Nutritional interventions


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Nutritional interventions

  1. 1. NUTRITIONAL INTERVENTIONS Dr.D.A.Gunawardane MSc Community Medicine Group 2011 1
  2. 2. Nutrition Care Process 1. Nutrition Assessment 2. Nutrition Diagnosis 3. Nutrition Intervention 4. Nutrition Monitoring and Evaluation.ADA. international Dietetics and Nutrition Terminology Reference Manual; 2011. 2
  3. 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. 3
  5. 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 package Circular letter no - 02.85/2010 5
  6. 6. Key Strategy- Life cycle approach Pre- pregnant Women Adolescent Pregnant Girl Women Infant & Young Child Lactating Pre school Mother child 6
  7. 7. Nutrition Rehabilitation Programme (NRP)• Is a component of INP NRP SAM MAM Severe Acute Moderate Acute Malnutrition Malnutrition Ready to Use Therapeutic Corn Soya Blend or Food(BP 100/Plumpy UNIMIX nut) High energy biscuits 7
  8. 8. Opportunities ThroughThrough Pre- • Home visits• Home visits pregnant • Clinics• School MI Women Adolescent Pregnant Girl Women ThroughThrough • Home visits• Home visits Infant & • Clinics• Preschool MI Young Child Lactating• CWC Pre school Mother child 8
  9. 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 9
  10. 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 10
  11. 11. Pregnancy WEIGHT GAINBMI CATOGARY Expected weight gain (Kg) <18.5kg/m2 12.5 - 1818.5 – 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. 12. Micronutrient supplementation for pregnant motherAfter 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 12
  13. 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 13
  14. 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 14
  15. 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 months2-5 years If growing Once in 3 Every 6 months well months If any Once a month Every 3 months problem 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 15
  16. 16. Pre school children• Growth monitoring & promotion• ECCD• Thriposha,CSB• Food demonstrations 16
  17. 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 17
  18. 18. Thriposha Intervention ProgrammeTarget 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. 18
  19. 19. Ingredients present in Thriposha Ingredients % Maize 66 Soya 30 Full cream milk powder 3 Vitamin premix o.1 Mineral 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 19
  20. 20. Ingredients present in ThriposhaReport on Evaluation of Thriposha Food Supplementation Programme 2008 Submitted byDepartment of Applied Nutrition Wayamba University of Sri Lanka 28 August 2008 20
  21. 21. Supplementation of ThriposhaThriposha is a cooked ready to eat supplementary food50 g = 150 kcalAge Triposha Sugar Oil/Coconut Kcal Tbs Tsp /TbsChild 6-9 mons 3 With breast 01 Oil Tsp 200 milkChild 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 350 TbsLactating Mothers 3 1 Tbs 02 Coconut 350 TbsIntergrated nurtitional package manual 2010 21
  22. 22. Supplements for school childrenIn Grade 7 & 10, all 01 tab of Mebendazole(500mg)-at the on setchildren 01 tab of Ironfolate/Ferrous Sulfate + 01 tab of Vit C(2009 all children - once a week for 24 weeksfrom grade 6 above ) - during school holidays the tablet should be given to the child with instructionChildren who are 01 tab of Mebendazole(500mg)-at the on setclinically anaemic 02 tabs of Ironfolate/Ferrous Sulfate + 01 tab of Vit C - for 1 month or till their Hb% levels normal After that same treatment for another 2 months to replenish the iron storesAll children in 1,4,7,10 Vit A mega dose(100 000)All children in 1,4 01 tab MebendazoleAll children (<200) 22
  23. 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 childs 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. 23
  24. 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 24
  25. 25. Growth monitoring of adolescents 25
  26. 26. School health clubs 26
  27. 27. Hygiene promotion 27
  28. 28. Vitamin A Megadose Supplementation Revised Schedule Vitamin A Megadose Supplementation Revised Schedule Circular no 01-05/2009 28
  29. 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 29
  30. 30. Corn Soya Blend or UNIMIX how to use• Mix with some drinking water to make a paste• Bring the boil for 10 minutes ( no more – no less) and serve UNIMIX/CSB 3 full tablespoons Water 1 cup Sugar 1 table spoon ( after 9/12) Oil /margarine/butter or 1 table spoon Coconut 3 tablespoons 50 g daily provide 150-190 kcal/day 1500g per month per child 30
  31. 31. Issues in CSB Programme • 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 31
  32. 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 32
  33. 33. Multiple Micronutrients (Sprinkles) (Nutritional Anemia Formulation) 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 dose Vitamin C 30 mg Enhance iron absorption 33
  34. 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 34
  35. 35. Issues in Multiple Micronutrients (Sprinkles)• Poor compliance• Poor knowledge on method of use• Discouraged by hospital setup 35