Nutrition Publication

Myths and facts

Editor(s): 3. 4

Myth 1: Homemade preparations (HMP) are sufficient wholesome nutritious food for Infants during weaning.
Homemade preparations – Not always the best option

Goyal and Singh in 2007 reported preference of home cooked food by 81 percent of the consumers in comparison to fast food outlets [Goyal and Singh, 2007]. However, in developing countries, homemade foods are often known to be of low nutritive value. Bulk is a major problem of homemade complementary foods. For adults and older children, it is usually possible to achieve an adequate protein and energy intake by increasing the daily consumption. But for infants and younger children, the volume of the homemade complementary diets may be too large to allow the child to ingest all the food necessary to cover his or her nutritional needs. E.g., a 4- to 6-month infant would need 62 g of corn gruel to meet daily needs of energy (740 kcal) and protein (13 g), which would be an impossible task considering the size of an infant’s stomach [Abeshu et al., 2016]. 

A study conducted by Mesch et al demonstrated that both homemade and commercial meals for infants of 6 and 9 months of age were low in vegetable varieties. However, at 12 months of age, infants fed with commercial meals got a higher vegetable variety than those fed with homemade meals. The study also noted that carrot was the most frequently used vegetable in both homemade and commercial meals [Mesch et al 2014].
Mosha et al evaluated nutritional composition and micronutrient status of homemade and commercial weaning foods consumed in Tanzania. It was seen that both homemade and commercial weaning foods had some shortcomings in terms of nutrient composition and energy balance. However, Ca, Fe and Zn were the commonly deficient nutrients in homemade weaning foods [Mosha et al, 2000].

Inference

Results of the above studies indicate that macronutrients are met by HMPs but they lack micronutrients for recommended daily allowances and thus, are unable to meet the nutritious need of most of the population. In developing countries like India, there is need to focus on the quality and variety of both homemade and commercial meals.

Reference

  • Goyal A, Singh NP. Consumer perception about fast food in India: An exploratory study.  British Food Journal. 2007;109:2 
  • Abeshu MA, Lelisa A, Geleta B. Complementary Feeding: Review of Recommendations, Feeding Practices, and Adequacy of Homemade Complementary Food Preparations in Developing Countries - Lessons from Ethiopia. Front Nutr. 2016 Oct 17;3:41.
  • Mesch CM, Stimming M, Foterek K, Hilbig A, Alexy U, Kersting M, Libuda L. Food variety in commercial and homemade complementary meals for infants in Germany. Market survey and dietary practice. Appetite. 2014 May;76:113-9.
  • Mosha TCE, Laswai HS, Tetens I. Nutritional composition and micronutrient status of homemade and commercial weaning foods consumed in Tanzania. Plant Foods Hum Nutr. 2000;55(3):185-205.

Myth 2: Infant nutrition needs are similar to that of an adult?
Infants need high energy and nutrients as compared to an adult

The child’s stomach capacity limits how much can be consumed in a single feeding. Generally, a child who weighs 8 kg will have a stomach capacity of 240 ml, about one large cupful, and cannot be expected to eat more than that at one meal. Thus, energy density of complementary foods should be more than breast milk beyond 6 months of age, that is, at least 0.8 kcal per gram. If the energy density of food is lower, a larger volume of food is needed to fill the gap, which may need to be divided into more meals, which is a challenge to achieve [WHO, 2009]. 
Infants have a much higher proportion of their body weight as highly active tissues (brain and viscera) than adults. Ensuring adequate infant nutrition during 6 to 24 month of age (the period of high energy and nutrient requirement) is a major global health priority as this is the age of foundation for these tissues which might have long term serious consequences in the absence of adequate nutrition. In a review article on complementary feeding, Dewey KG noted that infants need complementary foods with much higher nutrient density than is required for adult diets. It was calculated that per 100 kcal of food, a breast-fed infant at 6–8 month needs 9 times as much iron and 4 times as much zinc as an adult male (who needs 0.5 mg iron and 0.26 mg zinc/100 kcal based on 2700 kcal/d and recommended intakes of iron and zinc).

What are the problems in achieving it?

