Novel Strategies for Measuring Complementary Feeding and Achieving Behavior Change in East Africa Open Access

Faerber, Emily (Fall 2019)

Permanent URL:


Objective. Growth failure rapidly accumulates during the period of complementary feeding, from 6 to 23.9 months. Identifying strategies to ensure appropriate complementary feeding requires appropriate measurement methods. Current methods, including infant and young child feeding indicators that are amenable to large surveys, are lacking in scope and largely fail to assess the more complex interrelationships between complementary feeding practices. The goal of this dissertation was to describe novel methods for measuring complementary feeding practices and to evaluate impact pathways of a nutrition-sensitive agriculture project on complementary feeding outcomes.

 Methods. We use data from two countries in East Africa. We computed correlation coefficients to assess the relative validity of indicators of portion size and complementary food consistency in a sample of children 6 to 13 months in southern Ethiopia. We used exploratory factor analysis and exploratory structural equation modeling to identify patterns and predictors of complementary feeding practices in rural Malawi. Lastly, we used mediation analysis to assess potential impact pathways of a nutrition-sensitive agriculture project on complementary feeding outcomes in southern Ethiopia.

 Results. In Aim 1, we found that the indicator of portion size was significantly correlated with energy intake from and quantity of complementary foods consumed. The indicator of complementary food consistency was weakly but significantly correlated with energy density. Combining indicators of portion size and feeding frequency was more predictive of low complementary food energy intake than feeding frequency alone. In Aim 2, we found that complementary feeding indicators are correlated and that two-factor solutions fit the data well. Indicators of food access and availability were associated with complementary feeding. In Aim 3, we found that nutrition knowledge and food security mediate modest impacts of a nutrition-sensitive agriculture project in southern Ethiopia, but the strongest impact was seen among households receiving tangible child feeding tools, and was not explained by either mediator.

 Conclusion. Survey-based indicators can measure multiple dimensions of complementary feeding practices for use in epidemiological research. Drivers of complementary feeding practices include environmental and individual-level factors. Providing caregivers with tools to promote complementary feeding enhances the impact of a nutrition-sensitive agriculture project.

Table of Contents

Chapter 1 - Introduction. 1

1.1 Research Aims. 3

Chapter 2 - Background. 8

2.1 Evolution of Estimated Energy Requirements of Infants and Young Children. 8

2.2 Recommendations for Achieving Complementary Food Energy Intake. 10

2.2.1 Gastric Capacity and Portion Size Assumptions. 12

2.2.2 Feeding Frequency and Energy Density Recommendations. 13

2.2.3 Complementary Food Consistency Recommendations. 13

2.2.4 Other Guiding Principles. 14

2.3 Complementary Feeding and Nutrition Outcomes. 15

2.3.1 Portion Sizes, Total Energy Intake, and Nutrition Outcomes. 15

2.3.2 Complementary Foods Energy Density, Total Energy Intake, and Nutrition Outcomes. 15

2.3.3 Complementary Food Consistency, Total Energy Intake, and Nutrition Outcomes. 17

2.4 Comment on Complementary Feeding Recommendations. 18

2.5 Dietary Assessment in Infants and Young Children. 21

2.5.1 Doubly Labeled Water 23

2.5.2 Weighed Food Records. 23

2.5.3 Multiple-Pass 24-Hour Dietary Recall 24

2.5.4 Infant and Young Child Feeding Indicators. 25

2.5.5 Methods for Assessing Complementary Food Consistency. 28

2.5.6 Methods of Estimating Portion Sizes of Infants and Young Children. 30

2.6 Complementary Feeding Patterns. 31

2.6.1 Summary IYCF Indices. 32

2.6.2 Dietary Pattern Analysis. 33

2.7 Determinants of Complementary Feeding Practices. 33

2.7.1 Capability. 33

2.7.2 Opportunity. 34

2.7.3 Motivation. 35

2.8 Best Practices for Complementary Feeding Behavior Change. 35

2.8.1 The Healthy Baby Toolkit 37

2.8.2 Nutrition-Sensitive Interventions. 38

2.9 Knowledge Gaps. 39

Chapter 3 - Data Sources. 65

3.1 Operations Research in Mchinji, Malawi 65

3.2 Quality Diets for Better Health Project in Southern Ethiopia. 68

Chapter 4 - Relative Validity of Indicators of Usual Portion Size and Complementary Food Consistency. 75

Abstract 76

4.1 Introduction. 79

4.2 Methods. 80

4.2.1 Study setting and population. 80

4.2.2 Data collection. 81

4.2.3 Analytical Approach. 83

4.2.4 Ethical Approval. 86

4.3 Results. 86

4.4 Discussion. 90

Chapter 5 - Complementary feeding patterns in rural Malawi 112

Abstract 113

5.1 Introduction. 115

5.2 Methods. 117

5.2.1 Study Setting and Population. 117

5.2.2 Data Collection. 118

5.2.3 Variable Specification. 119

5.2.4 Analytical Approach. 119

5.2.5 Ethical approval 121

5.3 Results. 121

5.4 Discussion. 124

Chapter 6 - A Nutrition-Sensitive, Orange-Fleshed Sweet Potato Project in Southern Ethiopia Improves Complementary Feeding Practices: An Examination of Potential Impact Pathways. 138

Abstract. 139

6.1 Introduction. 141

6.2 Methods. 143

6.2.1 Description of intervention. 143

6.2.2 Study Design and Eligibility. 145

6.2.3 Data collection. 145

6.2.4 Variable specification. 147

6.2.5 Statistical Approach. 149

6.2.6 Ethical approval 151

6.3 Results. 152

6.4 Discussion. 155

Chapter 7 - Discussion. 180

7.1 Summary of Key Results. 180

7.2 Limitations. 182

Measurement Error 182

Limited Generalizability. 183

Potential Social Desirability Bias. 184

7.3 Strengths and Innovation. 185

7.4 Public Health Implications. 186

7.5 Future Directions. 187

7.6 Conclusions. 189

About this Dissertation

Rights statement
  • Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.
  • English
Research Field
Committee Chair / Thesis Advisor
Committee Members
Last modified

Primary PDF

Supplemental Files