MEETING REPORT - World Health Organization...consultation, leading report writing process and providing inputs to the draft report; Laurence Grummer-Strawn (WHO Headquarters), for

MEETING REPORT

Inter-Agency Technical

Consultation on Infant and Young

Child Feeding Indicators

11-13 July 2018Geneva, Switzerland

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CONTENTS

Acknowledgements 4

List of acronyms 5

List of annexes 5

1. Background and objectives 6

2. Breastfeeding indicators 7

2.1. Children ever breastfed 7

2.2. Early initiation of breastfeeding 7

2.3. Supplementation in the first 3 days of life 8

2.4. Exclusive breastfeeding under 6 months 8

2.5. Predominant breastfeeding under 6 months 9

2.6. Early water feeding 9

2.7. Early complementary feeding 9

2.8. Breastfeeding mixed with non-human milk feeding under 6 months 10

2.9. Median duration of exclusive breastfeeding 10

2.10. BFHI indicator 11

2.11. Continued breastfeeding at 1 year, continued breastfeeding at 2 years, and continued breastfeeding in the second year of life 11

2.12. Duration of breastfeeding 12

2.13. Breast milk expression 12

2.14. Age-appropriate breastfeeding 12

2.15. Milk feeding frequency for non-breastfed children 13

2.16. Infant formula feeding 13

2.17. Bottle feeding 14

3. Complementary feeding indicators 15

3.1. Minimum meal frequency (part of calculation related to non-breastfed children) 15

3.2. At least one non-dairy animal-source food (ASF) yesterday 16

3.3. Sugar-sweetened beverages (SSBs) yesterday 17

3.4. Foods of minimal intrinsic nutritional value yesterday 20

3.5. No vegetable or fruit yesterday 21

3.6. Composite indicator of unhealthy dietary practices 23

3.7. Unhealthy fat/oil consumption 23

3.8. Fast food consumption 23

3.9. Plain water consumption 24

3.10. Timing of solid/semi-solid foods 24

4. Area graphs 25

5. Prioritization of Operational Issues 25

6. Communication 26

7. Conclusion 26

Annexes 27

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ACKNOWLEDGEMENTS

This meeting report is an outcome of the WHO-UNICEF Technical Expert Advisory group on nutrition Monitoring (TEAM), which was supported by the Bill & Melinda Gates Foundation.

The members of TEAM: Mary Arimond, Jennifer Coates, Trevor Croft, Omar Dary, Rafael Flores-Ayala, Edward Frongillo, Rebecca Heidkamp, Purnima Menon, Lynnette Neufeld, Faith Thuita and Wenhua Zhao.

Kuntal Kumar Saha (WHO Headquarters), for coordinating and organizing the consultation, leading report writing process and providing inputs to the draft report; Laurence Grummer-Strawn (WHO Headquarters), for leading background work on breastfeeding and providing inputs on the draft report; Chika Hayashi, Julia Krasevec and Vrinda Mehra (UNICEF Headquarters), for leading background work on complementary feeding, and providing inputs to the draft report; Mary Arimond (TEAM), for her contribution to the concept note for the consultation, and providing comments on the draft report; Chessa Lutter and Mandana Arabi (Consultants), for conducting background work on breastfeeding and complementary feeding, respectively; Ligia Reyes (Rapporteur) for taking meeting minutes, writing and revising the report; All participants and presenters, for their time and providing invaluable inputs to formulate the recommendations.

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LIST OF ACRONYMS

ASF Animal-Source Food

BFHI Baby-Friendly Hospital Initiative

DHS Demographic and Health Surveys

EDNP Energy-Dense Nutrient-Poor

GNMF Global Nutrition Monitoring Framework

HKI Helen Keller International

ICU Intensive Care Unit

IYCF Infant and Young Child Feeding

LMIC Low and Middle-Income Countries

MAD Minimum Acceptable Diet

MDD Minimum Dietary Diversity

MICS Multiple Indicator Cluster Surveys

MMF Minimum Meal Frequency

NCD Non-Communicable Disease

SSBs Sugar-Sweetened Beverages

TEAM Technical Expert Advisory Group on Nutrition Monitoring

UNICEF United Nations Children’s Fund

WHO World Health Organization

LIST OF ANNEXES

Annex 1: List of participants

Annex 2: Meeting agenda

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1 BACKGROUND AND OBJECTIVES

The global Infant and Young Child Feeding (IYCF) indicators were published in 2008 with an accompanying operational manual released in 2010. In June 2017, WHO and UNICEF convened an expert consultation to review the standard IYCF indicators published in 2008. Subsequently, an expert consultation was planned in July 2018 to obtain input on proposals for change to the existing indicator manuals.

In the opening remarks for the July 2018 meeting, Kuntal Saha from WHO presented key events that preceded the current expert consultation. The 2015 World Health Assembly endorsed inclusion of the minimum acceptable diet (MAD) indicator in the Global Nutrition Monitoring Framework (GNMF). Based on requests from Member States to simplify and make reporting more relevant to a broader set of countries, the Technical Expert Advisory Group on Nutrition Monitoring (TEAM) recommended substituting MAD with the minimum dietary diversity (MDD) indicator in the GNMF in 2017. In June 2017, the inter-agency expert consultation was convened to consider revisions to the indicator definitions for MDD and MAD, prioritize actions for the revision of existing indicators, development of new indicators, and improvement of operational guidance.

Chika Hayashi from UNICEF presented the overall and specific objectives of the July 2018 expert consultation. The overall objective was to discuss proposed revisions to the 2008 and 2010 indicator manuals. The specific objectives of the consultation were as follow:

a. To discuss modifications of existing indicators on breastfeeding and complementary feeding;

b. To discuss modifications to refine operationalization of existing indicators;

c. To identify additional breastfeeding indicators to assess compliance with the recommended Ten Steps to Successful Breastfeeding;

d. To discuss additional indicators on breastfeeding and complementary feeding, particularly diet quality indicators;

e. To review performance of (i) minimum meal frequency (MMF) for non-breastfed children; and (ii) an alternate question for breastfed yesterday; and

f. To identify effective strategies to communicate changes to indicator definitions and operational guidance, and develop a plan for how the documents will be revised.

Mary Arimond from TEAM presented an overview of the history of IYCF indicators. The 1991 indicators for assessing breastfeeding practices were effective in leveraging advocacy for breastfeeding practices. The 2008 indicators for assessing IYCF practices sought to fill a gap about complementary feeding. The IYCF indicators were designed for assessment, targeting, monitoring and evaluation, and advocacy. They were intended to be feasible for large-scale household surveys. Among the reasons to revisit the IYCF indicators are the limited use of some indicators, the need for introduction of possible new indicators in light of the rise of non-communicable disease (NCD) risk factors among children, and the need for increased advocacy on IYCF. Future IYCF indicators have to be evidence-based and grounded on advancing advocacy and effective policy and programmatic action.

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2 BREASTFEEDING INDICATORS

Chessa Lutter presented recommendations for existing and new indicators for feeding during the first 6 months and continuation of breastfeeding, bottle feeding, and infant formula feeding through the first 2 years of life. This is further detailed in a background paper prepared for this consultation. The indicator recommendations were informed by the 2017 consultation, interviews with experts and stakeholders, literature review of the indicators, analysis using DHS data, and personal judgment from a long career working in IYCF. These recommendations applied the principles that the set of indicators should be as parsimonious as possible and that changes to existing indicators should be minimal where possible. Other considerations included validity, measurement issues, and having indicators as a set. This section presents the proposed revisions for existing indicators, proposed new indicators, and the main discussion points for each indicator where applicable. Discussion was facilitated by Larry Grummer-Strawn from WHO.

