IMPROVING DIETS IN THE FIRST 1000 DAYS:

UTILITY OF A [FAMILY BASED] NUTRITION

TOOLKIT

Amy Webb Girard, PhD

Hubert Department of Global Health

Nutrition and Health Sciences Program

Rollins School of Public Health

Emory University

awebb3@emory.edu

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In about 35 minutes we will discuss…

• Why educational innovations that are provided to

families in the first 1000 days are needed

• Development of the 1000 days nutrition toolkit

• Process and findings of acceptability testing in

India and Kenya

• Limitations and considerations for future work

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Bhutta et al. Lancet Volume 382, No. 9890, p452–477, 3 August 2013

Impact of Scaling Up Direct

Nutrition Interventions

Scale up of the entire package to 90% coverage

would reduce mortality by 15%, severe wasting

by 61.4% and stunting by 20%

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Enhancing FLW interactions

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India, Bangladesh: FLW training; Job aids, including marked katoris (150mL) for use in CF counseling

Indicators IFHI districts, R6 Non IFHI districts,R6

Advised CF initiation 20.0% 6.6%

Advised any frequency 24.5% 16.2%

Advised any quantity 5.6% 2.6%

Advised washing hands 19.6% 9.7%

Demonstrated preparation 3.3% 0.4%

Showed katori 5.0% 0.5%

Demonstrated how to feed 2.6% 0.3%

Data used with

permission of

CARE, India

IFHI team

Child Feeding Bowls: Improved CF

Latin America, Manoff Group: Acceptability testing with 28 mothers in Bolivia – highly acceptable, improved feeding of age appropriate amounts. http://www.manoffgroup.com/documents/ChildFeedingBowlPowerpointfinal0509.pdf

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The First 500 Days

“From conception to 6 months of age, an infant is

entirely dependent for its nutrition on the mother: via

the placenta and then ideally via exclusive breastfeeding.

This period of 15 months -- about 500 days--is the most

important and vulnerable in a child's life: it must be

protected through policies supporting maternal nutrition

and health.” (Mason et al, Global Health Action 2014)

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Implementation Gaps

Standard child feeding bowls target 6-24 months

and cue age appropriate amount per meal.

But….

How do we cue meal frequency?

How do we cue meal diversity?

How do we cue meal consistency?

How do we target the entire 1000 days?

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What is the IDEA? • Cues appropriate CF

frequency and amount with

demarcations and symbols

• Cues mothers for extra food

required from pregnancy

through the first 6 months

postpartum

• Cues consistency with

slotted spoon

• Cues other practices with

pictorial counseling cards

• Complements other strategies

HEALTHY MOTHER, HEALTHY CHILD

Pregnant Mothers

Clean bowl and spoon

after each use

Use clean water to

prepare food

0-6 months

Make sure food is

thick enough

Baby: breast milk only

Mother:

HEALTHY MOTHER, HEALTHY CHILD

6-9 months 9-12 months 1-2 years

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The Feeding Bowl and Spoon

Pregnant& breastfeeding

Baby: 6-9 months

Baby: > 12 months

Baby: 9-12 months

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HEALTHY MOTHER, HEALTHY CHILD

Pregnant Mothers

Clean bowl and spoon

after each use

Use clean water to

prepare food

0-6 months

Make sure food is

thick enough

Baby: breast milk only

Mother:

HEALTHY MOTHER, HEALTHY CHILD

6-9 months 9-12 months 1-2 years

FRONT BACK 10

Prototype Development and Production

• Volumes estimated based on following assumptions • Additional kcal needed from complementary foods assuming average breast milk intake of

infant (Dewey & Brown 2003 Food Nutr Bull)

• Based on age-specific total daily energy requirements + 2SD to meet the needs of almost all children minus the amount of energy provided by breast milk

• Energy density of 0.7-0.8 kcal/ g

• Additional kcal needs of healthy pregnant / lactating woman (NRC, 2006)

• Slot size (0.3mm) based on testing flow rate of porridges of varying energy densities through pre-drilled, standardized slots

• Designs for bowl and spoon generated in SolidWorks, a 3D modeling program

• Initial prototypes produced on Stratasys 3D printer

• Critical review provided by IYCFrMN programmers and academic nutrition community working in East Africa and India

• Final prototypes for field testing produced in food grade, opaque (white) polypropylene via a protomold® injection molding process by Proto Labs, Inc. • Molds run 8000 USD (stable for up to ~10,000 production units)

• Per piece costs run $3.00-5.00 USD b/c production is small scale

• For scaled production (>10,000), per piece costs estimated at < $3 USD (excluding costs of mold)

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FIELD TESTING

AND FINDINGS India Partner: CARE, India and the Integrated Family Health Initiative

Student: Deborah Kortso Collison, MSPH

Kenya Partner: International Potato Center, Mama SASHA Project

Student: Nidal Kram, MPH

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Field Testing for Acceptability and Feasibility

