semester ya 3 designing and planning nutrition programmes

Course Ante: HN 205

Course Title: DESIGNING AND PLANNING NUTRITION PROGRAMS

Contact Hours: 20L 20S (Credit 1)

SUMMARY OF MODULE• This module examines the causes and

consequences of nutritional disorders of public health significance and looks at some different intervention strategies available to alleviate and prevent these.

• The module also covers various skills and tools that we can use to gather pertinent information, the project cycle to facilitate planning and looks at some key intervention models.

MODULE AIMS

• To explore nutrition related public health in the country and to examine possible reasons for variations nutrition-related ill-health.

• To provide tools, and experience of their use, for information-gathering, problem identification, project design and monitoring and evaluation.

• To develop practical skills for the design, implementation, monitoring and evaluation of intervention strategies.

LEARNING OUTCOMES

• At the end of this module, it is expected that the successful student is able to:

• Discuss in detail the causes and outcomes of disorders of public health significance

• To argue the principles and limitations of a diverse range of interventions to maintain or improve the nutritional status at the population and community levels.

LEARNING OUTCOMES...

• Identify, and use, tools that are required to conduct situation assessments and to plan appropriate intervention strategies for defined nutritional problems

• Critically evaluate existing interventions and programmes

Background

• Child undernutrition is a serious and persistent problem contributing to over 1/3 of

deaths among children under 5 years of age • and is an underlying cause in one fifth of ‐

maternal deaths. • The children who survive are more vulnerable

to infections and have compromised physical growth, impaired cognitive development and reduced lifetime earnings.

Background ….

• To reach the Millennium Development Goals (MDG) maternal and child nutrition needs to improve at a rapid pace.

Millennium Declaration• In 2000, 189 nations made a promise to free

people from extreme poverty and multiple deprivations.

• This pledge became the eight Millennium Development Goals (MDGs) to be achieved by 2015.

• In September 2010, the world recommitted itself to accelerate progress towards these goals.

(http://www.beta.undp.org/content/undp/en/home/mdgoverview.html )

Millenium Development Goals

1. Eradicate extreme poverty and hunger 2. Achieve universal primary education 3. Promote gender equality and empower women 4. Reduce child mortality 5. Improve maternal health 6. Combat HIV / AIDS, malaria and other diseases 7. Ensure environmental sustainability 8. Develop a global partnership for development

Background ….

• Experts are calling for urgent and evidence based program action at ‐greater scale to prevent undernutrition in children by targeting pregnancy and the first two years of life.

Background ….• This development window of

opportunity (pregnancy and the first two years of life) is when nutrition has the greatest effect on child health, growth and development;

If action is not taken during this period, the damage can be irreversible.

Background …

• Moreover, there is general agreement that effective interventions exist and are available to prevent and treat undernutrition.

• If coverage of these evidence based ‐interventions increases and reaches a greater number of women and children, there could be substantial reductions in undernutrition and death.

Causes of Undernutrition

Malnutrition is the world’s most serious public health problem and the single biggest contributor to child mortality.

The conceptual framework on causes of malnutrition illustrates the causes of undernutrition and mortality.

Immediate causes…

Although the causes of malnutrition and death can be traced back directly to

• inadequate dietary intake and• diseases, Or a combination of the twoThe underlying and basic causes can be found

at each level in the society, for example:

Causes of malnutrition…

At the household level due to:– poverty and lack of land or income-generating

opportunities leading to inadequate access to food

– inequitable intra-household food distribution– poor child-feeding practices– poor hygiene– poor access to health facilities– poor child care due to heavy workload of women.


At the community level due to:-• inadequate opportunity for income

generation• low purchasing power• poor health care delivery systems• poor availability of potable water• inadequate agricultural extension services

affecting both crop and livestock production.


At the national level due to:-• unfavorable agricultural and pricing policies• ineffective application of existing policies• inadequate food storage practices for both

short-term and strategic reserves• poor communication and transport systems• inadequate accountability and transparency in

senior positions.

Underlying causes…Underlying the immediate causes are

elements including: • food insecurity, • inadequate care of mothers and

children and • poor availability and quality of water, • sanitation and• health services.

