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Designing a food plate for dietary counseling of pregnant women in

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 Participants of focus group discussion examine
Field Article
.........................................................
the second version of the food plate

By Abu Ahmed Shamim, Kathrin Tegenfeldt,

Kerry Aradhya, Tarana Ferdous, Nasrin Banu,
Sumitra Roy, Raisul Haque, Saydur Rahman
Siddiquee, Mosiqure Rahman and Nazma Shaheen

Abu Ahmed Shamim has managed

nutrition intervention and research
projects for the Bangladesh National
Nutrition Council, CARE and Johns Hopkins
University before joining FHI 360 as

Designing a food plate

technical director of the SHIKHA project.
He has steered the development and field-
testing process of the food plate for Bangladeshi pregnant

for dietary counselling

women and led the writing and editing of this article.
Kathrin Tegenfeldt is the former country

of pregnant women in
director for the FHI 360 Bangladesh office.
She served on the executive committee of
the Civil Society Alliance for Scaling Up

Bangladesh
Nutrition in Bangladesh.

Kerry Aradhya is a science writer and editor

at FHI 360 with extensive experience in the
areas of global health, population and
nutrition in developing countries.
Tarana Ferdous is a research officer at the
Center for Injury Prevention and Research,
Bangladesh. She was involved with the
SHIKHA project as a consultant and USAID-
supported fellowship at the James Pitter
Grant School of Public Health, BRAC
University.
Nasrin Banu is involved with the SHIKHA
project through a USAID-supported
fellowship at the James Pitter Grant School
of Public Health, BRAC University and
currently works as a consultant with
FHI360.
Sumitro Roy has more than two decades of
experience managing rural development,
health and nutrition projects. He was the
chief of party for the SHIKHA project and is
currently the project director with the Alive
& Thrive Initiative of Family Health
International Solutions in Uttar Pradesh, India.
Raisul Haque heads the health, nutrition,
and population programme at BRAC and
has three decades of experience in public
health service delivery and programme
management.
Saydur Rahman Siddiquee managed public
health and nutrition projects for the World
Health Organization and Alive & Thrive
before joining FHI 360 as a field
programme manager for the SHIKHA
project.
Mosiqure Rahman worked for ten years at
PLAN International before joining FHI 360
as a monitoring and evaluation specialist
for the SHIKHA project.
Nazma Shaheen is professor and director of
the Institute of Nutrition and Food Science
at Dhaka University. She has nearly three
decades of teaching and research experience
in nutrition and food science and was the
lead scientist in the recent update of the
Food Composition Table for Bangladesh.
Abu Ahmed Shamin, SHIKA Project, FH360
Acknowledgements: e SHIKHA project (2013-2016) is implemented by FHI 360 in
partnership with BRAC (Bangladesh’s largest non-governmental organisation). is
analysis was made possible with generous support of the American people through the
United States Agency for International Development (USAID) under Cooperative
Agreement # AID- 388-A-13-00003. e contents are the responsibility of the authors
and do not necessarily reflect the views of USAID or the United States Government.
e authors acknowledge the contribution of the pregnant women and field workers of
BRAC who contributed their time and the SHIKHA project implementation teams of
BRAC health division and FHI 360 and experts from many organisations who shared
their insights at different stages of developing the plate. e authors also acknowledge
the contributions of Dr. Lalita Bhattacharjee, senior nutritionist, FAO; Dr. Mohammad
Abdul Mannan, nutrition policy advisor, FAO and Dr. Quamrun Nahar, senior
research officer, BIRDEM, for providing technical insights in developing the food plate.
Location: Bangladesh
What we know: Undernutrition is common among women in
Bangladesh. For pregnant women, dietary diversity has been
associated with nutrition sufficiency and good pregnancy outcomes.
What this article adds: One of the objectives of the SHIKHA project
in Bangladesh is to promote dietary diversity among pregnant women
through nutrition education and counselling. With this objective in
mind, SHIKHA developed a food plate that is being used in
Bangladesh as a counselling tool to promote a healthy, balanced diet
during pregnancy. Experiences of developing the plate have shown
that systematically consulting with pregnant women and frontline
nutrition workers, as well as involving experts from relevant
organisations in the process, helps ensure quality and acceptance of
the plate and the messages it promotes. The experience in Bangladesh
could serve as a model for the development of similar educational
tools in other developing countries.
Background
Compared with other developing countries, Bangladesh has a high prevalence of
undernutrition among women (Osmani & Sen, 2003). According to the 2011
Bangladesh Demographic and Health Survey (BDHS, 2011), 24% of married women
aged between 15 to 49 years are undernourished (body mass index <18.5). In
addition, deficiencies in iodine (Shamim, Christian, Schulze et al, 2012) vitamin
B12, zinc (Shamim, Kabir, Merrill et al, 2014) and vitamin E (Shamim, Schulze,
Merrill et al, 2015) have been reported among rural pregnant women. Lack of
dietary diversity is common among poor and rural populations, particularly in de-
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Saydur Rahman Siddiquee, SHIKHA Project, FHI360 Field Article
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all the pregnancies in a register. rough five

