A child feeding index is superior to WHO IYCF indicators in explaining length-for-age Z-scores of young children in rural Cambodia

Figures & data

Table 1. Current infant and young child feeding recommendations in Cambodia²³

6–8 months	9–11 months	12–23 months
Continue breastfeeding (8 times/day)	Continue breastfeeding (6 times/day)	Continue breastfeeding (on demand)
Cup feeding (no bottle)
2–3 meals per day	3 meals/day	3 meals/day
Gradually increase	½–1 bowl/meal	1 bowl/meal
amount per meal
from 2 tablespoons
to ½ bowl
	1 snack/day	2 snacks/day

Table 2. Scoring system for child feeding index by age group

	6–8 months		9–11 months		12–23 months
Breastfeeding	NoYes	= 0 = +2	NoYes	= 0 = +2	NoYes	= 0 = +1
Use of bottle	NoYes	= +1 = 0	NoYes	= +1 = 0	NoYes	= +1 = 0
Dietary diversity (past 24 hrs)	Sum of: (grains/tubers + meat/fish + eggs + legumes + vitamin A-rich fruits and vegetables + other fruits/veg.)		Sum of: (grains/tubers + meat/fish + eggs + legumes + vitamin A-rich fruits and vegetables + other fruits/veg.)		Sum of: (grains/tubers + meat/fish + eggs + legumes + vitamin A-rich fruits and vegetables + other fruits/veg.)
	01–34+	= 0 = +1 = +2	01–34+	= 0 = +1 = +2	01–34+	= 0 = +1 = +2
Food frequency (past 7 d)	For egg/fish/meat0 times in past 7 d  =  01–3 times in past 7 d  =  14 times in past 7 d  =  2For staples (grains or tubers)0–2 times  =  0; 3+ times  =  1		For egg/fish/meat0 times in past 7 d  =  01–3 times in past 7 d  =  14 times in past 7 d  =  2For staples (grains or tubers)0–3 times  =  0; 4+ times  =  1		For each of milk and egg/fish/meat0 times in past 7 d  =  01–3 times in past 7 d  =  14 times in past 7 d  =  2
	Food frequency  =  sum of scores (egg/fish/meat + staples)		Food frequency  =  sum of scores (egg/fish/meat +)		Food frequency  =  sum of scores (egg/fish/meat + milk)
Meal frequency (past 24 hrs)	0 meals/d1 meal/d2 meals/d	= 0 = 1 = 2	0 meal/d1–2 meals/d3+meals/d	= 0 = 1 = 2	0–1 meal/d2–3 meals/d4+meals/d	= 0 = 1 = 2
Total score	10 points		10 points		10 points

* Adjusted by the authors based on Ruel & Menon;⁸

† meal frequency does not include breast-milk or any other liquids and only refers to solid, semi-solid or soft foods received in the past 24 hours

Table 3. Selected household characteristics, WHO IYCF indicators and child nutritional status

	%	Mean	SD	Range
No. per household (n  =  803)		5·09	1·86	2–13
No. of children <2 yrs (n  =  803)		1·03	0·17	1–3
Literacy rate respondents (n  =  803)	52·8
Main income sources (n  =  803)
Agriculture	70·7
Employment/salary	14·4
Homegarden ownership (n  =  803)	70·4
Household grows vegetables (n  =  803)	63·5
Sanitation facilities (n  =  803)
Improved	18·3
Unimproved	81·7
Drinking water source (n  =  803)
Protected	86·6
Unprotected	13·4
Household dietary diversity score (n  =  803)		6·78	1·72	2–12
WHO indicators achieved
Minimum dietary diversity (n  =  801)	43·9
Minimum meal frequency (n  =  773)	69·9
Minimum acceptable diet (n  =  798)	28·3
Mean child dietary diversity score (n  =  798)		3·24	1·50	0–7
Child’s nutritional status
Mean length-for-age Z-score (n  =  801)		−1·25	1·14	−5·82–4·15
Prevalence of stunting (<−2 SD LAZ)	25·1
Mean weight-for-length Z-score (n  =  802)		−0·77	1·03	−4·04–4·54
Prevalence of wasting (<−2 SD WLZ)	9·7
Mean weight-for-age Z-score (n  =  803)		−1·22	1·04
Prevalence of underweight (<−2 SD WAZ)	22·8			−5·44–2·88