Causes of malnutrition…In their efforts to reduce undernutrition,

NGOs often work directly on the• underlying and basic causes of

undernutrition at the community, household and individual level

Aim is to improve• food security, • care practices, • health and • the environment and • address social challenges such as gender and

other inequities.

Nutrition Programmes ..

Nutrition Programs therefore aim at addressing the existing nutritional problem by designing interventions that can either be: • preventive (Preventive Approach) or • Curative (Recuperative Approach)

Preventive Approach

A preventive nutrition approach is one that targets all members of a vulnerable population, regardless of nutritional status of individual children, to prevent undernutrition and its consequences

Preventive Approach…

• Such population based preventive strategies ‐are recommended for communities that have a high prevalence of undernutrition.

• Preventive programs are especially important where there are high rates of stunting, which is often irreversible, and therefore needs to be addressed before it occurs.


• Promoting and protecting growth for all children is proven to be more effective at reducing undernutrition in the population than intervening only on an individual basis after a child is already undernourished


• Most preventive nutrition programs focus on children during the “development window of opportunity” years of conception through age 2,

• This is the period when children are growing most rapidly, are most vulnerable to growth faltering and are most responsive to nutrition interventions.

Recuperative Approaches

Recuperative approaches are those that provide treatment to children who are undernourished, including:

• Therapeutic feeding and medical care for children with severe acute malnutrition (SAM), and

• Supplementary feeding and medical care for children who are moderately undernourished

The purpose is to bring the child back to a normal nutritional status.

Recuperative Approaches

• Recuperative programs are most appropriate in areas with high prevalence of moderate acute malnutrition (MAM) and Severe Acute Malnutrition (SAM) and very high prevalence of underweight.

MAM• MAM is indicated by moderate wasting:

WFH ≥ 3 Z scores and < 2 Z scores, or ‐ ‐ ‐ ‐MUAC ≥115 and <125 mm.

Children with MAM have a higher risk of death than well nourished and at risk ‐ ‐children and need nutrition support.

SAM

• SAM is indicated by bilateral pitting edema or severe wasting: WFH < 3 Z- scores or MUAC ‐< 115 mm (MUAC used only on children > 6 months of age).

Children with SAM are highly vulnerable and have a high mortality risk. These children need immediate medical and nutrition intervention.

Development Window of Opportunity: Pregnancy to Age 2

• The risk of undernutrition, though present throughout life, is heightened at certain stages of the life cycle, in particular during pregnancy, lactation and the first 24 months of life.

• This period, from pregnancy until a child’s 2nd birthday, during which children are most vulnerable to undernutrition and the accompanying irreversible deficits in growth and development,

Development window…

• This period also presents a crucial window of time during which undernutrition can be prevented

Development Window…• Because they are growing so rapidly,

children at this age are very responsive to nutrition interventions that promote growth and prevent undernutrition.

• Focusing on children under 2 years of age presents a great opportunity to intervene, promoting adequate growth and devt. when they are most able to benefit.

Gender and Other Factors in Undernutrition

In addition to vulnerable points in the life‐cycle, there are

• geographic, • socio-economic and• gender based constraints to undernut. ‐Over 80% of the world’s undernourished

children live in just 20 countries, concentrated in sub Saharan Africa and ‐South Asia

Gender….In both regions, gender inequities

substantially influence poor maternal and child feeding practices and undernutrition.

These inequities stem from inadequate attention to the needs and roles of women, resulting in:

• inadequate care for pregnant and lactating women,

Gender…

• lack of education, • poor self confidence,‐• low economic status and • a workload that allows little time for

modifying practices to improve nutrition.

Gender….

• To be effective, programs may have to address a range of factors affecting the care giving environment and dynamics of the household, such as women’s workload.

Nutrition interventions

• Nutritional interventions refer to programmes/strategies aimed specifically at improving nutritional situation in a community.

Nutrition interventions…Malnutrition is caused by a lot of factors (refer

conceptual framework of causes of malnutrition).

While governments begin to tackle these monstrous problems, the extent of malnutrition can be lessened by a number of nutrition programmes and health strategies.

These are not alternative approaches but should be co-ordinated efforts that proceed simultenously.

Nutrition interventions…

• Thus, while the government grapples with the problems of poverty and deprivation, some direct intervention programmes aimed specifically at improving nutrition can be implemented.

