Received: 24 July 2017 Revised: 4 September 2017 Accepted: 5 September 2017

DOI: 10.1111/mcn.12528
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OVERVIEW

First foods: Why improving young children's diets matter.

France Bégin | Víctor M. Aguayo

Nutrition Section, Programme Division, United

Nations Children's Fund (UNICEF), New York, Abstract
New York, USA Globally, only 52% of children aged 6–23 months meet the minimum meal frequency and a
Correspondence mere 29% meet the minimum dietary diversity, with large disparities across and within
France Bégin, Nutrition Section, Programme regions. With most of the stunting occurring during the first thousand days—from conception
Division, United Nations Children's Fund
to age 2 years—improving complementary feeding in children 6–23 months old is an urgent
(UNICEF), 3 UN Plaza, New York, New York
10017, USA. priority. With this evidence in mind, UNICEF collaborated with the governments of India
Email: fbegin@unicef.org and Maharashtra to convene a global meeting in Mumbai, India, under the theme: First Foods:
Funding information A Global Meeting to Accelerate Progress on Complementary Feeding in Young Children
UNICEF
(November 17–18, 2015). The global meeting provided a platform that aimed to (a) synthesize
the biological and implementation science on complementary feeding; (b) review the practice
and experience in improving access to nutritious complementary foods and good complemen-
tary feeding practices; and (c) consolidate a strong evidence base that can inform the develop-
ment of strategies and approaches to improve complementary feeding that are fit to context.
This overview paper summarizes the rationale on why improving complementary foods and
feeding for infants and young children matters and what it takes to improve them. It builds
on the papers presented at the First Foods Global Meeting and those commissioned as a
follow on to it.

KEY W ORDS

child foods, child growth, child nutrition, complementary feeding, stunting

1 | I N T RO D U CT I O N To date, a variety of programme strategies to improve comple-

A growing recognition of nutrition as a global development priority
and investment opportunity with high social and economic returns
has catalysed political commitment and increased the need to
identify concerted actions to end childhood undernutrition. Yet the
latest global figures indicate that ~23% of children under age
5 months (i.e., 155 million) have stunted growth because of chronic
nutrition deprivation (United Nations Children's Fund [UNICEF],
World Health Organization [WHO], & World Bank, 2017). With
most of the stunting occurring during the first thousand days, when
complementary feeding plays a major role (Aguayo & Menon, 2016),
the stakes are high for accelerating progress to improve the quality
of complementary foods and feeding practices for children aged
6–23 months.
[The copyright line for this article was changed on 11 April 2018 after original
online and print publication.]
mentary feeding have been implemented all over the world with dif-
ferent rates of success, most notably through the use of nutrition
education and behaviour change communication (BCC) approaches,
locally available foods and food systems, and/or supplementary
foods and food fortification initiatives. Progress in implementing
large‐scale and sustainable complementary feeding programmes has
been slow, but some recent country examples show that it is possible
to achieve significant improvements in complementary feeding
(Frongillo et al., 2017).
With this evidence in mind, UNICEF collaborated with the
Governments of India and the State of Maharashtra to convene a
global meeting in Mumbai, India, on the theme: First Foods: A
Global Meeting to Accelerate Progress on Complementary Feeding
for Young Children (November 17–18, 2015). The Global Meeting
was organized in partnership with Alive &Thrive, the Food and
Agriculture Organization, the Global Alliance to Improve Nutrition,
the University of California at Davis, the U.S. Agency for Interna-
tional Development, the World Food Programme, and the WHO.

Matern Child Nutr. 2017;13(S2):e12528. wileyonlinelibrary.com/journal/mcn © 2017 John Wiley & Sons Ltd 1 of 9
https://doi.org/10.1111/mcn.12528
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The Conference provided a platform that aimed to (a) synthesize the
biological and implementation science on complementary feeding;
(b) review the practice and experience in improving access to
nutritious complementary foods and good complementary feeding
practices in children aged 6–23 months; and (c) consolidate a strong
evidence base that can inform the development of strategies and
approaches to improve complementary feeding that are fit to
context.
The Global Meeting was attended by more than 150 participants
representing national governments and regional organizations,
bilateral, multilateral, and non‐governmental development partners,
representatives of research and academic institutions, and resource
persons from across the globe. This special issue of Maternal and Child
Nutrition includes the invited papers presented at the Global Meeting
and a series of papers that were commissioned in preparation for or as
a follow up to the Meeting.
2 | W H Y D O I M P R O V E D CO M P L E M E N T A R Y
FOODS AND FEEDING MATTER?
