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Revealing results from Rwanda's Home Fortification Report: A balanced diet may not be a nutritious one

23 January 2012 - A recent report on Home Fortification, conducted by the Ministry of Health, with support from UNICEF, the University of British Columbia, World Vision, CAR, Concern Worldwide, WFP and USAID finds that home fortification – using micronutrient powders (MNP) must not be used as a standalone method.

In-home fortification should be an integral part of infant and young child feeding practices as recommended by the WHO, particularly in areas where there is a high prevalence of anaemia among children and iron-fortified foods are not affordable or available.

Key findings from this formative research include the fact that:

  • Caregivers have limited understanding of appropriate feeding practices for young children with very few understanding the importance of energy dense foods or key foods important for reducing the risk of micronutrient deficiencies. Energy dense foods are particularly important in Rwanda as stunting is highly prevalent (44% of all children under the age of five 2010 DHS) and fat intake is considered to be the lowest in the world. Stunting, low ‘height for age’, is a commonly considered to be a physiological response to inadequate nutrition during the first ‘1000 days’ of life, or conception to about 2 years of age.
    Early child growth is dependent on children being introduced to complementary foods that are timely, of adequate quantity, consistency, frequency, and quality. The focus in Rwanda amongst mothers and caregivers is on a ‘balanced diet’, which may or may not meet the energy needs of a growing child.
  • The typical diet for children is very low in animal foods that are key sources of minerals, particularly iron, as well as providers of high quality protein and essential fatty acids. It is clear that these foods are not accessible on a regular basis to most families making preventing deficiencies challenging.
  • There is little knowledge amongst health care providers or caregivers of foods that can help prevent anaemia, with common examples being tree tomatoes and green vegetables. While the latter may contain iron, it is poorly absorbed and there is no evidence that it will prevent anaemia. Tree tomatoes do not contain appreciable iron, but are an example of the widespread disinformation in communities. Iron-fortified foods are not accessible due to cost, making in-home fortification an important intervention in this region.
  • In terms of the districts surveyed, few differences were found between districts although responses did seem indicate limited access to food in Nyraguuru. These limitations must be considered in the final implementation, particularly with regard to suitable foods to which the MNP may be added.
  • It is quite likely that the in-home fortification programme will be well received if messages are properly delivered to caregivers as they were very receptive to the concept and expressed willingness to add MNP to their children’s food.
    Of importance, caregivers want clear and accurate information. Messages must be developed with that in mind and community health workers and health staff must be trained such that they can provide answers to caregivers’ questions.
    Caregivers discussed important sources of information or where they would like to hear about MNP and recommendations included radio, community health workers and other health care providers. It is recognised that messages must be consistent, clear and frequently delivered if they are to be effective at changing behaviours.

From these findings, it is apparent that a strong complementary feeding education protocol is needed and the MNP program will greatly help as it is not a stand-alone intervention but will be introduced as part of improved infant and young child feeding.

Messages for caregivers will be targeted to the needs of young children for growth to include frequent feedings of energy dense thick porridge made from grains, with added foods such as meat, eggs, fish, ground nut paste, avocadoes, where available. Oil or other fat should be added to porridge every time in accordance with the current ‘Essential Nutrition Actions’. Fruits and vegetables add small amounts of micronutrients, and variety promotes a wider acceptance of food but they are generally lower in energy density and micronutrient bioavailability, other than vitamin C.

Poverty is an obvious issue, but nutrition knowledge can still play a role, as foods such as oil may be present, although family members may not know the high needs children have for fat in the diet. Similarly small amounts of organ meats, rich in iron and vitamin A, can be added to children’s food and may be present but their value not known.

Using these results, actual implementation of in home fortification will begin in six districts (Musanze, Bugesera, Kirehe, Nyaraguuru, Karongi and Kamonyi), targeted approximately 120,000 children between the age of 6 and 23 months.

For more information, please read the full report.



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