Evaluation of food-based recommendations to improve diet quality for children 12-23 months of age in Kathmandu Valley, Nepal

Abstract

EXECUTIVE SUMMARY Introduction: There has been significant improvement in the nutritional status of Nepali children in recent years, however high rates of stunting, anemia, and undernutrition still exist. Poor dietary practices are a major contributing factor for undernutrition among Nepalese children. A study by Helen Keller International’s Assessment and Research in Child Feeding (ARCH) project conducted in 2017 in Kathmandu Valley revealed an association between high consumption of unhealthy snack foods and beverages and stunted growth, as well as risk of dietary inadequacy among children aged 12-23 months. As the first two years of life are crucial for a child’s growth and development, it is important to identify strategies to improve children’s diets with locally available foods which are also sources of multiple micronutrients. Objective: This study aimed to evaluate food-based recommendations (FBR) to improve the diets of 12-23-month-old children in Kathmandu Valley, Nepal. Methods and analysis: An observational study using a mixed methods approach was conducted in Kathmandu Valley, Nepal. Study tools were adapted from ProPAN guidelines and modified to the Nepalese context. The study included four steps: Step 1 (Food Attribute Exercise), Step 2 (Recipe Creation Exercise), Step 3 (Household Trial), and Step 4 (Focus Group Discussion). A total of 36 caregivers of at least one child 12-23 months of age were recruited for the Food Attribute Exercise (FAE); the same participants were included in the Recipe Creation Exercise. For Household (HH) Trials, 75 caregivers of at least one child 12-23 months of age participated. Those who participated in the final visit of the HH trial were included in Focus Group Discussions (FGD). A thematic analysis approach was used to conduct data analysis of the FAE, HH trial, and FGD. A recipe tool was prepared from FAE data analysis which was used in the Recipe Creation Exercise. In the Recipe Creation Exercise, an analysis of two prepared dishes was conducted. Minimum Dietary Diversity from the HH trial was calculated and feeding practices of children 12-23 months of age before and after the HH trial of the recommendation was assessed using Microsoft Excel. 4 Findings: The findings from the study are presented around the four exercises conducted consecutively. 1. Food attribute exercise The first exercise was focused on food perceptions, current feeding practices, and availability of the food recommendations: milk, egg, lentils, vegetables. All the foods were considered nutritious and perceived as providing nutrition to children by most participants. 2. Recipe creation exercise Based on the findings and discussion with participants, the new recommended jaulo and pancake recipes were selected. The new recommended jaulo recipe would be used to fulfil the lentils and vegetables recommendation; and pancake recipe would be used to fulfil the lentils and egg recommendation. 3. Household trial The household trial assessed the compliance, acceptability, and feasibility of the four food-based recommendations. A recipe calendar used for introducing FBR in the initial household visit was found to be useful for participants to help them remember recommended foods and recipes. Compliance, acceptability, and feasibility of FBR were assessed from the second and third visit of HH trial. This trial found the percent of children achieving minimum dietary diversity (MDD) during initial and final household trials was 73.0% and 92.0% respectively and the increase in the proportion achieving MDD was found to be statistically significant. Statistically significant increase in the consumption of vitamin-A rich fruits and vegetables was also found. a. Compliance Most of the children were found to be consuming breastmilk, and among the non-breast-fed children, most were consuming milk. The majority of caregivers were feeding at least four eggs in a week. The consumption of lentils daily as recommended was also high, whereas cabbage, carrot and tomato were found to be fed in low amounts to young children. However, consumption of any vegetables daily in recommended amount was high. The new recommended jaulo recipe was used by most of the participants but full compliance was not achieved. Nearly half of participants did not feed pancake to their children. b. Acceptability Most participants reported their children liked to drink milk and eat eggs. The reason reported for the few children not consuming milk and egg was because they did not like them. Lentils were liked by the children either with new recommended jaulo or with rice. Adding vegetables enhanced the taste of new recommended jaulo, hence children liked it. Compared to carrot and tomato, children did not eat cabbage because it is not as soft as other vegetables, and green leafy vegetables were used instead. The acceptability of jaulo was good among participants and it was 5 found that cooking practices changed after the cooking demonstration. However, the pancake recipe was not liked by most of the children and they preferred eating lito or eggs. c. Feasibility Lentils were reported as a feasible recommendation in terms of cost. Most of the participants also reported milk and eggs were not costly. Vegetables were also not found to be costly by the participants in general. However, some participants perceived it as causing additional expense; buying different vegetables causes a slight increase in expenses. Time and effort was not reported to be a problem to prepare the new recommended jaulo and pancake for most of the participants. 4. Focus group discussion Participants perceived the recommended foods and recipes to be healthy and nutritious for their children. They were happy to learn new information for feeding young children. They further learnt proportions and frequency of recommended foods and recipes to be fed to their children. Conclusion: Findings from the study can be used to promote FBR at a larger scale and inform behavior change communication strategies for promotion of FBR in the future.