The promotion of exclusive breastfeeding for 6 months is a global
public health recommendation (WHO, 2002). The nutrient needs
of full‐term, normal birth weight infants typically can be met by
human milk alone for the first 6 months if the mother is well
nourished. However, after 6 months of age, it becomes increasingly
difficult for breastfed infants to meet their nutrient needs from
human milk alone (WHO, 1998). The global strategy for infant and
young child feeding (IYCF; WHO & UNICEF, 2003) recommends
that, from 6 months of age, infants should receive safe and nutri-
tionally adequate, solid, semi‐solid, and soft complementary foods,
whereas breastfeeding continues for up to 2 years of age or
beyond. Age‐appropriate, energy‐ and nutrient‐dense complemen-
tary foods help prevent deficiencies that could result in undernutri-
tion. The benefits of good complementary foods and feeding
expand beyond their well‐documented child survival benefits
(Bhutta et al., 2013).
In their paper in this special issue, Michaelsen, Grummer‐Strawn,
and Bégin (2017) remind us that the complementary feeding period
provides a window of opportunity for preventing not only undernutri-
tion but also overweight and obesity. The 6–23 months of age win-
dow is also important for long‐term health. Inappropriate feeding
can affect growth, organ development, and metabolism, which can
have long‐term programming effects on development and health and
nutrition.
The authors also take a close look at the recent evidence on the
effect of the quality and quantity of protein and fat intake on child
growth during the complementary feeding period. Although most of
the studies are observational in nature, it appears that a high intake
of protein, especially dairy protein, during the complementary feeding
period—not so much a high intake of fat—is associated with an
increased risk of childhood overweight and obesity. The role of
responsive feeding is also an area of interest, but the authors pointed
out that the evidence on its link with child undernutrition or over-
weight is weak and requires more research. With increasing
BÉGIN AND AGUAYO
Key messages
• Improvement of young child's diet is essential to reduce
child stunting and other forms of malnutrition.
• Only one in every six children in low‐ to middle‐income
countries is fed a diet that meets the minimum
requirements for healthy growth and development.
• Multiple strategies, supported by evidence‐based
behaviour change interventions, are needed to improve
complementary feeding.
• Learning how to improve complementary feeding
at scale is a high priority; adequately resourced
monitoring and evaluation systems need to be in place
to measure the performance of national systems
in delivering essential interventions to improve
complementary feeding.
prevalence of overweight and obesity globally, the authors call for
the careful revision of the guidelines on complementary feeding to
indicate how adequate complementary foods and feeding practices
can contribute to prevent undernutrition in early childhood as well
as overweight and obesity and associated complications in childhood
and later in life.
2.1 | The global situation
The paper by White, Bégin, Kumapley, Murray, and Krasevec (2017)
indicate that globally, only about half (52%) of the children aged
6–23 months are meeting the minimum meal frequency (MMF), that
is, children who are receiving solid, semi‐solid, or soft foods the
minimum number of times or more during the previous day, and less
than one third (29%) are meeting the minimum dietary diversity
(MDD), that is, children who received foods from more than or
equal to four (out of seven) food groups during the previous day,
with large disparities across and within regions. The situation is par-
ticularly worrying for the youngest children (6–11 months) among
whom only 46.3% meet MMF and a mere 17% meet MDD. Across
all regions, the consumption of fruits, vegetables, and foods of
animal origin (dairy, meat, fish, and eggs) is low. Most of the
complementary feeding indicators are worse in rural areas than in
urban settings, and children living in the poorest households—both
in rural and urban areas—are particularly at risk of poor complemen-
tary feeding. However, MFF and MDD are suboptimal even in
households from higher wealth quintiles, suggesting that other
factors such as cultural practices, traditional beliefs, and poor
knowledge regarding adequate diets for young children need to
be addressed. White et al. (2017) also highlight that globally, contin-
ued breastfeeding drops significantly from 74% among children
12–15 months to 46.3% among children 20–23 months of age.
Yet evidence indicates that continued breastfeeding from 6 months
through the first 2 years and beyond provides a safe and consistent
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source of key nutrients (Victora et al., 2016). Therefore, continued
breastfeeding needs to be promoted as an integral part of comple-
mentary feeding and be protected from commercial influences
(PAHO, 2003; Rollins et al., 2016).
