Determinants of complementary feeding practices among Nepalese children aged 6–23 months: findings from demographic and health survey 2011

In 2006 an estimated 9.5 million children died worldwide before the age of five; of which 35% were due to under nutrition [1, 2]. The major measures of under nutrition in developing countries include stunting, wasting, and micronutrient deficiency [2]. Children aged 6–23 months are at a greater risk to suffer from under nutrition. It is during this period that a child moves from mother’s milk to solid foods as its primary source of nutrition. When introduced to solid foods, the child may suffer from indigestion, infection, insufficient food or a combination of these. This can result in childhood under nutrition. Like many developing countries, wasting and stunting have long been problems in Nepal. There has been little improvement in the nutritional status of children over the past decade 2001–2011 [3, 4]. The proportion of children underweight (weight <2 SD below the mean) was 10% during 2001 and had increased to 13% in 2011. Stunting (defined as height for age <2 SD below the mean) was 43% in 2001 and 41% in 2011 [3, 4]. Given that under five mortality is 54 per 1000 live births, the existing high proportion of under nutrition makes it complicated to reduce under five mortality rates [4]. Under nutrition in early life has further long-term impacts when the child becomes an adult leading to an intergenerational effect and causing loss of productivity [5]. Providing an age appropriate and adequate diet is a proven measure to reduce under nutrition among children.

Complementary feeding practice is a significant factor that determines the nutritional status of children. Suboptimal infant feeding practices are the major reasons for childhood under nutrition in developing countries including Nepal. The transition period from exclusive breastfeeding to two years is a critical window for optimal growth and development of the child. During this period, appropriate, safe, adequately nourished and frequent feeding is essential. The caregiver should know what, how, and when to give appropriate food. Unknowingly, the food provided to a child might be too high or too low in some nutrients, the diversity of food might be adequate or inadequate, and micronutrient content including iron could be lower than required if they rely on certain food items such as cow’s milk and simple porridge [6]. The World Health Organization (WHO) has developed eight core infant and young child feeding indicators to monitor and to guide the feeding practices of young children [7]. WHO core indicators include: (1) early initiation of breastfeeding; (2) exclusive breastfeeding under six months; (3) continued breastfeeding for one year; (4) the introduction of solid, semi-solid or soft foods; (5) minimum dietary diversity; (6) minimum meal frequency; (7) minimum acceptable diet; and (8) consumption of iron rich or iron fortified foods.

Infant and young child feeding indicators are relatively new and; little has been explored in Nepal. Only one study has reported these indicators using the 2006 NDHS data [8]. The study reported that 82% of the children aged 6–23 met minimum meal frequency while 34% met diversity and only 32% had had an acceptable diet [8]. However, the study [8] excluded children who were not breastfed when examining the minimum acceptable diet indicator because not all information was collected in 2006. The 2011 NDHS did include information for non-breastfed children which enable their information to be included in the analysis giving more accurate estimates of feeding practices. Updated knowledge of feeding practices will assist the national nutrition program to better monitor the changes in the feeding practices and design interventions to increase the recommended feeding practices and thereby contribute in reducing under nutrition in Nepal and elsewhere. Utilizing the NDHS 2011 data, this study aimed to (i) describe the rate of providing minimum dietary diversity, minimum meal frequency and minimum acceptable diet amongst young children aged 6–23 months in 2011 and (ii) identify the factors associated with minimum dietary diversity, minimum meal frequency and minimum acceptable diet amongst young children aged 6–23 months.

Like many developing countries, stunting and wasting have long been major nutritional problems in Nepal. The existing high proportion of under nutrition (41% stunting and 13% underweight among under five children) makes it complicated to reduce the under-five mortality in Nepal [4]. Nepal is a signatory of the millennium development goals (MDG) [16] and has achieved a significant reduction in child mortality [17]. It has committed to reduce child mortality by a further two-thirds by 2015 from the 1990 figures. Nepal has also committed to reduce extreme poverty and hunger [18]. Both of these goals are closely related to under nutrition and progress towards reaching these goals will be limited if the under nutrition is not reduced substantially. Not limited to these two goals, all other MDGs are directly or indirectly related to nutrition and are likely to worsen by under nutrition [19]. To reduce under nutrition adequate, safe and acceptable child feeding is essential. For this reason, WHO and UNICEF have recommended eight core infant feeding practices to be adopted [7]. To better promote such recommended practices, it is essential to demonstrate the evidence on the existing proportion of children reaching the dietary practice’s goals. This study reports the proportion and the determinants of receiving the recommended diets among the 6–23 months Nepalese children.

