1

NUTRITIONAL INTERVENTIONS

Dr.D.A.GunawardaneMSc Community Medicine Group

2011

2

Nutrition Care Process

1. Nutrition Assessment2. Nutrition Diagnosis3. Nutrition Intervention4. Nutrition Monitoring and Evaluation.

ADA. international Dietetics and Nutrition Terminology Reference Manual; 2011.

3

Nutrition Intervention

• is defined as purposefully planned actions intended to positively change a nutrition-related behavior, environmental condition, or aspect of health status for an individual, target group, or the community at large.

• It consists of two components: planning and implementation.

ADA. international Dietetics and Nutrition Terminology Reference Manual; 2011.

4

NUTRITIONAL INTERVENTIONS

HEALTH

INTERGRATED NURTITIONAL PACKAGE

OTHER

NONHEALTH

5

INTERGRATED NURTITIONAL PACKAGE• A special nutrition intervention

programme, with inter- sectoral collaboration, using life cycle approach.(Currently only in 6 districts )

• The goal & objective of this package aiming to reduce the prevalence of low birth weight using the life cycle approach

Implementation of integrated nutrition packageCircular letter no - 02.85/2010

6

Key Strategy- Life cycle approachPre-

pregnant Women

Pregnant Women

Lactating Mother

Infant & Young Child Pre school

child

Adolescent Girl

7

Nutrition Rehabilitation Programme (NRP)

• Is a component of INP

NRP

SAM Severe Acute Malnutrition

Ready to Use Therapeutic Food(BP

100/Plumpy nut)

MAM Moderate

Acute Malnutrition

Corn Soya Blend or UNIMIX

High energy biscuits

8

Opportunities

Pre-pregnant Women

Pregnant Women

Lactating Mother

Infant & Young Child Pre school

child

Adolescent Girl

Through • Home visits• Clinics

Through • Home visits• School MI

Through • Home visits• Preschool MI• CWC

Through • Home visits• Clinics

9

PRE PREGNANCY CARE

• Registration of eligible couples early• Nutritional status assessment and

management (anaemia & wasting)• Health screening (DM,HT,BA,HEART DIS.)

• Folic acid supplementation (400mcg/day)(?5mg)• Family planning if necessary• Rubella immunization

10

Care of Pregnant mother

• Early registration• Domicilliary & clinic based care• Nutritional assessment (BMI & Hb)• Monitoring pregnancy weight gain• Iron, folate, Vit C , calcium lactate

supplimentation• De-worm treatment after first trimester• Thiposha /corn soya blend(CSB) suppliments

Pregnancy WEIGHT GAINBMI CATOGARY Expected weight

gain (Kg)<18.5kg/m2 12.5 - 18

18.5 – 24.9 kg/m2 11.5 - 16

25 – 29.9 kg/m2 7.0 – 11.5

≥30 kg/m2 < 6.8

Nutrition month guidelines 2008

12

Micronutrient supplementation for pregnant mother

After 12 wks of POA• Iron/folate – 01 tab (60 mg elemental iron & 400 mcg folic acid )

• Vit C – 01 tab ( 50/100mg)

• Calcium lactate – 01 tab (300mg)

• One tablet of Mebendazole ( 500 mg )

Single dose

13

Care of lactating mother• Vit A Mega dose• Educate on diet

Extra servings of starch based foods at each meal Consume extra piece of fish/egg/dried fish,extra servings of pulses,

vegetables and green leaves daily

• Postpartum visits Screening for comlications Nutrition education Support for breast feeding

• Provision of micronutrients (iron ,Vit C, & Ca) for lactating mothers – 6/12

• Promote family planning to space pregnancy

14

Infant & young children

• Code for breast feeding• Baby friendly hospital initiative• Lactation management centers• Exclusive breast feeding for completion of 6 months

& continue up to 2 years• Complimentary feeding programs• Growth monitoring & promotion• Vit A mega dose , Thriposha/CSB, immunization• ECCD

15

Growth monitoring & PromotionAge group Weighing Measuring lengthBirth to 2 years Once a month At 4,9,18,24 months

If any problem once in two months

2-5 years If growing well

Once in 3 months

Every 6 months

If any problem

Once a month Every 3 months

Growth monitoring – consist of measuring, recording and interpreting an individual’s growth over a period of time Promotion – providing interventions to maintain and optimize the growth of normal children and preventing at risk children becoming malnourished

16

Pre school children

• Growth monitoring & promotion• ECCD• Thriposha,CSB• Food demonstrations

17

Thriposha Intervention Programme• Thriposha program was initiated in 1973 by the Ministry of

Health, with the assistance of CARE, to combat the high incidence of child malnutrition (protein-energy malnutrition), low birth weight, and micronutrient deficiencies of iron and vitamin A in key biological groups in Sri Lanka.

• produces around 1.5 million packets of Thriposha every month and they are distributed among around 750,000 pregnant women, breast feeding mothers, and underweight children.

• For the current production amount which is only 60 % of the requirement, about 10,000 tonnes of maize and 8,000 tonnes of soya beans are required annually as ingredients.

• Sri Lanka government spends around Rs. 1.25 billion per year for the production of Thriposha

18

Thriposha Intervention Programme

Target group1. All pregnant (antenatal) mothers throughout their

pregnancy.2. All lactating (postnatal) mothers for a period of six

months after delivery.3. Children above 6 months of age to 5 years who are

• Underweight • Loss of weight for 3 consecutive months • Hospitalized children who fall into above categories.