2.1. CHILDREN EVER BREASTFED

Current definition: Proportion of children born in the last 24 months who were ever breastfed.

Proposition: No change in name, definition, or measurement.

• Rationale: Useful in settings where breastfeeding initiation is low, especially in high- income countries.

Discussion: The majority of the group agreed not to make any changes to this indicator. It was reinforced that the indicator is useful among high-income countries to assess breastfeeding status and for advocacy efforts.

Recommendation: The overall consensus was to endorse the proposition to not make any changes to the indicator.

2.2. EARLY INITIATION OF BREASTFEEDING

Current definition: Proportion of children born in the last 24 months who were put to the breast within one hour of birth.

Proposition: No change in name, definition, or measurement.

• Rationale: Maintains consistency with current indicator and recommendation from UNICEF technical consultation.

Discussion: The majority of the group agreed not to make any changes to this indicator. It was acknowledged that the indicator is prone to recall bias, but it is currently the only indicator that provides some insight into what is happening at health facilities. Facility surveys were mentioned as a vehicle to capture these data but the overall consensus throughout the meeting was that while promising, facility surveys have not yet been sufficiently scaled up and may introduce additional social desirability bias.

Recommendation: The overall consensus was to endorse the proposition to not make any changes to the indicator.

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2.3. SUPPLEMENTATION IN THE FIRST 3 DAYS OF LIFE

Proposition: New indicator to capture supplementation in the first 3 days of life.

• Proposed definition: Proportion of infants born in last 24 months who were given any fluid or food in the first 3 days of life.

• Rationale: Follows recommendation from UNICEF technical consultation and reflects consensus from interviews with experts and stakeholders.

Discussion: The group was initially divided. About half of the group supported adding this new indicator while the other half was unsure. Skepticism to add related to potential recall bias since it would be asked of children born up to 24 months prior to survey interview, potential separation of mother and newborn during those first 3 days, and potential for alternate data collection through facility surveys and discharge surveys. The discussion was revisited and greater support reached to add this indicator. Some of the support related to how early supplementation can interfere with successful breastfeeding and is a risky practice particularly in settings where infectious disease prevalence is high. Facility surveys have not yet been sufficiently scaled up and may introduce social desirability bias. Discharge surveys do not eliminate the mother newborn/separation issue and there is no standard system for conducting discharge surveys. It was recommended to reconsider the name since it has positive connotation.

Recommendation: The overall consensus was to endorse the proposition to add this new indicator, but potentially rename it.

2.4. EXCLUSIVE BREASTFEEDING UNDER 6 MONTHS

Current definition: Proportion of infants 0-5 months of age who are fed exclusively with breast milk.

Proposition: No change in name or measurement, but rewrite definition to clarify age range; emphasize to disaggregate for infants aged 4 to <6 months.

• Proposed definition: Proportion of infants 0 to <6 months of age who are fed exclusively with breast milk, with no other liquids or foods added including water.

• Rationale: The age range 0-5 months does not align with the WHO recommendation of continuing to 6 months of age as it is sometimes misinterpreted. to only cover children <5 months of age. This overestimates the true prevalence of complying with this recommendation. The proposed change maintains consistency with the current indicator and follows the recommendation from UNICEF technical consultation. The disaggregation of 4 to <6 months would capture a more accurate prevalence.

Discussion: Many agreed that the current definition is prone to misinterpretation, but the consensus was not to rewrite it. The notes section of the 2008 indicator manual clearly explains the way the indicator should and should not be interpreted. The 2010 operational guide also clearly indicates that the age range is 0 to 5.9 months and making the proposed change would cause confusion. It was added that the indicator captures exclusive breastfeeding in the last 24 hours, which is a characteristic that should be better communicated. On the issue of disaggregation, there was some concern about sample size. To look at age sub-groups, one idea was to look at how much variability there is over time in different countries and whether weighting should be done differently. The group recommended improving communication about what the indicator means and the exact age cut-off to prevent misinterpretation.

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Recommendation: The overall consensus was to endorse the proposition to not make changes in name and measurement but opposed that the definition needs to be rewritten as this is accurately captured in the 2008 and 2010 guides.

2.5. PREDOMINANT BREASTFEEDING UNDER 6 MONTHS

Current definition: Proportion of infants 0-5 months of age who are predominantly breastfed.

Proposition: Delete indicator.

• Rationale: Predominant breastfeeding is not a recommended practice. It mixes together the recommended practice of exclusive breastfeeding and the non- recommended practice of breastfeeding with the feeding of water, water- based drinks, and fruit juices.

Discussion: The main problem raised was that this indicator is not mutually exclusive from exclusive breastfeeding. The 2008 definition notes that the indicator is meant to capture babies where breastmilk is the primary/main source of nourishment. The indicator combines the lowest two categories from area graphs and it is used in impact models.

Recommendation: The overall consensus was not to proceed with the proposition to delete this indicator, but there is a potential issue with its definition/computation that remained unresolved as the indicator is not currently mutually exclusive from exclusive breastfeeding.

2.6. EARLY WATER FEEDING

Proposition: New indicator to capture water feeding under 6 months.

• Proposed definition: Proportion of infants 0 to <6 months of age who are fed water. • Rationale: Follows recommendation from UNICEF technical consultation and reflects

views from interviews with experts and stakeholders. In many countries, it is the primary reason exclusive breastfeeding is not practiced.

Discussion: This discussion took place in the context of predominant breastfeeding. Area graphs were used to illustrate mutually exclusive categories that explain non-exclusive breastfeeding. Much of the discussion related to the importance of having mutually exclusive categories, but that was weighed against the potential assumptions about introducing indicators for suboptimal practices, maintaining parsimony in the set of IYCF indicators, and the existence of area graphs for programmatic purposes. The consensus was not to add this indicator.

Recommendation: The overall consensus was not to proceed with the proposition to add this new indicator.

2.7. EARLY COMPLEMENTARY FEEDING

Proposition: New indicator to capture complementary feeding under 6 months.

• Proposed definition: Proportion of infants 0 to <6 months of age who are fed complementary foods.

• Rationale: Follows recommendation from UNICEF technical consultation and reflects views from interviews with experts and stakeholders. The practice is common in many countries.

Discussion: The discussion for this indicator was similar to that of early water feeding with regard to mutually exclusive categories and the use of area graphs. A distinction between these two indicators is that with early complementary feeding infants are partially getting nutritive foods,

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which is a practice closer to the concept of partial breastfeeding. The idea of a partial breastfeeding indicator was introduced, which would combine the practice of feeding breast milk with other milks/formula and complementary foods. However, it is not recommended to combine these practices together. The consensus was not to add this indicator but to improve guidance so that the mutually exclusively categories shown in areas graphs can be used for programmatic purposes.


2.8. BREASTFEEDING MIXED WITH NON-HUMAN MILK FEEDING UNDER 6 MONTHS

Proposition: New indicator to capture breastfeeding mixed with non-human milk under 6 months.

• Proposed definition: Proportion of infants 0 to <6 months of age who are fed breast milk and non-human milk.

• Rationale: This practice is common across many countries. Non-human milks are likely to displace breast milk.

Discussion: The idea for this indicator emerged from an earlier discussion that used area graphs. In that discussion, the concept of partial breastfeeding was briefly introduced as an indicator but decided against due to the issue of combining non-human milks with complementary foods. In the absence of an indicator that captures partial breastfeeding, the discussion was reframed on the value of measuring the practice of breastfeeding mixed with non-human milks. Complementary foods also displace breast milk, but not to the same extent in this age group. In environments with poor sanitation, there is also risk especially with using bottles. Countries have different problems that hinder exclusive breastfeeding, but the consensus was that this indicator is well-justified and it would assess the extent to which this is a global problem.

