143 100.00 62 100.00 100.00 352 100.00

Educational

Status

Illiterate 35 54.69 40 48.19 51.02 82 57.34 28 45.16 53.66 185 52.56

Read&Write 2 3.13 1 1.20 2.04 3 2.10 1 1.61 1.95 7 1.99

Elemen.(1 - 8) 20 31.25 29 34.94 33.33 40 27.97 26 41.94 32.20 115 32.67

HighSch.(9-12) 6 9.38 12 14.46 12.24 17 11.89 7 11.29 11.71 42 11.93

College/Univ. 1 1.56 1 1.20 1.36 1 0.70 0 0.00 0.49 3 0.85

Total 64 100.00 83 100.00 100.00 143 100.00 62 100.00 100.00 352 100.00

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Table: Background characteristics of sampled households in Dugna Fango & Kindo Koysha woredas, Wolayita zone

Complementary Feeding (CF) Knowledge and

Practice parameters

Respondents response against

recommendations Remark

No % of total resp.

How long after

birth to start

Breastfeeding

< 1 hour** 36 52.9

1 – 6 hours 30 44.1

After 6 hours 2 3.0

Age of

introduction of

CFs

4 – 6 months 3 4.4

At 6 months** 60 88.2

After 6 months 5 7.4

Knowledge about

CF

When to start CF** 66 97.1

Benefit of CF** 63 92.6

How to keep hygiene** 51 75.0

How to prepare CFs** 58 85.3

Frequency of feeding** 46 67.6

Others 4 5.9

Continued

Breastfeeding

Until & beyond 24 months** 67 98.5

During Illness** 67 98.5

After Recovery** 68 100.0

Source of CF

Information

Health Extension Workers 67 98.5

Radio/TV 1 1.5

Health Volunteers 11 16.2

Neighbors 3 4.4

Others 6 8.8 ** Desired complementary feeding knowledge and/or practices (PAHO/WHO, 2001)

Knowledge of Complementary Feeding among mothers/caregivers

Table: Knowledge & Practice of respondents on selected Complementary Feeding Parameters

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• Age of complementary foods introduction:

– at 6 months - 88.2% Vs National - 49.0% (DHS,

2011)

• Target - 54% to 65%, over 2011 to 2015 (HSDP IV, 2010)

– difference could be attributed to improved

knowledge:

• when to start, benefits, how to prepare & keep hygiene

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Homemade complementary foods

Preparation of the complementary foods

• Average number of preparation per day was 2.26 (range - 1 to 4)

– More than 20 food items were used

• Average number of food types prepared/served per day 2.79 (range

- 1 to 6).

– About 23 different food types were prepared/served

– Some food types were combination of more than 2 food items

– others were single food items processed fully/partially

1/15/2016 17

Table: Common food types and food items (recipe) used to prepare complementary foods

Frequently

served

Homemade Complementary Foods

Prepared from multiple Food Items Prepared from Single Food

Item

Name of

Comp. Food

Common Food Items used Observation

No (%)

Name of

Comp. Food

Observation

No (%)

1 Kita/Nifro

(Bread)

Maize (Bekolo), Wheat (Sinde), Broad-

beans (Bakela), Teff, Barley (Gebs),

Butter/Oils

29 (42.6%) Milk/

Yogurt 24 (35.3%);

2 Porridge

Maize (Bekolo), Wheat (Sinde), Barley

(Gebs), Teff, Oat, Pea (Ater), Broad-

beans (Bakela), Lentils (Misir), Milk

(Wetet), Butter or some form of oil

21 (30.9%) Avocado 17 (25.0%)

3

Injera Teff, Maize (Bekolo)

Injera and wet (stew) made from Garlic,

Onion & Butter or some form of oil

17 (25.0%) Banana 17 (25.0%) Injera based

preparation

4 Beso

Barley (Gebs) powder, Milk (Wetet).

