Introduction to nutrition surveillance
Module Units and Time Allocations
Unit
No
1.
2.
3.
4.
5.
6.
7.
Total
Name
Introduction to nutrition
surveillance
Methods of nutrition surveillance
Surveillance information
Types of nutrition survey
Application of nutrition surveys
Program monitoring and
Evaluation
Emerging issues and trends
Time
(Hours)
Theory
4
Practical
2
Total
6
6
2
5
7
5
2
5
6
9
5
8
7
11
16
10
1
30
1
30
2
60
Module outcomes
a)
b)
c)
d)
e)
f)
g)
By the end of this module unit, the learner should be able to:
Recognize the role of nutrition surveillance in nutrition and dietetics
Apply the nutrition surveillance principles
Develop skills in nutrition surveillance
Collect nutrition information and data in nutrition for use in surveillance
Use malnutrition and growth monitoring data in nutrition surveillance
Conduct programme monitoring and evaluation
1: INTRODUCTION TO NUTRITION SURVEILLANCE
1.1: Meaning of terms
DEFINITION OF KEY TERMS AND TERMINOLOGIES
Surveillance: It refers to the act of carefully watching someone or something
especially in order to prevent or detect an occurrence of a given situation. It can
also be defined as a continuous observation of a place, person, group, or ongoing
activity in order to gather information:
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Nutrition surveillance: Definition one: Nutrition surveillance refers to a
continuous process and focuses on monitoring trends in the nutrition situation over
time rather than providing one off estimates of absolute levels of malnutrition.
Definition two: The term can also be referred to as information system. It involves
the collection, analysis, interpretation and reporting on information about the
nutritional status of populations and most importantly are used to inform
appropriate response strategies.
It is important to distinguish between the terms ‘surveillance’ as a general
activity, and ‘surveillance systems’ as a specific process within this activity.
A nutrition surveillance system is: A system, coordinated by a central institution
that collects representative primary data at recurrent intervals on indicators of
nutrition and the factors that influence them, for making decisions.
Objectives of surveillance systems
 To aid in long term planning of health and development
 To provide input for program management and evaluation
 To give timely warning of the need for an intervention to prevent critical deterioration on
food consumption
Nutrition surveillance is: Regular and systematic collection of data on nutritional
indicators.
Monitoring: The term ‘monitoring’ implies recurrent observation. In nutrition this
word usually refers to an activity related to evaluating programmes, so is more
specific than surveillance. However, the term monitoring is often also used interchangeably with the term surveillance, and in fact surveillance has been defined in
terms of monitoring both academically (Bender, 2009 p.386) and in practice:
It can also be defined as to watch over nutrition, in order to make decisions that
lead to improvements in nutrition in populations
Nutrition status: It refers to the physiological state of an individual that results
from the relationship between nutrient intake and requirements and from the
body’s ability to digest, absorb and utilize these nutrients. It can also be defined as
the health status of an individual as influenced by the intake and utilization of
nutrients in the body
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Poor nutritional status: It is the inadequate intake/use of nutrients to meet the
body’s requirement for energy, growth and maintenance. Therefore, a
malnourished individual has a poor nutritional status
Screening: It refers to application of rapid tests, examinations or other procedures
to sort out apparently well persons who probably have malnutrition or disease from
those who probably do not have malnutrition or the disease.
Screening- Nutritional screening is the process of identifying characteristics
known to be associated with nutrition problems. Its purpose is to identify
populations, sub-groups or individuals who are malnourished or at nutritional risk.
Four different methods are used to collect data used in assessing nutritional status:
Anthropometric assessments e.g. weight, height and MUAC
Biochemical assessments e.g. Laboratory tests for urine and blood
Clinical assessments e.g. Hair texture and colour, skin condition etc.
Dietary assessments e.g. 24 hour recall, food frequency records
Screening procedures
The population comprises of apparently health members is subjected to a
screening test.
The screening test negative are allowed to go home depending on the nature of
the disease in question but in some special cases everybody whether negative
or positive may be subjected to diagnostic test.
The screening test positive are subjected to a diagnostic test to confirm their
status. Those who are diagnostic negative are allowed to go away while
diagnostic positive cases are subjected to an intervention
The screening test is then repeated after some regular prescribed interval
Purpose of nutrition assessment
i.
ii.
iii.
