Results of odds ratios and 95% confidence intervals of low MUAC, low WAZ, low WLZ and low LAZ among those who did not meet complementary feeding criteria are shown as below: Results of Table 9 showed there was no association between MUAC, WAZ and WLZ with MMF expect LAZ which had association with MMF. This means Compared children who meet MMF, children who not meet MMF, marginally significant more likely to have low weight for age and low weight for length and significantly more likely to have low length for age.
Odds ratios and CI of (low MUAC, low WAZ, low WLZ and low LAZ) with MDD, which there is no association between MUAC and MDD but there is significant association between WAZ, WLZ, LAZ and MDD. This means Compared children who meet MDD, children who not meet MDD, significantly more likely to have low weight for age, low weight for length and low length for age. There is no association between MUAC and MAD too but there is association between WAZ, WLZ, LAZ and MAD which this means compared children who meet MAD, children who not meet MAD, significantly more likely to have low weight for age, low weight for length and low length for age. We were not found association between MUAC, WAZ, WLZ and LAZ with introduction of CF at six months old. This means there is no odds ratio for low MUAC, low WAZ, low WLZ and low LAZ because of children who not meet introduction of CF at six months old.
According to our finding from Table 5 and 6 expect regarding the variable intitled introduction of complementary feeding at six-month-old, none of CF indicators (MMF, MDD and MAD) associated with MUAC. MUAC is one of the methods for finding malnutrition children, which proper complementary feeding especially start CF at six months old of children may help to children for having good MUAC and prevent from malnutrition. So MUAC is very important and this part of study showed early or late start of complementary feeding may have effect on MUAC. Secondly all CF indicators (introduction of CF at six months old, MMF, MDD and MAD) associated with weight for age z-score (underweight) and all CF indicators associated with weight for length z-score (wasting) too. It is logical which infants need to extra feeding after a long time (after six month) so should start CF on that time and when infants grow after six months need to eat different foods frequently, so if a child start CF on time and receive MMF and MDD it is acceptable and would prevent from underweight and wasting. So, this part of study showed for having good WAZ and WLZ should meet all complementary feeding indicators. Expect MMF none of CF indicators (introduction of CF at six months old, MDD and MAD) associated with length for age z-score (stunting). Trend of children growth is very fast so they need to more energy for growing better. If a child be hungry and miss energy intake frequently, it would be suffered to chronic malnutrition (stunting). So, MMF is important for a child’ growth and it would prevent from stunting.
In the study result of Udoh and Amodu, there was a significant association (p<0.05) between introduction of CF at six months old with wasting, the MDD was significantly associated with underweight and similarly, MAD was significantly associated with underweight too. Also, this study showed significant association between stunting and MMF, MDD and MAD [17].
In Saaka et al. study (which conducted for explore the relationship between IYCF indicators and child growth indicators in rural northern Ghana) the main finding was that three of the WHO core IYCF indicators were not associated with mean length for age z-score expect timely initiation of CF at 6 months and this study did not show any association between MDD or MMF and stunting. All WHO core IYCF indicators (introduction of CF at six months old, MMF, MDD and MAD) were not associated with mean weight for height/length z-score. Saaka et al. study presented significant positive association between introduction of CF at six months old and higher height for age z-score [18] but our study showed there is no association between introduction of CF at six months old and length for age z-score (stunting). In Ahmad et al. study there was no association on indicators of CF, namely MMF, MDD, MAD and timely introduction to CF with wasting, underweight and stunting [17]. Kimiywe et al. found that CF practices were significantly correlated with nutritional status, particularly MDD [19]. Korir JK’s study also found that low MAD significantly correlated with wasting [20]. So, we can say a child have appropriate complementary feeding when he/she was breastfeeding at the time of study, met minimum meal frequency in the past 24 hours, met minimum dietary diversity in the past 24 hour and complementary feeding were introduced at six-month-old. As we discussed before most of previous studies found association between anthropometric measurements of children with complementary feeding indicators expect Ahmad et al’ study which found no association between anthropometric measurement of children with complementary feeding indicators. Like most studies, the result of this study confirmed most of hypotheses and found associations between anthropometric measurement and complementary feeding indicators. But we need to more studies for confirm these associations like systematic review or meta analyze.
Result for odds ratios and 95% confidence intervals for low MUAC, low WAZ, low WLZ and low LAZ among food insecure subjects are shown in Table 8. This Table shows there is no association between MUAC and household food insecurity, but there is significant association between WAZ, WLZ and LAZ with household food insecurity. This means compared children who were food secure, children who were not food secure, significantly more likely to have low Weight for age, low weight for length and low length for age.
