PRINCIPLES OF PUBLIC HEALTH NUTRITION PROGRAMME.pdf

PRINCIPLES OF PUBLIC HEALTH
NUTRITION PROGRAMMES
Osahon Otaigbe
Department of Community Medicine, ISTH, Irrua 09 April 2018

OUTLINE
• List of Abbreviations
• Introduction
• The Global Picture
• The Nigerian Picture
• Principles of Public Health Nutrition Programmes
• Common Public Health Nutrition Programmes in Nigeria
• Organizing a Community-Based Nutrition Programme
• UN Decade of Action on Nutrition 2016 – 2025
• Conclusion
• References
OTAIGBE O. I. Principles of Public Health Nutrition Programmes 9-Apr-18 2

LIST OF ABBREVIATIONS…1
• DFID – Department for International Department
• eLENA – e-Library of Evidence for Nutrition Actions
• FAO – Food and Agriculture Organization
• FMOH – Federal Ministry of Health
• GAIN – Global Alliance for Improved Nutrition
• GINA – Gender Informed Nutrition and Agriculture
Programme

• IFAD – International Fund for Agricultural
Development
• IYCN – Infant and Young Child Nutrition
• MDG – Millennium Development Goal
• NDHS – Nigeria Demographic and Health Survey
• NPC – National Population Commission
• SDG – Sustainable Development Goal

• UN – United Nations
• UNICEF – United Nations Children’s Fund
• USAID – United States Agency for International
Development
• WFP – World Food Programme
• WHO – World Health Organization

INTRODUCTION…1
• Nutrition is a very vital aspect of life.
• It has been said, “we are what we eat”.
• Nutrition is literally a matter of life and death.
• Good nutrition is essential to life while poor
nutrition can ultimately lead to death.

INTRODUCTION…2
• Public health nutrition is the promotion and
maintenance of nutrition-related health and well-
being of populations through the organized efforts
and informed choices of society. (Barcelona
Declaration, 2006)
• It focuses more on the nutrition issues affecting
whole populations rather than the specific dietary
needs of individuals.

INTRODUCTION…3
• The aims of public health nutrition are to promote
and maintain nutritional health, and to prevent
nutrition-related disease.
• Over the years, several programmes have been
established to meet these aims both globally and
locally.

THE GLOBAL PICTURE…1
• In the early 2000s maternal and child
undernutrition was the main cause of death
worldwide. (Forouzanfar et al, 2015)
• Consequently, the MDGs focused on reducing
poverty and child underweight.
• However, the nutrition-related targets were not fully
achieved.

• In 2015, at the endpoint of the MDGs
– over 156 million children under 5 years of age were
stunted and 51 million were wasted
– Undernutrition was an underlying cause in 45% of
deaths of children under 5 years
– Obesity affected 42 million children under 5 years
of age, of whom 31 million live in developing
countries
(UNICEF, WHO and World Bank Group, 2016)

• Presently, nearly 800 million people remain
chronically undernourished. (FAO, IFAD and WFP. 2015).

• The global epidemic of noncommunicable diseases
rapidly changed the picture, and unhealthy diet rose
to the top of the list of risk factors for the Global
Burden of Disease. (Forouzanfar et al, 2015)

• This has meant more involvement in nutrition
programmes and strategies focused on reduction of
noncommunicable diseases.
• Public health nutrition programmes are set to take
the centre stage globally with the United Nations
declaring 2016 – 2025, the UN Decade of Action on
Nutrition.

THE NIGERIAN PICTURE…1
• Nigeria, with 13 million people undernourished has
the highest number of undernourished people in
Africa and 7th in the world. (FAO, IFAD and WFP, 2015)
• It is also home to the highest number of stunted
children in the continent and ranks second globally
with more than 10 million stunted children.
(FAO, IFAD and WFP, 2015)

• The 2013 Nigeria Demographic and Health Survey
(NDHS) reported 37% of children under five as
being stunted, 29% as underweight, and 18% as
wasted. (NPC and ICF International, 2013)
• Additionally, micronutrient deficiencies, which may
be hidden to the naked eye, are pervasive
throughout Nigeria with vitamin A, zinc, iron, folic
acid, and iodine being the most common.