Community health workers counselling
pregnant women, showing food plate
in the presence of her mother-in-law
veloping countries where starchy staples are
prominent and few, if any, animal products, fruits
and vegetables are included in the daily diet.
Several studies have shown that nutrition
education and counselling during pregnancy
improves maternal diet, gestational weight gain
and birth outcomes (Fowles, 2004; Piirainen,
Isolauri, Lagström et al, 2006). According to a
systematic review of the topic, nutritional edu-
cation and counselling can significantly improve
gestational weight gain by 0.45 kg, reduce the
risk of anaemia in late pregnancy by 30%,
increase birth weight by 105g, and decrease the
risk of preterm delivery by 19% (Girard & Olude,
2012). Moreover, research has shown that an
effective nutrition education programme not
only improves health outcomes among pregnant
women but can also help reduce medical expenses
(Hermann, Williams, Hunt et al, 2001).
What is a food plate?
Some countries use a ‘food plate’ as an educational
tool to help citizens follow national dietary
guidelines. An example from the United States,
called MyPlate, is a colourful image of a plate of
food divided into basic food groups, designed
as part of a campaign against obesity and to re-
mind consumers about the basics of a healthy
diet. MyPlate is based on the dietary guidelines
for Americans (Office of Disease Prevention
and Health Promotion, 2015), a set of evidence-
based nutrition practices developed by the De-
partment of Health and Human Services (HHS)
and the Department of Agriculture (USDA).
MyPlate was created by the USDA and released
in June 2011 to replace MyPyramid, which was
not so user-friendly (USDA 2011 [1]); (USDA
2011 [2]).
In developed countries, the food plate concept
has been adapted for specific populations such
as pregnant women. e SHIKHA project (see
Box 1) wanted to design and test a customised
plate for pregnant women specific to the
Bangladeshi context. Given that obesity and
excess weight gain during pregnancy is a serious
problem in developed countries, the emphasis
of the plates in these contexts has been on re-
ducing the intake of energy-dense foods and
promoting fibre and micronutrients. In
Bangladesh, where undernutrition is common
and families oen have very little money to
spend on food, the emphasis needs to be on
promoting both quantity and quality (diversity)
of foods.
The SHIKHA project and its
initiative to develop a food plate
e SHIKHA project promotes diet quality
among pregnant women and children under
the age of two in 26 rural sub-districts in
Bangladesh, with nutrition education and coun-
selling one of its core components. Community
volunteers are involved in identifying pregnant
women, and frontline nutrition workers record
follow-up home visits, the nutrition workers
provide hands-on counselling and demonstrations
to the pregnant women and their families about
healthy and balanced diets during pregnancy.
No standardised tools for dietary counselling
of pregnant women were previously available
in Bangladesh. is article describes the steps
used to design the original food plate and
develop an improved, final version of the plate
based on field experience.
Designing the original plate
Literature review
SHIKHA reviewed desired dietary patterns de-
veloped by the Bangladesh Institute of Research
and Rehabilitation in Diabetes, Endocrine and
Table 1
Photographs of the original
plate and its limitations
Few limitations
• Photo quality was poor
• Cultural acceptability (for example, guava is
generally not eaten with rice)
• Affordability of suggested foods (both egg
and fish in same meal is not affordable for
most women)
• No clear messages and about desired
behaviours