Recommendation: The overall consensus was to endorse the proposition to add this new indicator.

2.9. MEDIAN DURATION OF EXCLUSIVE BREASTFEEDING

Proposition: New indicator considered but not recommended for addition.

• Proposed definition: Age at which 50% of infants are exclusively breastfed and 50% are not.

• Rationale: Communicating what the indicator means in the context of the recommendation that infants be exclusively breastfed during the first 6 months is challenging.

Discussion: The majority of the group agreed not to add this indicator. This indicator is conceptually difficult to communicate. Infants who are exclusively breastfeed beyond the first 6 months would increase the median duration even though this is not a recommended practice. This indicator is also operationally challenging because it tries to come up with a median estimate from data that are not designed to do that. The group acknowledged that from a policy perspective, duration of exclusive breastfeeding is valuable. Area graphs are useful tools to see changes in breastfeeding practices across different ages in the 0-5 month age group.

Recommendation: The overall consensus was to endorse the proposition to not add this new indicator.

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2.10. BFHI INDICATOR


• Proposed definition: None was provided. • Rationale: The set of IYCF indicators reflects practices while BFHI indicators reflect

policy and systems.

Discussion: The consensus was not to add this indicator. Many voiced that it is important to differentiate between practice indicators and systems indicators as these reflect different kinds of issues. There is emerging work to strengthen measurement of programs/policy that support breastfeeding. It was suggested that adherence to the Ten Steps to Successful Breastfeeding could be measured through discharge surveys. DHS and MICS collect related data with questions on breastfeeding counselling and skin-to-skin contact.


2.11. CONTINUED BREASTFEEDING AT 1 YEAR, CONTINUED BREASTFEEDING AT 2 YEARS, AND CONTINUED BREASTFEEDING IN THE SECOND YEAR OF LIFE

Current definitions:

• Continued breastfeeding at 1 year: Proportion of children 12-15 months of age who are fed breast milk.

• Continued breastfeeding at 2 years: Proportion of children 20-23 months of age who are fed breast milk.

Proposition 1: Change the age range for each indicator in order to center at 1 year and 2 years to more accurately represent the age. The indicator definitions would change as follows:

• Continued breastfeeding at 1 year: Proportion of children 10 to <14 months of age who are fed breast milk.

• Continued breastfeeding at 2 years: Proportion of children 22 to <26 months of age who are fed breast milk.

Proposition 2: Collapse the two indicators into one indicator to reflect continued breastfeeding in the second year of life.

• Calculations remain the same with reference age of 12 to <24 months. This approach better captures the underlying construct and the age range increases sample size, therefore allowing disaggregation across the second year of life.

Discussion: The current definition is conceptually problematic because for the indicator at 1 year, the age range is 4 months after, whereas for the indicator at 2 years, the age range is 4 months before. The group was not convinced that proposition 1 sufficiently addressed the problem because sample size would still be small and data would be needed beyond 24 months. The majority of the group was supportive of proposition 2, with the recommendation that disaggregates for 12-15 months and 20-23 months be provided. Support for this proposition, which would create a new indicator and eliminate the two existing indicators, was that expanding the age range to the second year of life would provide more precise estimates.

Recommendation: The overall consensus was to endorse proposition 2, which eliminates the two existing indicators for continued breastfeeding at age 1 and at age 2 and creates a new indicator for the second year of life. The group further recommended disaggregates for 12-15 months and 20-23 months.

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2.12. DURATION OF BREASTFEEDING

Current definition: Median duration of breastfeeding among children less than 36 months.


• Rationale: Its calculation is complicated, to an extent captured in the continued breastfeeding indicator(s), and reported as not particularly useful in the expert and stakeholder interviews.

Discussion: The majority of the group agreed to delete the indicator, but two points were made to convey its value. From a monitoring perspective, this indicator has been instrumental in Indonesia in identifying decreasing trends of breastfeeding duration. From a programmatic perspective, it is useful for targets of continued breastfeeding through 2 years. To this, it was added that the benefits need to be weighed against the mentioned challenges with calculations and interpretation.

Recommendation: The overall consensus was to endorse the proposition to delete this indicator.

2.13. BREAST MILK EXPRESSION


• Proposed definition: None was provided. • Rationale: The practice could be beneficial or harmful depending on the reasons

milk is expressed. Given that the indicator would not distinguish between situations, the policy implications are unclear.

Discussion: The majority of the group agreed not to add this indicator but its utility was voiced.

As economies are transitioning and more women entering the workforce, this is the practice that should be promoted that allows women to continue feeding breast milk. There are also special settings, such as ICU, where this practice is encouraged. On the other hand, where direct breastfeeding is possible, breast milk expression may not have as much benefit for the infant. The consensus was not to add this indicator given that there is no clear direction across the board whether this is a beneficial or a harmful practice.


2.14. AGE-APPROPRIATE BREASTFEEDING

Current definition: Proportion of children 0-23 months of age who are appropriately breastfed.


• Rationale: This is a composite indicator, which is intrinsically more difficult to interpret, and it is to an extent captured in the exclusive breastfeeding and continued breastfeeding indicator(s).

Discussion: The majority of the group agreed to delete this indicator. There was some discussion about how to prioritize constructs that are not indicators. To this, it was added that countries can always calculate estimates for other indicators even if they are not global standard indicators.

Recommendation: The overall consensus was to endorse the proposition to delete this indicator.

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2.15. MILK FEEDING FREQUENCY FOR NON-BREASTFED CHILDREN

Current definition: Proportion of non-breastfed children 6-23 months of age who receive at least 2 milk feedings.


• Rationale: This indicator is rarely reported.

Discussion: The discussion to delete this indicator happened in the context of adding an indicator for formula feeding, which is presented in the next section. The group was initially divided on deleting this indicator. Some of the division had to do with the importance of distinguishing the types of milk due to nutrient composition. While this distinction is important, the decision was not to delete this indicator because it captures an important behavior for non-breastfed children that they need to have a milk source. The guiding principles for non-breastfed children 6-23 months of age states that the amount of milk needed to meet nutrient requirements depends on other foods consumed and whether the diet includes fortified foods or supplements. The target of 2 milk feedings is based on the amount of milk needed, which ranges from 200-400ml/d to 300-500ml/d. It was also added that the proposed new indicator on milk formula feeding does not provide information on compliance with the recommendation, and thus this remains an important indicator.

Recommendation: The overall consensus was not to proceed with the proposition to delete this indicator on the basis that it captures an important behavior for non-breastfed children that they need to have a milk source.

2.16. INFANT FORMULA FEEDING

Proposition: New indicator to capture formula feeding.

• Proposed definition: Proportion of children <24 months of age who are fed milk formula (infant formula, follow-up formula or growing up milk).

• Rationale: Infant formula use is rapidly expanding, especially in LMIC, and thus would be important to monitor. The MICS and DHS questionnaires already have a separate question for infant formula and DHS already tabulates the results in statcompiler as well as the DHS reports. However, it is possible that respondents are not able to respond correctly to distinct questions about consumption of formula as well as those for other milks.

Discussion: The group was initially divided. In support of adding the indicator was the importance to distinguish infant formulas from other milks because these do not have the same nutrient composition. Part of the objection to this indicator was that it is operationally difficult to distinguish these types of milks. Powdered milk is cheaper and may be confused with formula. Different types of formula are also available for different age groups (e.g. infant formula meant for <6 months old, follow-on formula, etc.) and it is unclear which types the definition should cover. DHS and MICS currently ask about infant formula for all children <2 years but do not differentiate type. If formula types would need to be distinguished, it is unclear how much effort would be needed to customize the questionnaires and train interviewers; methodological work involving cognitive interviewing would also be essential before introducing such distinctions in the questionnaires. The question of policy implications was raised, and it was added that availability of data for such an indicator could support efforts related to marketing of formula products.