Teff, Wheat (Sinde), Maize (Bekolo), and

Oat

7 (10.9%) Cassava 14 (20.6%)

5 Shorba

(Soup) Oat 6 (8.8%)

Potato &

Yam

6 (8.8%), for

both Items

1/15/2016 18

• Most frequently served food types were similar to

family foods :

– Kita/Nifro, Injera/Injera firfir, Shiro/Misir wet, and Potato.

• Similar observations in other parts of the country

(Temesgen, 2013; Baye et al, 2012).

• Such transition, however, may put the infant at risk of

multiple micronutrient deficiencies (Dewey, 2013)

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1 (12%)

2 (37%)3

(38%)

4 (12%)

5 (1%)

1 Category

2 Categories

3 Categories

4 Categories

5 Categories

Figure: Number of food categories used to prepare complementary foods

Average - 2.54

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Dietary Diversity

• Dietary Diversity ≥ 4 – only 13.2%.

• Slight improvement compared to the national figure of 4%

(DHS, 2011)

• fails to comply with recommendations (WHO, 2008).

• No Animal Source Foods (ASF); poor Vit A – rich fruits &

vegetables:

• Plant-based complementary foods are insufficient for micro-

nutrients’ (WHO/UNICEF, 1998; Gibson et al., 1998; Dewey &

Brown, 2003).

• ASF – are well-documented diet approach to improve quality

(Santos et al, 2001).

1/15/2016 21

Measurement of Daily Complementary Food Intakes

Complementary Feeding Practice mean score by age

6 – 8 mo 9 – 11 mo 12 – 23 mo 6 -23 mo

No of serving episodes/day (Meal Frequency) 2.90 2.91 3.16 3

Amount of CF served (g/day)

Fresh basis 263.3 317.09 334.92 307.57

Dry basis 64.17 96.43 120.34 93.01

Amount of CF consumed (g/day)

Fresh basis 165.70 204.26 258.40 212.82

Dry basis 40.38 62.12 92.84 64.36

% of servings consumed 64.84% 69.36% 78.4% 69.19%

Table: Comparison of Selected Complementary Feeding practice indicators by age to recommended

levels

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Meal frequency was 3 times per day, In line with:

• WHO recommendations and other similar studies.

Complementary Feeding Practice mean score by age & recommended levels

6 – 8 months 9 – 11 months 12 – 23 months

Observed Recommen. Observed Recommen. Observed Recommen.

Gastric Capacity per Kg

(g/Kg), & C.I.**

19.96*

(15.37, 24.55) 30.0

21.50*

(17.83, 25.17) 30.0

22.47*

(17.41, 27.53) 30.0

Functional gastric

capacity (g/meal or

day), & C.I. **

165.70 *

(127.54, 203.86) 249.00

204.26 *

(169.35, 239.17) 285.00

258.40 *

(200.18, 325.10) 345.00

* Observed values lower than recommended levels based WHO recommendations (PAHO/WHO, 2001; WHO, 2003)

** Functional gastric capacity is calculated based on median body weight at 7 months for 6-8, 10 months for 9 – 11, and 18 months

for 12 – 23 ages, which is 8.3, 9.5 & 11.5Kg, respectively (WHO/ UNICEF, 1998).

C.I. - is an acronym for Confidence Interval of the mean values

Table: Selected Complementary Feeding practice indicators by the age to recommended levels

1/15/2016 23

• Gastric capacity:

higher than findings reported by Baye et al (2012) – 9.00 g/Kg

Much lower than theoretical gastric capacity (WHO/UNICEF,1998; PAHO/WHO, 2001).

May be due to: lack of responsive feeding, underlying health conditions and/or

Inappropriate consistency of the foods

1/15/2016 24

• Solid preparations in diets served & amount consumed!

– 75.0% for 6 – 23 months, AND 55.0% for 6 – 8 months.

