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Infant and Young Child Feeding [message #1693] Fri, 28 March 2014 13:53 Go to next message is currently offline
Messages: 1
Registered: March 2014
Location: Washington DC
The Pan American Health Organization/World Health Organization (PAHO/WHO) and Helen Keller International (HKI) strongly support the current child food frequency question (Q558) in the questionnaire. The data generated from this question is widely used to calculate the WHO/UNICEF indicators for assessing infant and young child feeding practices, develop and strengthen policies and programs to support optimal feeding, monitor trends and evaluate the impact of policies and programs. In the face of new trends and developments in maternal and young child nutrition, we wish to propose the deletion of one question (Q446), one new question and a small modification to response options for Q558.

DELETIONS: We propose that Q446 ("In the first two months after delivery, did you receive a Vitamin A dose like (this/any of these)?" be deleted. The rationale is that WHO no longer recommends postpartum Vitamin A supplementation for women .

REVISIONS: We propose three new response options for Q558 ("Now I would like to ask you about liquids or foods that (NAME FROM 557) had yesterday during the day or night. I am interested in whether your child had the item I mention even it was combined with other foods.").

• Add back the option "Any sugary foods such as chocolates, sweets, candies, pastries, cakes, or sweet biscuits?" (and adding the word "sweet" before biscuits). This option was included in the DHS 5 core questionnaire but not in the DHS 6 core questionnaire; however, many countries have continued to include it.

• Add two additional options: "Any soft drinks/soda/fizzy drinks/carbonated beverages?" and "Any savory snacks such as fried chips, crisps, or salted biscuits?"

Recent analyses of DHS datasets from 18 countries found significant consumption of sugary snack foods especially in Asia: 42%-75% among 18-23 month-olds. Having this option added back to the new DHS questionnaire will allow for monitoring trends in sugary food consumption. The reintroduction of the sugary foods option and two additional options are needed because there is clear evidence that diets high in sugar and salt are related to increasing rates of overweight among young children, long term impacts on chronic diseases and a high prevalence of dental caries. Such diets may also contribute to undernutrition by replacing breast-milk and more nutritious foods. A recent study by Helen Keller International (HKI) study showed that 45% and 43% of children 6-23 months of age in Cambodia consumed sugary and savory snacks in the previous 24 hours, respectively. In Nepal, these figures were 75% and 34%. Questions to assess the consumption of soft drinks have been used in large national surveys in Mexico and Brazil and by HKI in two countries so far. In Brazil in 2006, 12% of 2006 month old children consumed soft drinks. In the HKI study of capital cities of Cambodia, 19% of children 18-23 months of age consumed soft drinks and in Nepal, 2% did so

The data from the additional response options to Q558 will be used to develop new policies and programs to promote healthy child growth and prevent overweight and obesity, monitor trends in consumption of these foods and evaluate the impact of policies and programs to reduce their consumption. Preventing the increase in child obesity is also a global nutrition target endorsed by the World Health Organization (WHO) and so the information garnered from these additional options will contribute toward its achievement.

The proposed response options have been pretested and used in Cambodia, Nepal, Senegal and Tanzania and provide valid and reliable data. The response option on sugary foods was previously used extensively in previous versions of the DHS questionnaire. Tabulation of the date should be the same as is currently done for the other response options for Q558.

1. A new question is needed because the International Code of Marketing of Breast-milk Substitutes (Code), adopted by nearly all DHS countries, prohibits the promotion of infant formula and other breast-milk substitutes. Such promotion is well documented to reduce breastfeeding. Nonetheless, data show that this provision of the Code is widely violated. A recent study conducted by HKI showed that 86% and 28% of women had read, heard or seen a commercial promotion in Cambodia and Nepal, respectively. A Save the Children study showed this figure to be 11% in Pakistan. This question will provide information relevant to increasing exclusive breastfeeding, one of the global nutrition targets endorsed by the World Health Assembly (WHA).


This question could come after Q457 (what child was given to drink in first 3 days after delivery).