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2.17. BOTTLE FEEDING

Current definition: Proportion of children 0-23 months of age who are fed with a bottle.

Proposition: No change in definition or measurement but change the indicator name to “bottle feeding of young children.”

• Rationale: The name change reflects that the indicator covers children as well as infants. Bottle feeding is not recommended by WHO and UNICEF.

Discussion: The arguments supporting retention of this indicator included the common practice among working women to use bottles to continue feeding breast milk. In Malawi, there has been an increasing use of bottles and what is put in the bottles has been changing from milk to beverages of any kind. The use of bottles is not recommended due to hygiene issues, and their use is particularly dangerous in environments with poor sanitation. From an overweight and obesity risk perspective, there is evidence of behavior to finish the bottle. Deleting the indicator might deter efforts and send the wrong message that bottle use is not concerning. The consensus was to retain the indicator.

Recommendation: The overall consensus was to retain the indicator as it currently is, including its definition, measurement, and name.

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3 COMPLEMENTARY FEEDING INDICATORS

Julia Krasevec and Mandana Arabi presented and facilitated discussion on complementary feeding indicators, which covered new indicators on diet quality and revisions to existing indicators. The expected outcomes were to reach agreement on which new indicators to move forward with and prioritization of main operational issues, including appropriate steps to address them. The proposed new indicators to capture diet quality would require new data collection (3 unhealthy dietary practices, 1 composite) or use existing data (animal-source food consumption and timing of solid/semi-solid foods). These recommendations were based on literature review, key informant interviews, feasibility to collect data in DHS and MICS, and are a first step to have indicators that address unhealthy diets which pose a risk for overweight and chronic disease in children 6 to <24 months. This section presents the indicators that were proposed and the main discussion points for each indicator where applicable. More detail for each indicator is available in the background documents prepared for this consultation. The sub-headings are not necessarily the final indicator names but constructs that the indicators would capture.

RECOMMENDED INDICATORS3.1. MINIMUM MEAL FREQUENCY (PART OF CALCULATION RELATED TO NON-BREASTFED CHILDREN)

Current definition: Proportion of non-breastfed children 6-23 months of age who received solid, semi-solid, soft foods or milk feeds 4 times or more during the previous day.

Proposition: Revise definition.

• Proposed definition: Allow a maximum of 2 milk feeds for non-breastfedchildren 9-23 months of age.

• Rationale: The current definition allows non-breastfed children up to 4 milk feedsper day to meet MMF. Recommendations exist that daily milk intake should not exceed 750-950 ml for children 9-23 months. There is evidence that children who had 2 cups of milk daily had healthy levels of vitamin D and iron, but those who had more than 2 cups had no additional vitamin D benefit but had lower iron stores. Thus, the American Academy of Pediatrics recommends 2 servings per day but no more than 4 per day for this age group. It is also unlikely that children would meet energy requirements (purpose of the indicator) with only 4 milk feeds as per simulation calculations.

Discussion: While the simulation calculations indicated that it was unlikely that a child of these ages could meet required energy intake, it was argued that it was possible for a child to meet the daily energy requirements only with milk feeds if fed on demand. However, the indicator does not capture on demand feeding and required only 4 milk feeds to be counted in the numerator. Also, if feeding is based on formula company recommendations for children 12-23 months, then a child would unlikely meet those requirements since formula companies by definition provide recommendations that would not make up the full diet of a child in this age group and would leave room for other foods. With the potential removal of the age-appropriate breastfeeding indicator, there was support for limiting milk feeds that could be counted for this indicator. While insufficient scientific rationale was presented to limit to 2 feeds,there was support to require at least 1 non-milk feed, as that is consistent with the guidance of complementary feeding starting at 6 months.

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Recommendation: The overall consensus was not to endorse the proposition as stated but to change the definition to require at least 1 of 4 feeds to be a complementary food feeding for non-breastfed children.

3.2. AT LEAST ONE NON-DAIRY ANIMAL-SOURCE FOOD (ASF) YESTERDAY

Proposition: New indicator that uses existing data to capture ASF consumption, these are the potential indicators for consideration.

Indicator Definition

Egg consumption Percentage of children 6-23 months of age who consumed eggs during the previous day.

Animal milk/animal milk product consumption

Percentage of children 6-23 months of age who consumed animal milk/animal milk product during the previous day.

Flesh food consumption Percentage of children 6-23 months of age who consumed flesh foods during the previous day.

Composite Indicator

Zero animal source food consumption

Percentage of children 6-23 months of age who did not consume any type of animal source food during the previous day.

At least one type of animal source food consumption

Percentage of children 6-23 months of age who consumed any type of animal source food during the previous day.

All 3 types of animal source food consumption

Percentage of children 6-23 months of age who consumed all 3 types of animal source food during the previous day.

• Rationale: WHO guidelines on complementary feeding suggest that meat, poultry, fish or eggs should be eaten daily or as often as possible. There is evidence that diets lacking ASF limit meeting the dietary needs for infants and young children and of independent effects of different types of ASF on stunting. There is also evidence of low prevalence for egg and flesh food intake across many countries.

Discussion: The majority of the group agreed that there should be an indicator on ASF. The guiding principles state that meat, poultry, fish or eggs should be eaten daily or as often as possible. Dairy was excluded because it is not a good source of iron, marginally of zinc, and it plays a different role than the other forms. Most of the group agreed that dairy should be excluded from ASF and supported that this indicator be a measurement of at least one non-dairy ASF. There was some discussion about including insects but the group was divided. In settings where insects are consumed, it was suggested that those countries could customize their food lists to include them. However, it was clarified that the same would need to be considered for MDD, where insects are not currently counted as a food group. The group was also asked about counting ultra-processed meats as flesh foods. From the 2017 consultation, ultra-processed meats like hot dogs and bacon remained counted when considering the MDD definition discussions due to their iron and protein content. However, there are concerns about consumption of these meats for other untoward health effects such as cancer

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risk. Discerning these meats in household surveys has been tried but it can be very difficult. In the United States, healthier options of what would be considered ultra-processed meats are on the market. Participants from African and Asian countries expressed that consumption of ultra-processed meats was not a major problem in this age group. For Mexico, these meats are a problem but its national survey already separates ultra-processed meats from other ASF. Other Latin American countries also mentioned concern of consumption of such items during a separate WHO consultation in the previous week. Consensus could not be reached on whether ultra-processed meats should be excluded from the indicator or be counted as flesh foods. If these meats are excluded from the indicator, it would also be necessary to revise the MDD ‘flesh food’ food group. If these meats are counted as flesh foods, guidance for countries should include the option to measure consumption of ultra-processed meat.

Recommendation: Overall consensus not to use any of the proposed indicators as presented in the background document but to include an indicator defined as “percentage of children 6-23 months of age who consumed eggs and/or flesh foods in the previous day.” There was a lack of consensus on whether to count ultra-processed meats or insects as flesh foods; some due to potential problems in operationalization.

3.3. SUGAR-SWEETENED BEVERAGES (SSBS) YESTERDAY

Proposition: As part of the new indicators to monitor diet quality, consumption of sweet-tasting beverages and/or sweeteners added by caregivers to beverages/foods was presented as a component with three potential indicators for consideration.


Sweet-tasting beverage and/or sugar/sweetener consumption

Percentage of children 6-23 months of age who consumed sweet-tasting beverages and/or had sugar/sweeteners added to beverages/food during the previous day.