To accurately determine nutritional status
To identify current and potential nutritional and medical problems
To monitor changes in nutritional status during national policy changes, fortification
programs, nutrition intervention or the course of a chronic or acute illness
Nutrition assessment is important because acute and chronic malnutrition can be identified.
The methods for nutrition assessment will be covered in detail in topic three.
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Characteristics of a good surveillance system
The following are characteristics of a good surveillance system:
• Capacity to act on information. First and foremost, the system must be able to act
on information produced, whether in terms of a well-organized response to the
rising nutrition problem or of managers using the information to make better
medium- and long-term decisions.
• Standard case definitions and reporting protocols. These allow correct and timely
documentation and reporting.
• Basic and sound investigation methods. These use appropriate analysis and
interpretation techniques.
• Adequate laboratory support. Appropriate actions require accurate detection.
Cases detected in the field may require more sophisticated laboratories for
confirmation of the diagnosis.
• Efficient communication systems. Information and feedback must be passed on
quickly.
• Cost-effective resource use. The system must focus on priorities to keep
nutritional problems under control and also, where appropriate, on cooperation to
save duplication of effort.
• A network of interested people. The surveillance system is only as good as the
people who operate it.
Geographic coverage: The geographic coverage of most surveillance systems
tend to vary to some extent. While these systems are supposed to be national in
scale, only 9 of the 13 systems collect data in all/nearly all sub-national regions.
Other systems target sub-national areas of heightened vulnerability to food
insecurity or are sub-national at the moment with future plans to expands to
national coverage.
2.0: Methods of Nutrition Surveillance
2.1: Nutrition Surveillance methods
Various criteria can be used to establish nutrition surveillance systems. A decision
on the best approach to adopt will depend on:
 the objectives
 resources,
 Environment and capacities available.
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The following are the main methods used for surveillance/types of nutrition
surveillance
i.
ii.
iii.
iv.
v.
Large scale national surveys
Repeated small scale surveys
Clinic based monitoring
Sentinel site surveillance
School census data
In an emergency setting additional sources are also used:
Rapid nutrition assessments
 Rapid screening based on mid upper arm circumference (MUAC)
measurement either exhaustive community screening or screening groups of
children to provide an indication of a problem
 Selective feeding programme or services statistics monitoring (monitoring
the use of services such as health facilities)
NB: There is no single prescribed method for nutrition surveillance systems in
emergencies. What often occurs is that a variety of nutrition information sources
are used depending on the context, what is appropriate, available and feasible. It is
best to use representative data collected from the population.
LARGE SCALE NATIONAL SURVEYS
National level representative population based surveys, such as the demographic
and health surveys (DHS) or the United Nations Children’s Fund (UNICEF)
multiple indicator cluster surveys (MICS) are generally conducted every three to
five years. Nutrition information is collected with regional and national level
prevalence estimates of wasting, underweight and stunting reported
Large scale national surveys are not appropriate to conduct in an emergency setting
given the scale and the frequency of these studies. Regardless of that, they are a
useful baseline for comparison of estimates of acute malnutrition at regional levels
as well as other health and nutrition indicators such as immunisation coverage, care
practices and mortality (death) data.
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Information from large scale national surveys is available at DHS or MICS website
and is stored with National Bureau of Statistics for DHS or UNICEF for the MICS
reports. National level surveys using the standardized monitoring and assessment
of relief and transitions (SMART) method can also be conducted.
Repeated small scale surveys/ Repeated nutrition surveys
Small scale random sample nutrition surveys are the most common method used to
assess the nutrition situation in emergencies. Nutrition surveys are designed to
provide representative point prevalence estimates of rates of acute malnutrition of
children six to 59 months in a given population. Mortality rates can provide a good
picture of the severity of the situation. In addition, information to assess the
underlying causes of acute malnutrition is collected such as public health status,
immunisation coverage, food security and care practices. Small scale surveys are
frequently used as a source of information in emergency nutrition surveillance
systems.
Clinic based monitoring/ Data from health clinics
Clinic based monitoring of the nutritional status of children is one method that can
be applied both in emergency and non emergency situations. During the 1970’s and
80’s, heath centre based growth monitoring was established in many developing
countries as a component of health information systems (HIS). However, over time
the efficiency and effectiveness of growth monitoring has been questioned in the
absence of parallel development programmes, as a method to reduce high rates of
malnutrition in young children.