3. The data from the new question will be used to provide evidence for the need to strengthen countries' Code legislation and monitoring, and enforcement of their national laws that protect breastfeeding. It will also be used by programs to tailor breastfeeding messages to counteract inappropriate marketing of infant formula and other breast-milk substitutes. The proposed question has been extensively pretested and used most recently in Pakistan, Cambodia, China, Nepal, Senegal and Tanzania and provides valid and reliable data. Tabulation of the data should be in standard DHS format as a prevalence (those exposed to commercial promotion/those asked the question).

4. The new question is a priority for the reasons cited in #1 above. No question exists in the questionnaire on this important subject.

5. We are suggesting the deletion of one question, the addition of a one question and only small modifications to response options in another question. We consider all these changes important so that DHS maintains its status as the most comprehensive, up to date, and reliable source of information on infant and young child feeding and nutrition.

6. The proposed question and modifications to the options of an existing question are relevant for all DHS countries.
Re: Infant and Young Child Feeding [message #1697 is a reply to message #1693] Mon, 31 March 2014 07:08 Go to previous messageGo to next message
fmason is currently offline  fmason
Messages: 1
Registered: March 2014
Location: London, UK
Save the Children supports the proposals made by PAHO and HKI.
Frances Mason
Senior Hunger Policy and Research Advisor

Frances Mason
Re: Infant and Young Child Feeding [message #1700 is a reply to message #1693] Mon, 31 March 2014 13:55 Go to previous messageGo to next message
slhuffman is currently offline  slhuffman
Messages: 1
Registered: March 2014
I strongly support this proposal. The DHS provides unparalleled national data that countries need to develop programs to improve young child nutrition and the increasing rates of obesity, dental caries, and chronic diseases necessitate inclusion of foods that impact on these issues.

WHO is now revising guidelines on free sugar consumption suggesting that it be less than 5% of energy (free sugars include added sugar and fructose found in juice/juice drinks). The current DHS questionnaire includes a question on consumption of juice and juice drinks which will help monitor compliance to new guidelines, but does not contain information on other sugary foods or soft drinks. Since many countries continued to add the sugary foods question (in Q558) which was in DHS 5 in their version of the DHS 6 questionnaire, including it for all countries in DHS 7 would be extremely important for monitoring purposes and policy and program development. Adding a soft drink question would provide needed information. Recent analyses from research in Cambodia found 44% of children 18-23 mo of age drank soft drinks in the last week.

The high consumption of salty snacks such as fried chips and crisps is also a concern because of impacts on chronic disease development, both because of the relationship of early use of salt and increased salt preference, intake of salt and hypertension, and the fact that many such foods contain trans-fatty acids.

An illustration of how such data will be used can be found in :Huffman, S.L., Piwoz, E., Vosti, S. Dewey, K.G. Babies, soft drinks and snacks: A concern in low- and middle-income countries? Maternal and Child Nutrition, in press 2014.

Several organizations are working to reduce the negative impacts of marketing of breastmilk substitutes in low- and middle- income countries by encouraging the private sector to change marketing practices through indices ranking companies. These include FTSE4Good Index and Access to Nutrition Index, but they are now inhibited because of a lack of quantitative data. Additionally, policy makers in countries do not have the quantitative data needed to enforce regulations. A simple new question (that has been pretested extensively through numerous surveys) as suggested by PAHO/WHO and HKI, will provide this needed data. A reference illustrating the use of this question is :Mason, F., Rawe, K., & Wright, S. Superfood for Babies: How Overcoming Barriers to Breastfeeding will Save Children's Lives. Save the Children. London. 2013.

Sandra L. Huffman, Sc.D.
Nutrition Researcher
University of Calif, Davis
Program in International and Community Nutrition
Re: Infant and Young Child Feeding [message #1701 is a reply to message #1693] Mon, 31 March 2014 20:13 Go to previous messageGo to next message
rperezescamilla is currently offline  rperezescamilla
Messages: 1
Registered: March 2014
I strongly support this proposal. Infant/child feeding data should now reflect the nutritional transition low and middle countries are going through. Also, the question addressing WHO Code violation is extremely relevant.