Sadly, the proliferation of unhealthy snack foods and sugar‐
sweetened beverages in developing and emerging markets has con-
tributed to an increased consumption of these products in low‐ and
middle‐income countries (LMICs). The paper by Pries et al. (2017)
reporting the findings of a cross‐sectional survey conducted in
Cambodia, Nepal, Senegal, and Tanzania showed that the proportion
of children 6–23 months of age who had consumed commercially pro-
duced sugar‐sweetened beverages the day prior to the interview
ranged between 16% and 32%. The increased consumption of commer-
cially produced snack foods and beverages is a cause for concern
because these products are often energy‐dense, nutrient‐poor, and
high in salt or sugar, making them inappropriate for IYCF (Moodie
et al., 2013). In addition, their consumption can displace breast milk
and replace the consumption of more nutritious foods. It is imperative
to increase the awareness of caregivers and families about the health
risks associated with the consumption of unhealthy foods and
beverages. It is also vital that governments put in place adequate
measures to control the proliferation of these unhealthy products,
which are often presented and marketed as suitable (and desirable)
for young children.
2.2 | Diet‐related factors associated with stunting
Complementary feeding interventions have the potential to improve
the nutritional status of children in LMICs. However, the evidence of
the association between feeding practices and linear growth is mixed
as shown by the systematic review conducted by Lassi, Das, Zahid,
Imdad, and Bhutta, (2013). The authors concluded that more research
is needed to assess the actual impact of complementary feeding inter-
ventions (including education and/or provision of food) on growth.
There is also the question as to how the WHO indicators on comple-
mentary feeding (MMF, MDD, and Minimum Acceptable Diet) relate
to different anthropometric outcomes. Few studies have attempted
to answer this question. Furthermore, their findings are mixed, often
due to methodological and sampling issues (Darapheak, Takano, Kizuki,
Nakamura, & Seino, 2013; Jones et al., 2014). In their paper, Krasevec,
An, Kumapley, Bégin, and Frongillo (2017) examine the association
between two indicators of dietary quality—dietary diversity and ani-
mal source food (ASF) consumption—and child stunting analysing
pooled data from 39 Demographic and Health Surveys. Their findings
indicate that poor dietary diversity is a risk factor for stunting.
Children 6–23 months consuming no food groups in the previous
day (i.e., receiving no solid, semi‐solid, or soft food and no milk) were
34% more likely to be stunted than children who were fed at least five
food groups. Further, children who were not fed any ASF in the
previous day had a 44% higher odds of being stunted than children
who were fed all three types of ASF (egg + meat + dairy). The associations
between dietary diversity and stunting were fewer and significantly
weaker in low‐income countries than in lower middle‐income and upper
middle‐income countries and lower middle‐income countries. The
authors argue that in countries with lower level of resources,
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determinants of stunting other than diet diversity must also be addressed
such as access to safe water, hygiene practices, and care during illnesses
for example. Having a diverse diet is an important factor, but not the
only one. However, it is clear from this paper that too many children
aged 6–23 months are not fed with diets that meet the minimum ade-
quacy and that dietary diversity—particularly consumption of ASF—are
clearly associated with children's linear growth and stunting. The
authors conclude that further research assessing the role different types
of ASF on stunting in different settings is needed. They also indicate
that it might be timely to review WHO indicators of complementary
feeding because these were developed several years ago when only a
limited number of datasets and sample sizes were available.
UNICEF's conceptual framework for maternal and child undernu-
trition shows that one of the underlying causes of undernutrition is
household food insecurity. In their paper, Chandrasekar, Aguayo,
Krishna, and Nair (2017) used data from a comprehensive nutrition
survey in the Indian State of Maharashtra to examine the relationship
between household food security, children's diet diversity, and child
nutrition. They find that 4 out of every 10 households were food inse-
cure and that 75% of children aged 6–23 months were fed two food
groups or fewer. They find that the odds of a child being severely
stunted, underweight, or wasted were significantly higher in house-
holds that were severely food insecure. After controlling for children's
diet diversity, and other child, maternal and household characteristics,
they find that household food security is no longer statistically associ-
ated with stunting, wasting, or underweight. However, diet diversity of
children is significantly associated with whether a child is stunted or
underweight, supporting the hypothesis that household food security
affects children's diet diversity and that both affect nutrition outcomes
in children. Several policies and programmes in India intend to address
child undernutrition. It will be essential that these efforts contribute to
improve the nutritional quality of the foods delivered to meet the
nutrition needs of young children.
Although children's poor diets are not the only factor associated
with children's linear growth and risk of stunting, these two papers
indicate that improved diet diversity is strongly associated with a lower
risk of stunted growth. It is also important to recognize that in food‐
insecure households, reaching an MDD for children may be more diffi-
cult and that multipronged strategies—as described later in this paper—
will be required to meet children's nutrition needs.