• Also of public health importance is the rising
prevalence of overweight and obesity, which is
affecting more and more Nigerians.
• The need for effective public health nutrition
programmes is critical to stem the tides of these
nutritional problems.

WHAT ARE THE PRINCIPLES OF PUBLIC
HEALTH NUTRITION PROGRAMMES
18

PRINCIPLES OF PUBLIC HEALTH
NUTRITION PROGRAMMES
• Evidence-based
• Equity-oriented
• Community participation
• Intersectoral collaboration
• Sustainability
• Ethics

EVIDENCE-BASED…1
• Public health nutrition programmes must always be
backed up by sufficient evidence.
• Evidence-based nutrition programmes ensure
scientific soundness, promote optimal outcomes,
promote consistency in care and ultimately save
cost.
• There must be evidence justifying both the need and
the intervention.

• Evidence justifying the need speaks of the relevance
of the programme.
• Programmes must be relevant.
• To ensure relevance, there must be a needs
assessment prior to the programme.
• Nutritional surveys help in assessing the nutritional
status of a community and hence provide
information on where improvement is needed.
EVIDENCE-BASED…2

• Depending on the particular community, objectives
should be set to address the specific causes of
malnutrition in the area.
• There must also be evidence justifying the proposed
intervention.
• For example, breastfeeding promotion programmes,
tobacco-control programmes, etc.
EVIDENCE-BASED…3

• The WHO e-library of Evidence for Nutrition
Actions (eLENA) is an online library of evidence-
informed guidelines for an expanding list of
nutrition interventions. www.who.int/elena
• It is a single point of reference for the latest nutrition
guidelines, recommendations and related
information.
EVIDENCE-BASED…4

• It aims to help countries successfully implement and
scale-up nutrition interventions by informing as
well as guiding policy development and programme
design.
EVIDENCE-BASED…5

EQUITY-ORIENTED…1
• Equity is the absence of avoidable or remediable
differences among populations or groups defined
socially, economically, demographically or
geographically.
• The overall aim of public health programmes should
be to reduce health inequities.
• More attention should therefore be given to the
malnourished.

EQUITY-ORIENTED…2
• Programmes should be well-targeted to ensure that
interventions reach those most in need of them.
• This aids efficiency as wastages are minimized.

COMMUNITY PARTICIPATION…1
• Community participation should be in the planning,
implementation and evaluation of the programme.
• This can be done by different methods:
– Participation in the needs assessment and
decision making process
– Government support for community participation
– Creation of community groups or strengthening
of existing institutions

– Selection and training of local community
members as programme workforce
– Utilization of existing local manpower
– Financial contributions towards programme
resources
– Participation in evaluation of programme

• Community participation can range from passive
participation to full community mobilization and
self-reliance.

Fig 1: Degrees of community participation
33
Collective Action
Co-Learning
Cooperation
Consulting
Compliance
Co-Option
Towards
ownership
&
sustainability
Away
from
ownership
&
sustainability

Some benefits of community participation include:
• Improvement in the conceptualization process by
making maximal use of local knowledge
• Decreased dependence on external assistance
• Adaptation of programme to local socioeconomic
and technological conditions
• Improved access to services for vulnerable groups

INTERSECTORAL COLLABORATION
• Nutrition is a multisectoral problem with
multisectoral solutions.
• Active collaboration is needed from a range of
sectors such as health, agriculture, trade, education
as well as within sectors.
– Direct nutrition-specific interventions
– Indirect nutrition-sensitive interventions