19

Ingredients present in ThriposhaIngredients %Maize 66Soya 30Full cream milk powder 3Vitamin premix o.1Mineral premix 0.9

Report on Evaluation of Thriposha Food Supplementation Programme 2008 Submitted by Department of Applied Nutrition Wayamba University of Sri Lanka 28 August 2008

20

Ingredients present in Thriposha

Report on Evaluation of Thriposha Food Supplementation Programme 2008 Submitted by Department of Applied Nutrition Wayamba University of Sri Lanka 28 August 2008

21

Supplementation of Thriposha

Age Triposha Tbs

Sugar Oil/Coconut Tsp /Tbs

Kcal

Child 6-9 mons 3 With breast milk

01 Oil Tsp 200

Child 10-12 mons 3 1 Tsp 01 Oil Tbp 250Child 1-5 yrs 3 1 Tbs 01 Co.nut Tbs 300Pregnant Women 3 1 Tbs 02 Coconut

Tbs350

Lactating Mothers 3 1 Tbs 02 Coconut Tbs

350

Thriposha is a cooked ready to eat supplementary food50 g = 150 kcal

Intergrated nurtitional package manual 2010

22

Supplements for school childrenIn Grade 7 & 10, all children(2009 all children from grade 6 above )

01 tab of Mebendazole(500mg)-at the on set01 tab of Ironfolate/Ferrous Sulfate + 01 tab of Vit C - once a week for 24 weeks - during school holidays the tablet should be given to the child with instruction

Children who are clinically anaemic

01 tab of Mebendazole(500mg)-at the on set02 tabs of Ironfolate/Ferrous Sulfate + 01 tab of Vit C - for 1 month or till their Hb% levels normalAfter that same treatment for another 2 months to replenish the iron stores

All children in 1,4,7,10 Vit A mega dose(100 000)All children in 1,4All children (<200)

01 tab Mebendazole

23

Issues in Thriposha Programme1. Sharing - the supplement may be consumed by the entire

family rather than the target beneficiary;2. Substitution - when the supplement is given for the under-

five child, the mother may reduce the child's regular food, resulting in no increase in nutrient intake;

3. Distortion of growth monitoring - since Thriposha eligibility is linked to recording of the child as under weight on the growth card, weights may not be recorded accurately;

4. Dependency - the free distribution of the food may reinforce a dependent attitude on the part of the recipient;

5. Sustainability - the production of Thriposha is dependent on supply o f raw materials and imported commodities (Milk powder) and they are quite expensive.

24

School children & adolescents• School medical inspection• Immunization• Ferrous folic acid supplementation• Growth monitoring• Dental care• Hygiene promotion• School health clubs• School feeding programmes (milk,mid-day meal)• Canteen policy• School exercise programme

25

Growth monitoring of adolescents

26

School health clubs

27

Hygiene promotion

28

Vitamin A Megadose SupplementationRevised Schedule

Vitamin A Megadose Supplementation Revised ScheduleCircular no 01-05/2009

29

Corn Soya Blend or UNIMIX• A supplementary food • Admission criteria

children aged 6 months – 5 years with Moderate Acute Malnutrition (MAM)(weight for height/length less between -2SD to -3 SD) in districts with INP

• If child is having wt/ht less than – 3SD Therapeutic feeding Programme of the Nutrition Rehabilitation Programme – Ready to Use Therapeutic Food (BP 100/Plumpy nut)

• Discharge criteria-1. when child reach above – 1 SD for WT/HT and remain so at two

consecutive Programme distributions2. Not improved even after 3 months – refer to paediatrician

30

• Mix with some drinking water to make a paste• Bring the boil for 10 minutes ( no more – no less) and serve

Corn Soya Blend or UNIMIXhow to use

UNIMIX/CSB 3 full tablespoonsWater 1 cupSugar 1 table spoon ( after 9/12)Oil /margarine/butter or 1 table spoon Coconut 3 tablespoons

50 g daily provide 150-190 kcal/day1500g per month per child

31

• Not focused on targeting group (not using the admission criteria properly)

• Not adhere to the discharge criteria

• Problems in growth monitoring – because use of WT/HT instead of WT/AGE

Issues in CSB Programme

32

Multiple Micronutrients (Sprinkles)• Home based fortification• Target All

infants & young children between 6 to 24 months• Exclude Children completing 24 months to be excluded• Dose 15 sachets to be consumed within 30 days(EOD/DAILY)

• Duration For a period of 4 consecutive months (120days) for each child from the date of commencement

33

Multiple Micronutrients (Sprinkles)

Micronutrient Amount Iron 12.5 mg Zinc 5 mg Zn & Iron deficiency

generally co -exist

Folic Acid 160 µg Vitamin A 300 µg RE Children continue to get

Vit A mega doseVitamin C 30 mg Enhance iron absorption

(Nutritional Anemia Formulation)

34

Multiple Micronutrients - Administration• Whole sachet should be added to half a cup of semi

solid or solid food – one per day• Mixed well and fed to the child within 30 min

because the vitamins and minerals in the Sprinkles will cause the food to noticeably darken.

• Should be never mixed with water or any other fluids as it is not water soluble

35

Issues in Multiple Micronutrients (Sprinkles)

• Poor compliance• Poor knowledge on method of use • Discouraged by hospital setup