In an emergency, information from established HIS can be very useful and often
may be the only available information about nutrition in the early days of an
emergency. In most cases growth monitoring refers to measuring underweight or
weight for age. Children who attend maternal and child health clinics (MCH) are
measured on each visit and their weight for age plotted on a chart, while health
staff document the results in a register. Ideally the data from these registers is
collected at a more centralised level where it is compiled into a larger register,
analysed and the results and recommendations reported back to the district and
health centre level. However, one of the main challenges of such systems is the
lack of timely centralisation, analysis and reporting.
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While the information can provide a picture of the level of underweight children in
a given community, there tends to be a bias towards younger children (below one
year of age) who attend the MCH clinic for immunisation purposes. then older
children do attend, they are generally sick, which can also bias the data. A further
potential bias is toward populations who can actually access the health centre.
Those communities who are far from the clinic will not be represented in the
sample.
In many emergency settings, NGOs establish links with a local MCH clinic in
order to provide training, equipment and incentives to MCH staff to routinely
assess the nutritional status of all children who attend. This can be a useful way of
monitoring the nutrition situation as well as identifying acutely malnourished cases
who can be referred to the nearest appropriate selective feeding programme.
Sentinel site surveillance/ Community based sentinel site
Sentinel site surveillance refers to the monitoring of purposively selected
communities or service delivery sites, such as a health centre, in order to detect
changes in context, programme or outcome variable. Communities are purposively
selected for a number of reasons, such as vulnerability to food insecurity in times
of stress. Sentinel sites can range from health centres, to villages, to districts.
Sentinel site surveillance can be technically sophisticated with large scale
assessments at site level or as simple as community based monitoring of a few key
indicators. The objectives are to monitor the trends in the nutrition situation in
these identified vulnerable areas in order to provide early warning. Community
based surveillance also has the potential advantage of empowering the community,
being relatively low cost and is particularly useful in emergencies where insecurity
prevents representative sampling.
School census data
Nutritional indicator monitoring is occasionally undertaken in schools. The usual
form of measurement is height for age (a measure of stunting). children are often
measured through censuses that are carried out every two to three years. The
method has been used to identify high risk populations with poor health,
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malnutrition and low socio economic status. The main strengths of this method are
that it is both cheap and provides very good population coverage. It can, however,
be easily confounded by external factors such as a reduction of attendance rates so
that the data cannot be extrapolated (generalized) to the general population.
Although this type of information is not useful in detecting nutritional changes
during an emergency, it may serve as a useful baseline indicator for assessing
attendance rates. Attendance rate can be seriously affected by a shock and be an
indicator of food insecurity where children, particularly girls, are taken out of
school in order to support the households to access food.
Rapid nutrition assessments
Rapid nutrition assessments are conducted to get a quick snapshot of the nutrition
situation. Depending on the context, different indicators can be used such as weight
for height or MUAC. Agencies have developed a variety tools which can be
modified according to the context and the type of information considered
appropriate to collect. Although the information may not always be representative
and thus not statistically valid, the results from a rapid assessment, even of a small
sample of children, can provide a basis for determining whether a more detailed
assessment is required to establish the actual prevalence of acute malnutrition or
whether an emergency response is required. For this reason rapid assessments are
an important source of information especially at the onset of an emergency to
determine the magnitude and severity of a crisis. See module 7 for more
information about rapid nutrition assessments.
Selective feeding centre statistics/ Data from feeding programs admissions
In large scale nutrition emergencies a component of the response will be selective
feeding for acutely malnourished children. These usually include therapeutic care
for the severely malnourished and supplementary feeding for moderately
malnourished cases. See modules 12 and 13 for more information. In selective
feeding programmes, statistics are collected on admissions, cure rates, defaulter
rates and case fatality rates. These indicators provide a measure of programme
quality as well as act as a source of information on the trends in acute malnutrition.