Nutrition interventions…The nutrition interventions which can be used

are:1. Food fortification or enrichment• The term fortification is used here is for the

addition of one or more nutrients to a food for the purpose of improving its nutritional value.

Fortification

• fortification refers to "the practice of deliberately increasing the content of an essential micronutrient, ie. vitamins and minerals (including trace elements) in a food irrespective of whether the nutrients were originally in the food before processing or not, so as to improve the nutritional quality of the food supply and to provide a public health benefit with minimal risk to health,"

Enrichment

• Enrichment is defined as "synonymous with fortification and refers to the addition of micronutrients to a food which are lost during processing.

1. Fortification…

• The advantages of fortification are that it can improve the nutritional status of people without any special action or change of behaviour on their part and that it is usually fairly inexpensive.

Fortification

• Iodine deficiency disorder (IDD) is the single greatest cause of preventable mental retardation. Severe deficiencies cause cretinism, stillbirth and miscarriage. But even mild deficiency can significantly affect the learning ability of populations.

• Iodine is added to salt

Fortification…

Folic Acid• Folic acid (also known as folate) is necessary

for maturation of red blood cells and synthesis deficiencies lead to neural tube defects (NTDs).

• In many industrialized countries, the addition of folic acid to flour has prevented a significant number of NTDs in infants.

• Niacin Is added to bread to prevent pellagra • Vitamin D is a fat soluble vitamin . Foods that it is commonly added to are margarine, vegetable oils and dairy products• Fluoride the fortification of water supplies

with fluoride for prevention of tooth decay and maintaining adequate dental health

Others Some other examples of fortified foods:• Calcium is frequently added to fruit juices,

carbonated beverages and rice.• White rice is frequently enriched to replace

lost nutrients during milling or adding extras in.

• "Golden rice" is a variety of rice which has been genetically modified to produce beta carotene.

• Sugar and margarine -fortified with vitamin A

Difficulties & disadvantages of fortification…

1.It is necessary to find a food suitable for fortification; one that passes through a limited number of manufacturing or processing plants where a nutrient can be added, and is consumed at regular intervals by the nutritionally vulnerable groups of the population

Difficulties & disadvantages of fortification…

2. Fortification is only desirable if the deficiency to be corrected is fairly prevalent / the nutrient to be added is very cheap.

Ideally the addition of the nutrient should not cause any marked increase in the cost of the food to the consumer.

It is obvious that any addition will add to the cost but this may be borne either by the government or the manufacturer, or the very modest rise in the price of the commodity.

2. Medicinal nutrients

The provision of specific nutrients in medicinal form to groups of population is another way to control malnutrition.

All the vitamin and mineral nutrients can be used in this way. Any nutrient that is suitable for fortification could as an alternative be given medicinally to groups of the population.

Medicinal…

• The provision of iron tablets to pregnant women attending antenatal or prenatal clinics has been successfully practiced in many countries for a long time.

• Fluoride tablets taken by children on a regular basis are an effective way of limiting dental caries in areas where local water supply is low in fluoride (containing les than 0.5 ppm).

Medicinal…

• The provision of high-dose capsules of vitamin A to children every 4 to 6 months as a means of preventing xeropthalmia is being increasingly practiced.

• In some countries niacin tablets to prevent pellagra are regularly issued in certain institutions.

Advantage…

• The advantage is that the nutrient can be selectively administered to those at risk whereas with fortification many well-nourished persons not requiring additional quantities of the nutrient receive it.

Disadvantages

• The disadvantage of this method compared with fortification is that the delivery system is of necessity more difficult and much more expensive.

• When medicinal nutrients are provided in a control programme it is impossible to reach all those in need, and it is often the most vulnerable people who are the most difficult to reach.

3. Supplementary foods and feeding programmes

• It is recognized that the weaning period is a critical one from a nutritional point of view.

• Breast milk alone is adequate for the first 4 to 6 months, and then while breastfeeding continues other foods need to be introduced.

Supplementary foods and feeding programmes

Thus there is a period between about 5 months of age and up to about 3 years of age during which the infant or young child needs more than breast milk but cannot do well on the

• limited number of meals and the• type of food that older members of the

family may be consuming.


In areas where poverty and malnutrition exist, and especially in urban or densely populated rural areas, supplementary feeding programmes may be useful in the control of childhood malnutrition.