The greatest challenge for meeting iron, zinc & other micronutrient needs of breast-fed children typically occurs post 6 months of life up to 2 years. Traditional staples inherently contain certain anti-nutrients e.g. phytates, which is present in cereal and legume-based diets, has a strong negative effect on iron and zinc absorption from composite meals. This is problematic for infants as the needs for iron and zinc are high during infancy. Target nutrient densities are lower from breast-feeding infants at 9–11 month than at 6–8 month, as average expected intake from complementary foods increases to 300 kcal/d at 9–11 month. This again increases to 550 kcal/d at 12–23 month. During this age while the need for iron is lower than during infancy, the need for zinc stays the same. But since the iron stores in the body is exhausted thus the intake of iron becomes crucial.
Also the iron and zinc densities of complementary foods are also considerably lower in the second year of life (1.0 and 0.46 mg/100 kcal, respectively) than in the first year. [Dewey KG, 2013].
It has been reported that adults should get 45 percent to 65 percent of their calories from carbohydrates, 20 percent to 35 percent from fat, and 10 to 35 percent from protein. Acceptable ranges for children are similar to those for adults, except that infants and younger children need a slightly higher proportion of fat (25 -40 percent) [Hoeger WWK and Hoeger SA, 2016]. Table 1 depicts the current infant meal pattern in India.
The Child and Adult Care Food Program, US in its recommendations on revised meal requirements for different age groups highlights that the amount of food in the meal patterns increases across the four younger age groups (age 1 year, 2–4 years, 5–13 years, and 14–18 years), and then decreases for adults to approximately the same level as for children 5–13 years of age [Murphy et al., 2001].


Table 1: Current Infant Meal Pattern in India [Tewari et al., 2016]

Food Components

6-8 months

9-11 months

12-23 months

Thick Porridge + Well mashed foods

2-3 meals/day (2-3 tablespoon full) + Breastfeed

 

 

Fine chopped or well mashed foods or  foods that can baby pick up

 

3-4 meals/day (1/2 of a 250ml cup) + Breastfeed

 

Family foods chopped or meshed if necessary

 

 

3-4 meals/day (3/4 to 1 250ml cup) + Breastfeed

Snacks

 

Depending on appetite

Depending on appetite


Inference

This concludes that the infant need complementary foods with much higher nutrient density than is required for adult diets. High energy and varied nutrient requirement requires infants to be fed more number of meals than adults which should be high in nutrient and energy density. Young children even in the high wealth index families are at risk of micronutrient deficiencies, including those of iron, zinc, and vitamin A. Thus strategies for achieving adequate nutrition for infants and young children must be different from those of adults, and shall be sustainable over the long term.

Reference

  • Dewey KG. The challenge of meeting nutrient needs of infants and young children during the period of complementary feeding: an evolutionary perspective. J Nutr. 2013 Dec;143(12):2050-4.
  • Institute of Medicine (US) Committee to Review Child and Adult Care Food Program Meal Requirements; Murphy SP, Yaktine AL, West Suitor C, et al., editors. Child and Adult Care Food Program: Aligning Dietary Guidance for All. Washington (DC): National Academies Press (US); 2011. Summary. Available from: https://www.ncbi.nlm.nih.gov/books/NBK209813/
  • Hoeger WWK, Hoeger SA. Lifetime Physical Fitness and Wellness: A Personalized Program. 2016; Page 74.
  • Tiwari S, Bharadva K, Yadav B, Malik S, Gangal P, Banapurmath CR, Zaka-Ur-Rab Z, Deshmukh U, Visheshkumar -, Agrawal RK. Infant and Young Child Feeding Guidelines, 2016. Indian Pediatr. 2016 Aug 8;53(8):703-13.
  • World Health Organization. Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals. Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals.. 2009.

Myth 3: To provide complete nutrition to child, we can just add a portion of fruits to the regular diet?

Almost all nutrition experts agree that all children 2 years and above, should eat more fruits, vegetables, and grain products, while consuming diets that are lower in total fat, saturated fatty acids, and dietary cholesterol.

What's wrong with this perception?

According to WHO, addition of a portion of fruits to the regular diet improves the absorption of Iron from other foods in the same meal but has a small effect on energy, protein and vitamin A gap [WHO, 2000].

Feeding Infants and Toddlers study (2004) alarmingly revealed that toddlers ate more fruits than vegetables and 1 in 4 did not consume even 1 vegetable on a given day. They were more likely to be eating fatty foods and sweet-tasting snacks and beverages [Mennella et al., 2006]. Given children’s innate preference for sweet foods, it is not surprising that some children might consume relatively large amounts of fruit juice, than whole fruits and vegetables. Excess fruit juice consumption has been associated with diarrhoea, growth failure, and short stature in some children, while in other children; excess juice intake has been associated with obesity [Dennison et al., 1997].

What do the guidelines say?