2.3 | What will it take to improve complementary
feeding?
2.3.1 | Understanding risk factors and barriers
In many settings, poor complementary feeding is partly due to poor
knowledge about children's nutritional needs among caregivers and
inadequate counselling and support by health and nutrition care pro-
viders on age‐appropriate feeding.
In Pakistan, Na, Aguayo, Arimond, and Stewart (2017) studied the
risk factors of poor complementary feeding in children 6–23 months
using multilevel analysis of the 2013 Demographic and Health Surveys.
Their findings show that indicators of access to health and nutrition
care (such as the number of antenatal clinic visits, the timing of postna-
tal check‐up visits, and overall access to maternal and child health and
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nutrition services at the community level) were strong predictors of
several of the complementary feeding practices studied. These findings
support the “knowledge pathway”; that is, caregivers may have
acquired child feeding advice through facility‐ and/or community‐
based services provided by the health care system. Contacts with
service providers during antenatal, postnatal, and immunization con-
tacts are precious opportunities to integrate counselling on IYCF.
However, as pointed out by Lutter et al. (2013), the full potential of
multiple contacts during pregnancy, childbirth, and early childhood is
often not used.
The comprehensive review by Aguayo (2017) on the effectiveness
of information, education, and counselling interventions aimed at
improving complementary feeding in children aged 6–23 months in
South Asia shows three important findings: (a) In intervention study
settings, different types of well‐trained frontline workers and commu-
nity resource persons can contribute to improve several complemen-
tary feeding practices (timeliness, frequency, diversity, and minimum
adequacy); (b) the intensity of the training and supervision of these
frontline workers and community resource persons in intervention
research settings and the small scale of most of such studies raise
the question of the potential for scale of such interventions in
programmatic settings; and (c) in some studies, there was indication
that the uptake of the recommended practice/s was limited by the
availability and affordability of complementary foods.
Therefore, it is important to understand the pathways that enable
or constrain the uptake of recommended complementary feeding prac-
tices by caregivers while increasing the quality of the training and
supervision of frontline workers given the multiple contacts they have
with caregivers and families. A review of a large‐scale programme in
Bangladesh showed that improving the performance of frontline
workers and volunteers in delivering timely and quality counselling to
mothers while reinforcing interpersonal counselling with mass media
campaigns and community mobilization were central to the success
of the programme (Sanghvi et al., 2016).
In general, ongoing efforts in LMICs to improve complementary
feeding in young children are small in scale, and the interventions that
are being implemented are not intense enough to bring about large and
sustained improvements in complementary feeding. This is also
reflected in the paper by Avula, Oddo, Kadiyala, and Menon (2017)
where the authors assessed India's readiness to deliver IYCF interven-
tions by examining elements related to policy, implementation,
financing, and evidence. All of the 17 IYCF programmes reviewed
included interventions to support breastfeeding, and 15 of them
included complementary feeding interventions. All of the 15 focused
on timely initiation of complementary feeding, but only 7 promoted
age‐appropriate quantity, quality, and safe handling of food.
Overall, national governments and development partners need to
become more rigorous in implementing large‐scale, evidence‐based
programmes for the protection, promotion, and support of improved
complementary feeding. Although in India and many other countries,
national policies are aligned with global guidance, lack of political and
financial commitment limits the country's ability to bring programmes
to scale (Avula et al., 2017).
It is clear from this set of papers that the primary health care system
offers opportunities—both in facilities and in communities—to inform,
BÉGIN AND AGUAYO
educate, and counsel caregivers about age‐appropriate feeding practices.
Frontline workers need to be adequately trained to maximize the poten-
tial of their contacts with caregivers and families. At the same time, it is
essential to fill the evidence gap about the constraints that families and
caregivers encounter to uptake the full spectrum of recommended feed-
ing practices. Addressing capacity and financing gaps are also critical ele-
ments of scaling up. The work by Perez‐Escamilla, Curry, Minhas, Taylor,
and Bradley (2012), in developing health care systems integrated
frameworks for breastfeeding scaling up models may help guide similar
approach to scale up complementary feeding programmes.