Result of Table 3 is shown association of household food security with complementary feeding indicators with p value. This result showed there was no association between food security (secure and total insecure) and MMF, but there are associations between food security and MDD and food security and MAD. There is no association between food security and introduction of CF at six months old too. This means better household food security help children for having better MDD and MAD. Table of 4 is shown association of food security and insecurity with their sup groups (Food insecure without hunger, food insecure with moderate hunger and food insecure with severe hunger) among CF indicators. This Table also had the same result with Table of 3 with different p-value. There is no association between household food security (secure and insecure with their subgroups) and MMF, but there are associations between household food security (secure and insecure with their subgroups) and MDD and food security (secure and insecure with their subgroups) and MAD and also there is no association between food security (secure and insecure with their subgroups) and introduction of CF at six months old. The findings confirm that most of Kabul households live in insecurity situation as only 9.3% of the households in the study were food secure. Low level of household food secure may be because of bias: In Afghanistan some health services providers or NGOs had some services to malnutrition mother/children like giving malnutrition materials (RUTF, RUSF, sprinkle powder, grains and etc.) to malnutrition child/mother they thought food security questionnaires are belong to these materials and from other side when we had interview about food security questionnaire, some of them asked: You asked me these questions for financial or material helping? Or after this questionnaire you would give malnutrition material to me or my child? After asking these questions by two or three persons, to solve this problem, I first explained to them that this questionnaire was not for any financial or material help, this is just a research for finding nutrition or complementary feeding problems of Kabul children.
Our study result showed there is no association between food insecurity and MMF and introduction of CF at six months old, but showed association between household food insecurity and MDD and MAD. We categorized MDD as met when children consumed 4 groups out of 7 food groups and MAD were good when children met both MMF and MDD. A child for having a good growth and prevent from underweight, wasting and stunting should follow CF practices guideline. So those children who live in food insecurity situation cannot receive MDD or MAD and risk of malnutrition is more between these children. Macharia et al. study showed similar result: infants living in food secure household were significantly more likely to achieve appropriate infant feeding practices than those in food insecure household. Infants living in food secure household were significantly associate with introduction of CF at six months old, MDD and MAD which compared with infants from food insecure household without MMF [21]. Two other studies conducted in rural Bangladesh reported similar finding. Saha et al. study showed better household food security status was associated with better infant feeding practices for children aged 6-12 months [22] and Owais et al. showed that the odds of receiving a minimally acceptable diet for infants in most food secure households was higher than for infants living in least food secure households [23].
Result of Table 2 showed receive of all nutrients and food groups were sub optimal and lower than recommended amount which can have different reasons. In our study were many children who were completed their six months old or may more, but were did not start complementary feeding and receive of their nutrients and food groups from way of diet were zero which these zeros had effect on total mean and SD of nutrient and food intake which this can be one of those reasons. The fruits of Afghanistan are seasonal, Fruits are cheap and more in their seasons and most of people can use from, but after end of their seasons fruits come from other countries which they are less and expensive because Afghanistan don’t have especial refrigerator for saving seasonal fruits, So because of that most of people can’t sue enough fruits and this study were done in season which fruits were less. This can be another reason for low level of nutrient and fruit intake. There is a high rate of illiteracy, poverty and food insecurity in the country which can affect people’s nutrient and food intake. Finally, there is no previously study which explored complementary feeding practices and dietary intake of infants and children aged 6-23 months within the Afghanistan so, we need to do more researches to focus on nutrient intakes and its relationship with complementary feeding indicators and other variables.
According to definition of complementary feeding indicators our result showed that all CF indicators (MDD, MAD, introduction of CF at start of sixth month, consumption of Iron or multivitamin supplementation and fortified feeding) in this study were sub-optimal and still low , without MMF and Exclusive Breast Feeding (EBF) which they are better than other but they are not completely good. Prevalence of complementary feeding practices in this study was similar with a study conducted by Ahmad et al. in Aceh, Indonesia. Result of Ahmad et al’ study was showed that 39% of children were exclusively breastfed, only 61% received prolonged breastfeeding and 50% received timely introduction CF. MMF, MDD and MAD were met by 74%, 50% and 40% of the children, respectively [17]. In a previous study from Muzi Na and et al. in Afghanistan which conducted for predictors of CF practices and were used from analysis of the 2015 demographic and health survey data, the prevalence of introduction of CF at six months old between 6-8m aged, MMF, MDD and MAD among children 6-8 months were 56%, 55%, 23% and 18%, respectively [4]. Our study result showed better situation in part of CF indicators than study of Muzi Na and et al, surely this is result of health services and giving health education to people as we can see in community. Globally, 64.5% of infants 6-8 months of age were received introduction of CF at six months old on 2017, and global rates of MMF, MDD and MAD were low at 50.3%, 28.2, and 15.9% respectively [1]. The present study finding was also higher than global and that reported by WHO found that less than one-fourth of the children aged 6-23 months in developing countries had good consumption quality [24] but they still remained under the optimal level. I should add, our study was designed in capital of Afghanistan which most of Kabul people may have better economic situation, better accessibility to health services and may have higher education level than people of other provinces and from other side our sample size was very small. So, these four reasons or perhaps more, may show high level of CF indicators in all Afghanistan.