The general dietary recommendations of the expert group of the Indian Council of Medical Research (ICMR) for infants and children younger than 5 years of age stress a diet that should be less bulky, rich in energy and protein such as legumes, pulses, nuts, edible oil/ghee, sugar, milk and eggs [Dietary guidelines for Indians, 2011]. ICMR recommendations captured in Table 1 provides recommended balanced diet for infants and children aged between 6 months to 6 years (Number of Portions).
Higher intakes of fruit (including fruit juices) were associated with reduced intakes of dietary total fat, saturated fatty acids, and cholesterol. In a national study, children meeting the USDA recommended intakes for fruits had significantly lower intakes of total fat [Munoj et al., 1997].

Inference

Thus, dietary guidance over time has supported the principles of moderation and variety. While addition of fruits is useful measure & an important effort towards meeting the daily recommended nutrition, but addition of only fruits cannot be the only measure to achieve the increased nutritional requirements. Therefore, emphasis should be to achieve involvement of all the food groups in a meal to ensure balanced nutrition needed for normal growth & development in infancy

Table 1. Balanced Diet for Infants and Children age 6 months to 6 years (Number of Portions)


Food groups

g/ portion

 Infants 6-12 months

 1- 3 Years

4-6 Years

Cereals & millets

30

0.5

2

4

Pulses

30

0.25

1

1

Milk (ml) & milk products

100

4

5

5

Roots & tubers

100

5

0.5

1

Green leafy vegetables

100

0.25

0.5

0.5

Other vegetables

100

0.25

0.5

1

Fruits

100

1

1

1

Sugar

5

2

3

4

Fat/ oil (visible)

5

4

5

5


Reference

  • Saadeh R, Martines J. Complementary Feeding: Family foods for Breastfed Children. Geneva: World Health Organization; 2000
  • Gidding SS, Dennison BA, Birch LL, Daniels SR, Gillman MW, Lichtenstein AH, Rattay KT, Steinberger J, Stettler N, Van Horn L; American Heart Association.; American Academy of Pediatrics.. Dietary recommendations for children and adolescents: a guide for practitioners: consensus statement from the American Heart Association. Circulation. 2005 Sep 27;112(13):2061-75
  • Mennella JA, Ziegler P, Briefel R, Novak T. Feeding Infants and Toddlers Study: the types of foods fed to Hispanic infants and toddlers. J Am Diet Assoc. 2006;106(suppl):s96–s106.
  • Dennison BA, Rockwell HL, Baker SL. Fruit and vegetable intake in young children. J Am CollNutr. 1998 Aug;17(4):371-8.
  • Muñoz KA, Krebs-Smith SM, Ballard-Barbash R, Cleveland LE. Food intakes of US  children and adolescents compared with recommendations. Pediatrics. 1997 Sep;100(3 Pt 1):323-9.
  • Dietary guidelines for Indians. Nat Inst Nutrition. 2011; 2:89-117.
Myth 4: I had iron supplementation during pregnancy; my child cannot suffer from Iron deficiency.

Iron requirements in pregnancy

The iron requirement during pregnancy is increased gradually through gestation from 0.8 mg/day in the first trimester to 7.5 mg/day in the third trimester. During the entire gestation period, the average demand for absorbed iron is approximately 4.4 mg/day [Milman N, 2006].

Importance of Iron during pregnancy

During pregnancy, the absorbed iron is predominantly used to expand the woman’s erythrocyte mass, fulfil the foetus’s iron requirements and compensate for iron losses (i.e. blood losses) at delivery. To a large extent, the newborns’ iron content depends on their birth weight which is generally 200-270 mg for infants weighing between 2500-3500g respectively. Low-birth-weight infants (less than 2500 g) are born with fewer iron stores and are at high risk of deficiency after 2 months [Saddi and Shapira, 1970].

Impact of maternal iron status on adequate store of newborns

A study to assess the effect of maternal IDA on the iron store of newborns revealed that newborns of IDA mothers had significantly lower levels of serum ferritin (𝑃 = 0.017) than newborns of non-anaemic (NA) mothers. Though these newborns had reduced iron stores, the prevalence of anaemia among newborns of the two groups was not significantly different [Terefe et al., 2015; 𝑃 = 0.593]. This is because visible difference that can be evidenced in the form of anaemia is not expected at such an early stage in life [Chaparro CM, 2008]. Therefore, maternal IDA may have an effect on the iron stores of newborns till the age of 6 months [Zetterstrom R, 2008; Ziegler et al., 2009]. Table 1 provides haematological profile and ferritin status of newborns by anaemia and iron status of their mothers.
However, beyond 6 months of age, iron content of breast milk/ mother's milk is not sufficient to meet infants’ requirements and complementary foods are required to bridge this gap, but common staples are low in iron. But infants need a relatively high iron intake because they are growing very rapidly and their iron stores have exhausted by the age of six months. Thus, infants need an external source of iron, which may be in form of iron rich/fortified complementary foods or iron supplements to fulfill their iron needs during first 2 years of life to avoid long term consequences.

