The development of food based dietary guidelines (FBDGs) for 6 to 23 month old Rwandan children

Abstract

Background: Stunting (low height for age), a measure of chronic malnutrition among young children, is a public health problem in Rwanda. Exclusive breastfeeding for the first six months is common and routinely practised. Complementary feeding practices, on the other hand, are inadequate, which could explain the high prevalence of stunting seen among Rwandan children aged between six and 23 months. Inadequate nutrition has significant short and long term consequences for both the physical and cognitive development of children. Nutrition education given to caregivers using appropriate tools, such as food-based dietary guidelines (FBDGs), can improve infant and young child feeding practices and nutritional status. FBDGs are nutrition education messages based on scientific evidence, intended to present nutrition information using language and symbols easily understandable to the general public, health providers and lay individuals. Aim: The aim of this thesis was to develop FBDGs to improve the feeding practices and the nutritional status of children of six to 23 months old in Rwanda. This study investigated the complementary foods consumed, the dietary diversity and the energy and nutrient intake of children aged six to 23 months in Rwanda. In addition, the factors influencing caregivers’ complementary feeding practices were studied. Design: This was a cross-sectional study using interviewer-administered food frequency questionnaires and single 24-hour dietary recalls with the main caregivers of 765 children aged six to 23 months from eight of Rwanda’s 30 districts. For mixed dishes, local recipes were collected and the average proportion of each individual ingredient calculated. A food composition database for the purposes of this study was compiled by adding data from, in order of preference, the Ugandan food composition table, food composition table for Rwanda, and South African food composition tables. Furthermore, a descriptive qualitative study was done in which ten focus group discussions were conducted with caregivers from five districts to investigate the knowledge and practices of complementary feeding. Results: Dried beans and green leafy vegetables were consumed by more than half of the children, according to both the food frequency questionnaire and the 24-hour recall. Dried small fish and cow milk were the only animal products consumed by more than 5% of the children. Breast milk was consumed by 79.9% of the children. The median daily energy intake was 650 (549-839) kcal/d, 765 (607-1051) kcal/d and 801 (592-1236) kcal/d for children aged six to eight months, nine to 11 months and 12 to 23 months respectively. Around half of the children in the age groups six to eight months (43.4%), nine to 11 months (53.1%) and 12 to 23 months (57.8%) had an energy intake below the recommendation. Over 80% of the children in the age groups six to eight months and nine to 11 months did not meet the recommended nutrient intake for calcium, iron, zinc and vitamin A. Apart from breast milk, the top five foods that contributed to energy were dried beans (11.36%), cassava pap (6.41%), cow milk (5.86%), maize (5.08%) and sweet potato (4.49%). Dried beans contributed most to iron (33.54%) and second most to zinc (21.35%). The complementary diet on average did not reach the desired nutrient density for iron and zinc, and a high proportion (>60%) of the children, in all age groups, had iron and zinc intakes below the recommendation. Caregivers’ knowledge and beliefs about the benefits of breastfeeding and timely introduction of complementary food seemed to be the primary factors promoting good practices. However, the common belief that infants should be given liquids (thin gruel, fruit juices and meat broth) as first foods instead of semi-solid foods might compromise child nutrition in the first months of complementary feeding. The community-based nutrition education and counselling programmes were facilitators of good complementary practices. The knowledge and understanding acquired through the above-mentioned quantitative and qualitative studies and infant and young child feeding (IYCF) recommendations from the WHO were used to formulate the following food-based dietary guidelines : (1) Breastfeed exclusively for six months and start complementary feeding at six months, while continuing to breastfeed your baby until two years or beyond; (2) Feed your baby food of a thick consistency; (3) Feed your baby a variety of nutritious foods; (4) Feed your baby small dried fish, cow milk, eggs or meat every day or as often as you can; (5) Follow hygienic practices while preparing, storing and feeding the complementary food; (6) Create a clean environment for your baby. Conclusion: Nutrient intakes are reported for the first time for this population in this thesis. This was made possible by adapting existing food composition tables to contain local foods and recipes. The findings generated contribute to scholarly knowledge about IYCF in Rwanda and probably also in other developing countries, especially in Africa. We propose that FBDGs, as a nutrition education tool, may complement other interventions to address sub-optimal complementary feeding practices in Rwanda