2.3.2 | Multiple strategies are needed
Infants and young children have high nutrient requirements for growth
and development. Further, because of their small stomach capacity,
they need to be fed nutrient‐dense foods frequently. Behaviour
change interventions have a great potential to improve feeding prac-
tices, by helping caregivers to make the right choice and prepare and
feed their children with nutrient‐rich foods. Interventions that make
effective use of formative research to identify barriers and enablers
and have clearly outlined impact pathways are more effective in
improving feeding practices (Fabrizio, van Liere, & Pelto, 2014). In this
issue, Sanghvi, Seidel, Baker, and Jimerson (2017) analysed four
programmes (2–5 years in duration) that have been implemented at
scale and have documented improvements in feeding practices using
social and behaviour change approaches. The authors concluded that
complementary feeding practices, in particular dietary diversity, can
be improved rapidly in a variety of settings using available programme
platforms if interventions focus on specific constraints to food access
and enable families to prepare and feed appropriate foods. The authors
proposed five steps for strengthening behaviour change interventions:
(a) Select a few priority complementary feeding behaviours; (b) Focus
on underlying determinants (including food access) and key influencers
of those behaviours; (c) Test concepts, recipes, messages, and tools for
feasibility/acceptability and clarity; (d) Select programme channels to
achieve desired coverage, intensity, and scale; and (e) Sustain exposure
for at least 2 years while continually monitoring and adjusting the
programme.
As mentioned above, a nutritious, diverse diet is essential to
ensure optimal physical growth, cognitive development, health, and
well‐being for infants and young children in the first 2 years of life.
The role of agriculture in supplying nutritious and affordable diets is
increasingly recognized as well as its contribution in reducing under-
nutrition, provided that agriculture and nutrition education for behav-
iour change be integrated. The paper by Muehloff et al. (2017)
provides an overview of the main facilitating factors and barriers that
influenced the adoption of desirable IYCF practices in two compre-
hensive food security projects in Cambodia and Malawi that included
agricultural support and community‐based nutrition education. Adop-
tion of improved IYCF practices was facilitated by participation in
nutrition education and practical cooking sessions, and supportive
family and community structures. Women's workload was identified
as in important barrier preventing some women from attending
nutrition education sessions and putting dietary advice into practice.
A better alignment of agriculture interventions with dietary
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requirements was also proposed as a way to improve access to high
quality foods.
Even when use of locally available foods is optimized, young
children's needs of iron and zinc are often not met and other cost‐
effective strategies to ensure adequate intake of these essential nutri-
ents are needed (Osendarp et al., 2016). The WHO recommends home
fortification of foods with micronutrient powders (MNP) to reduce iron
deficiency and anaemia in young children. Several countries are now
using MNPs to improve the nutrient quality of complementary foods.
In their paper, Siekmans, Bégin, Situma, and Kupka (2017) reviewed
11 country experiences with MNP interventions and proposed a theo-
retical framework to illustrate the potential mechanisms through which
MNP interventions could influence and strengthen complementary
feeding practices at the household level. Although in a few settings,
MNP interventions have contributed to improve timely introduction
of complementary foods and dietary diversity through the training
provided and the increase in access to IYCF counselling, overall pro-
gramme evidence of improved complementary feeding practices
among MNP users is limited. Siekmans et al. (2017) highlight that
MNP interventions should not be implemented as a stand‐alone
approach. The full potential of MNP can only be achieved when the
design, implementation, monitoring, and evaluation of MNP implemen-
tation activities is fully integrated as part of IYCF programming (Locks
et al., 2017).
There is recognition that there is no “one‐size‐fits‐all” strategy to
improve complementary feeding and that the complex and multicausal
problems of malnutrition require all players, including the private sec-
tor, to collaborate and to invest towards the same objective (UNICEF,
2016). However, evidence of positive contribution or impact of private
sector approaches to nutrition outcomes is lacking in spite of the fact
that it is the private sector, be it small farmers or large food processors
that produces locally available foods including fortified foods. In this
issue, Van Liere, Tarlton, Menon, Yellamanda, and Reerink (2017) dis-
cuss the multiple ways in which the private sector can leverage its
expertise to improve nutrition in general, and complementary feeding
in particular, using illustrative case studies. The authors argue that
technical organizations, such as non‐governmental and non‐for‐profit
organizations, can play a fundamental role and bring private and public
sector players together around one common goal while creating trans-
parency around noncommon goals. Such organizations can help busi-
ness to design an effective approach, support governments in
establishing an enabling regulatory environment, and work with the
research community to ensure the implementation of a rigorous learn-
ing agenda.
In summary, the set of papers included in this issue shows that
multiple strategies are needed to improve complementary feeding
among children 6–23 months. Food‐based approaches are important
for sustainability and need to be promoted and supported, whereas
the use of MNP may be required when increasing the intake of nutri-
ent‐rich foods poses a challenge. These strategies need to be sup-
ported by evidence‐based behaviour change interventions. It is also
important to recognize that non‐health sectors (agriculture, education,
water, sanitation, gender, social protection, and media) and the private
sector can play an important role by alleviating some of the significant
constraints to appropriate complementary feeding.