By including these indicators in a nutrition surveillance system they can provide
useful information of the most vulnerable groups (by profiling the type of
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individual admitted i.e. children under two years of age, adolescents, their location
etc). They can also help identify the underlying causes of malnutrition such as
morbidity (illness) patterns. Monitoring the trends in admissions and assuming
reasonable coverage and access can provide additional information on seasonal
trends in the nutrition situation (i.e. during the rains pre harvest the numbers of
cases admitted to the feeding programmes may increase). One challenge is that
NGOs have established different admission criteria for selective feeding
programmes making it difficult to compare data between centers. However,
monitoring rates of cure, case fatality and defaulting can still contribute to an
understanding of the nutrition situation.
OBJECTIVES OF NUTRITION SURVEILLANCES
 Describe the population’s nutritional status, with particular reference
to de�ned subgroups who are identi�ed as being at risk.
 Monitor nutrition programs and to evaluate their e�ectiveness.
 Raise awareness about nutritional problems
 Provide guidance to health-related local intervention programs
 Enable predictions to be made on the basis of current trends in order to
indicate the probable evolution of nutritional problems
 To describe the nutritional status of the population, with particular
reference to de�ned subgroups that are identi�ed as being at risk
 To monitor nutritional programmes and to evaluate their e�ectiveness
Surveillance Information
3.1: Importance of nutrition surveillance information
3.2: Principle users of surveillance information
Considering there are there are many factors leading to malnutrition and
there is a close relationship with socioeconomic status, the potential users of
nutrition surveillance information are found in many sectors.
Even though, it sounds unrealistic to expect nutrition to play a critical role
in decisions on overall resource allocations, nutrition surveillance can be used to
analyze policies for nutritional consequences, to suggest alternative policy options
and eventually to assess their nutritional effects.
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There is an advocacy role for long-term nutrition surveillance to reinforce
other similar methods trying to detect the fundamental causes of malnutrition.
However, surveillance probably has the most potential for bringing about policy
changes favorable to nutrition with reference to specific, selected issues.
These issues may often be less fundamentally related to the basic causes of
malnutrition, such as the inequitable distribution of resources, but in reality
decisions on them have a better chance of influencing nutritional status.
Some of the principles users of the surveillance information include:
Stakeholders of food and nutrition surveillance data (5)
Table 2 summarizes the important stakeholders of food and nutrition surveillance
data
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Types of Nutrition survey
Meaning of terms
What is a survey?
Most of us are familiar with surveys and are likely to have participated in several
of them in the past. A common type of survey frequently done in humanitarian
emergencies is a nutrition survey of children less than 5 years of age. In such
situations, surveys are used to provide a snapshot of the health and nutritional
status of the population or coverage of relief programmes. The technical names for
these are cross-sectional surveys.
Cross sectional survey:
It refers to the collection of data at a single point in time from a specific
population.
What is a nutritional survey?
It refers to a method of obtaining information regarding the nutritional status of a
population or a subgroup. Such information is collected by using various methods
such as questionnaires, interview schedules, and etc to a representative sample of a
population.
Mostly surveys are essential to monitor ongoing nutrition transition and
initiate an appropriate intervention.
One of the main features of surveys is that, instead of collecting information
from all individuals or households in the community, they select a representative
sample, and, based on that sample, produce an estimate of the indicators of interest
which can be generalized to the entire population.
Types of outcomes and indicators measured in a survey
a) Prevalence
It refers to the proportion of the population which has a specific disease at a
single point in time. Because survey data are collected at a single point in time,
surveys are especially good a measuring prevalence. In general, prevalence is used
to measure the occurrence of chronic diseases or diseases which last a long time.
Prevalence frequently measured in health and nutrition assessment surveys
in humanitarian emergencies include:
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 The prevalence of acute protein-energy malnutrition among children
6-59 months of age
 The prevalence of malnutrition among non-pregnant women of childbearing age
 The prevalence of households having a safe water supply
 The prevalence of households having adequate sanitation facilities
b) Program coverage
Program coverage is the proportion of individuals who are eligible for a
program or service who actually receive the program or service.
Some examples of programme coverage measured in health and nutrition
assessment surveys include:
 Vaccination coverage
 Coverage of targeted supplemental feeding programmes
 Coverage of health services, as measured by frequency of use of
health facilities
c) Incidence rate
Incidence rate is the rate at which new cases of disease occur in a specified
population during a defined time period. Note that only new cases of disease are
counted.