Three infant and young child feeding practices (minimum dietary diversity, minimum meal frequency and minimum acceptable diet) were assessed in this study based on the WHO recommendation and indicators [7, 9, 15]. It was found that only 30.4% of children received the recommended minimum dietary diversity, 26.5% received an acceptable diet and 76.6% received the recommended minimum meal frequency.The proportion of breastfed children provided with minimum acceptable diet was 27.4% which was slightly lower than the figure in 2006 (32%) [8]. In 2006 [8], 34% and 82% of the breastfed children received the minimum diversity and minimum meal frequency, respectively.

The prevalence of meeting these infant feeding practices varies across the countries in South Asia. The minimum diversity criteria reported in this study was higher than India (15.2%) but lower than Bangladesh (41.9%) and Sri Lanka (71.1%) [12]. Likewise, meal frequency was also less than in Bangladesh (81.1%) and Sri Lanka (88.3%). Current findings for attaining the minimum acceptable diet for children were also lower than previous studies in Nepal, Sri Lanka and Bangladesh [12]. It is difficult to determine how high the population percentage for infant and young child feeding practices would need to be in order to significantly eliminate current levels of under nutrition among children in Nepal. The WHO guidelines on infant feeding do not provide the baseline or the minimum standard that needs to be reached nor what percentage should be considered alarming for public health significance [7, 15]. Logically, it is desirable that all young children (6–23 months) meet the recommended feeding practices.

To understand the low levels of dietary diversity and acceptable diet provided to Nepalese children, it is necessary to look at the food items provided to children. The majority of food items given to Nepalese children were from the grains, roots or tubers (Food Group 1) that are rich in carbohydrate (energy). Food items from the other six food groups were given to less than a half of the children. When diversity does not exist across the food items, it negatively affects the findings for minimum dietary diversity and acceptable diet.

A notable finding was a major change in diets across the various age groups that improved with age. This finding suggested that the youngest age group 6–11 months received the lowest proportion of food from all seven categories of food. This age group was least likely to meet the recommended meal frequency, meal diversity and acceptable diet standard than the older (12–23) children. It shows that 6–11 months children were even more at risk of under nutrition and micronutrient deficiency. The children of age group 6–23 months go through a reasonably rapid dietary transition from exclusive breastfeeding to complementary feeding. While changing the diet, they are vulnerable to diarrhoeal infections [20, 21]. During this period, young children need more nutrition to overcome the adverse effect of such illness. Unfortunately, the current finding indicated that the children in this age group were not getting complementary foods as recommended by the WHO.

Nepal has achieved significant progress in reducing vitamin A deficiency disorders such as night blindness [16]. This achievement was mainly due to the high dose vitamin A supplementations that are provided twice a year to all under-five children. This supplementation is important given that currently only a third of the children in Nepal received vitamin A rich foods in their diet. A major public health strategy to increase vitamin A in the diet is to focus on dietary modification and increase consumption of vitamin A rich foods. Adequate vitamin A can be achieved through local foods but it requires careful attention to reach the need based on existing practices [22, 23]. Miller et al. [24] quantified the dietary modification required if a child were to depend entirely on normal diet for vitamin A without any supplementation. They reported that a child in a developing country would need to increase the proportion of vegetable and fruit by about 10 folds to attain minimally adequate liver vitamin A storage. This 10-fold increase in vitamin A rich food may not be feasible to reach in Nepal in the short term. Therefore, the existing twice a year supplementation of high dose vitamin A (2,00,000 IU) should be maintained to prevent the reversal of progress made in controlling the vitamin A deficiency disorders so far [16, 23, 24].

Factors found to be associated with one of the three infant feeding practices were attending antenatal care visits, age of mothers, development region, and ecological region, education of mothers and education of fathers.

Antenatal visits during pregnancy are not very common in Nepal. Less than a half of all pregnant mothers meet the recommended four or more ANC visits [4, 16]. Mothers who have attended at least four ANC visits may be more informed, have greater access to services and may be from a well off family, and thus more likely to be able to afford and provide a variety of foods to their children more frequently. This could explain why ANC was a significant determinant in meeting the recommended acceptable diet and meal frequency criteria.

The age of mothers at pregnancy was another determinant for dietary diversity and acceptable diet. Mothers who were pregnant at an older age (>=35 years) were more likely to provide diversity food and minimum acceptable diet than those mothers who were pregnant at the age of under 20 years. This could be due to the fact that older mothers may be more experienced/confident in feeding children and encouraging different types of foods than younger mothers [25].