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2.3.3 | Tools to improve planning, implementation,
monitoring, and evaluation of complementary feeding
programmes
To be effective, complementary feeding programmes need to be
informed by sound situation analyses and formative research that take
into consideration the local context and main determinants of stunting.
Tools to assess the IYCF situation exist, but until recently, they did not
include (a) a systematic, quantitative assessment of the nutrient con-
tent of the prevailing diet and ways to improve it based on locally avail-
able natural and processed and fortified foods; and (b) factors that
affect the availability of and accessibility to complementary foods,
such as purchasing power (Daelmans et al., 2013). In their paper,
Untoro et al. (2017) describe tools that are increasingly being used to
inform the development of complementary feeding programmes, par-
ticularly ProPAN, Optifood, Fill the Nutrient Gap, Cost of the Diet,
and the Monitoring Results for Equity System, although the latter is
not specific to nutrition or complementary feeding programmes. The
paper discusses their strengths and limitations and how the tools can
be used in different combinations to improve situation analysis, plan-
ning, implementation, monitoring, or evaluation of context‐specific
approaches to improving complementary feeding.
The tools can use secondary data for analysis with the exception
of ProPAN, which requires primary data collection. Some of the tools
are more complex than others and may require external support to
facilitate the process at country level. However, the availability of soft-
ware and/or operational manuals is proving useful to facilitate the use
of these tools; investment in capacity development for their use in
countries is worth considering to strengthen IYCF programmes. In
addition, the tools can be used alone or in combination; information
obtained by one tool can be integrated into or used by another. When
used in combination, they gain strength in providing guidance for
developing complementary feeding recommendations, prioritizing
interventions and developing key messages and communication strat-
egies to advocate for improving complementary feeding programmes
and policies. Strengthening capacity of local institutions such as aca-
demic or research institutions or national NGOs like it is being done
in India with the use of ProPAN would help make the use of these
tools more sustainable.
2.3.4 | Monitoring and evaluation to improve complemen-
tary feeding
We have stressed the urgency of accelerating progress to improve
complementary feeding of young children. In order to do so, it is nec-
essary to have monitoring and evaluation (M&E) systems in place to
identify problems in a timely manner, take corrective action if needed,
and assess programme performance. However, monitoring progress on
complementary feeding counselling is still a challenge for many coun-
tries. Although most countries have a health management information
system, nutrition indicators are not always included comprehensively.
As indicated by UNICEF Nutridash report 2016, only one in five
respondent countries (n = 64) has IYCF indicators included in its health
management information system, meaning that many countries are not
able to minimally monitor key indicators, including the number of
mothers reached with counselling.
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In her paper, Jefferds (2017) highlights that strengthening moni-
toring through government information systems may increase the
quality and implementation of IYCF programmes. However, she argues
that too often programmes do not have a sound description and con-
ceptual model explaining how programme inputs and activities are
expected to lead to outputs and outcomes, ultimately resulting in pop-
ulation level nutrition impact. Programme description and conceptual
models are key for developing monitoring systems, indicators, and
tools. Without them, the ability to design effective monitoring systems
and programmes is limited.
Multiple data sources can be used to monitor IYCF programmes. In
many cases, the only data sources available are those of programme
management and government information systems. This has some
benefits because it reduces costs by taking advantage of the existing
infrastructure of the system and uses data that are routinely collected
and reported. There are also some limitations as the data collected may
not be representative of the population if only a small proportion of
the population utilizes the services. In addition, IYCF indicators that
are routinely collected in the information systems are often limited
and not always those of the highest interest. For example, information
on breastfeeding practices is often collected; however, information on
receipt of complementary feeding counselling or messages by care-
givers is seldom available. Moving forward, given the importance of
IYCF counselling, it would be useful to distinguish between caregiver's
receipt of group counselling and caregiver's receipt of individual
counselling because the nature of individual counselling is different
and would likely be more tailored and specific to the child. It will also
be important to document if the mother/caregiver received counsel-
ling at key ages to match programme guidance over the 0–23 month
period. Jefferds also describes other examples of data sources that
could be used for internal or external monitoring including cross‐sec-
tional surveys, sentinel sites, mobile phone text messages, and media
assessment audits.