What do the guidelines say?

Recent expert recommendations on iron fortification in infants suggested cow or goat milk protein or Soy protein based formulas with 2-4 mg/L of iron for 3-6 month old iron deficient infants and similar formulas with 4-8 mg/L iron content for 6-12 month old healthy infants [Kleinman RE, 2015].
The American Academy of Pediatrics (AAP) has concluded that universal screening for anaemia should be performed, with determination of haemoglobin concentration, at approximately one year of age. Universal screening should include an assessment of risk factors associated with iron deficiency, exclusive breastfeeding beyond 4 months of age and complementary foods [Baker and Greer, 2010]. Infant and Young Child Feeding Guidelines (IYCF) 2016, state that appropriate complementary foods after completion of 6 months is the most appropriate feeding strategy.
WHO recommends universal supplementation with 2 mg/kg/day of iron in children aged 6 to 23 months whose diet does not include foods fortified with iron or who live in regions (such as developing countries) where anaemia prevalence is higher than 40% [WHO, 2001].


Table 1: Haematological profile and ferritin status of newborns by anaemia and iron status of their mothers (𝑛 = 89).

Parameters

Group median (IQR)

P value

IDA (n=21)

NA (n=68)

Hb (gm/dL)

15.6
(14.8-16.4)

16.7
(15.5-17.6)

0.024*

Ferritin (ng/mL)

138.9
(105.0-211.7)

200.7
(151.4-265.3)

0.017*

Frequency (%) of anaemia

3 (14.3%)

5 (7.9%)

0.593**


Inference

To a large extent, the newborn’s iron status depends on the mother iron status during pregnancy. Infants born to mothers who have taken iron supplements during gestation have enough body iron reserves for 4-6 month period. This reserve depletes after 6 months of age thus iron rich/fortified complementary foods or iron supplements of adequate nutritional value becomes a need post 6 months of age.

Reference

  • Milman N. Iron and pregnancy--a delicate balance. Ann Hematol. 2006 Sep;85(9):559-65.
  • Saddi R, Shapira G. Iron requirements during growth. In: Hallberg L, Harwerth HG, Vanotti A (eds) Iron deficiency. Academic, London, 1970; 183–198.
  • Terefe B, Birhanu A, Nigussie P, Tsegaye A. Effect of maternal iron deficiency anemia on the iron store of newborns in ethiopia. Anemia. 2015;2015: 808204.
  • Chaparro CM. Setting the stage for child health and development: prevention of iron deficiency in early infancy. J Nutr. 2008 Dec;138(12):2529-33.
  • Zetterström R. Iron deficiency and iron deficiency anaemia during infancy and childhood. ActaPaediatr. 2004 Apr;93(4):436-9.
  • Ziegler EE, Nelson SE, Jeter JM. Iron supplementation of breastfed infants from an early age. Am J ClinNutr. 2009 Feb;89(2):525-32.
  • Kleinman RE. Expert recommendations on iron fortification in infants. The Journal of pediatrics. 2015 Oct 1;4(167):S48-9.
  • Baker RD, Greer FR. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0–3 years of age). Pediatrics. 2010 Nov 1;126(5):1040-50.
  • World Health Organization. Iron Deficiency Anaemia: Assessment, Prevention, and Control. World Health Organization, 2001.
  • Tiwari S, Bharadva K, Yadav B, Malik S, Gangal P, Banapurmath CR, Zaka-Ur-Rab Z, Deshmukh U, Visheshkumar -, Agrawal RK. Infant and Young Child Feeding Guidelines, 2016. Indian Pediatr. 2016 Aug 8;53(8):703-13.

Myth 5: Homemade Preparations are a good source of iron

Given that a majority of young term infants are largely protected from iron deficiency by their birth iron stores, iron deficiency is not often considered in infants less than six months of age. However, even in the context of the exclusively breastfed, term infant, iron deficiency and iron deficiency anaemia may be observed, with population estimates in the range of 0%–15% (ID) and 0%–4% (IDA) of six-month-old infants in different settings worldwide [Ziegler et al., 2011].