Some incidence rates frequently measured in health and nutrition assessment
surveys include:
 The incidence rate of death, also called the crude mortality rate
 The cumulative incidence rate of diarrhea in children less than 5 years
of age
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REASONS TO DO A SURVEY
Surveys can be time-consuming and expensive activities. As a result,
surveys should be done to answer program-oriented questions:
 Include only information useful to design or revise interventions
 Do not include information which is just "of interest" or already
proven or obvious
Answers to such program-oriented questions may be necessary to:
 Determine need for new program
 Help design new program
 Evaluate existing program
Surveys may also be done to gather data to use to advocate for additional
resources in order to meet the needs of a neglected emergency-affected population.
Questions to ask before beginning or commissioning a survey
Therefore, before embarking on survey planning, ask the following questions:
I.
II.
III.
IV.
Are the results likely to be used for decision making?
Are the results likely to be used to take action?
Is the affected population accessible?
Is there no easier or better way to gather the information necessary?
If the answer to all 4 questions is not YES, you may not need to do a survey.
In addition to these questions, ask yourself if your agency has the necessary
technical know-how and resources to carry out a quality survey or the ability to
hire someone who does? If not, perhaps your organization should not be
considering carrying out a survey.
Alternatives to conducting new surveys
In addition to surveys, there are many other methods of data collection.
Before deciding to do a survey, ask yourself if your questions could be answered
better by another type of data collection, such as:
Prospective surveillance
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II.
IV.
V.
Secondary data collection, including the results of previous surveys
Programme data
Food market monitoring
Qualitative assessments
Rapid assessment
If another type of data collection could answer your question, it may be a
better method. If this is true, perhaps a survey is not the best thing to do in this
situation.
Subsequent material in this course will provide more information on some of
these other types of data collection, as indicated by the hyperlinks above.
Limitations of surveys
When deciding whether or not to carry out or commission a survey, you must
keep in mind the limitations of surveys:
Individual surveys are not good at following trends in real time or over short
periods of time: Because surveys collect data at a single point in time, it is
difficult to measure changes in the population unless two or more surveys are done
at different points in time. Such repetition is often expensive and time-consuming,
making frequent periodic surveys impractical.
Individual surveys generally cannot provide strong evidence of cause
and effect: Because surveys collect data on disease and risk factors at the same
time, you often cannot tell which came first, the risk factor or the disease. Without
this temporal association, it is very difficult to prove that the reputed risk factor
actually causes the disease. For example, a survey in a refugee population may find
high incidence rates of diarrhea, a low prevalence of access to clean water, and a
high prevalence of malnutrition.
However, a single cross-sectional survey cannot disentangle the different
contributions of each of these factors to the others; in fact, it is likely that
malnutrition and limited access to clean water contribute to high diarrhea
incidence, while the high diarrhea incidence also contributes to malnutrition.
Other constraints to using surveys to gather data:
I. Insecurity limiting access to the population of concern
II. The lack of time to carry out a survey
III. The lack of funding necessary to carry out a survey
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IV.
The lower priority for carrying out a survey because of competing
urgent tasks
Formulation of goals and objectives
The goal of a survey, when written out, ought to explain in one sentence why
the survey is being done. It is a general statement. The objectives of a survey
should be more detailed descriptions of what indicators and outcomes will be
measured in what population. Both goals and objectives should be written down at
the start of survey planning.
After the goal of the survey is determined, you need to write clear, detailed
objectives for each of the major outcomes to be measured. Each objective should
include:
I.
II.
III.
The specific health or nutrition indicator or outcome to be measured,
The target group in which it will be measured, and
The population or geographic area in which the survey will be
conducted
Of course, the health outcomes to be measured will depend on what program
questions you want to answer. You may also wish to explicitly state in the goals
and/or objectives the time period during which the data will be collected and to
which the conclusions will refer.
Two of the objectives of a survey done in Mugunga Camp, Goma, Zaire, in
1994:
 Measure what proportion of the population of Mugunga Camp had died
since arrival in Zaire in mid-July, as reported by a household informant.
 Measure what proportion of persons ill with diarrhoea in Mugunga Camp
since arrival in Zaire sought health care at a health facility during this
illness.
Which of the following outcomes would you want to measure in a survey if you
want to know whether or not anaemia is a serious problem in adult women?
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A.
B.
C.
D.
E.