Geographic differences are important in terms of determining the access to food and other services. The children from the Mid-western region were less likely to meet the minimum diversity and frequency criteria when compared to the children from Eastern region. Similarly, children from the Far -western region were less likely to get minimum frequency compared to the children from the Eastern region. While current results confirm the international findings for regional difference [11, 13, 14], it also reiterates an issue of insufficient child feeding in the Far-western and Mid-western part of Nepal. This could be a function of remoteness, geographic difficulties, less food production and higher levels of poverty in these regions [26]. Children as a general rule suffer greater disadvantage when living in impoverish conditions. Mid-western and Far-western regions have been suffering from the food insufficiency for a long time especially in the hilly and the mountainous areas [26, 27]. Poverty is very high in the Mid-western and Far-western Hilly regions of Nepal. Deraniyagala [28] reported that the poverty levels in the Far-western and Mid-western hills were as high as three times than in the Eastern regions. Most of the Far-western and Mid-western regions have to depend on the limited amount of food provided by the government subsidies through the Nepal Food Corporation and international donors such as the World Food Program [26, 27, 29]. Unfortunately, such food aid (especially rice) has discouraged local food production such as potato, maize, barley and beans making these areas even more vulnerable for food insecurity than before. Historically there is a tension between the continuous push of imported rice and the option of encouraging locally cultivable food items such as potato, millet and barley [29]. This tension although not directly related to the health sector, it affects the food availability in the regions and cannot be ignored as a contributing factor to child under nutrition. Our finding further re-iterated the vulnerability of the children in the Mid-western and the Far-western development regions. This finding also suggests that policy makers and program managers of health and development assistance programs need to consider the regional differences when planning for further programs aimed at improving child nutrition in order to meet the MDG.

The education level of mothers and fathers has been consistently reported as the determinant of infant feeding [14, 30]. This study also found similar results. A recent comparison of five Asian countries on infant feeding reported that mother’s education was a significant determinant of appropriate infant feeding [12]. Sri Lanka had the highest proportion of children meeting the infant feeding guidelines for diversity, frequency and acceptability; and this was linked to the higher education status of mothers and overall literacy [12]. The similar positive impact of education on feeding practices was also reported in a previous Nepalese study [8]. Educated mothers and fathers are more likely to understand the education message, more likely to be engaged in the paid work and may have a higher socioeconomic level which could positively impact on infant feeding practices.

There are a number of strengths of this study. This study is based on the NDHS which used internationally validated questionnaires and methodology [31]. The NDHS 2011 is nationally representative survey with a high response rate (>94%); therefore, the three infant feeding indicators reported in this study are generalisable for the entire country [8]. The current findings give an indication for future interventions and a benchmark for future comparisons. It should be noted that minimum acceptable diet was closely related to the minimum dietary diversity that was similar to the findings from other South Asian countries [12]. In future studies, dietary diversity could be considered as a simple proxy indicator for acceptable diet [12, 32].

Like any other observational studies, this study has some limitations. The cross sectional nature of the study prevents it from developing causal inference. The information in DHS surveys is based on interviews and retrospective information. There is possibility that some of the responses might suffer from recall bias and socially desirable response. This study does not take account the multistage sampling during statistical analysis. This may cause less precise estimation of standard errors and confidence interval. Another limitation related to the three infant feeding practices included in this study is the quality and amount of food given. Although the definition of the indicators deals with the variety and frequency of food, it does not take account of the quality and amount of food provided. For instance, a child who has been provided all three recommended infant feedings criteria might still not have a nutritionally adequate diet. However, for the countries whose data rely on the DHS surveys, this is the best possible evidence on the infant feeding practices at this time [1, 7].

The study revealed that a high proportion (>90%) of children received tuberous foods. Less than one third (30.6%) of the children were getting vitamin A rich fruits and vegetables. Children were getting energy rich foods but not all of the required nutrients. Only one in three children was meeting the recommended dietary diversity and acceptable diet. A comparatively higher proportion (76.6%) of children met the recommended minimum meal frequency. The age of mother during pregnancy, the development region, mother’s education, and father’s education were the significant determinants of achieving the recommended dietary diversity. ANC visits, and the place where the family lives (development region, and ecological region) were significant determinants impacting on meeting the recommended meal frequency. ANC visits and education of mothers were significant determinants of meeting the recommended minimum acceptable diet. An appropriate mix of educational intervention and supplementation could be feasible option to improve infant feeding practices in Nepal with a special focus on the Far and Mid-western region. There is a need for future intervention studies for improving the infant feeding practices.

VK holds an MPH degree. He has been working in child health programs in Nepal for more than five years. Newborn care and child nutrition is the focus of his work in Nepal and MPH studies. Yun Zhao is a senior lecturer in the School of Public Health and teaches in the postgraduate programs. She has an MSc and PhD in statistics. Kay Sauer is a senior lecturer in the School of Public Health and coordinates the MPH/DrPH programs. She has an MSc and PhD in Behavioural Sciences.