ACCELERATING NUTRITION IMPROVEMENT (ANI) APPLICATION OF FOOD BASED APPROACH TO IMPROVE COMPLEMENTARY FEEDING MINISTRY OF HEALTH

Of all children under five in Uganda BACKGROUND Of all children under five in Uganda One third are stunted 14% are underweight 5% are wasted, Prevalence peaks during the complementary feeding (CF) period. Poor infant and child (IYC) nutrition indicators are linked to high rates of infection and mortality rates

BACKGROUND - IYCF including breastfeeding and complementary feeding is not optimal 63% of children are exclusively breastfed for the first 6 months. - 5.8% of children aged 6-23 months receive minimum acceptable diet. 12.8% of children aged 6-23 months receive minimum dietary diversity. NB: Nationally over a third of Uganda children aged 6-23 months had low dietary diversity rising to well over half in the Western Region by 55%

WHO-ANI PROJECT In 2012 World Health Organization received funding from the Canadian International Development Agency (CIDA)/DFATD entitled “ANI- Accelerating Nutrition Improvements” to support 11 countries in Sub-Saharan with aim of reducing stunting among under 5 children. The countries include: Uganda, Burkina Faso, Rwanda, Ethiopia, United Republic of Tanzania, Zimbabwe, Mali, Senegal, Mozambique, Sierra Leone, and Zambia.

WHO-ANI PROJECT FOR UGANDA The project is in in line with Uganda Nutrition Action Plan (UNAP) strategy to reduce malnutrition. Aimed at improving infant and young child feeding practices through increasing consumption of nutritious foods and adequate complementary feeding, improving nutrition knowledge and practices, especially in the “critical window” of conception through 23 months.

THE PROJECT OBJECTIVES FOR UGANDA General Objective: Reduce stunting among children under 5 years. Specific Objectives: Support the scaling-up of evidence-informed nutrition actions focusing on improvement of complementary feeding of children 6-23 months by use of a Food Based approach. Strengthen nutrition surveillance systems in collaboration with government national Health Information Management Systems (HMIS).

PROJECT’S INTERVENTION DISTRICTS MASINDI NAMUTUMBA HOIMA LUUKA KIBAALE IGANGA

Development of the Food based recommendations – Process in ANI Uganda 4. Developing and rolling out SBCC strategy 3. Testing for feasibility through TIPs 2. Optimizing complementary food recipes 1. Generating evidence through surveys

GENERATING EVIDENCE THROUGH SURVEYS Awareness on nutrition problems Capacity to implement nutrition actions Nutrition interventions coverage - Landscape analysis - Mapping Barriers and facilitators Influencers IYCF practices Feasible and effective channels that can be to promote IYCF practices KAP study on IYCF practices Dietary patterns, Dietary adequacy in terms of nutrients Nutritional status including hemoglobin level Adequacy of current feeding practices Cost and seasonality of principle food sources for child feeding Food based pattern survey DISTRICT COMMUNITY HOUSEHOLD

Nutritional Status of children (6-23 months) District Stunting Underweight Wasting Iganga 25.3 14.8 2.9 Namutumba 26.6 11.4 4.1 Luuka 31.7 15.8 3.7 Hoima 29.5 7.7 1.3 Masindi 21.9 7.0 2.0 Kibaale 38.9 16.1 5.2 Total 28.9 12.6 3.1 UDHS, 2011–National 27.2 15.7 8.3 UDHS, 2011–Eastern 20.6 8.5 UDHS, 2011-Western 35.8 17.6 4.8

Prevalence of Anemia in Children (6-23 months) Background characteristic Any anemia (<11.0 g/dl) Mild anemia (10.0-10.9 g/dl) Moderate anemia (7.0-9.9 g/dl) Severe anemia (<7.0 g/dl) Number of children Overall 81.0 27.7 47.6 5.1 1,407 Districts Iganga 89.3 25.1 57.8 26.4 422 Namutumba 83.8 18.4 58.7 29.0 179 Luuka 91.0 24.8 57.1 9.0 210 Total Eastern region 88.5 23.6 7.2 811 UDHS, 2011 67.0 27.9 38.1 3.1 419 Hoima 69.6 31.6 34.2 3.8 237 Masindi 69.0 36.1 32.3 0.6 155 Kibaale 68.6 32.8 33.8 2.0 204 Total Western region 69.1 33.2 26.9 2.3 596 UDHS, 2011, Western 48.8 26.0 14.9 2.2 285 UDHS 2011, National 62.3 25.2 34.4 2.8 759