36
Child
nutrition
Food/Nutrient Intake Health
Access
to
food
Water &
Sanitation
Health
Services
Maternal
and child
care
practices
INSTITUTIONS
POLITICAL AND IDEOLOGICAL FRAMEWORK
ECONOMIC STRUCTURE
ENVIRONMENT, TECHNOLOGY, PEOPLE
• Infant and young
child nutrition and
treatment of severe
undernutrition
• Micronutrient
supplementation and
fortification
• Hygiene practices
• Agriculture and food
security
• Health systems
• Social
protection/safety nets
• Water and sanitation
• Gender and
development
• Girls’ education
• Climate change
• Poverty reduction and
economic growth
programmes
• Governance
• Conflict resolution
• Environmental
safeguards
Immediate
causes
Underlying
causes
Basic
causes
Nutrition
specific
interventions
Nutrition
sensitive
interventions
Fig 2: Determinants of child nutrition and interventions to address them

ETHICS…1
• Public health nutrition programmes are fraught with
many ethical considerations.
• These usually revolve around behavioural, cultural,
religious, as well as political issues.

ETHICS…2
• Discouraging the use of certain food substances
• Food bans and food taxes
• Stigmatization and discrimination
• Evaluation of interventions
• Breastfeeding practices
• Conflict of interest in public-private-partnerships

ETHICS…3
• Excessive paternalism
• Suitability of evidence in differing contexts
• Resource allocation
• Research ethics

SUSTAINABILITY…1
• This involves the ability to maintain the positive
impact (or make further improvements) of a
programme, once the programme has achieved its
objectives.
• Political commitment is vital for sustainability

SUSTAINABILITY…2
Factors affecting sustainability include:
• Supportive policy environment
• Active intersectoral collaboration
• Adequate funding commitment from government
• Availability of good technical expertise
• Access to adequate basic services
• High level of community participation

COMMON PUBLIC HEALTH NUTRITION
PROGRAMMES IN NIGERIA…1
• Food supplementation programmes e.g.
– Iron and Folic Acid Supplementation for Women
of Reproductive Age
• Breastfeeding promotion programmes e.g.
– DFID’s Improving Maternal, Newborn and Child
Nutrition in Northern Nigeria,
– Baby Friendly Hospital Initiative

• Maternal, Infant and Young Child Nutrition
Programmes e.g
– USAID’s Infant and Young Child Nutrition (IYCN)
Project in conjunction with the FMOH, Federal
Ministry of Women Affairs and Social
Development, UNICEF, WHO and other partners
2009 – 2011,
– National Maternal Newborn and Child Health
Strategy

• Food Fortification Programmes e.g.
– GAIN Large-scale Food Fortification Programme,
– Salt iodization Programmes
• School-Based Nutrition Programmes e.g.
– School feeding programmes,
– Vitamin A Supplementation for Pre-School Age
Children

• Community-Based Nutrition Programmes e.g.
– Gender Informed Nutrition and Agriculture
(GINA) Programme,
– Growth monitoring programmes,
– Food demonstrations, etc.

ORGANIZING A
COMMUNITY-BASED
NUTRITION PROGRAMME
46

ORGANIZING A COMMUNITY-BASED
NUTRITION PROGRAMME…1
• Identification of the nutritional problems
• Prioritization of the problems based on available
resources
• Defining of goals and objectives
• Deciding on how to tackle the problems based on the
objectives and available resources
• Implementation of the intervention
• Monitoring and evaluation
• Nutrition surveillance

1. IDENTIFICATION OF THE NUTRITIONAL PROBLEMS
• Find out about the community
• Their occupation and educational levels
• Types of local foods and their availability
• Seasonal factors affecting food availability
• Food habits and preferences
• Cultural factors that may be barriers to adequate nutrition
• Assessment of nutritional status

49
Fig. 3: Carrying out nutritional assessment

2. PRIORITIZATION OF THE PROBLEMS
• Who sees the problem?
• Who is affected?
• How feasible is it to solve the problem?
• What is the cost of solving the problem?
• What is the severity of the problem in terms of
morbidity/mortality?
• What is the social impact of the problem?

