1. Food and Nutrition Technical Assistance III Project (FANTA)
FHI 360 1825 Connecticut Ave., NW Washington, DC 20009
Tel: 202-884-8000 Fax: 202-884-8432
Email: fantamail@fhi360.org Website: www.fantaproject.org
THE “C” IN NACS:
Counseling as part of Nutrition,
Assessment, Counseling and Support
Sub-title
Serigne Diene, PhD, MPH Technical Advisor – Nutrition & Infectious Diseases - Country
programs
Rebecca Egan Technical Advisor, Nutrition & Infectious Diseases
CORE Group
May 6, 2014

2. Objectives
 Introduction to NACS
 Counseling approaches in NACS
 Effectiveness of counseling and areas for
improvement
2

3. Objectives
 Introduction to NACS
 Counseling approaches in NACS
 Effectiveness of counseling and areas for
improvement
3

4. 4
NACS: A platform for integrating nutrition
into the continuum of care
Nutrition care
and support
Economic
strengthening,
livelihoods, and
food security
Health system
strengthening
HIV-free survival
OBJECTIVES:
• Improve nutritional status
• Improve infant survival
• Reduce food insecurity
• Strengthen health systems
GOAL:
Improved health and quality of life

5. The three components within the NACS
continuum of care:
1. Nutrition assessment
2. Counseling
3. Support
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6. NACS Hinges on Nutrition Assessment
1. Routine comprehensive assessment.
• Anthropometric
• Biochemical
• Clinical
• Dietary
• Household food security
2. Analyze/interpret data using evidence-based standards.
3. Identify nutrition problems.
4. Determine causes/contributing risk factors.
5. Cluster signs/symptoms and defining characteristics.
6. Determine an appropriate Nutrition Care Plan.

7. NACS Counseling Focus Areas
1. Understanding of client preferences, constraints, and
options
2. Discuss the “Nutrition Care Plan” assigned
3. Optimal diet
4. Dietary management of symptoms and drug side-effects
5. Adherence to medications and clinical visit schedule
6. Chronic disease management
7. Exercise
8. Water, sanitation, and hygiene (WASH)
9. Referrals to additional services
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8. Treatment of
malnutrition
Prevention of
malnutrition
Food security and
livelihood support
Water, sanitation,
and hygiene (WASH)
• Medical care
and treatment
• Prescription of
specialized food
products
• Provision of MN
supplements
• Routine medical
care and
treatment
• Provision of MN
supplements
• Food
fortification
• Provision of
complementary
foods and
dietary
supplements
• Savings
• Microcredit
• Income-
generating
activities
• Household food
production
• Food assistance
• Distribution of
POU water
treatment
products or
vouchers
• Latrine
construction
Nutrition Support

9. CommunityClinic
NUTRITION
ASSESSMENT
NUTRITION
SUPPORT
NUTRITION
COUNSELING
WASH
IYCF / GMP
Nutrition
Care Plan
Adherence to
medications
Dietary management of
symptoms, drug side-
effects and drug-food
interactions
Maternal nutrition
Exercise
Treatment
of infections
Household
food
rations
Food by
prescription:
therapeutic,
supplementary,
complementary
foods
Micronutrient supplements
Point-of-use water treatment
Anthropometric
Biochemical
Clinical
Dietary
Food security
Support
groups
Community
Health
workers Economic
strengthening,
livelihoods,
and food
security

10. Targeting NACS Services
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Nutrition
Assessment
All clients receive
nutrition assessment
Nutrition
Counseling
All clients receive
counseling based on
assessment
Nutrition Support
Support is targeted
based on client
needs

11. Objectives
 Introduction to NACS
 Counseling approach in NACS
 Effectiveness of counseling and areas for
improvement
11

12. FANTA’s counseling products
12
Brochures Clinic Cards
Flipcharts
Training
Research

13. Skills to facilitate NACS counseling
 Using helpful non-verbal communication
 Showing interest
 Showing empathy
 Asking open-ended questions
 Reflecting back what the client says
 Avoiding judgement
 Praising what a client does correctly
 Giving a little relevant information at a time
 Using simple language
 Giving practical suggestions, not commands
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14. The NACS “Critical Nutrition Actions”
messages
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15. Objectives
 Introduction to NACS
 Counseling approaches in NACS
 Effectiveness of counseling and areas for
improvement
15

16. Measuring impact: some of the key
constraints
• Counseling is rarely a standalone intervention, making it difficult to
measure the degree of impact of the counseling itself
• Counseling impact pathway: behavior may change but not result in
improvements in health or nutrition status
• Counseling environments vary across programs – community vs
facility; clinician vs community volunteer
• Monitoring the quality of counseling in programs – we often measure
whether or not a client was counseled, not what counseling the
client received or the duration
• The intensity of the intervention - how frequently is the client
counseled, for how long, etc
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17. Making NACS counseling (more) effective
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• Has the intervention assessed the
local context?
• What cultural factors in the
community affect nutrition-related
behaviors?
• How many clients do clinicians see
per day?
• How many different populations
being counseled (e.g. adults,
adolescents, PLW)?
• Has the clinician been trained (in-
service or pre-service) in nutrition
and/or counseling?
• Is the clinician incentivized to
counsel?
• Is the message easy for the client to
understand?
• Does the counseling address the
client’s specific needs?
Community
Health facility
Clinician
Client