Sweet-tasting beverage consumption

Percentage of children 6-23 months of age who consumed sweet-tasting beverages during the previous day.

Added sugar and/or sweetener consumption

Percentage of children 6-23 months of age who consumed sugar/sweeteners added to beverages/food during the previous day.

• Rationale: There is strong evidence for the association of SSBs with overweight risk among infants and young children, emerging evidence for increased risk of infant overweight, increased preferences for sweet foods, changed blood lipid profiles and increased insulin resistance with non-caloric sweeteners exposure in utero, prevalent consumption of sweet-tasting beverages among young children, and guidance that recommends against giving infants and young children SSBs, including 100% fruit juice. In addition, there is some evidence that links consumption in early years to future preferences and habit forming as well as evidence that sugar and sweeteners added by caregivers is prevalent. Evidence on chronic disease risk later in life was also presented as a follow on to the habit-forming evidence.

Discussion: Some questions were presented to the group, but the group expressed a need to first discuss the evidence for the proposed definition and all of its components. The group also requested not to include the operational issues in the initial discussion with the aim of keeping pure to the evidence for defining the indicator. All agreed that diet quality

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is a pressing issue to address and that SSBs is a food category that requires monitoring for this age group. The group underscored that the evidence needs to be unassailable for all proposed components of the definition and that a meta-analysis review for this age group would be an optimal reference for such decision-making, noting that one had been recently submitted for publication and could hopefully be referred to in the near future. Many participants asserted that from what was presented, 100% fruit juice and beverages sweetened with non-caloric sweeteners had the least strong evidence; including these beverages in the indicator definitions would not be aligned with current guidance on IYCF. The proposed inclusion of sweetened dairy beverages was also contended on the basis that dairy is inherently a positive food group for this age group; dairy should not be included in the definition even if it contained added sugar such as in flavored milks or yogurts. However, one country participant from Mexico indicated that sweetened dairy beverages are a major source of sugar intake in this age group. For this purpose, Mexico’s national nutrition surveys have been specifically asking about these beverages. The CDC definition of SSBs was suggested for consideration. This definition does not include 100% fruit juice or beverages sweetened with non-caloric sweeteners, but it does include any liquids that are sweetened with various forms of added sugars as well as sugar/caloric sweeteners added to beverages such as coffee and tea. In addition to obesity and chronic disease prevention, an important rationale that could be included is the displacement of nutritious foods. Further details on discussion of specific proposed components to count as SSBs follows:

• Fruit juices as SSBs: The discussion focused on whether to include 100% juice as SSBs. WHO recommendations on sugar intake relate to reducing consumption of free sugars, which by definition include sugars naturally present in fruit juices. Some participants voiced that fruit juices are not a strong indicator for unhealthy behavior because these contain some micronutrients. Others contested that the micronutrient content in fruit juices is minimal and it is operationally difficult to distinguish fruit drinks from fruit juices. Some participants added that fruit juice made at home can be quite nutritious. In Malawi, the recommendation is to prepare fruit juices at home as a healthier practice. The idea was introduced to distinguish between homemade and store-bought, which DHS and MICS representatives saw as feasible. The discussion was further refined on whether 100% juice that is not homemade should be included in SSBs. Several participants voiced strong opposition to include 100% juice in SSBs as this is not what this indicator is conceptually trying to capture and would countering healthier behavior efforts that include fruit juice in LMIC and high-income countries.

• Sweet dairy categorization: Sweetened/flavored dairy drinks and yogurts were among the products proposed to be counted as SSBs in the background documents. Several participants voiced concern about counting these products as SSBs. There are many different yogurt products and some participants refuted the idea that any kind of yogurt but plain is unhealthy. As was indicated earlier, sweet dairy products are a source of sugar consumption in this age group in Mexico. Other country participants did not express this as a problem in their respective countries. When deciding what products should be counted as SSBs, it was highlighted that there is a distinction between beverages with no intrinsic nutritional value and sweetened animal-source products that have some inherent nutritional value. The proposition was to only include sugar-containing beverages that have no-inherent nutritional value.

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• Added sugar: The group agreed that adding sugar to beverages at home is problematic, but the main issue is how much counts as added sugar and what is it being added to. This was framed as an important issue to settle because it is common practice in some countries to add a bit of sugar to what can be quite nutritious foods. In Bangladesh, some of the recommended recipes contain sugar. On the other hand, added sugar can be quite high and Mexico raised this as an in-country problem; the background document also cited examples of high levels of sugar added to beverages/food for infants from the literature. The question on whether to distinguish between sugar added to beverages and sugar added to foods was also posed in the background documents given that the literature shows different effects and it could also be difficult for respondents to distinguish between the two. This discussion was revisited and most of the group agreed that sugar added to beverages (but not food) in the home should be included in SSBs with the option for disaggregation between added sugar by caregiver and industrially produced sugar-containing beverages that are of no intrinsic nutritional value.

In summary, the group seemed to reach consensus that SSBs consumption is a good indicator of unhealthy dietary practices. The group was not comfortable including 100% fruit juice in SSBs. There were uncertainties about including sweetened dairy and yogurts as SSBs and thus determined that these products should not be counted as SSBs, recognizing that there are some settings where very nutrient-poor dairy products are a problem. On the issue of adding sugar to beverages in the home, the majority of the group agreed to include beverages sweetened at home as SSBs with the option for countries to disaggregate by type due to different policy and programmatic implications.

Recommendation: The overall consensus was not to use the proposed indicator as defined in the background document but to include an indicator which includes SSBs that have no intrinsic nutritional value as well as caloric sugar/sweeteners added to beverages at home. Therefore, the proposed parts of the indicator which overall consensus was to omit include: 100% fruit juice, sweetened dairy beverages, any other beverage with intrinsic nutritional value even if sugar was added, beverages sweetened with non-caloric sweeteners. Outstanding issues included how to deal with distinguishing between beverages that would and would not count (e.g. how to ensure that respondents could distinguish between 100% fruit juice and other fruit drinks; how respondents could distinguish between beverages sweetened with non-caloric sweeteners versus those sweetened with caloric sweeteners).

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3.4. FOODS OF MINIMAL INTRINSIC NUTRITIONAL VALUE YESTERDAY

Proposition: Consumption of junk foods was also proposed as part of the new indicators for unhealthy dietary practices; one component with three potential indicators. Junk foods are foods that are high in sugar, salt and/or fat that contribute to high energy density of the diet without sufficient contribution to other micro- and macronutrients. Other terms used include energy-dense nutrient-poor (EDNP) foods, discretionary foods, ultra-processed foods, and unhealthy snacks.


Junk food consumption Percentage of children 6-23 months of age who consumed savory and/or sweet junk food during the previous day.

Sweet junk food consumption Percentage of children 6-23 months of age who consumed sweet junk food during the previous day.

Savory junk food consumption Percentage of children 6-23 months of age who consumed savory junk food during the previous day.

• Rationale: The rationale for this component included evidence of health risk for infants and young children associated with excess salt consumption, displacement of other foods in relationship to weight gain, impact of junk food consumption on psychosocial development, and impact for future preferences and formation of habits. Consumption of junk foods is widespread among infants and young children and focus should be on consumption at any point, meal or snack. The literature does not adequately distinguish liquid from solid consumption to allow for distinction of the effects of junk food consumption in solid form versus liquid or semi-solid.

Discussion: The discussion covered terminology, the importance of separating foods from beverages, the issue with separating sweet and savory foods, and operational guidance for countries to customize.

