The present study aimed to evaluate maternal performance in relation to food security during the complementary feeding period and its correlation with anthropometric indicators of infants. The results indicated that more than 50% of the mothers in Bushehr performed inadequately in providing their infants with an acceptable daily intake from all food groups. The only exception was meat, which was included by slightly more than 50% of the mothers. We believe that the main issue was the mothers’ lack of practical knowledge about food for infants, despite a good academic education and general knowledge of complementary feeding (Yeganeh et al., 2017). This indicated that although Iran has made major improvements in the level of education on complementary feeding (as provided by comprehensive health service centers) the feeding performance of the mothers was still inadequate particularly beyond the infants’ first year of age. Apparently, the complementary feeding education in Bushehr’s health service centers had mainly focused on the onset of complementary feeding and infants’ readiness, but less on their needs beyond the first year of age. Note that nutritional education is not taught at Iranian schools, nor does Iran have special centers that provide the mothers with practical training on nutrition.
In a study by Farivar et al. (Farivar et al., 2009), the mean level of knowledge among the people in Bushehr about the role of different food groups was 50%. Shuo Wang (China, 2021) reported that the infants aged 12-23 months were not fed according to nutrition standards (Wang et al., 2021). In line with our results, Beshadu Bedada Feyisa et al. reported that vegetable intake only among 37.8% in Southern Ethiopia infants, aged 6-23 months, was sufficient (Feyisa, Tefera, Endris, Asayehu, & Gebreyesus, 2020). Despite the importance of vegetable consumption on a child’s health and in the prevention of chronic diseases (Liu et al., 2021), the intake of vegetables by children in Bushehr was only 1-3 times weekly. Such deficiency could be due to the short shelf life of vegetables, the misperception that children cannot digest vegetables, or the fear of parasitic contamination of raw vegetables. In a review study, Hendrie et al. (2016) proposed measures to increase vegetable consumption among children. They recommended additional availability of vegetables in the market, increased vegetable consumption by families, and providing the necessary education and social support (Hendrie, Lease, Bowen, Baird, & Cox, 2017).
One of the highly consumed food groups in complementary feeding is cereals, for which the maternal performance of the mothers in Bushehr was inadequate. Some of the commonly consumed cereals by children in Bushehr were rice and wheat bread. The intake of other cereals, such as barley and ready-to-eat cereals (e.g., corn flakes), was significantly lower. This could be due to the lack of access and product knowledge (as a suitable breakfast) or higher costs. Michelle Klerks (2019) considers it necessary to introduce cereals for use in complementary feeding(Klerks & Bernal, 2019).
Dairy products, as well as breastmilk, form the other important food group during the complementary feeding period and play an important role in the growth of children. Moreover, among Muslims, breastfeeding is strongly associated with Islamic culture, beliefs, and practices (Kamoun & Spatz, 2018; Mehrpisheh, Memarian, Ameri, & Saberi Isfeedvajani, 2020). Among the Iranians, the traditional belief is to breastfeed for two full years with a difference of 2-month for male and female infants. Some mothers tend to breastfeed beyond the first year and consider breast milk as the main food source for their infants. In the absence of solid food and the irregularity of the feeding times, formula milk is also used. Note that the Iranian health centers recommend the consumption of Iranian adult food as suitable for infants older than 1 year. However, the appropriateness of this recommendation is questionable (abdi, atarodi, mirmiran, & esteki, 2015).
In the present study, we found no association between the anthropometric indicators and the consumption of food groups by infants (i.e., maternal performance). In contrast, in a study, Thaweekul et al. (2021) reported a negative relationship between the infant and child feeding index and nutritional status (Thaweekul, Sinlapamongkolkul, Tonglim, & Sritipsukho, 2021). However, in line with our findings, a study among 1,816 children under five years by Joe et al. (2019) reported very weak association between anthropometric indicators and the food failure (Joe et al., 2019). Such discrepancies could be explained by the fact that we only included the main food groups for the evaluation of maternal performance, while other foods (e.g., fat, snacks, and fast food) could also have been consumed. Furthermore, anthropometric indicators are affected not only by nutrition, but also by parameters such as genetics, environment, climate, and physical activities. The lack of estimation of the calorie intake and level of children’s physical activities could also have contributed to the difference in the findings.
Our results showed that the risk of overweight and obesity among the infants aged 1-2 years was 26% (i.e., one in four of the sample size). Based on previous studies, weight gain and obesity can continue into adolescence, and obese adolescents can become obese adults (Su-Jung & Jong-Ho, 2021). Obesity stigma is one of the problems in long-term childhood obesity that can cause psychosocial damage in the future of these infants(Haqq, Kebbe, Tan, Manco, & Salas, 2021). Jones et al. (2017) reported that the level of obesity in European children aged >5 years was 28.6% (Jones, Jewell, Saksena, Ramos Salas, & Breda, 2017). The guiding principles for feeding infants, in addition to undergrowth and underweight prevention, are also concerned with excess weight, obesity, and imbalanced nutrition. Appropriate dietary habit and education of the parents are the key factors in ensuring a healthy food regimen during both childhood and adulthood ("Samuel, F. , Akintayo, B. and Eyinla, T. (2021) Complementary Feeding Knowledge and Practices of Caregivers in Orphanages Improved after Nutrition Education Intervention in Ibadan, Nigeria. Open Journal of Nursing, 11, 642-652. ,"). Considering the high overweight/obesity rate (26%) in Bushehr, implementation of such intervention programs, particularly for the mothers of infants aged 1-2 years, is essential.
To the best of our knowledge, this is the first study that evaluated maternal performance in food security in Bushehr using a localized questionnaire and allowing for cultural sensitivities. We strongly recommend educating the mothers in Bushehr on complementary feeding to achieve the required level of food security in infants and children. This could be in the form of an educational booklet, taking the local cuisine into account that specifies the quantity of the servings of each food type, how to estimate food portions, and how to properly prepare and store food. To determine the cause of the weight gain in Bushehr, further studies are required on the way the parents gather the nutritional information and accurate measurement of food consumption both in the form of micro- and macro-nutrients, as well as whole foods, is needed.
Limitation in study
The main limitation of the present study was the mothers’ lack of understanding of some items in the questionnaire, despite extensive explanations. They had inadequate knowledge about the quantity of the servings of each food type, and at times could not remember the food groups. This in turn adversely affected the accuracy and generalizability of the results. In addition, by excluding other foods (e.g., fat, snacks, and fast food) we could not evaluate their association with anthropometric indicators.