Bihar, India Western, Kenya

Phase I: Acceptability, KAP,

Counseling Cards

Comprehension

16 FGDs

8 key informant

interviews

12 FGDs

5 key informant

interviews

Phase II: 14-20 day user testing

• Baseline

• Midline

• Endline

• FGDs with user families

20 PW

20 LM <6 mos

20 CF mothers, 6-18

mos

2 FGDs

14 PW

14 LM < 6 mos

32 CF mothers, 6-

15 mos

2 FGDs

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Nutrition in the first 1000 days: It’s a

guessing game “It is difficult to show. We just estimate from what the child

eats. Each child and his stomach” -- Mother of child 6-24

months, India”

“They tell us to eat more, one extra meal to what we eat

but we do not know the amount just the number” pregnant

woman, India

“I am afraid to feed the child too much for fear they will

constipate” Rural Kenyan mother with 11 month old infant

“Feeding frequency is majorly determined by the baby’s

appetite. One with high appetite is fed many times”. Urban

Kenyan mother with10 month old infant

“When the ASHA comes to visit me, she stays just for a

short time and she is always in a hurry to leave so the

information she gives is not clear enough. I cannot ask her

questions because she talk and then says she has to

leave so I can come and ask anytime I visit the ANM…”

Rural PW, India

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Pregnant and Breastfeeding

Mothers 3-4 meals /d extra meal / d Animal protein

(meat/eggs)

BL EL

BL

EL

BL

EL

India

Pregnant Women 2 / 20

10%

18 /20

90%

0 /20

0%

20 /20

100%

5 /20

25%

15 /20

75%

Breastfeeding

Women

0 / 20

0%

20 /20

100%

0 /20

0%

20 /20

100%

10 / 20

50%

20 / 20

100%

Kenya

Pregnant Women 4/14

28%

10/10

100%

0 /14

0%

9/10

90%

Breastfeeding

Women

6/15

40%

12/14

86%

6/15

40%

12/14

86%

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Pregnant and Breastfeeding

Mothers

“Earlier I used to feel lazy. Now I don't feel like that. Everyone says the child is

looking healthy and he is not crying anymore and was asking why I do not give him

other milk anymore.”- Breastfeeding Mother, India

“It helped me. I am now eating more food than what I used to eat before... Even if I

have forgotten, when I look at the chart, I remember and say “oh I haven’t eaten

today”. I have to make thick porridge and eat in the bowl. When I went to the

hospital, I found out that I have gained more weight.” Rural pregnant mother,

Kenya

“I take a bowl full of githeri or bananas and then I take

porridge afterwards. I now have strength in the body to be

able to work. I used to eat before, but I would still feel weak

afterwards. But I now have strength because of the extra

porridge that I take...”- Urban Pregnant Mother, Kenya

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Recommended

number of

meals per day

Recommended

quantity of

meals

Recommended

Thickness

BL

d0

EL

d14

BL

d0

EL

d14

BL EL

India

6-8 mo (n=6) 0% 100% 0% 100% 0% 100%

9-11 mo (n=6) 0% 100% 0% 100%

12-18 mo (n=8) 0% 100% 0% 100% 50%1 100%

Kenya

6-8 mo (n=14) 28% 100% 42% 92% 21% 83%

9-11 mo (n=10) 70% 86% 10% 100% 70% 86%

12-18 mo (n=11) 45% 72% 0% 50%2 45% 70% 1 Combined 9-24 mo; 2 Depicts lower uptake-mothers of 12-18 month olds who used the bowl for ugali only and did not

measure accompaniments (vegetables, meat/eggs) even though they were consumed

Complementary Feeding

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Consumption of Protein Rich Foods, Kenya

0%10%20%30%40%50%60%70%80%90%

100% Baseline

Midline

Endline

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

6-8 months 9-11 months 12-18 months

“…I just used to deny my child [new] foods thinking she couldn’t chew

them, but she actually enjoys eating them.” Rural mother who began

feeding vegetables during testing

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“I used to estimate the food my child will eat. I did not know the right amount to give

him and ASHA also never told me the amount to feed the child. She always says I

should feed my 8 month old child 2-3 times a day using this measurement. She

carried a bowl that she never gave to us to use and also never demonstrated in the

anganwadi center on how thick the food should be. I am happy I have this bowl with

the marks and spoon with holes to use…Now my child is eating at the 6-9month full

mark after 14 days and he is very active and healthier and does not cry like he used

to”. Rural Indian mother of 8 months old

“For me it was the demarcations on the bowl that pleased me as they enabled me to

feed my baby food that was adequate for his stomach since before then I didn’t feed

enough food, but when you gave me the bowl I now see that the baby has good

health.” Rural Kenyan Mother of 11 months old

Before l would prepare the baby’s food and add water thinking that it was too thick

then l would stir using the normal spoon until it was like porridge and that is what l

termed as good food. My co-wife passed by my house today and told me that l was

feeding the baby thick food and that l should add water but l refused l told her that he

would eat it slowly and eventually finish the food” Urban Kenyan mother of 7 months

old

Complementary Feeding

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Engaging Families and Communities