• Terminology: The use of the term “junk” foods was not seen as fully appropriate for capturing the construct targeted in this discussion. In addition to the terms presented earlier, participants brought up “ultra-processed” foods, foods of “minimal nutritional value,” and foods of “minimal intrinsic nutritional value,” with the latter having the most support. This was partly done to improve the understanding of what the construct is trying to capture, and ensuring that it would not leave room for fortification of utterly unhealthy foods to give them some nutritional value (e.g. add some vitamins, etc.). Ultra-processed foods was an attempt to separate healthy from unhealthy foods, but it is often misunderstood and the distinction made in its definition between healthy and unhealthy is not clear-cut for this age group and cannot be uniformly applied.

• Foods and beverages: Some participants voiced discomfort with combining foods with beverages in this indicator. From a policy perspective, soda tax was mentioned as one of the important reasons to keep them separate. It was added that if consumption of SSBs is taken up as an indicator, then this indicator should be capturing foods of minimal intrinsic nutritional value that are not beverages.

• Sweet and savory foods as separate indicators: There was some lack of clarity about the rationale for separating sweet and savory foods, and whether there would be added value in having an indicator for each group. The information presented on salt stated that many of savory foods also contain high sugar and eventually these two categories seem to conceptually hang together.

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• Operational guidance: From a conceptual perspective, consensus was reached about the value of this indicator and what it is trying to capture. The issue remained on how to operationalize it as a global indicator that can be customized country by country in DHS and MICS surveys while still retaining comparability. It was raised that scalar equivalence can still be achieved with customization, though the list of foods should be relatively short and one proposition was to have a minimal set of worse offenders. With customization, the group was reminded that DHS and MICS already undertake country customization but it is inconsistently done. Further guidance on how to undertake customization with specific examples would be needed.

In summary, the group agreed with the addition of this indicator to capture consumption of foods of minimal intrinsic nutritional value, which would not include beverages. Combining sweet and savory foods was favored from an evidence standpoint but also for the potential implications of separating them. One topic that was raised but not discussed in detail was fat content and quality. Further guidance will be needed on operationalization but the general consensus was to maintain a standard frame that still allows country by country customization.

Recommendation: The overall consensus was to use the proposed indicator as defined in the background document which included both sweet and savory junk foods under one indicator but not to include the proposed separate indicators for sweet and savory. Other outstanding issues included how to better support country customization of the questionnaires and interviewer instructions with the addition of this more complex set of food items.

3.5. NO VEGETABLE OR FRUIT YESTERDAY

Proposition: Zero vegetable and fruit consumption was also presented as part of the new indicators for diet quality. Like the two preceding indicators, this was initially presented as one component with three potential indicators.


Zero vegetable consumption Percentage of children 6-23 months of age who did not consume any vegetables during the previous day.

Zero fruit consumption Percentage of children 6-23 months of age who did not consume any fruits during the previous day.

Zero vegetable or fruit consumption Percentage of children 6-23 months of age who did not consume any vegetables or fruits during the previous day.

• Rationale: The rationale for this component included evidence of low vegetable intake in infancy linked to low intake in later life, evidence of low vegetable and fruit consumption associated with obesity and chronic disease, and the high prevalence of zero consumption among infants and young children across many countries. It was proposed as a negative indicator that works towards 0%, adding that is difficult to capture servings per day.

Discussion: Most of the group agreed that it would be useful to have an indicator capturing lack of vegetable and fruit consumption. The discussion covered treatment of starchy and non-starchy tubers and roots, classification based on sugar content, fruity junk foods, and counting condiment vegetables.

• Starchy and non-starchy tubers and roots: The group was asked about separating starchy roots and tubers from non-starchy roots and tubers, such as using cut-offs for only white-fleshed roots and tubers or for any color-fleshed roots and tubers. The group did not agree with cut-offs and it was added that the majority of food-based dietary guidelines globally exclude potatoes from counting as a vegetable. The exclusion of white starchy roots and tubers was not contested.

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• Classification based on sugar content: The group was asked about using a sugar cut-off per 100g to distinguish vegetables and fruits. There was no support for this proposition. It was added that the lack of clear distinction between vegetables and fruits is one of the reasons why it is difficult to separate them in terms of risk factors as these are often the same foods with similar properties.

• Fruity junk foods: The group was presented with the idea of capturing foods of minimal intrinsic nutritional value that contain fruit so as not to count them under fruit consumption. One idea was to use a culinary approach where sweetened desserts could be separated from fruits, noting that this might not eliminate all types of fruit containing foods of minimal intrinsic nutritional value.

• Condiment vegetables: The group was presented with the idea that some vegetables are consumed as condiments in small quantities and thus should not be counted as consuming vegetables. MICS with open-recall and more probing might capture this, but DHS with the list-wise approach might not. From DHS perspective, this might be doable depending on the degree of questionnaire customization and training.

A major part of the discussion focused on whether vegetables and fruits should be captured separately or as a combined indicator. An issue discussed was the difficulty in distinguishing them, such as the case of unripe fruits. DHS and MICS currently collect data on fruits and vegetables aligned with the food groups needed to assess MDD of (i) dark leafy greens (ii) vitamin-A rich orange-fleshed fruits, (iii) vitamin-A rich orange-fleshed roots and tubers (which currently has a mix of starchy and non-starchy vegetables), and (iv) other fruits and vegetables which from a conceptual perspective, some participants argued that while it is good for children to have both vegetables and fruits, it is a bigger problem if they do not have either and a combined indicator captures that. In summary, the consensus was that the combined indicator has strong evidence.

Recommendation: The overall consensus was to use the proposed indicator as defined in the background document which included both fruits and vegetables under one indicator but not to include the proposed separate indicators for fruits and vegetables. Outstanding issues include how to deal with non-white starchy tubers and fruit containing food items that are high in sugar, fat and/or salt that have little other intrinsic nutritional value.

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NOT RECOMMENDED INDICATORS3.6. COMPOSITE INDICATOR OF UNHEALTHY DIETARY PRACTICES

Proposition: New indicators to capture any unhealthy dietary practice and all three unhealthy dietary practices during the previous day (SSBs, foods of minimal intrinsic nutritional value, and no vegetable or fruit).

• Rationale: The rationale for reporting on the “any unhealthy practice” indicator is that it would be a better portrayal of the extent of the problem since unhealthy practices often occur in combination. It would also provide a better tool for policy decisions. The rationale for reporting on all the three unhealthy dietary practices indicator is the existing evidence of multiple risky behaviors, which increase the risk of overweight and chronic disease.

Discussion: Some participants voiced concern with having a composite indicator on the basis that the components are not equivalent unhealthy behaviors. Furthermore, strong evidence would be needed to support that if a child has all of these three unhealthy behaviors that child would have poor outcomes, and there is not enough evidence of that. It was reinforced that it is important to first understand what is captured from the 3 potential new indicators, including how they fit together, before moving forward with a composite indicator.


3.7. UNHEALTHY FAT/OIL CONSUMPTION

Proposition: New indicator to capture the percentage of children 6-23 months who consumed unhealthy fat/oils during the previous day. This indicator was considered but not recommended for addition.

• Rationale: Difficult to distinguish between healthy and unhealthy fats. Without adequate distinction, positive practices may be distorted.

Discussion: An earlier discussion raised the issue of fat quality, adding that the use of margarine is growing in Africa due to refrigeration. It was agreed that saturated and trans fats are problematic but operationally difficult to separate from other fats. Little further discussion during this session.

Recommendation: The overall consensus was to endorse the proposition and not to include as an indicator.

3.8. FAST FOOD CONSUMPTION

Proposition: New indicator to capture the percentage of children 6-23 months who consumed foods from fast-food establishments during the previous day. This indicator was considered but not recommended for addition.