Box 1 The SHIKHA Project Table 2 Organisations/projects

consulted during the
development of the food plate
The U.S. Agency for International Development (USAID) SHIKHA project works to reduce 1 Alive & Thrive
undernutrition among pregnant women and children under the age of two years old. The 2 Bangladesh Institute of Research and
project scales up maternal nutrition and infant and young child feeding (IYCF) interventions in Rehabilitation in Diabetes, Endocrine and
26 sub-districts in Bangladesh. The project is implemented by FHI 360 and funded by USAID Metabolic Diseases
under the Feed the Future initiative. BRAC, another project partner, implements community- 3 Bangladesh University of Health Sciences
level activities. 4 BRAC and BRAC University
SHIKHA engages 5,313 community volunteers, 373 community health workers and 653 nutrition 5 Food and Agriculture Organization of the
workers through BRAC and trains them in maternal nutrition and IYCF. The project focuses on United Nations
changing the feeding-practice behaviours through five core interventions: home visits (five 6 Helen Keller International
during pregnancy and 12 post-natal); mobilisation engaging fathers and doctors; health forums 7 Institute of Nutrition and Food Science,
(community meetings) targeting pregnant women, mothers of children under years old, Dhaka University
mothers-in-law and adolescent girls; antenatal and postnatal visits; and mass media and 8 International Potato Centre
communication campaigns (involving media experts and including TV ads). 9 Ministry of Food
In addition to regular monitoring and evaluation, the project is partnering with the Centre for 10 SPRING
Injury Prevention and Research (www.ciprb.org), Bangladesh to conduct household surveys at 11 UNICEF
three intervals, in 2013, 2015 and 2016. The surveys will be used to assess progress on knowledge 12 U.S. Agency for International Development
and practice-level indicators for maternal nutrition and IYCF among pregnant women and
13 WASHplus
mothers of children under two years old.
14 WorldFish
For more information, visit: www.i360.org/projects/shikha 15 World Food Programme
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 Field Article
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Table 3
Metabolic Disorders (BIRDEM) with sample melamine plates were produced Data collection methods and participants
support from the Ministry of Food and for field use and testing. who provided data
the Food and Agriculture Organization Method of Target audience Number of Total
of the United Nations (FAO) (Nahar, Finalising the plate data participants number of
Faruque, Sultana et al 2013). Baseline Field experience of using the plate collection participants
survey findings from the SHIKHA project e melamine plates were distributed to 3A: Data collection during first round of field-testing
and research on nutrition and dietary SHIKHA’s nutrition workers and incor-
Focus group Pregnant women 11 16
practices of pregnant women in porated into counselling sessions to pro- discussion
mote dietary diversity in the intervention Frontline nutrition 5
Bangladesh were also reviewed to con- workers
ceptualise the food plate. A decision was areas. Feedback was gathered through
In-depth Nutrition workers 5 5
made to use the plate primarily to promote focus group discussions and in-depth interview and supervisors of
dietary diversity. Dietary diversity is interviews with ten nutrition workers, BRAC
known to be associated with micronu- 11 pregnant women, and four experts in Key Senior staff engaged 4 4
the management and design of nutrition informant in designing and
trient adequacy among women of re- managing nutrition
productive age (Arimond, Wiesmann, projects (Table 3A). projects
Becquey et al, 2010), but such diversity Pregnant women and frontline workers 3B: Data collection during second round of field-testing
was lacking in SHIKHA intervention classified foods according to their per- Focus group Rural women 16 28
areas (Shamim, Mashreky, Ferdous et al, missibility (accessibility) and aspiration discussion Frontline nutrition 12
2016). (desirability). Certain foods that are usu- workers
ally promoted in nutrition programmes, In-depth Nutrition workers 2 2
First version of the plate and interview and supervisors of
such as carrots, were identified as neither
approval by expert consultation desirable nor accessible in the rural areas
BRAC
e original food plate had a border il- (Table 4). Feedback and suggestions were
Total 55
lustrating food groups that pregnant also provided on picture quality and
Table 4
women should eat every day during preg- Segregation of foods according to
messages (Table 5). e following is a permissibility (accessibility) and aspiration
nancy. e middle of the plate contained summary of the field suggestions: (desirability) by pregnant women and
a photo of a typical lunch or dinner 1. Sample meal: e quantity of foods frontline nutrition workers
meal. A main message about eating a to be eaten in a main meal should be High permission
variety of foods in sufficient amounts shown within a circle in the centre • Leafy • Small fish
during pregnancy was written in Bangla of the plate. vegetables • Some seasonally
across the bottom of the plate. e original 2. Food groups: Do not show too many • Pulses available local fruits
design (Table 1) was presented and ap- • Rice • Few local vegetables
food groups (but sub-groups can be Low (gourds) High
proved during an expert consultation shown in different shades of colour aspiration • Carrot • Large fish aspiration
held in Dhaka on September 4, 2014. (A within the same group). • Flesh foods
list of organisations that participated in 3. Messages: Printing a few more • Fruits like grapes,
the meeting or were otherwise consulted messages than the original plate may apples
during the development of the plate is • Milk
help pregnant women follow
shown in Table 2). Aer the meeting, Low permission
improved practices.