I would like to propose adding a second WHO Code violation question to capture the distribution of free or reduced price samples of infant formula. This practice is a disincentive for breastfeeding, has not been systematically documented in low and middle income countries, and represents a fragrant Code violation.

I suggest the following wording:


Rafael Perez-Escamilla, PhD
Yale School of Public Health
Re: Infant and Young Child Feeding [message #1722 is a reply to message #1693] Wed, 02 April 2014 07:43 Go to previous messageGo to next message
Messages: 2
Registered: March 2014
The Bill & Melinda Gates foundation supports the modifications proposed by PAHO/HKI. This information will be valuable to our work to improve breastfeeding and promote healthy growth of children worldwide. Better and more timely data on dietary patterns in vulnerable populations -- in this case children -- will be essential for tracking World Health Assembly targets and for future efforts to ensure food and nutrition security for all.
Re: Infant and Young Child Feeding [message #1795 is a reply to message #1693] Thu, 03 April 2014 11:44 Go to previous messageGo to next message
Messages: 2
Registered: March 2014
We are writing to strongly support the proposals put forward by PAHO/WHO and HKI, and by the FANTA Project.

Previous rounds of the DHS have provided critical information on infant diet quality; in the context of urbanization and rapid nutrition transition throughout the developing world, the additional response options on infant/young child consumption of sugar-sweetened beverages and energy-dense, nutrient poor snacks are urgently needed to provide information for global tracking and to inform national programs.

PAHO/WHO/HKI have provided specific and field-tested options. We suggest a modification to one of their specific proposals, to expand the wording of the proposed question for soda to include all sugar-sweetened beverages. Precise wording would benefit from a continued consultation process prior to finalization of the new DHS core questionnaire, but it could be along the lines of:

• "Any sweet drinks, such as juice drinks, tea with sugar, or soft drinks/soda/fizzy drinks?"

In many areas, "juice drinks" and sweet tea provide much more added sugar to infant diets than do soft drinks/sodas.

There is also an urgent need to fill an information void about the quality of women's diets, globally. Recent reviews(1-2) have documented many gaps between micronutrient intakes and needs, and analytic work previously published (3) and on-going (as mentioned by FANTA) show consistent associations between simple proxy indicators of food group consumption and the micronutrient adequacy of women's diets, at population level. Dietary diversity indicators have been incorporated in the results framework of on-going USAID-funded projects; in addition, global advocacy initiatives to address the entire "1000 Days" are now calling explicitly for dietary diversity indicators to track women's diet quality ( -in-the-Post-2015-Agenda-Technical-Brief.pdf). DHS data on food group consumption by adult women would also be useful to national governments aiming to track adherence to national food-based dietary guidelines.

Finally, we also strongly support the WHO/PAHO/HKI proposal to add a simple and field-tested question to provide information on threats to the International Code of Marketing of Breast-milk Substitutes.

Mary Arimond, Analyst, and
Kathryn G. Dewey, Director, Program in International and Community Nutrition
University of California, Davis

1.Torheim LE et al. Women in resource-poor settings are at risk of inadequate intakes of multiple micronutrients. J Nutr. 2010 Nov;140(11):2051S-8S.

2.Lee SE et al. Dietary intakes of women during pregnancy in low- and middle-income countries. Public Health Nutr. 2013 Aug;16(8):1340-53.

3.Arimond M et al. Simple food group diversity indicators predict micronutrient adequacy of women's diets in 5 diverse, resource-poor settings. J Nutr. 2010 Nov;140(11):2059S-69S.

Re: Infant and Young Child Feeding [message #1856 is a reply to message #1693] Fri, 04 April 2014 10:30 Go to previous messageGo to next message
Messages: 2
Registered: April 2014
Location: Atlanta, GA
CDC endorses the proposed questions submitted by PAHO/WHO and HKI.

