The objective of this analysis was to describe the food and beverage consumption patterns among 6-23.9 month old Filipino infants and toddlers, and the associated impact on nutrient intakes, by household wealth status. The analysis highlights differences in food group consumption patterns, according to wealth status and provides insight into complementary feeding behaviours that may drive inequities in nutrient intake in infants and toddlers in the Philippines.
The prevalence of breastmilk consumption in this population has been previously reported by Denney et al. as 60% in 6-11.9 month old infants and 37% of 12-23.9 month old toddlers . This analysis showed that there was higher breastmilk consumption among infants and toddlers from poorer households (Infants; Poor: 69%, Rich: 42%), and as a result breastmilk had a greater contribution to energy among these infants and toddlers (Infants; Poor: 44% Rich: 21%). Overall, the prevalence of breastfeeding in Filipino infants is sub-optimal and does not adhere to the guidelines of continued, on-demand breastfeeding until 2 years of age and beyond . Nonetheless, the situation is better than that reported in national surveys from other geographies e.g. China (44% 0-5.9mo)  and Mexico (15% 0-3.9mo) . Public health strategies, including educational campaigns and the availability of lactation consultants, are required to further increase the rates of breastfeeding among Filipino mothers.
In the current study, breast milk contributes 7-40% of energy intakes of infants and toddlers between 6-24 months, depending on the child’s stage and wealth status, with infant/toddler formula providing from 1-50% of energy intakes. Additionally, rice contributed from 8-23% of energy intakes in this population. However, breast milk and rice are low in minerals such as iron and zinc, and infant need complementary foods, in particular, those that provide iron, zinc and calcium, from the age of 6 months [19, 20]. Infants typically consume relatively small amounts of complementary foods between 6-11.9 months, therefore, the nutrient density of these foods needs to be high . The current analysis suggests that consumption of nutrient dense food at this age is low, therefore educational strategies are needed to inform mothers of the importance of consuming nutrient dense foods at this early life stage. An extensive study examining Filipino infant and child feeding (6-23 months of age) in urban areas reported that children who are breastfed were more likely to be anaemic or iron deficient after 6 months of age than those receiving fortified foods . This is similar to results reported in other countries including India, China and Japan [22-24]. Fortified young child beverages provide a source of iron among Filipino infants (6-11.9mo) and toddlers (12-23.9mo), respectively . However, consumption of these products was more prevalent in infants and toddlers from higher income households. This may, in part, explain some of the differences in nutrient intakes according to household wealth category.
Rice is the most commonly consumed (94.8%) food in the Philippines, and is also the primary source of energy, protein, iron, thiamin and niacin . In the current study the percentage contribution of rice to total daily energy, was consistently higher among children from the poorest households in infants and toddlers. This was reflected by poorer intakes of vitamins and minerals in toddlers from poorer backgrounds. However, a recent paper by Denney et al. in the same population, identified inadequate of protein and B vitamins in Filipino infants and toddlers at population level . Ideally, the mandatory rice with vitamins and minerals in the Philippines could provide a public health opportunity to improve nutrient intakes, particularly among children from poorer households. For example, a study among school kids revealed significant reduction in anaemia after a 120 day supervised fortified lunch feeding program . Unfortified complementary foods that are plant-based generally do not provide sufficient key nutrients such as iron, zinc and calcium in adequate amounts for very young children in developing countries . The current analysis identified low intakes of iron, zinc and calcium in young Filipino children, particularly in those from poor households. Therefore, initiatives to support fortification of commonly consumed foods could help to close this gap in nutrient intakes.
In general, infant cereal consumption is low in the Philippines, with the exception of a sub-population from the rich households. In the current study, iron-fortified infant cereal, as recommended in complementary feeding by the American Academy of Paediatricians , was lacking from the diet, except among 6% of 6-11.9mo infants from the middle and rich households. The current study identified a very limited diversity of foods in the diets of Filipino infants and children, with less than 5 foods making up 80% of the diet in 6-11.9 month olds and 60% of the diet in 18-23.9 month olds. Nutrient-dense protein foods such as eggs, pork and chicken were more likely to be consumed by children from richest households. Whereas, fish was more likely to be consumed by children from low wealth households. Improving access to nutritious or fortified foods for children, particularly breast-fed infants such as infant cereal, could help to improve micronutrient intakes. However, it must be noted, that even in the U.S., iron and zinc were identified as problem nutrients  despite the widespread availability of fortified foods for infants. Therefore, ensuring adequate nutrient supply in complementary feeding is clearly complex and requires further detailed study in order to examine how young children can meet their nutrient needs in these challenging circumstances.
In the current study, SSBs were more likely to be consumed by infants and young toddlers from the poorest households. However, SSBs were consumed at approximately equal prevalence across wealth categories in 18-23.9 month olds. Since the nutrient needs, according to body weight, of infants and young children are very high  there is typically no room in the diet for nutrient-poor foods such as SSBs. In the current study, infants were more likely to consume fruit juice and powdered chocolate milk than other types of SSBs. In order to help combat the nutritional inadequacies in the Philippines, fruit juice and chocolate milk are often fortified and have been shown to be among the top sources of micronutrients in the diets of Filipino children . Fortified fruit juice has been effective at reducing the basal level of iron deficient anaemia in Filipino school children from 100% to 13% [29, 30]. However, it must be noted that unpublished data from the most recent Philippines National Nutrition Survey shows that the prevalence of overweight has increased in 3-5 year old children between 2015 and 2018, with a similar trend observed in school-aged children (Preliminary Results National Nutrition Survey 2018, Food and Nutrition Research Institute). Evidence suggests that excess weight gain in infancy, of which consumption of a poor diet (low in fruit and vegetables and high in sugar) or a high calorie diet, in early childhood could be a contributing factor, has been associated with increased risk of developing obesity and associated comorbidities in later life [31-33]. The current study demonstrated that the diet of Filipino infants is rich in carbohydrates, with limited protein intakes and low adherence to the local Filipino Pinggang Pinoy recommendation for frequent consumption of fruit and vegetables. This may be due to a number of factors including high cost, limited access to fresh fruit and vegetables, poor nutrition knowledge and family members’ food preferences . Therefore, the importance of fruit and vegetables, meat, poultry, fish and eggs, should be emphasised in Filipino households, regardless of wealth status. Public health authorities may wish to investigate methods to improve accessibility to such foods, particularly among low-income households.