Nutritional interventions

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

2. Nutrition Care Process Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring and Evaluation. 2 ADA. international Dietetics and Nutrition Terminology Reference Manual; 2011.

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. 3 ADA. international Dietetics and Nutrition Terminology Reference Manual; 2011.

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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 5 Implementation of integrated nutrition package Circular letter no - 02.85/2010

6. Key Strategy- Life cycle approach 6

7. Nutrition Rehabilitation Programme (NRP) Is a component of INP 7

8. Opportunities Through Home visits Clinics Through Home visits School MI Through Home visits Preschool MI CWC Through Home visits Clinics 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/m 2 12.5 - 18 18.5 – 24.9 kg/m 2 11.5 - 16 25 – 29.9 kg/m 2 7.0 – 11.5 ≥30 kg/m 2 < 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 13 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

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. 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 well Once in 3 months Every 6 months If any problem Once a month Every 3 months 15 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

16. Pre school children Growth monitoring & promotion ECCD Thriposha,CSB Food demonstrations 16

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 All pregnant (antenatal) mothers throughout their pregnancy. All lactating (postnatal) mothers for a period of six months after delivery . Children above 6 months of age to 5 years who are U nderweight Loss of weight for 3 consecutive months Hospitalized children who fall into above categories . 18

19. Ingredients present in Thriposha 19 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

20. I ngredients present in Thriposha 20 Report on Evaluation of Thriposha Food Supplementation Programme 2008 Submitted by Department of Applied Nutrition Wayamba University of Sri Lanka 28 August 2008

21. Supplementation of Thriposha Age Triposha Tbs Sugar Oil/Coconut Tsp / T bs Kcal Child 6-9 mons 3 With breast milk 01 Oil Tsp 200 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 Tbs 350 Lactating Mothers 3 1 Tbs 02 Coconut Tbs 350 21 Thriposha is a cooked ready to eat supplementary food 50 g = 150 kcal Intergrated nurtitional package manual 2010

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

23. Issues in Thriposha Programme S haring - the supplement may be consumed by the entire family rather than the target beneficiary ; S ubstitution - 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; D istortion 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; D ependency - the free distribution of the food may reinforce a dependent attitude on the part of the recipient; 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 24

25. Growth monitoring of adolescents 25

26. School health clubs 26

27. Hygiene promotion 27

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

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- when child reach above – 1 SD for WT/HT and remain so at two consecutive Programme distributions Not improved even after 3 months – refer to paediatrician 29

30. Mix with some drinking water to make a paste Bring the boil for 10 minutes ( no more – no less) and serve 30 Corn Soya Blend or UNIMIX how to use 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

31. 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 Issues in CSB Programme

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) 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 (Nutritional Anemia Formulation)

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