• Rationale: Despite several studies in the literature which used a similar indicator, the proposal was not to include this indicator. The recommendation not to include this indicator is in the interest of maintaining a minimum set of indicators, and there might be some overlap with at least some of the other proposed indicators for unhealthy dietary practices indicators. This would also require additional questions which might sit outside of the current food list question.

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Discussion: Some participants added that foods of minimal intrinsic nutritional value can also be provided in the home. Another problem with this indicator is that that these kinds of foods could be provided in many different environments, and some of those environments also offer healthy alternatives.

Recommendation: The overall consensus was to endorse the proposition and not to include as an indicator.

3.9. PLAIN WATER CONSUMPTION

Proposition: New indicator to capture the percentage of children 6-23 months who consumed plain water during the previous day. This indicator was considered but not recommended for addition.

• Rationale: While plain water consumption is recommended for this age group instead of SSBs, water is not necessary if the child is still breastfed. There are also concerns about access to clean and safe water in some settings.

Discussion: Little discussion, noting that it is not compelling enough to consider as an indicator.

Recommendation: The overall consensus in the group was to endorse the proposition and not to include as an indicator.

3.10. TIMING OF SOLID/SEMI-SOLID FOODS

Proposition: New indicators to capture the percentage of children with early introductions of complementary foods (3-5 months) and those with late introduction of complementary foods (9-11 months).

• Rationale: To provide a full picture, not only of the 6-8 month age group but for the period before and after as well. Negative outcomes with early introduction include increased risk of being overweight later in childhood, increased exposure to pathogens, early weaning, and reduced duration of breastfeeding. Prevalence of early introduction is also very high in some countries/regions. Negative outcomes with late introduction are that after 6 months, breast milk no longer meets nutritional needs and may falter growth. Prevalence of late introduction among 10-11 month olds was upwards of 20% in some countries and regions.

Discussion: The majority of the group was undecided. In principle, the group agreed with the construct. In some countries, early introduction to solid and semi-solid foods is the main reason for not achieving exclusive breastfeeding during the first 6 months, but in other countries there are cases in which children up to 9 months are getting nothing but liquids. In some countries, the high rate of introduction at 6-8 months may only be evident due to high rates for early introduction. In other words, if only looking at feeding solids at 6-8 months, countries may seem to be fine when it comes to the topic of introduction of solids, but they are not. However, the group wanted to look at all items in the early introduction period as a whole in relation to breastfeeding where feeding of water and other liquids would also apply. For this, the area graphs provide some of the information needed to diagnose these problems. The consensus was not to add these indicators.

Recommendation: The overall consensus was not to proceed with the proposition to add these new indicators.

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4 AREA GRAPHS Area graphs are useful tools from a programmatic perspective to understand breastfeeding practice changes and the timing of those changes. Area graphs help diagnose a problem and how to address it, but unlike indicators, they are not intended to compare from one country to another, quantify, or track trends. The group recommended creating tools to improve the interpretation and use of area graphs, which could include instructions on how to combine mutually exclusive categories that may simplify interpretation for programmatic purposes. It was added that an interpretation guide on use of area graphs for advocacy is under development.

5 PRIORITIZATION OF OPERATIONAL ISSUESJulia Krasevec from UNICEF presented on prioritization of existing operational issues related to response bias, caregiver respondent, different IYCF data collection in DHS and MICS, and revisions to the operational guide.

• Response bias: The issues identified relate to inadequate interpretation and social desirability. Cognitive interviewing is a way to address this problem.

• Caregiver respondents: These respondents are usually the mothers, but they are not with the children the entire time during the previous day in some settings. This has been evident with the open-recall approach that MICS uses. One way to address this problem is to add a question about how long the mother was with the child, then try to get the person who was with the child. Additional indicators could be tabulated to provide insight into potential quality problems, such as % of respondents who were away from the child for ≥4 hours in the previous day. This approach would require pilot-testing.

• Different IYCF data collection in DHS and MICS: The two main sources of IYCF data operationalize data collection differently. DHS uses a 24-hour recall and MICS uses open-recall. The operational guideline documents provide a recommended approach and an alternate approach.

• Revisions to operational guide (Part 2): Revisions to the document need to communicated in a user-friendly format.

Discussion: The group agreed that social desirability is a major issue and supported its prioritization to address it, noting that TEAM can endorse the advancement of these efforts. The group also agreed that DHS and MICS operationalizing differently needs to be prioritized. DHS does not intend to change to the open-recall approach until there is evidence that the results are better. The group acknowledged that studies are expensive, but having the two main sources of IYCF data collecting data differently is a problem requiring high priority. The group agreed that caregiver respondents is an issue from a data quality perspective. Helen Keller International (HKI) has tried different approaches, such as interviewing other caregivers in the household and going into daycares. In a broader context, there is a need to call attention to innovative methodologies that can validate IYCF question, noting that there is little work in the context of complementary feeding measurement. There was no discussion about the revisions to the operational guide but agreed it needs to be user-friendly.

Recommendation: The group agreed that these are all important priorities and should be pursued, but the overall consensus was that DHS and MICS operationalized differently and response bias are the highest priorities.

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6 COMMUNICATION

Kuntal Saha from WHO presented the communication plan to disseminate changes to IYCF indicators, including target audiences and effective channels. It was noted that so far some of the recent changes have not been adequately communicated, and there is a need for more concerted efforts for communication and dissemination of indicators in future. A tentative timeline was presented and included the release of manual revisions by end of first quarter in 2019. Input from the group included the following:

• Contextualize the indicators. As the changes are communicated, provide sufficient context for adequate interpretation about what the indicators are and their use.

• Integrate social media. The use of social media should be a strategic communication plan with extended duration where repetition will be essential.

• Maintain a standard deck of slides. A standard deck will facilitate members of this group to prepare presentations that are accurate when invited to speak.

• The group shared several regional and country-level channels to effectively communicate changes. From a regional perspective, it is important to harmonize with regional offices to ensure guidance is available for use. At country level, it is important to consider that coordination of nutrition programs may be housed under cabinets where government transitions take place.

• More coordination with high-income country data collection partners.

7 CONCLUSION

In bringing the meeting to conclusion, Mary Arimond from TEAM presented a synthesis of the discussions and decisions reached by the group, which WHO and UNICEF will use to inform and finalize decisions about the indicators. Francesco Branca from WHO made the closing remarks highlighting the critical role of measurement, the transformation of food environments, and the double-burden of malnutrition.

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ANNEX 1 LIST OF PARTICIPANTSNo Name Organization Email

1 Alex Kalimbira Assoc. Prof & Head, Dept of Human Nutr & Health, Faculty of Food & Human Sciences, Bunda Campus, Lilongwe Uni of Agriculture & Natural Resources, Lilongwe, Malawi

[email protected]

2 Alissa Pries Technical Advisor, Assessment & Research on Child Feeding (ARCH), Helen Keller International, Washington, D.C, USA

[email protected]

3 Anna Herforth Independent consultantWest Haven, CT, USA

[email protected]

4 Cesar Victora Emeritus Professor of EpidemiologyFederal University of Pelotas, Brazil

[email protected]

5 Cria Perrine Epidemiologist, Division of Nutrition, Physical Activity and Obesity, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA

[email protected]

6 Edward Frongillo Professor, Global Health InitiativesArnold School of Public Health, University of South Carolina, Columbia, SC, USA

[email protected]

7 Elaine Ferguson Associate ProfessorLondon School of Hygiene and Tropical Medicine, London, UK

[email protected]

8 Ellen Piwoz Senior Program OfficerNutrition Division, Bill & Melinda Gates Foundation, Seattle, Washington, USA

[email protected]