18. New approaches undertaken to enhance
NACS counseling
• Quality improvement activities
• Leveraging alternative counseling points of contact
(beyond the clinician)
• Introducing nutrition and counseling curriculum
into pre-service clinical training
• Implementing stronger monitoring of counseling
to identify what is effective
• Systematic approaches to facilitate contextualizing
messages
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19. FANTA’s ongoing activities on counseling
• Developing a literature review focusing on the
“clinician and client” counseling paradigm and its
impact on nutrition outcomes & behavior change
• Looking at performing an RCT comparing HIV+
clients receiving:
– ART
– ART + NACS assessment and counseling
– ART + NACS assessment, counseling, and food support
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20. FANTA’s ongoing activities on counseling
(Continued)
• Counseling materials that are under development or
being revised
• Training materials that cover counseling that are
being developed (Uganda)
• NACS Guidance module on counseling
• New countries (Lesotho, Malawi, Nigeria) where we
will be providing TA on counseling
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21. Discussion… and questions
• Are there existing M&E systems already to monitor
the quality of counseling?
• Are there more effective in-service training methods
that foster stronger counseling skills?
• Can clinicians effectively provide nutrition counseling
to clients with limited time?
• Should we advocate more for counseling in the
community instead of the clinic setting?
• Are there simple formative research methods to
facilitate contextualizing messages?
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22. Discussion… and questions
• Are there existing M&E systems already to monitor
the quality of counseling?
• Are there more effective in-service training methods
that foster stronger counseling skills?
• Can clinicians effectively provide nutrition counseling
to clients with limited time?
• Should we advocate more for counseling in the
community instead of the clinic setting?
• Are there simple formative research methods to
facilitate contextualizing messages?
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23. References
• Penny, M et al. Effectiveness of an educational intervention delivered through the health services to improve nutrition in young
children: a cluster-randomised controlled trial The Lancet - 28 May 2005 (Vol. 365, Issue 9474, Pages 1863-
1872) http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)66426-4/abstract
• Srivastava, Rachana, Anita Kochhar, and Rajbir Sachdeva. "Impact of Nutrition Counselling in the Management of Malnutrition among
Juvenile Diabetics."Ethno-Med 3.1 (2009): 11-18. http://www.krepublishers.com/02-Journals/S-EM/EM-03-0-000-09-Web/EM-03-1-
000-2009-Abst-PDF/EM-03-1-011-09-091-Srivastava-R/EM-03-1-011-09-091-Srivastava-R-Tt.pdf
• Santos, Iná, et al. "Nutrition counseling increases weight gain among Brazilian children." The Journal of nutrition 131.11 (2001): 2866-
2873. http://jn.nutrition.org/content/131/11/2866.short
• Walsh, C. M., A. Dannhauser, and G. Joubert. "The impact of a nutrition education programme on the anthropometric nutritional status
of low-income children in South Africa." Public health nutrition 5.01 (2002): 3-9.
http://journals.cambridge.org/abstract_S1368980002000022
• Waters, Hugh R., et al. "The cost-effectiveness of a child nutrition education programme in Peru." Health Policy and Planning 21.4
(2006): 257-264. http://heapol.oxfordjournals.org/content/21/4/257.short
• Roy, Swapan Kumar, et al. "Intensive nutrition education with or without supplementary feeding improves the nutritional status of
moderately-malnourished children in Bangladesh." (2005). http://imsear.hellis.org/handle/123456789/778
• Guldan, Georgia S., et al. "Culturally appropriate nutrition education improves infant feeding and growth in rural Sichuan, China." The
Journal of nutrition 130.5 (2000): 1204-1211. http://nutrition.highwire.org/content/130/5/1204.short
• Bhandari, Nita, et al. "An educational intervention to promote appropriate complementary feeding practices and physical growth in
infants and young children in rural Haryana, India." The Journal of nutrition 134.9 (2004): 2342-2348.
http://nutrition.highwire.org/content/134/9/2342.short
• Aidam, Bridget A., Rafael Pérez-Escamilla, and Anna Lartey. "Lactation counseling increases exclusive breast-feeding rates in
Ghana." The Journal of nutrition 135.7 (2005): 1691-1695. http://nutrition.highwire.org/content/135/7/1691.shortBhandari,
• Nita, et al. "Effect of community-based promotion of exclusive breastfeeding on diarrhoeal illness and growth: a cluster randomised
controlled trial." The Lancet 361.9367 (2003): 1418-1423. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)13134-
0
• Picolo, MR. “Results of the Survey to Prioritize Nutrition Counseling Messages for People Living with HIV and/or Tuberculosis in
Mozambique .” FANTA Project, October, 2013. http://fantaproject.org/sites/default/files/resources/Relat%C3%B3rio-resultados-
question%C3%A1rio-Oct2013-ENG-2013.pdf
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24. This presentation is made possible by the generous support of the
American people through the support of the Office of Health, Infectious
Diseases and Nutrition, Bureau for Global Health, U.S. Agency for
International Development (USAID) (also include any additional USAID
Bureaus, Offices, and Missions that provided funding as needed), under
terms of Cooperative Agreement No. AID-OAA-A-12-00005, through the
Food and Nutrition Technical Assistance III Project (FANTA), managed by
FHI 360. The contents are the responsibility of FHI 360 and do not
necessarily reflect the views of USAID or the United States Government.
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