Table 5 Comments of pregnant women and nutrition

workers on quality of images and messages Table 6 Two food plate options presented at the second expert consultation

Features Problems/ Photo of the panel Photo of food plate Main features
suggestions
Option 1
Complexity Confused
to mango with • Three food groups:
understand papaya and 1. Protein (legumes and nuts, flesh and eggs in three shades of
pictures of hog palm green)
different with guava
foods and olive Message: Various protein-rich foods every day (alternative
message: daily various protein for proper growth of foetus, but
Confused bigger baby is not desirable to avoid delivery complications)
bean with
okra/ peas 2. Energy-giving foods (cereals, tubers and oil in two shades of
sky blue)
Chickpeas
were poorly Message: A little more energy-giving foods
understood
3. Foods to remain healthy coloured and green leafy
vegetables, vegetables and fruits in four shades of purple
Message: To remain healthy every day, vitamin-rich coloured
Perception Flesh foods
and green leafy vegetables, vegetables, fruits and milk
of and eggs
illustration should be in • A prominent message about quantity of foods and another
including the same message about hand-washing
background panel but in
colour two different Option 2
shades of
background • Four food groups (milk as a separate group)
colour • No message about food groups, but a message about the
Glass of milk quantity of foods that need to be eaten every day
will look
transparent • Other features similar to the previous design