Table 4. Child feeding index (CFI) components by CFI age-group

Component	6–8 months n  =  158		9–11 months n  =  169		12–23 months n  =  417
Breastfeeding, %	98·8		95·2		71·3
No bottle used, %	43·6		39·5		27·3
Dietary diversity score, %
Low	0–2 groups:	6·1	0–2 groups:	4·7	0–2 groups:	1·5
Medium	3 groups:	73·6	3 groups:	59·2	3 groups:	48·2
High	≧4 groups:	20·2	≧4 groups:	36·1	≧4 groups:	50·3
Food Frequency
Range	0–3		0–3		0–4
Median	2		3		2
Mean (SD)	2·08 (1·1)		2·44 (0·9)		1·96 (0·8)
Meal frequency, %
Low	0 meals/d:	6·2	0 meals/d:	3·0	0–1 meal/d:	6·4
Medium	1 meal/d:	11·7	1–2 meals/d:	25·4	2–3 meals/d:	79·8
High	2 meals/d:	82·1	≧3 meals/d:	71·6	≧4 meals/d:	13·8
CFI
Range	2–10		2–10		1–10
Median	8		8		6
Mean (SD)	7·52 (1·8)		7·93 (1·6)		5·96 (1·2)

Figure 1. Mean (SD) LAZ per 2-months age-group (n  =  798). (The error bars show −1 SD of the mean).

Table 5. Associations of WHO IYFC indicators and LAZ - results from independent sample t-test

		n	Mean LAZ	SD	SE (mean)	t (dF)	P	95% CI LAZ difference
Minimum dietary diversity (6–23 mths)	Yes	351	−1·28	1·05	0·06	0·68 (788)	0·49	−0·10, 0·21
	No	448	−1·22	1·20	0·06
Minimum meal frequency (6–23 mths)	Yes	538	−1·21	1·16	0·05	−1·42 (769)	0·16	−0·30, 0·49
	No	233	−1·34	1·09	0·07
Minimum acceptable diet (6–23 mths)	Yes	225	−1·21	1·03	0·07	−0·50 (794)	0·62	−0·22, 0·13
	No	571	−1·26	1·18	0·05

Table 6. Bivariate correlations between CFI components and LAZ by age group

Age group, mths	Breastfeeding		No bottle used		DDS		FFQ		Meal frequency
	r	n	r	n	r	n	r	n	r	n
6–23	0·189	799	−0·035	797	−0·038	801	0·136	801	0·140	800
6–8	−0·019	163	0·048	163	0·097	163	0·189	163	0·046	162
9–11	−0·126	167	0·093	167	0·030	169	0·202	169	0·032	169
12–23	0·003	469	−0·061	467	0·003	469	0·005	469	−0·050	469

* Pearson’s r;

† correlation is significant at the 0·01 level (2-tailed);

‡ correlation is significant at the 0·05 level (2-tailed).

Figure 2. Estimated marginal means of LAZ scores by CFI scores. No. of cases: CFI 1  =  1, CFI 2  =  7, CFI 3  =  25, CFI 4  =  35, CFI 5  =  105, CFI 6  =  201, CFI 7  =  189, CFI 8  =  106, CFI 9  =  83, CFI 10  =  45.

* Covariates appearing in the model are evaluated at the following values: CFI, CFIsq, age (days), household members aged <2 years, education respondent (years of schooling), household’s wealth index, age of mother, height (cm) of mother, BMI of mother, sex of child; ** CFI score 1 represents one case only, thus the estimation might be biased. (See Table 1 in supplementary material for the exact value of the estimated marginal means, standard error and 95% confidence intervals, www.maneyonline.com/doi/suppl/10.1179/2046905514Y.0000000155.)

Table 7. Linear model of predictors of LAZ disaggregated into CFI_1–4 and CFI_5–10

CFI		b	SE B	t	P
1–4 (n  =  67)	Constant	−4·64	3·98	−1·17	0·25
	Age in days	−0·0001	0·0008	−0·16	0·87
	CFI	−0·45	0·18	−2·49	0·02
	Age in days × CFI	0·0004	0·0013	0·33	0·75
5–10 (n  =  696)	Constant	−10·05	1·13	−8·89	0
	Age in days	−0·002	0·0003	−6·52	0
	CFI	0·03	0·03	0·76	0·45
	Age in days × CFI	−0·0004	0·0002	−1·99	0·05

Ministry of Health Cambodia. National Communication Strategy for Behavioural Impact. Campaign to Promote Complementary feeding for children 6–24 months in Cambodia 2011–2013. Phnom Penh. 2011. Available from: http://camnut.weebly.com/policy-guidelines.html

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