Although monitoring is needed to assess programme performance,
monitoring alone is not sufficient. Evaluation of complementary feed-
ing programmes is also needed to enhance knowledge on what works,
document the responsible use of resources, and inform planning and
advocacy. However, there is no point in evaluating a programme if
monitoring data shows poor implementation; corrective measures
should be put in place before evaluating the programme to use
resources effectively.
In his paper, Frongillo (2017) argues that the articulation of a pro-
gramme theory, which is different from logic model as it underlines the
programme pathways though which the programme has impact, is
essential to the success of any evaluation. Using the example from
the Alive & Thrive IYCF project in Bangladesh and Vietnam, he explains
the role of evaluation in generating information for each of the three
periods of the programme life cycle—during programme conceptualiza-
tion and design, during programme implementation, and after pro-
gramme implementation—to determine effectiveness (Rossi
Freeman, 1989).
Evaluating implementation is done through addressing questions
about needs, coverage, provision, and utilization using information
obtained from process evaluation, operations research, and monitor-
ing. There are various evaluation designs to assess effectiveness
BÉGIN AND AGUAYO
depending on the nature, scope/scale of the programmes. Practical
designs can be used to evaluate complementary feeding programmes.
Frongillo also stresses the challenge of obtaining objective measures
of feeding behaviours because most of the time they are self‐reported.
Further research is needed to develop alternative measures of comple-
mentary feeding that minimize or eliminate potential recall and social
desirability bias and to develop practical evaluation designs for evalua-
tion of large‐scale country programmes on complementary feeding.
In summary, learning how to improve complementary feeding
practices at scale is a high priority; having strong M&E systems to learn
and influence decisions is essential. M&E need to be planned at the
time of programme conceptualization. It is important for M&E tools
and processes to be aligned with programme design, information
needs, and the time and resources available.
2.4 | Way forward
Building on the presentations, discussions, and inputs from participants
during the Global Meeting, seven recommendations addressed primar-
ily to policy makers were proposed to accelerate progress on comple-
mentary feeding for young children. The recommendations were
presented during the Global Meeting and a written draft was later
shared with all participants for review and approval. These are summa-
rized below.
Recommendation 1. Programmes should communicate clearly that
adequate complementary feeding with healthy and nutritious com-
plementary foods contributes to a broad spectrum of short and
long term outcomes.
Improvement of complementary foods and feeding practices con-
tribute to improve not only child survival, growth, and development
but also children's future achievements as an adult, as well as to the
prevention of micronutrient deficiencies, morbidity, and obesity later
in life. It is possible to achieve age appropriate complementary feeding
incorporating all food groups when appropriate strategies are in place.
Breastfeeding is a key component of complementary feeding and
should be protected by the implementation and enforcement of the
International Code of Breastmilk Substitutes. At the same time, with
the increased availability of and accessibility to unhealthy foods, there
is a pressing need to implement and enforce policies that regulate the
marketing of unhealthy food products to young children.
Recommendation 2. Programmes need to combine two or more
strategies to effectively increase the adoption of optimal comple-
mentary feeding practices across diverse population groups.
There is no single strategy that can work universally or in isolation.
Implementation of evidence‐based strategies and interventions needs
& to be informed by adequate situation analyses. BCC alone will not be
effective if appropriate foods are not available or accessible or if other
economic or sociocultural constraints are not taken into account. Agri-
cultural diversification has great potential to improve the availability
and accessibility of nutrient‐rich foods but needs to be combined with
other strategies such as nutrition education, counselling, BCC, and
BÉGIN AND AGUAYO
income‐generating activities to alleviate cultural and economic con-
straints. In certain circumstances, products to improve the nutrient
content of young children's diets may be needed but they need to be
integrated into IYCF programmes. In addition, improving or maintain-
ing adequate complementary feeding practices may be particularly
challenging during emergencies, thus the importance of having strong
IYCF programmes in place before an emergency strikes. To ensure sus-
tainability, complementary feeding programmes need realistic strate-
gies and resources to strengthen programme capacity for design,
implementation, M&E, and leadership. Such strategies can be scaled
up rapidly with adequate commitment, planning, and resources.
Recommendation 3. To be effective, sound situation analysis and
formative research tailored to the local context must serve as the
basis for the design, planning and implementation of complemen-
tary feeding programmes.
Strategies and interventions put in place must be evidence‐based
and informed by adequate situation analysis regarding food availability,
accessibility, affordability and consumption, nutritional status of the pop-
ulation, maternal/parental knowledge, beliefs, skills and social norms,
among others. Good formative research is key and helps to identify the
barriers, enablers, cultural taboos, practices, and underlying emotional
motivations, which in turn can inform the design of interventions. Differ-
ent tools and analytical approaches can be used to help better under-
stand the extent and magnitude of nutrient gaps and likely
determinants of complementary feeding practices in young children.