Font size No problem

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Table 7 Final version of the food plate
Photo of food plate
Messages
Prominent message: Half plate of rice and at least four other
varieties of food
Eating a variety of food in appropriate amounts keeps mothers
and children healthy
Eat a little more food during pregnancy
Wash both hands with soap and running water before preparing
and eating food
Second expert consultation
e design was revised based on the feedback
from the field. Two new food plate options were
presented at a second expert consultation held
in Dhaka on June 10, 2015. e two options are
described in Table 6. e experts preferred a
combination of both options, but suggested
adding more messages and fine-tuning them
through additional field-testing. e following
is a summary of their recommendations:
1. Include four to five food groups on the plate.
2. Include one central message about quantity
of rice and food diversity.
3. Include three additional messages: one
about the importance of eating a diverse
diet, one about quantity of food, and one
about hand-washing.
4. Incorporate these recommendations into a
second version of the plate, collect the
opinions of pregnant women and frontline
nutrition workers, and finalise the design
accordingly.
References
Arimond M, Wiesmann D, Becquey E, Carriquiry A, Daniels
MC, Deitchler M & Torheim LE, 2010. Simple food group
diversity indicators predict micronutrient adequacy of
women’s diets in 5 diverse, resource-poor settings. The
Journal of nutrition, 140(11), 2059S-2069S.
BDHS 2011. Bangladesh Demographic and Health Survey
2011. National Institute of Population Research and
Training, Mitra and Associates, and ICF International. 2013.
dhsprogram.com/pubs/pdf/FR265/FR265.pdf
Fowles ER, 2004. Prenatal nutrition and birth outcomes.
Journal of Obstetric, Gynecologic, & Neonatal Nursing,
33(6), 809-822.
Girard AW, & Olude O, 2012. Nutrition education and
counselling provided during pregnancy: effects on maternal,
neonatal and child health outcomes. Paediatric and
Perinatal Epidemiology, 26(s1), 191-204.
Hermann J, Williams G, & Hunt D, 2001. Effect of Nutrition
Education by Paraprofessionals on Dietary Intake, Maternal
Weight Gain, and Infant Birth Weight in Pregnant Native American
and Caucasian Adolescents. Journal of Extension, 39(1), n1.
.......................................................................................................................................
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Key informant interview with Monira Parveen, PhD, Senior
Program Officer, Nutrition, World Food program, Bangladesh
More field-testing and final design and
development of a guideline for the
nutrition workers
e recommendations were incorporated and
images of the revised plate were printed and
laminated for field-testing. Focus group discus-
sions and in-depth interviews were held with
16 rural women and 14 nutrition workers (Table
3B) and feedback was incorporated into the
final design. e final design (Table 7), which
contains four messages, was transformed into
more than 5,500 melamine plates that nutrition
workers and pregnant women can hold in their
hands during counselling sessions.
Conclusion
is practical, colourful, evidence-based food
plate is an educational tool with the potential to
improve maternal nutrition not only within the
SHIKHA intervention areas but throughout
Bangladesh and in similar countries where proj-
ects are working to promote healthy maternal
Nahar Q, Faruque O, Sultana SS, Siddiquee AA, 2013.
Dietary Guidelines for Bangladesh. Bangladesh Institute of
Research and Rehabilitation in Diabetes, Endocrine and
Metabolic Diseases. www.fao.org/3/a-as880e.pdf
Office of Disease Prevention and Health Promotion, 2015.
Dietary guidelines. www.health.gove/dietaryguidelines.
Accessed July 2015.
Osmani S, & Sen A, 2003. The hidden penalties of gender
inequality: fetal origins of ill-health. Economics & Human
Biology, 1(1), 105-121.
Piirainen T, Isolauri E, Lagström H, & Laitinen K, 2006.
Impact of dietary counselling on nutrient intake during
pregnancy: a prospective cohort study. British Journal of
Nutrition, 96(06), 1095-1104.
Shamim AA, Christian P, Schulze KJ, Ali H, Kabir A, Rashid
M, Labrique A, Salamatullah Q, & West KP, 2012. Iodine
status in pregnancy and household salt iodine content in
rural Bangladesh. Maternal & Child Nutrition, 8(2), 162-
173. www.ncbi.nlm.nih.gov/pubmed/20977661.
Shamim AA, Kabir A, Merrill RD, Ali H, Rashid M, Schulze K,
Labrique A, West KP & Christian P, 2013. Plasma zinc,
vitamin B12 and α-tocopherol are positively and plasma γ-
Field Article
Abu Ahmed Shamin, SHIKA Project, FH360
diets. Several organisations have shown interest
in using the plate in their own nutrition education
and counselling efforts, including the Integrated
Agriculture and Health Based Intervention
(IAHBI) project of FAO and UNICEF, which is
procuring several thousand food plates. In its
final year, SHIKHA is working with the
Bangladesh Government to explore opportunities
for wider use of the tool; at the time of writing,
a process was underway to get approval of the
plate from the National Nutrition Service and
the Ministry of Health and Family Welfare for
use as a counselling tool in improving diet
quality of pregnant and lactating women.
For more information and guideline on the
food plate, contact: Abu Ahmed Shamim,
Technical Director, SHIKHA Project, FHI 360
Bangladesh, Road 35, House 5, Gulshan-2,
Dhaka 1212, Bangladesh,
email: ashamim@i360.org; and
aashamim@gmail.com
tocopherol is negatively associated with Hb concentration in
early pregnancy in north-west Bangladesh. Public Health
Nutrition, 16(08), 1354-1361.
www.ncbi.nlm.nih.gov/pubmed/23469947.
Shamim AA, Mashreky SR, Ferdous T, Tegenfeldt K, Roy S,
Rahman AKM, Rashid I, Haque R, et al, 2016. Pregnant
women diet quality and its socio-demographic determinants
in south-western Bangladesh. Food and Nutrition Bulletin
37 (1), 14-26.
Shamim AA, Schulze K, Merrill RD, Kabir A, Christian P,
Shaikh S, Wu L, Ali H, Labrique AB, Mehra S, Klemm RD,
Rashid M, Sungpuag P, Udomkesmalee E, West KP, 2015.
First trimester plasma tocopherols are associated with risk of
miscarriage in rural Bangladesh. The American Journal of
Clinical Nutrition, ajcn-094920.
www.ncbi.nlm.nih.gov/pubmed/25646326.
USDA 2011 [1]. United States Department of Agriculture.
MyPlate. www.choosemyplate.gov. Accessed Feb 2015.
USDA 2011 [2] United States Department of Agriculture.
MyPlate. www.choosemyplate.gov Aug. 2011. Accessed
Oct 4, 2013.
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