1. Nutrition Care in package of
service
Dr. May Khin Than
Deputy Director ( Nutrition)
Department of Health
2. Nutrition and the MDGs
Goal
Role of nutrition
Goal 1: Eradicate extreme poverty
& hunger
Hunger – undernutrition – undermines economic growth and
perpetuates poverty. Malnutrition erodes human capital
through irreversible and inter-generational effects on cognitive
and physical development
Goal 3: Promote gender equality
and empower women
Under nutrition in women (e.g., moderate and severe anemia)
is often a reflection of gender inequality.
Goal 4: Reduce child mortality
Malnutrition is directly or indirectly associated with more than
50% of all child deaths, and it is the main contributor to the
burden of disease in the developing world.
Goal 5: Improve maternal health
Maternal health is compromised by malnutrition, which is
associated with most major risk factors for maternal mortality.
Maternal stunting and iron and iodine deficiencies particularly
pose serious problems.
Goal 6: Combat HIV/AIDS, malaria
and other diseases.
Malnutrition may increase risk of HIV transmission,
compromise antiretroviral therapy and hasten the onset of fullblown AIDS and premature death. It increases the chances of
and prolongs tuberculosis infection even while being treated,
resulting in spread of disease, and it reduces malaria survival
rates.
3. Causes of children U5 deaths in
UNICEF East Asia Pacific region
Total number of
deaths: 1.265 million
2
7
16
Pneumonia *
8
Diarrhoea *
“Childhood
underweight
is the leading
cause of the
global burden
of disease”
Malaria *
Undernutrition
53%
17
Neonatal
Injuries
5
Others
45
Ref: WHO causes of death database & Undernutrition as an
underlying cause of child deaths associated with diarrhoea,
pneumonia, malaria and measles, Caulfield et al, 2004
Vaccine-preventable
diseases*
4. Reduction of U5MR according to intervention
13%
Exclusive Breastfeeding
Insecticide treated
materials
7%
Continued BF with
Complementary feeding
6%
5%
Zinc
Hib va ccine
4%
Clean delivery
4%
Water, sanitation,
hygiene
3%
Antenata l steroids
Infants not breastfed
have 6-fold increased
chance of dying in
first two months;
3%
0%
2%
4%
6%
8%
10%
12%
14%
Source: Lancet Child Survival Series 2003
5. Aim of Nutrition promotion
"Attainment of nutritional well-being
of all citizens as part of the overall
social-economic development by
means of health and nutrition
activities together with the
cooperative efforts by the food
production sector
7. Specific objectives
To control/eliminate all forms of
nutritional deficiency
To promote healthy dietary habits
and lifestyles among people
To prevent over-nutrition and dietrelated chronic diseases
8. Objectives towards
achievement of MDG
To reduce underweight among under 5 children
To increase exclusively breast fed rate
To increase receiving high potency vitamin A
supplementation among 6 months to 5 years old
children
To reduce IDA prevalence among pregnant
women and under five children
9. Public Health Nutrition Problems
1. Protein Energy Malnutrition (PEM)
2. Micronutrient Deficiencies
- Iron Deficiency Anemia (IDA)
- Iodine Deficiency Disorders (IDD)
- Vitamin A Deficiency (VAD)
- Vitamin B1 Deficienciy ( VB1D)
10. Strategies
Community involvement in nutrition activities
Nutrient supplementation (VA,B1,iron)
Supplementary feeding
Nutrition education
Integrated deworming
National Nutrition Surveillance System
Intersectoral cooperation
Food fortification (IS, Home fortification)
11. PEM Control activities
by health staff
Community
based
1.
2.
Growth Monitoring and
Promotion (GM/P)
1.
Community Nutrition
Centres (CNCs)
2.
3.
Hospital Nutrition Units
(HNUs)
3.
Growth Monitoring
and Promotion
(GM/P)
Community Nutrition
Centres (CNCs)
Village Food Banks
(VFBs)
12. I. Protein Energy Malnutrition Control Project
1. Growth Monitoring /Promotion
by BHS
Started in 1982
Each midwife monitors the growth
of about 100 under-3 children
Coverage -33% of all under-3
Community Nutrition Centres (CNCs)
2. CNC by BHS
Started in 1982
Funds: community donations
Each centre takes care of 20-30
mal-nourished children
100 CNCs all over
One meal a day
Cooking demonstration
13. I. Protein Energy Malnutrition Control Project
(cont)
3. Hospital Nutrition Unit (HNU)
)
Started in 1982
20 HNUs all over the country
Management of severely malnourished
children
Therapeutic feeding (WHO guideline),
Treatment of infections, Nut Education
4. Village Food Banks ( VFB)
Community based-, started in 1999
Management for severely
malnourished children in remote
villages
205 VFBs in 34 tsps all over the
country
Take care of moderately malnourished
children as well
Supplementary feeding/ therapeutic
feeding , Nut. education
14. II. IDD Elimination project
Goal – IDDE
Strategy – Universal salt iodisation ( USI)
Visible Goitre Rate Among 6-11 Year Children
(by year)
TGR
40
35
34.48
33.08
VGR
32.48
30
25.1
%
25
21.84
20
15
12.7
12
10
5.5
5
7.58
1.01
0
1994
1997
1999
2001
Year
2003-04
2006
16. III. Vit A deficiency control
project
High potency vitamin A capsule
- every 6 months for 6-59 m children
- once within 1 m after delivery
Coverage;
Prevalence children
> 90 % of < 5 of Bitot's Spot Among
Under-5 Children
60 % of lactating women
0.7
0.6
0.6
%
0.5
0.38
0.4
0.3
0.23
0.2
0.1
0.03
0
1991
1994
1997
Year
2000
17. IV. Nutritional Anemia
Anemia status of women as
follow.