These tools (ProPAN, Optifood, Cost of the Diet, Fill the Nutrient Gap,
and Monitoring Results for Equity System) are easily accessible and have
been used in diverse settings and can be adapted for country use.
Recommendation 4. To be successful, complementary feeding
programmes need to be multi‐sectoral and have mutually agreed
and clearly articulated roles and responsibilities based on situation
analysis.
The decision on which other sectors need to be involved should be
guided by situation analysis and formative research that provide evi-
dence on the underlying causes of poor feeding practices and malnutri-
tion. The sectors usually engaged to alleviate specific constraints to
improve complementary feeding are health, agriculture, water and san-
itation, education, social protection, and the media. Effective coordina-
tion and communication among the sectors is required. In addition, the
private sector, particularly the food industry, has a role to play in cre-
ating food solutions but they must be hold accountable for complying
with food production, labelling, and marketing regulations. In this
regard, governments need to be at the forefront by establishing quality
standards and enforcing adequate regulation and legislation measures.
Recommendation 5. Evidence‐based BCC is an essential component
of strategies to improve complementary feeding practices in all
settings.
BCC strategies are critical given that improvement of complemen-
tary feeding relies heavily on feeding practices and behaviours. They
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need to be developed based on rigorous formative research, data on
media habits, models of behaviour change, and tested theories of what
drives it. BCC strategies should focus on a few specific feeding prac-
tices and help address underlying barriers of such behaviours to be
more effective. Lastly, a variety of programme channels such as inter-
personal contacts (individually and in groups) at health facilities and
community venues, mass media, mobile phones, and community mobi-
lization events are needed for intensity and scale.
Recommendation 6. M&E tools and processes must be aligned with
programme design, information needs, and the time and resources
available.
LMICs and their development partners that are serious about
improving complementary feeding programmes need to have M&E
systems in place to measure the performance of national systems in
delivering essential interventions to improve complementary feeding.
Effective M&E requires prioritization of a minimum set of data needed
for decision‐making in programme settings. Supportive supervision
and capacity building are as important for M&E as for programme
implementation. Investments in M&E are worthwhile only if the data
are used to improve programmes; timely feedback to persons who
can act based on the data is required to inform and improve pro-
gramme implementation.
Recommendation 7. Advocacy for complementary feeding
programmes needs to address the significant resources required
to build capacity, scale up and institutionalize effective
programmes and strategies for the longer term.
Many countries' policies are aligned with global guidance but the
lack of financial commitment is often an issue to bring programmes
to scale. The cost (human and financial) of not investing in nutrition
needs to be used to advocate for mobilizing more resources to improve
the quality of complementary foods and feeding and to support deliv-
ery and scale up of IYCF programmes; secondary data can be used to
generate country‐specific estimates for national policymakers.
Although donor investment and innovative financing mechanisms are
needed, the bulk of investment for routine, nationally scaled up
programmes should come from government resources to ensure
sustainability.
3 | CO NC LUSIO NS
Improvement of infant and young child nutrition is fundamental to
reduce child stunting and other forms of malnutrition. Yet only one
in every six children in LMICs is fed a diet that meets the minimum
requirements for healthy growth and development. The policies are
available and the solutions are within reach. However, commitments
and investments from governments and development partners are
required if we truly want to change this devastating figure. We hope
that the wealth of research and programmatic evidence included in this
special issue of Maternal and Child Nutrition will be used to create a
collective impetus to support families in feeding their children.
8 of 9 bs_bs_banner
CONF LICT S OF INT ER E ST
FB and VMA are staff members of the United Nations Children's Fund
(UNICEF). The authors alone are responsible for the views expressed in
this publication and declare that they have no conflicts of interest.
CONT R IBUT IONS
FB and VMA wrote the draft of the manuscript.
ACKNOWLEDGMENTS
The recommendations are based on the meeting proceedings of “First
Foods: A global meeting to accelerate progress on complementary
feeding in young children November 17–19 2015, Mumbai, India.”
We thank all the participants for their valuable contribution.
ORCID
France Bégin http://orcid.org/0000-0001-8545-1545
Víctor M. Aguayo http://orcid.org/0000-0003-1825-4108
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How to cite this article: Bégin F, Aguayo VM. First foods: Why
improving young children's diets matter. Matern Child Nutr.
2017;13(S2):e12528. https://doi.org/10.1111/mcn.12528