Unless supplementary foods and supplementary feeding programmes are either

• highly subsidized or • provided to poor families, They will fail to help the most vulnerable group

of the population.


Foods used in supplementary feeding programmes should be:

• locally produced as far as possible; • they should fit in with cultural food habits and

practices, • meet nutritional needs

Supplementary foods and feeding programmes…

Wherever possible supplementary feeding programmes should include nutrition education

Nutrition education:

The basis of any nutrition education programme should be to encourage the consumption of a nutritionally adequate diet and to stimulate effective demand for appropriate foods.

Nutrition education:• An inadequate total intake of food by

young children (an energy deficiency) is the main cause of malnutrition in Africa.

• Therefore, initial advice might be to continue feeding the infant with the same food as before but to do this more frequently or to provide just a little more of the food.

Nutrition education:

This advice should be more acceptable to parents than the attempt to make major, often unrealistic changes in the diet.

Priority points for nutrition education in many African countries might include:

• More frequent feeding of young children with existing foods

• Increased amounts of foods at each meal for children during the weaning and post-weaning period

• Greater consumption by children of whatever legumes are available and commonly consumed by the family

Priority points for nutrition education• Inclusion of foods such as groundnuts that are

rich in protein and provide a concentrated source of energy;

• Encouragement of breast-feeding and discouragement of bottle-feeding (i.e. the protection and promotion of breast-feeding);

• Increase use of foods rich in carotene (dark green leafy vegetables, yellow fruits and vegetables) by young children in areas where vitamin A deficiency is a problem;

Priority points for nutrition education

• Attendance by pregnant women at clinics where iron and other supplements are available and where the progress of pregnancy can be checked;

• Encouragement of families to attend with their young children at under-fives and similar clinics, and to follow the growth of children;

Priority points for nutrition education

• Provision of information about the need for immunizations and where these can be obtained;

• Information that will help to reduce infectious diseases, which often contribute to malnutrition.

ESSENTIAL NUTRITION ACTIONS (ENA)The ENA are seven affordable and evidence‐

based nutrition interventions delivered at health facilities and communities to improve the nutritional status of women and children.

The ENA provide a holistic framework on which to base nutrition programming.

ESSENTIAL NUTRITION ACTIONS (ENA)

• The ENA framework maximizes coverage of these interventions by delivering key messages and services through multiple contact points in relevant areas:

• nutrition,• health and • social sector programs,

The ENA focus on six critical contact points:

Six critical points..

1. Prenatal visits, 2. Delivery care,3. Postpartum care for mothers and infants, 4. Immunization, 5. Sick child visits and ‐6. Well child visits (including counseling and

growth monitoring and promotion [GMP]).

The seven ENAsThe seven ENA are:1.Promotion of optimal breastfeeding during

the first six months2. Promotion of optimal complementary feeding

starting at 6 months with continued breastfeeding to 2 years of age and beyond

3. Promotion of optimal nutritional care of sick and severely malnourished children

4. Prevention of vitamin A deficiency in women and children

The seven ENAs…

5. Promotion of adequate intake of iron and folic acid and prevention and control of anemia for women and children

6. Promotion of adequate intake of iodine by all members of the household and

7. Promotion of optimal nutrition for women

Details of the seven ENAs

1. Promotion of optimal breastfeeding during the first six months

• Promote early initiation of breastfeeding (i.e., within one hour of birth); do not give pre lacteal feeds‐

• Promote exclusive breastfeeding (EBF) for the first six months of life (i.e., no other liquids or foods)

• Promote breastfeeding on demand, day and night (i.e., usually 8 12 times per day) for an adequate ‐time at each feeding; offer the second breast after infant releases the first

• Practice correct positioning and attachment of infant at the breast

• Promote good breast health care

2. Promotion of optimal complementary feeding starting at 6 months with continued

breastfeeding to 2 years of age and beyond

• Continue frequent, on demand breastfeeding ‐through 24 months of age and beyond

• Introduce complementary foods at 6 months of age

• Prepare and store all complementary foods safely and hygienically

2. Promotion of optimal complementary feeding…

• Increase food quantity as child gets older 6 8 months: 200 kcal/day from complem. foods‐ 9 11 months: 300 kcal/day from compl. foods‐ 12 23 months: 550 kcal/day from compl. foods‐