• Inability to chew and swallow foods

• at odds with the recommendations – semi-solid or pureed foods

(EFSA, 2009; Caballero, Allen & Prentice, 2005; WHO/UNICEF, 1998)

% of Households to have served these food consistencies Remark

Solid Thick semi-solid Thin semi-solid Liquid

Age Category

6 – 8 months 55.0 55. 0 40.0 40.0

9 – 11 months 69.6 57.0 22.0 30.4

12 – 23 months 96.0 16.0 16.0 24.0

6 -23 months

(Average) 75.0 41.2 41.2 30.9

Table: Percentage constituency of different complementary food consistencies in diets served

Nutrient composition of the complementary foods

Proximate and Mineral Content

1/15/2016 25

y = -4.3328x + 421.16R² = 0.9754

0.00

20.00

40.00

60.00

80.00

100.00

120.00

140.00

160.00

62.00 64.00 66.00 68.00 70.00 72.00 74.00 76.00 78.00

Ene

rgy

De

nsi

ty in

Kca

l

% Moisture content of the food

Energy Density (kCal)

Linear (Energy Density(kCal))

Figure: Relationship between the moisture level and Energy Density by the age of the child

1/15/2016 26

25

8.287.38

y = 0.7791x - 14.494R² = 0.9616

0

5

10

15

20

25

30

0 10 20 30 40 50 60

Cal

ciu

m c

om

po

siti

on

(m

g/1

00

kcal

)

Proportion of diets that contained Milk/Yogurt

Difference in Calcium composition in diets by age group, explained by Milk/Yogurt consumption

mg/100kcal

Linear(mg/100kcal)

Figure: Difference in Calcium level among the diets of children of different age groups explained by the consumption of Milk/Yogurt

1/15/2016 27

Density and adequacy of

Energy & Protein intakes from complementary foods

1/15/2016 28

ENERGY INTAKE from complementary foods

200

300

550

240.34

393.95 472.77

151.25

253.77

364.76

0

100

200

300

400

500

600

6 - 8 months 9 - 11 months 12 - 23 months

Am

ou

nt

of

en

erg

y in

kca

l/d

ay

Age groups

Recommended

Served

Consumed

Figure: Comparison of Energy served and/or consumed (in kcal/day) to recommended intakes

p=0.013

p=0.048

p=0.000

1/15/2016 29

Notes:- Intake GAP- Similar values from

Literature- PARADOX- Caution

Nutrient Density for Ca, Fe and Zn in the complementary foods

Table: Comparison of observed Nutrient Density (ND) to desired levels in complementary foods by age of the children

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Micronutrients

Age category of the children

6 - 8 months 9 - 11 months 12 - 23 months

Observed

ND Desired ND

a Observed

ND Desired ND

a

Observed

ND Desired ND

a

Ca

(mg/100kcal) 25 125* 7.38 78* 8.28 26*

Fe

(mg/100kcal)

Low biov

2.15

7.7*

1.63

4.6*

2.04

1.6**

Med. biov. 4* 2.4* 0.8**

High biov 2.5* 1.5** 0.5**

Zn

(mg/100kcal) 0.64 1.6* 0.47 1* 0.54 0.8*

a: Value for desired nutrient density adopted from WHO recommendations (WHO/UNICEF, 1998)

* mean for Observed Nutrient Density is significantly lower than the Desired Nutrient Density at α < 0.05 (p = 0.000)

** mean for Observed Nutrient Density is significantly higher than the Desired Nutrient Density at α < 0.05 (p = 0.000)

ND – is the Nutrient Density of the foods (in mg/100kcal)

Adequacy of Ca, Fe & Zn Intakes from complementary foods

Nutrients

Age category of the children

6 - 8 months 9 - 11 months 12 - 23 months

Amount

Consumed Recommended

a Amount

Consumed Recommended

a Amount

Consumed Recommended

a

Ca (mg/day) 37.76 336.00* 18.83* 353.00* 30.13 196.00*

Fe

(mg/day)