• “I now feed my child 3 times a day and my husband and mother in law support me. When I am away my mother in law feeds the child with the bowl and spoon and my husband always remind me or his mother not to forget to feed the child with the bowl”. ”-Urban Indian mother of 7 month old

• What I liked about it [counseling card] was that there is information on the types of food that l should feed the baby so that he can completely get energy. It has made also ask his father to sometimes buy him bananas and he would bring. I also sometimes make beans so that he can eat or eggs ” Kenya rural mother, 7 months

• One woman told me that if I was living near her, she would come borrow the bowl and use it to measure food and mark the correct levels on her cup so that she can know the correct amount of food to feed [her] baby – FGD with rural users, Kenya

• When people visit my home, they usually ask about the card. That is when I pretend that I am a teacher. I teach them about the card and I even show them the bowl and the spoon. Rural Kenyan mother, 10 month old infant

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Challenges for Mothers

Pregnant

• Forgetfulness

• Resistance from family members

(India only)

• Fear of having large babies due to

consumption of too much foods

• Competing priorities

• “I don’t eat more because we are

buying food and there are other

needs. My other children are in

school and they require school fees.

I cannot concentrate on eating food

and forget about their education”

Kenya, urban PW

Lactating

• Misunderstanding number of

times to use the bowl

• Forgetfulness

• Food insecurity

• “Sometimes brother can

go and look for food and

sometimes he gets and

sometimes he does not

get” Kenya, rural LW

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Challenges for Complementary Feeding

• Preparation of thick porridge (especially Kenya)

• Feeding eggs, protein rich foods

• taboos vs food insecurity

• Force-feeding (Kenya)

• when he refuses to take his porridge… I press his cheeks and pour

porridge on my palm and I let it flow into his mouth. He at least

takes about two palms of porridge.” urban mother 8 month old,

Kenya

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Feedback on the toolkit components

• The spoon and bowl should be in steel … in this community we do not eat in plastic and so we don’t know how to clean it and will bring about hygiene problems so it will be better if all the marks and holes are in a steel bowl.”- India mother of 6-23 month old

• “What I liked about it [counseling card] was that there is information on the types of food that l should feed the baby so that he can completely get energy. It has made also ask his father to sometimes buy him bananas and he would bring. I also sometimes make beans so that he can eat or eggs ” Kenya rural mother, 7 months

• “I just want a lid, then lengthen the handle of the bowl and smoothen the edge of the spoon” – FGD with rural users, Kenya

• “The food in the card is not so clear whether that is chapatti or for the sweet potatoes one can’t tell whether it is potatoes or carrots, so make correction -- but for the rest even a blind person can see” -- FGD with rural users, Kenya

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Updated Prototype

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Limitations

• Small sample size

• Intensive counseling by highly trained RAs

• Qualitative assessment

• Short study period

• No comparison group

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LESSONS LEARNED

AND GOING FORWARD

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LESSONS LEARNED

• Toolkit: Plastic not acceptable in India; prefer steel; Spoon considered

too sharp / big; Counseling cards useful to families to understand, share

information and serve as a reminder /reference

• Concept enthusiastically received by community members

• Inclusion of family members in initial counseling was critical and

appreciated

• Food security and fears of a big baby could be problem for maternal

nutrition

• Need to include components on responsive feeding to avoid potential

forced feeding

• Hygiene needs greater emphasis – In India, most bowls were oily even

after washing, some used mud to wash, some only used water; both

settings food allowed to sit in bowls for extended times

• May be very useful “cue to action” for adequate diet during the entire

1000 days but needs rigorous testing in field settings

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The Way Forward • Bowl and spoon should be evaluated for effectiveness / cost

effectiveness

• Compare against counseling / counseling cards alone

• Diet and nutritional status through 1000 days

• Modifications to the bowl and spoon to increase

acceptability:

• Adding extra handle to bowl

• Manufacturing in steel (India)

• Making spoon handle longer, basin smaller and smoother

• Refine counseling cards; make them appealing to whole

family (ie. calendars)

• Incorporate responsive feeding; hygiene counseling; and

cooking demos to show quantity, consistency and how to

incorporate diversity

• Utility as FLW job aid

• Partnerships between academics, organizations, ministries,

manufacturers for production and testing in program contexts

8 month old child who had not started

CF but MIL and mother started after the counseling and user testing of bowl

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Acknowledgements

• Development and Testing Team: Jonathan Colton (GT),

Sarah Melgen, Nidal Kram, Debbie Collison and Wendy

Blount (GT)

• Prototype reviewers: Lenette Golding, Ann DiGirolamo,

Alysse Lowe, Elizabeth Noznesky, Usha Ramakrishnan,

Reynaldo Martorell, Helena Pachon, Sridhar Srikantiah

• BMGF Grand Challenges Explorations

• CARE India Integrated Family Health Initiative, Bihar

• International Potato Center, Mama SASHA project,

Western Kenya

• Participants, field teams and mentors in India and Kenya

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QUESTIONS

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