What is the recommended daily intake of iron for infants as per guidelines?

Expert group of the ICMR recommends 5 mg/day iron for 7-12 month old and 9 mg/day iron for 1-3 year old infants and young children [Dietary guidelines forIndians, 2011]. Thus, they require special foods of adequate nutrient density, consistency, and texture, and they need to be fed more often than adults [Ruel et al., 2004].

Nutrient deficiencies that is incredibly common among Indian foods

Studies on homemade diets of Indian children aged 6 months to 12 years have highlighted that diet was of poor quality and was also unable to provide sufficient quantity of iron, calcium and zinc. Jani et al found that mean densities of all the nutrients especially calcium and iron was low in the various foods fed to the children of Mumbai, India. The calcium, iron and zinc contents for the selected recipes, according to the dilution are shown in table 1 [Jani et al, 2009].

Table 1: Energy and Nutrient Density Calculated in Terms of Kcal/1g and Mg/100 gm Respectively for Nutrients Calcium, Iron and Zinc [Jani et al., 2009]

Items

Mixing ratio (Raw item + water)

Energy Density
(Kcal/gm)

Calcium (Ca) mg/100 gm

Iron (Fe) mg/100 gm

Zinc (Zn) mg/100 gm

Chapatti (gm)

3 : 1

2.69

16.8

0.9

1.0

Rice

1 : 3

0.91

4.6

1.0

1.0

Khichdi

1 : 3

0.99

20.5

2.4

1.9

Mung Dal

1 : 3

0.87

23.7

0.9

0.8

Milk

Undiluted

1.18

148.0

1.7

2.0

Potato vegetable

-

1.12

13.8

0.2

0.1


Data on dietary nutrient deficiencies from other South Asian countries

In a study from Guatemala, main homemade complementary foods were found to be significantly short in micronutrients, such as iron, zinc, and calcium, even if adequate amounts of protein, B vitamins [vitamins B1 (thiamine), B2 (riboflavin), B6, and B12], and vitamin C were supplied [Allen LH, 2012]. Similarly, in Philippines, homemade complementary foods were not able to supply sufficient energy and important nutrients such as calcium, iron, zinc, vitamins A and vitamin C to infants and young children as percentage WHO estimated needs [Perlas LA, 2013].
Unfortified complementary foods that are predominantly plant based generally provide insufficient amounts of certain key nutrients (particularly iron, zinc, and calcium) to meet the recommended nutrient intakes during 6–23 months of age [Abeshu et al., 2016].
Current child-feeding recommendations state that children at 6-23 months of age should be fed animal source foods daily, especially if they do not have access to fortified foods or vitamin and mineral supplements [Ruel et al., 2004].

Inference

Homemade complementary foods are based pre-dominantly on cereals and legumes, and are mostly an extension of family foods, such as porridge. Thus, HMPs such as dal water, suji kheer and dalia may provide good energy density, however, intake of micronutrients, such as iron, zinc, and calcium, from such foods are not adequate.

Reference

  • Ziegler EE, Nelson SE, Jeter JM. Iron supplementation of breastfed infants. Nutr Rev. 2011 Nov;69Suppl 1:S71-7.
  • Burke RM, Leon JS, Suchdev PS. Identification, prevention and treatment of iron deficiency during the first 1000 days. Nutrients. 2014 Oct 10;6(10):4093-114.
  • Ruel MT, Menon P, Loechl C, Pelto G. Donated fortified cereal blends improve the nutrient density of traditional complementary foods in Haiti, but iron and zinc gaps remain for infants. Food Nutr Bull. 2004 Dec;25(4):361-76.
  • Jani R, Udipi SA, Ghugre PS. Mineral content of complementary foods. Indian J Pediatr. 2009 Jan;76(1):37-44.
  • Allen LH. Adequacy of family foods for complementary feeding. Am J ClinNutr. 2012; 95:785–6.
  • Perlas LA. Nutrient Adequacy of Complementary Diets in Cebu, Philippines and Evaluation of Household Methods for Their Improvement. Graduate Student’s thesis, University of Otago, New Zealand 2013.
  • Abeshu MA, Lelisa A, Geleta B. Complementary Feeding: Review of Recommendations, Feeding Practices, and Adequacy of Homemade Complementary Food Preparations in Developing Countries - Lessons from Ethiopia. Front Nutr. 2016 Oct 17;3:41.
  • Dietary guidelines for Indians. Nat Inst Nutrition. 2011;2:89-117.