Non pregnant women
(NNC 2001)
45%
Delta
Region
↔
Prevalence of Anaemia Among Non-pregnant
Women by Region (2001)
55.6
Coastal
48.2
Plain
43.4
Hilly
31
0
↔
Adolescent school girls
(NNC 2002) 26%
↔
71%
Under five children
(NNC2005)
76 %
30
40
50
60
Prevalence of Anaemia Among
Adolescent Schoolgirls by Region (2002)
Pregnant women (NNC
2005)
20
Prevalence (%)
Delta
Region
↔
10
38
Plain
31.7
Coastal
28.3
Hilly
7.6
0
5
10
15
20
25
Prevalence (%)
30
35
40
18. IV. Anaemia Control Project (cont)
4.1. Iron supplementation
for pregnant women (all tsp)
for adolescent schoolgirls ( 20 tsp)
under five children (with GMP) – iron syrup,
Initial trial on iron sprinkles ( also known as Home
fortification)
Coverage ;
95% of adolescent school girls received full dose
70 % PW
4.2. Nutrition education
4.3. Integated Mass Deworming campaign
Since Jan 2006
Coverage
> 60 % of 2-9 y children
> 70 % of pregnant women
19. V. Infantile Beriberi project
5.1. Vitamin B1 supplementation:
for pregnant – 9 month till 3 month after delivery (
1/2tab (50mgtab), alternate day* 4 m)
5.2.Effective treatment provided for babies with
infantile beriberi
5.3.Nutrition education
- Dietary diversification
- Proper cooking methods
VI. Nutrition Promotion Month campaign
NPW since 2003 – 2008 in September
Since 2009 – Breast feeding week & NPWs in
August
20. VII. Nutrition in Emergency
4 key areas
1. Comprehensive
information on the
nutrition status of children
through rapid assessment,
surveillance and survey
2. Management of acute
Malnutrition
3. Prevention of
micronutrient deficiencies
4. Infant feeding in
Emergencies
21. Nut. Situation & target
Situation
Target
2015-16
Underweight among
< 5 children
35.3% (2000 MICS)
31.5%(2003MICS)
28.0% (2009MICS) 19.3% by 2015
Vit A last (6) month
> 90 % by tsp rep.
65% (2003 MICS)
55.9% ( 2009
MICS)
>90%
Bitot’s spot < 5
0.23% in 1997
0.03% in 2000
<0.05%
Iron Deficiency
Anemia
45% NPW (01)
26.4% adol (2002)
71% PW and
75 % <5 children
(2003).
<30% NPW
<60% PW
22. Situation
VGR among 6-11 year
12% in 2000
Target
2015-16
2 % in 2006
< 5%
iodated salt
consumption
86% HH in 2003.
>90% HH
Median UIE
136ug/l in 2006
>100 ug/ l
BeriBeri
7.12% of
death amg
1-11 m old
children
<6 %
28. Measure the circumference of left upper arm at
mid point
Locate tip of shoulder
(Arrow-1)
Tip of shoulder
(Arrow-2)
Locate tip of elbow
(Arrow-3)
Note: Elbow is bent 90°
29.
Measure distance
between tip of shoulder
and tip of elbow
Note: The elbow is bent
90°
Mark mid point between tip
of shoulder and tip of elbow
(Arrow-6)
Note: The elbow is bent
90°
30. How do you measure MUAC?
Measure the circumference of
the arm at mid point
with correct tape tension. Note:
The elbow is extended.
tv,frSwfwGif vufarmif;
vHk;ywfukd wkdif;yg/
wdyfjudK;=ym;onf
ravsmhvGef;
rwif;vGef;ygapESifh/
31. How do you interpret MUAC?
Less than 11.5 cm: Severe acute malnutrition (SAM)
11.5 -12.4 cm: Moderate acute malnutrition (MAM)
12.5-13.4 cm: At-risk
13.5 cm and above: Well-nourished
32.
Severe with complication=> refer to
hospital
Severe without complication/ mod =>
locally available food
No AMW => NE, Cooking
demonstration
38. Targets
200
6/
201
1
201
1201
2
Target
Sr
Particular
A/U
1
Prevalence of PEMamong under-5 children
(WFA < - 2SD, NCHS)WHO; GSTD
(%)
2
Visible goitre rate among 6- 11 year children
(%)
2
-
3
Median Urinary Iodine excretion
ug/d
l
123
100
200
4
Proportion of households consuming effectively iodated
salt
(%)
47
57
5
Prevalence of Bitot's spot among under-5 children
(%)
0.03
.03
<0.03
6
Proportion of under-5 children with normal serum
vitamin A status
(%)
>95
>95
>95
7
Prevalence of anaemia among non-pregnant women
(%)
45
40
[<30%]
8
Prevalence of anaemia among pregnant women
(%)
71
67
[<60%]
9
Worm Infestation among under five children
%
71
67
(<60%)
1
0
Vit. B1 deficiency among pregnant women and lactating
women
%
12.9
<1
2.9
<5%
1
Vitamin B1 deficiency among under one children
%
7.1
<7.
<6
31
29
[ <25%
]
[<5%]
>100
µg/dl
[>90%]
40. State/Division Nutrition Teams (SDNT)
S/D Health Director
Nutrition Team Leader
Functions of
SDNTs
Public Health
Nurse(1)
Public Health
Nurse (2)
Public Health
Nurse (3)
Training
Education
Nutritionist
Statistician
Supervision
Nutrition
surveillance
Nutrition
surveys