IYCF Practices Initiation of breast feeding within one hour of birth Background characteristic Initiation of breast feeding within one hour of birth Exclusive breastfeeding Timely start of complementary foods from age 6 months Minimum Meal Frequency District Iganga 65 62 46 52.7 Namutumba 57.4 56 44 48.4 Luuka 61.1 54 43 47.1 Hoima 45.4 74 50 46.6 Masindi 44.2 73 51.6 Kibaale 55.9 69 51 44.9 UDHS 2011 52.5 63 67 44.8

KEY FINDINGS FROM THE KAP SURVEY BF and complementary practices do not meet the ideal practices for most of the IYFC indicators assessed Less than a third meet their daily energy requirement and less than 10% met their daily intake of key nutrients, Very low consumption of iron rich foods, iron supplements and deworming medications, low consumption of animal source foods Limited exposure to health messages related to IYFC

BARRIERS TO OPTIMAL IYCF PRACTICES –KAP Limited knowledge in IYCF Early initiation, Importance of colostrum, When and what complementary feeding to start with, Recommended number of meals per day, Nutrient and energy dense foods, How to increase feeds during and after illness Myths and misconceptions such as First thick yellow milk is dirty , pre-lacteal feeds strengthen the digestive system , Breast milk does not satisfy a child less than 6 months, When the baby eats solid food, it doesn’t need breastfeeding, Thicker foods constipate children Variety of foods is limited Selling of most food by households

2. Optimizing complementary food recipes Using Optifood : A software program that uses linear programing and mathematical optimisation to generate the nutritionally best diet for specific populations and test food based recommendations. using specific criteria such as locally available foods; dietary patterns; cost. Optifood can select the best diets from a range of possible combinations up to 1000 combinations The software identifies the lowest-cost combination of local foods that will meet or come as close as possible to meeting nutrient needs of specific target groups and local diets.

Optifood Food Composition Table 1- Primary source: HarvestPlus FCT for Eastern and Central Uganda (Hotz et al., 2012. 2-United States Dietary Association (USDA) Rationale Updated regularly Relatively few missing data Reliable in terms of quality Data for raw and cooked forms for many foods

HOW OPTIFOOD WAS USED Identified nutrients whose requirements are difficult to meet using locally available foods (problem nutrients) Identified the best local food sources of multiple nutrient problem nutrients Formulated food-based recommendations (FBRs) for specific target groups Combined and tested FBRs (dietary patterns, cost, nutritional adequacy) Identified the lowest cost, nutritionally best diet, given local food availability and usual dietary patterns

OUTPUTS The target groups for which recipes were developed 6-8, 9-11, and 12-23 months-old breastfed children and 12-23 months Non breastfed children from Eastern Uganda 6-8, 9-11, 12-23 months-old breastfed children and 12-23months Non- breastfed children from Western Uganda NB: Recipes for 8 different groups in total.

3. Testing for feasibility of recipes through TIPs: Tested feasibility and acceptability of the FBR (recipes) developed using household trials in the two regions. What is easier to implement for mothers and families, which is more difficult and motivations for their use The results informed modifications to the recipes in terms of food promoted, preparation, frequency, serving size and seasonality of access. The recipes trial results used to inform the development of the SBCC strategy, incorporating motivations to putting the recipes into practice and barriers and facilitators to implementation and potential strategies for overcoming these barriers

RECIPES FOR CHILDREN IN THE EASTERN AND WESTERN REGIONS

4. Developing and rolling out SBCC strategy: Based on the optimized and tested complementary feeding recipes and the KAP survey, SBCC materials - flip charts, posters of recipes, radio spots - were generated to achieve behavior change and strategies developed to reach the care givers through influential stakeholders within health facilities, communities and through media. The SBCC strategy with food based messages is tailored to the specific context of the targeted population.

SBCC strategy and communication channels Capacity building on DHIS2 Supportive supervision Development of the recipes Development of the SBCC strategy Development of the IEC materials Monitoring and reporting Orientation of stakeholders Orientation of science teachers Radio programs Management of malnutrition Recording and reporting BCC on IYCF Health activation Cooking demonstration Growth Monitoring and Promotion Community dialogues Food fairs National level Districts Health facility Community Recipes

SUSTAINABILITY: The intervention is in line with UNAP strategy and MOH priority areas. All nutrition stakeholders were involved through out the steps including; surveys, capacity building to gather and utilize local data to design effective, targeted interventions. Health systems were strengthened following the structures in place. Recipes are based on locally available foods

ACKNOWLEDGEMENTS WHO Uganda, AFRO and HQ Staff Steering Committee (Nutrition Working Group) Ministry of Health- Nutrition Unit REACH Mwanamugimu Nutrition Team IBFAN Team Service for Generations (SFG) International Study Team Communication for Development Foundation Uganda Team / Feed the Children Uganda District Local Governments, Communities in all the six ANI districts.

Appropriate Breastfeeding and Complementary Feeding is Key

FOR GOD AND MY COUNTRY Thank you for your attention