9 Erin Milner Nutrition AdvisorUSAID, Bureau for Global Health, Maternal and Child Health and Nutrition, USAID

[email protected]

10 Faith Thuita Public Health Nutrition SpecialistSchool of Public Health, University of Nairobi, Nairobi, Kenya

[email protected]@uonbi.ac.ke

11 Jillian L. Waid Research DirectorHelen Keller International, Dhaka, Bangladesh

[email protected]

12 Kaleab Baye Associate Prof & Director, Center for Food Science and Nutrition, College of Natural Sciences, Addis Ababa University, Ethiopia

[email protected]

13 Kathryn G. Dewey Professor, Department of Nutrition University of California, Davis, USA

[email protected]

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No Name Organization Email

14 Lynnette Neufeld Director, Monitoring, Learning and Research,Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland

[email protected]

15 Marieke Vossenaar Independent ConsultantTechnical Nutrition Advisor, Gex, France

[email protected]

16 Mary Arimond Senior Technical Advisor, Intake – Center for Dietary Assessment, FHI 360, Washington DC, USA

[email protected]

17 Monica Kothari Deputy Director and M&E LeadMaximizing Quality of Scaling Up Nutrition Plus (MQSUN+), PATH, Washington, DC, USA

[email protected]

18 Purnima Menon Senior Research Fellow, International Food Policy Research Institute, New Delhi, India

[email protected]

19 Rebecca Heidkamp Research Associate, Center for Human Nutrition Johns Hopkins Bloomberg School of Public HealthBaltimore, MD, USA

[email protected]

20 Siti Halati Programme Policy Officer (Nutrition)Nutrition Division, WFP, Rome, Italy

[email protected]

21 Sorrel Namaste Senior Nutrition Technical AdvisorDHS Program, ICF, Rockville, MD, USA

[email protected]

22 Teresa Shamah Levy Deputy DirectorCenter for Evaluation and Surveys Research CIEE-INSP, Mexico City, Mexico

[email protected]

23 Trevor Croft Technical DirectorICF, Rockville, MD, USA

[email protected]

24 Umi Fahmida Deputy Director for Program, SEAMEO-RECFON, Regional Center for Food and Nutrition, University of Indonesia, Jakarta, Indonesia

[email protected]

25 Wenhua Zhao Professor in Nutrition and Public Health Deputy Director, National Institute for Nutrition and Health, Beijing, China

[email protected]

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Consultants


1 Chessa Lutter (not attending) Consultant (breastfeeding), USA [email protected]; [email protected]

2 Jane Badham (Facilitator) Managing Director, JB Consultancy, Johannesburg, South Africa

[email protected]

3 Mandana Arabi Consultant (complementary feeding), NY, USA

[email protected]; [email protected]

4 Ligia Reyes (Rapporteur) Arnold School of Public Health, University of South Carolina, USA

[email protected]

UNICEF/WHO Secretariat


1 Chika Hayashi UNICEF [email protected]

2 France Begin UNICEF [email protected]

3 Julia Krasevec UNICEF [email protected]

4 Vrinda Mehra UNICEF [email protected]

5 Bernadette Daelmans WHO [email protected]

6 Kuntal Kumar Saha WHO [email protected]

7 Laurence Grummer-Strawn WHO [email protected]

8 Maria Pura Solon WHO [email protected]

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Day 1: Wednesday, 11 July

9:00 – 9:30 Welcome and introductions

- Objectives and expected outcomes of the meeting- Introduction of participants- Administrative issues

Chika Hayashi/Kuntal Kumar Saha

9:30 – 9:45 Overview presentation: Development of 2008 indicators, issues that have come up since then/rationale for current work and meeting

Mary Arimond

9:45 – 10:15 Recommended indicators for breastfeeding and bottle feeding: Part 1 – Background and methodology

Chessa Lutter (virtual)

10:15 – 10:45 Tea/Coffee

10:45 – 11:30 General discussion of issues on breastfeeding and bottle feeding Laurence Grummer-Strawn

11:30 – 12:00 Recommended indicators for breastfeeding and bottle feeding: Part 2 – Indicators on the first 6 months


12:00 – 12:30 Discussion of Ever Breastfed, Early Initiation, Exclusive Breastfeeding, Predominant Breastfeeding, and Median Duration of Exclusive Breastfeeding

Laurence Grummer-Strawn

12:30 – 13:30 Lunch

13:30 – 14:15 Discussion of Early Supplementation, Early Water Feeding, and Early Complementary Feeding


14:15 – 15:00 Discussion of BFHI indicators Laurence Grummer-Strawn

15:00 – 15:30 Tea/Coffee

15:30 – 16:00 Recommended indicators for breastfeeding and bottle feeding: Part 2 – Indicators on 6-23 months and overall milk feeding indicators


16:00 – 16:30 Discussion of continued breastfeeding, median duration of breastfeeding, age-appropriate breastfeeding, and breast-milk expression


16:30 – 17:00 Discussion of bottle feeding and feeding of other milks Laurence Grummer-Strawn

17:00 – 17:10 Wrap-up Day 1 Jane Badham

Day 2: Thursday, 12 July

9:00 – 9:15 Overview of complementary feeding background papers and topics to be reviewed for input at this consultation

Julia Krasevec

9:15 – 9:30 Diet quality (unhealthy) indicators for infants and young children – overview of proposed indicators

Mandana Arabi

9:30 – 10:45 Component 1 of diet quality (unhealthy) indicators – sweet-tasting beverage consumption and sweeteners added by caregiversPresentation of rationale – 15 minDiscussion points – 1 hour

Julia Krasevec

ANNEX 2 MEETING AGENDA

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10:45 – 11:15 Tea/Coffee

11:15 – 12:30 Component 2 of diet quality (unhealthy) indicators – sweet and savory junk foods consumptionPresentation of rationale – 15 minDiscussion points – 1 hour

Mandana Arabi

12:30 – 13:30 Lunch

13:30 – 15:00 Component 3 of diet quality (unhealthy) indicators – zero vegetable and fruit consumptionPresentation of rationale – 15 minDiscussion points – 1 hour 15 min

Julia Krasevec

15:00 – 15:30 Tea/Coffee

15:30 – 16:45 Overall (composite) indicator of diet quality (unhealthy)indicatorsPresentation of rationale – 15 minDiscussion points – 1 hour 15 min

Mandana Arabi

16:45 – 17:00 Wrap-up Day 2

Chika Hayashi

Day 3: Friday, 13 July

9.00 – 10.30 Component 2 of diet quality (unhealthy) indicators – sweet and savory junk food consumptionSweeteners added by caregivers

Mandana Arabi

10:30 – 11:00 Tea/Coffee

11.00 – 11.30 Overall (composite) indicator of diet quality (unhealthy) indicators Mandana Arabi

11.30 – 12.30 Breastfeeding continued Larry Grummer-Strawn

12:30 – 13:30 Lunch

13.30 – 14.15 Minimum Meal Frequency for non-breastfed children Julia Krasevec

14.15 – 15.15 Recommended new indicators to add using existing questions Julia Krasevec

15.15 – 15.30 Diet quality (unhealthy) indicators for infants and young children – rationale for non-included indicators

Mandana Arabi

15:30 – 16:00 Tea/Coffee

15:30 – 16:00 Revision of the WHO 2008 and 2010 documents: proposals for communication and input from the group

Kuntal Saha

16.30 – 16.50 Wrap-up of the consultation and next steps Mary Arimond

16.50 – 17.00 Closing remarks Francesco Branca

Documents

MEETING REPORT - World Health Organization...consultation, leading report writing process and providing inputs to the draft report; Laurence Grummer-Strawn (WHO Headquarters), for