3. DEFINING OF GOALS AND OBJECTIVES
• Objectives should be SMART – Specific, Measurable,
Achievable, Relevant/Realistic, Time-Bound.
• E.g. to reduce the prevalence of malnutrition among
under-5 children by 50% by the year 2020

4.DECIDING ON HOW TO TACKLE THE PROBLEM
• Technical feasibility
• Financial feasibility
• Resource availability
• Community acceptability

5. IMPLEMENTATION OF THE INTERVENTION
Examples of nutrition interventions include:
• Nutrition education
• Promotion of breastfeeding and appropriate
complementary feeding
• Supplementary feeding
• Micronutrient supplementation and fortification
• Deworming

6.MONITORING AND EVALUATION
• Based on objectives
• Evaluate for relevance, adequacy, accessibility,
acceptability, effectiveness, efficiency, impact

7.NUTRITIONAL SURVEILLANCE
• Continuous watchfulness over the nutritional status
of a population
• Collection of facility-based and community-based
data, repeated cross-sectional surveys etc.

UNITED NATIONS DECADE OF ACTION ON
NUTRITION 2016 – 2025 …1
• Declared by the UN General Assembly in April 2016
• It is a commitment of member states to undertake
ten years of sustained and coherent implementation
of public health nutrition policies and programmes.
• It is based on the ten commitments of the Rome
Declaration on Nutrition which were adopted at the
ICN2 in November 2014 and the 2030 Agenda for
Sustainable Development.

NUTRITION 2016 – 2025 …2
The ten commitments made globally through the Rome
Declaration on Nutrition
1. Eradicate hunger and prevent all forms of
malnutrition.
2. Increase investments for effective interventions and
actions to improve people’s diets and nutrition.
3. Enhance sustainable food systems.
4. Raise the profile of nutrition with national strategies
and align national resources accordingly.

NUTRITION 2016 – 2025 …3
5. Strengthen human and institutional capacities to
improve nutrition.
6. Strengthen and facilitate contributions and action
by all stakeholders.
7. Ensure healthy diets throughout the life course.
8. Create enabling environment for making informed
choices.

NUTRITION 2016 – 2025 …4
9. Implement these ten commitments through the
Framework for Action.
10. Integrate the Declaration’s vision and
commitments into the post-2015 development
agenda process.

• SDG 2 End hunger, achieve food security and
improved nutrition and promote sustainable
agriculture
NUTRITION 2016 – 2025 …5

CONCLUSION
• The UN declaration of decade of action on nutrition has
provided a great momentum for the whole world to
attain the highly ambitious goal of zero hunger.
• The ingredients are set.
• All hands must be on deck as we cook this meal with the
right utensils of evidence-based, equity oriented,
sustainable and ethically sound nutrition programmes.
• Then we can savour our palatable meal with pride.
Bon appétit!

REFERENCES
• FAO, IFAD and WFP, 2015. The State of Food Insecurity in the World 2015.
Meeting the 2015 international hunger targets: taking stock of uneven
progress. Rome, FAO.
• Forouzanfar, M.H., et al. Global, regional, and national comparative risk
assessment of 79 behavioural, environmental and occupational, and
metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic
analysis for the Global Burden of Disease Study 2013. The Lancet. 2015; 386:
2287-2323. doi: http://dx.doi.org20/10.1016/S0140-6736(15)00128-2.
• National Population Commission [Nigeria] and ICF International. 2013.
Nigeria Demographic and Health Survey (NDHS) 2013. Abuja, Nigeria:
National Population Commission and ICF International.
• Proceedings of the 1st World Congress of Public Health Nutrition, 28 – 30
September 2006, Barcelona, Spain. Nutr Rev. 2009 May; 67 Suppl 1:S1-150.

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