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1. NUTRITIONAL INTERVENTIONS
Dr.D.A.Gunawardane
MSc Community Medicine Group
2011
1

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. 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

4. NUTRITIONAL
INTERVENTIONS
HEALTH NONHEALTH
INTERGRATED
NURTITIONAL PACKAGE
OTHER
4

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. Key Strategy- Life cycle approach
Pre-
pregnant
Women
Adolescent Pregnant
Girl Women
Infant &
Young Child Lactating
Pre school Mother
child
6

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. Opportunities
Through
Through Pre- • Home visits
• Home visits pregnant • Clinics
• School MI Women
Adolescent Pregnant
Girl Women
Through
Through • Home visits
• Home visits Infant & • Clinics
• Preschool MI Young Child Lactating
• CWC Pre school Mother
child
8

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. 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. Pregnancy WEIGHT GAIN
BMI 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
12

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. 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
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15. Growth monitoring & Promotion
Age group Weighing Measuring length
Birth to 2 years Once a month At 4,9,18,24 months
If any problem once in
two months
2-5 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
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16. Pre school children
• Growth monitoring & promotion
• ECCD
• Thriposha,CSB
• Food demonstrations
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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. Thriposha Intervention Programme
Target group
1. 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. 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. 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 20

21. Supplementation of Thriposha
Thriposha is a cooked ready to eat supplementary food
50 g = 150 kcal
Age Triposha Sugar Oil/Coconut Kcal
Tbs Tsp /Tbs
Child 6-9 mons 3 With breast 01 Oil Tsp 200
milk
Child 10-12 mons 3 1 Tsp 01 Oil Tbp 250
Child 1-5 yrs 3 1 Tbs 01 Co.nut Tbs 300
Pregnant Women 3 1 Tbs 02 Coconut 350
Tbs
Lactating Mothers 3 1 Tbs 02 Coconut 350
Tbs
Intergrated nurtitional package manual 2010
21

22. Supplements for school children
In Grade 7 & 10, all 01 tab of Mebendazole(500mg)-at the on set
children 01 tab of Ironfolate/Ferrous Sulfate + 01 tab of Vit C
(2009 all children - once a week for 24 weeks
from grade 6 above ) - during school holidays the tablet should be
given to the child with instruction
Children who are 01 tab of Mebendazole(500mg)-at the on set
clinically 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 stores
All children in 1,4,7,10 Vit A mega dose(100 000)
All children in 1,4 01 tab Mebendazole
All children (<200)
22

23. Issues in Thriposha Programme
1. 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.
23

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
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25. Growth monitoring of adolescents
25

26. School health clubs
26

27. Hygiene promotion
27

28. Vitamin A Megadose Supplementation
Revised Schedule
Vitamin A Megadose Supplementation Revised Schedule
Circular no 01-05/2009
28

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 distributions
2. Not improved even after 3 months – refer to paediatrician
29

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. 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. 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. 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. 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. Issues in Multiple Micronutrients (Sprinkles)
• Poor compliance
• Poor knowledge on method of use
• Discouraged by hospital setup
35