• Increase frequency of feeding complementary foods as child gets older6 8 months: 2 3 meals per day‐ ‐9 23 months: 3 4 meals per day, 1 2 snacks per ‐ ‐ ‐

day (as desired)

2. Promotion of optimal complementary feeding…

• Increase food consistency and variety gradually as child gets older

• Feed a variety of foods daily to ensure adequate nutrient intake, including animal products, fortified foods and vitamin A rich ‐fruits and vegetables

• Practice responsive feeding (i.e., feed infants directly and assist older children, encourage children to eat, do not force feed, minimize distractions, show love to children by talking and making eye contact)

3. Promotion of optimal nutritional care of sick and severely malnourished children

• Continue feeding and increase fluids during illnessChild under 6 months of age: increase frequency of

EBFChild 6 24 months: increase fluid intake, including ‐

breast milk, and offer food• Increase feeding after illness until child regains

weight and is growing well• For diarrhea: provide zinc supplementation for

10 14 days, according to WHO protocol‐

Promotion of optimal nutritional care…

• For diarrhea: provide low osmolarity oral rehydration solution (ORS) to children over 6 months

• For measles: provide vitamin A treatment, according to WHO protocol

• Refer severely malnourished children for treatment according to WHO protocol, through community based management of ‐acute malnutrition (CMAM), inpatient care, or other appropriate program

4. Prevention of vitamin A deficiency in women and children

• Breastfeed children exclusively for the first 6 months, and continue breastfeeding until the child is 24 months or older

• Treat xerophthalmia and measles cases with vitamin A, according to WHO guidelines

• Provide high dose vitamin A supplementation ‐to children 6 59 months of age, every six ‐months according to WHO guidelines

Prevention of vitamin A deficiency in women and children…

• Provide post partum high dose vitamin A ‐ ‐supplementation to women as soon as possible after delivery: If breastfeeding, within eight weeks of

delivery If not breastfeeding, within six weeks

of delivery

Prevention of vitamin A deficiency in women and children…

• Promote consumption of vitamin A rich foods, ‐including liver, fish, egg, red palm oil, dark yellow or orange fruits (e.g. mango ripe and dried, papaya ripe and dried, apricots fresh and dried, persimmon), dark green leafy vegetables, and orange or dark yellow fleshed vegetables, roots and tubers (carrots, pumpkin, squash, sweet potatoes).

• Promote consumption of vitamin A fortified ‐foods, where available

5. Promotion of adequate intake of iron and folic acid and prevention and control of

anemia for women and children

• Promote intake of iron rich foods, especially ‐animal products and fortified foods

• Provide iron/folic acid (IFA) supplementation to all pregnant women; continue supplementation for three months post‐partum in areas with anemia prevalence greater than 40 percent

• Provide IFA supplementation for children

Promotion of adequate intake of iron and folic acid…

• Deworm children over 12 months of age, pregnant women after the first trimester and lactating women according to WHO protocol in areas where parasitic worms are a common cause of anemia

• Prevent and control malaria:Intermittent preventive treatment for pregnant

womenLong lasting insecticidal nets (LLINs) for women and ‐

children

6. Promotion of Adequate intake of iodine by all members of the household

• Promote consumption of iodized salt• Supplement pregnant and lactating

women and children 6 24 months of age ‐with iodized oil capsules when iodized salt is not available, according to WHO‐recommended doses

7. Promotion of optimal nutrition for women

• Consume more food during pregnancy and lactationPregnancy: 285 extra kcal/day (one additional

small meal each day)Lactation: 500 extra kcal/day (1 2 additional small ‐

meals each day)• Increase protein intake during pregnancy and

lactation (e.g., beans, lentils, legumes, animal source foods, oilseeds)

• Provide IFA supplementation for all pregnant women, according to WHO protocol

• Treat and prevent malaria

7. Promotion of optimal nutrition for women…

• Deworm during pregnancy (after 1st trimester) in areas where parasitic worms are a common cause of anemia

• Provide post partum vit. A supplementation‐• Promote consumption of iodized salt• Supplement pregnant lactating women with

iodized oil capsules when iodized salt is not available, according to WHO recommended doses

THANK YOU

semester ya 3 designing and planning nutrition programmes

Health & Medicine