Laurence M. Grummer-Strawn
Chief, Nutrition Branch
Centers for Disease Control & Prevention
Re: Infant and Young Child Feeding [message #1859 is a reply to message #1693] Fri, 04 April 2014 10:51 Go to previous messageGo to next message
twilliam is currently offline  twilliam
Messages: 3
Registered: March 2014
Location: Arlington, VA, USA
The USAID-funded Strenghtening Partnerships, Results and Innovations in Nutrition Globally (SPRING) Project strongly endorses the proposed revisions to IYCF questions suggested by PAHO, WHO, and HKI. The revisions would enable valuable improvements to measuring key IYCF indicators.

Tim Williams
Senior Strategic Information Advisor
SPRING Project
Arlington, VA, USA
Re: Infant and Young Child Feeding [message #1870 is a reply to message #1693] Fri, 04 April 2014 14:24 Go to previous messageGo to next message
agnes guyon
Messages: 3
Registered: April 2014
Location: USA
I strongly endorses PAHO/HKI proposal and other colleagues' comments. DHS questionnaires need to adapt to the current nutrition transition and change of dietary habits.
Re: Infant and Young Child Feeding [message #1874 is a reply to message #1693] Fri, 04 April 2014 14:46 Go to previous messageGo to next message
Messages: 1
Registered: April 2014
Location: New York
UNICEF NYHQ Nutrition and Data & Analytics sections support the proposal made by WHO/PAHO and HKI to (1) better capture intake of sugar-sweetened beverages and poor nutrient quality snacks in the context of rapid transition in diet in the developing world; and (2) include a question specific to the violation of the International Code of Marketing of Breast-milk Substitutes.

More specifically, we propose a small modification to the beverages question to include the word "sweet". The question could read as follows:
" Any sweet beverages such as soft drinks, soda/fizzy/carbonated drinks, juice drinks, tea/coffee with sugar"?

For the Code-related question, we would agree with prof Escamilla-Perez to capture the distribution of free or reduced price samples of infant formula. While more general forms of promotion of infant formula and other breastmilk substitutes targeted to infants and young children can be monitored through other means besides household surveys, the distribution of free samples and/or vouchers through the health system or retail outlets is more subtle. Including such a question in the DHS questionnaire would therefore provide valuable information on Code violations that are otherwise not systematically documented.

France Begin, David Clark, Julia Krasevec

France Begin, Ph.D.
Senior Nutrition Adviser, IYCN
Re: Infant and Young Child Feeding [message #1882 is a reply to message #1693] Fri, 04 April 2014 16:55 Go to previous messageGo to next message
cintialombardi is currently offline  cintialombardi
Messages: 1
Registered: April 2014
I endorse the proposal by PAHO/WHO and HKI. The modifications suggested will allow for developing indicators that reflect changes in dietary patterns with considerable impact on children's nutrition and health. Due to the rapid increase in the prevalence of overweight/obesity prevalence in children, and associated NCDs, observed worldwide, adding a measure of consumption of energy-dense snacks and sugar-sweetened drinks is a key step to provide a more comprehensive information on diet.
Monitoring of the Code's violations will be instrumental in development of policies to protect breastfeeding with the goal to increase exclusive breastfeeding rates, which have been persistently low in many countries.
Cintia Lombardi, ScD
Consultant, Food and Nutrition
Re: Infant and Young Child Feeding [message #1926 is a reply to message #1700] Wed, 09 April 2014 16:11 Go to previous messageGo to next message
Marie Ruel is currently offline  Marie Ruel
Messages: 11
Registered: April 2014
I strongly support the changes to the IYCF questionnaire proposed by PAHO/WHO and HKI.

Marie Ruel
Poverty, Health and Nutrition Division
International Food Policy Research Institute
Re: Infant and Young Child Feeding [message #1991 is a reply to message #1693] Fri, 11 April 2014 17:34 Go to previous message is currently offline
Messages: 6
Registered: April 2014
Location: Washington, DC
The World Bank Group supports the recommendations for deletions, revisions, and additions, posted above by PANHO. Contributed by Leslie Elder, Health, Nutrition & Population, HD.


Emmanuel Skoufias
Lead Economist
Poverty, Gender and Equity Group
Poverty Reduction and Economic Management
The World Bank
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