Low biov

3.25

20.80*

4.17

20.80*

7.42

11.80*

Med. biov. 10.80* 10.80* 5.80**

High biov 6.80* 6.80* 3.80**

Zn (mg/day) 0.96 4.20* 1.21* 4.30* 1.96 5.80*

a: Value for estimated nutrient requirement adopted from WHO recommendations (WHO/UNICEF, 1998)

* amount of micronutrients consumed per day is significantly lower than minimum daily requirement at α < 0.05 (p = 0.000)

**amount of micronutrients consumed per day is significantly higher than the minimum daily requirement at α < 0.05 (p = 0.000)

Table: Amount of micronutrients consumed per day compared to estimated nutrient needs from

complementary foods by age of the children

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Nutrient Density

• Micronutrients: Ca, Fe & Zn, continue to be problem nutrients – very low

nutrient density compared to desired levels.

• poor diversity of the diets and virtual absence of animal source foods.

• similar conclusion has been reached by Gibson et al (2012).

• Zinc met desired values when moderately bioavailable (Baye et al, 2012).

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Nutrient Intakes

• Daily intake of the three micronutrients was inadequate. None of the children obtained

sufficient Ca, Fe & Zn (mg/ day)

o Exception, Fe consumption in the 12 – 23 age groups, Where:

Intake was adequate - assuming Moderate to High Bioavailability

Declining Fe requirement (in mg/day) by age, not improved Fe composition of the

diets, is the reason for the differences observed.

• Eminent deficiencies of these micronutrients

inadvertently leads to:

– adverse health consequences and

– restricted child growth and development (WHO, 2001;

Gibson et al, 2010; Brown, 1998; Gibson et al, 1998).

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Limitation of the study

• In spite of interesting findings this study has brought forward, the

following limitations should also be noted.

– Design/method:

• the cross-sectional nature of this study didn’t allow seasonal variation in food intakes to

be considered.

– Hello effect:

• Although caregivers were instructed not alter their children’s complementary food

preparations and dietary patterns, this doesn’t warrant the absence of deliberate

changes in their diets.

– Scope of the study:

• This study does not assess nutritional status of the children investigated. It rather looked

into nutrient composition of their diet and daily intakes, to evaluate adequacy.

1/15/2016 34

• Caregivers had good knowledge of basic complementary feeding practices.

• Most of the homemade complementary foods were an extension of family foods.

– Dietary diversity was very poor: no ASF & vitamin A rich fruits and vegetables.

– The Ca, Fe & Zn composition (in mg/100kcal) of the CFs was very poor.

– Energy and protein composition, however, was more than adequate.

• The amount of Energy, Ca, Fe & Zn consumed per day was significantly lower than

estimated daily intake from CFs.

– Shortfalls in Energy intake, despite the high density & more than adequate size of servings,

calls for more investigation.

– From this study:

• high amount of leftovers observed from each servings and

• Consistency of some servings was inappropriate for developmental stage of the children.

Conclusion

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Recommendation

• Targeted CF education & promotion is required to improve the Knowledge

& CF practices, with emphasis on:

• Improving diet diversity, inclusion of ASFs and fruits & vegetables.

• Age & order of introduction of different food consistencies.

• Improving feeding behavior through promotion of responsive feeding.

• Micronutrient intervention to curb the gaps in intakes and

potential/eminent deficiencies.

– Combination of methods including – supplementation, diversification and/or

fortification of foods.

• Further researches/investigations are required.

– on larger catchment areas and sample bases.

1/15/2016 36

Acknowledgements

• Special thanks to:

– My advisors: Dr Abdulaziz Adish & Dr Gulelat Desse

– Micronutrient Initiative (MI) Ethiopia for supporting me financially.

– Mrs Azeb Lelisa, Mr. Ermias Lewtie and Girma Bogale of MI.

• SNNP RHB, Wolayita ZHD, Dugna Fango & Kindo Koysha WoHOs.

• AAU, Center for Food Science and Nutrition.

• My friends and colleagues for support during data collection

process.

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