Urinary iodine levels
Shoe size
Height
Haemoglobin
Knowledge of diarrhea treatment
The answer is D: Correct. Haemoglobin level is the most common measure of
anaemia. To calculate the prevalence of anaemia, you must determine if each
survey subject is anaemic.
What target group would you include in the survey if you are interested in whether
or not anaemia is a serious problem in adult women?
A.
B.
C.
D.
E.
F.
Children 5-14 years of age
Adult men
Pregnant women
Women 15-49 years of age
Boys 6-59 months of age
Girls 6-59 months of age
The answer is D: Correct. You measure anemia in the population subgroup
you are interested in, that is, women of child-bearing age. You often narrow down
the survey target group to those who are most susceptible to the disease or those
who might be targeted by an intervention.
Obviously, you must carefully define both the indicator or outcome of
interest and the target group in which that indicator or outcome will be measured.
You should have already defined the population in which the survey will be done.
The diagram below shows the relationship among these groups.
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To check if your definitions are clear, ask yourself if your definition of the
population and the target groups allow someone else to determine if any individual
on earth is eligible to be included in your survey. For example, as above, if you are
targeting women of child-bearing age (15 -49 years of age) who currently live in
country X, this will exclude all women of child-bearing age living elsewhere in the
world and all women older than 49 years and girls younger than 15 years of age
who live in country X. This definition could be used to determine if any individual
human on earth is eligible or ineligible to be included in the survey sample. If a
survey report you are reading does not define the target groups and indicators and
outcomes to this level of detail, perhaps the survey workers or managers
themselves were a bit unclear as to whom they included in the survey and what
outcome was measured in them.
Which of these objectives is adequate to describe a survey measuring anaemia in
refugee camps in Tanzania?
A. This survey will assess anaemia
B. This survey will study children less than 5 years of age in all refugee
in Tanzania
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C. This survey will estimate the current prevalence of anemia in all
refugee camps in Tanzania
D. This survey will estimate the current prevalence of vitamin A
deficiency among children less than 5 years of age in all refugee
camps in Tanzania
E. This survey will estimate the current prevalence of anaemia among
children less than 5 years of age.
F. This survey will estimate the current prevalence of anaemia among
children less than 5 years of age in all refugee camps in Tanzania
The correct A is f: Correct. This objective contains all the essential parts of an
objective.
We should not labor the point, but having clear objectives will greatly help you
with:




Negotiations with collaborating organizations
Writing the questionnaire
Planning logistics and needs for supplies and equipment
Data analysis
Not having clearly defined objectives may result in:
Misunderstandings and bad feelings from collaborating organizations
whose outcomes were left out of the survey
Poor direction to those who are commissioned to do a survey, potentially
producing survey results which do not answer the questions which the
sponsoring organization needs answered
A poor questionnaire which does not gather the data required to measure
one or more important indicators or outcomes
Lack of appropriate supplies and equipment
Undirected and unfocused data analysis and wasted time
These are certainly qualities no one wants to have in a survey. Will you trust
the results of a survey in which objectives were not clearly defined and listed in the
survey report? Probably less than if specific objectives are clearly presented
Surveys - Description of sampling methods
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Types of Nutrition Survey
Rapid Appraisal
In a rapid appraisal of the nutritional situation, information on the nutritional
condition of the target community should first be obtained during the planning
phase using qualitative methods. Anthropometric data (such as height and weight)
are not recorded in this type of survey.
Rapid Appraisal (RA) is an approach that draws on multiple evaluation methods
and techniques to quickly, yet systematically, collect data when time in the field is
limited. RA practices are also useful when there are budget constraints or limited
availability of reliable secondary data. For example, time and budget limitations
may preclude the option of using representative sample surveys.
Benefits – When To Use Rapid Appraisal Methods
Rapid appraisals are quick and can be done at relatively low cost. Rapid appraisal
methods can help gather, analyze, and report relevant information for decisionmakers within days or weeks. This is not possible with sample surveys. RAs can be
used in the following cases:
i.
ii.
iii.
iv.
v.
for formative evaluations, to make mid-course corrections in project design
or implementation when customer or partner feedback indicates a problem
(See ADS 203.3.6.1);
when a key management decision is required and there is inadequate
information;
for performance monitoring, when data are collected and the techniques are
repeated over time for measurement purposes;
to better understand the issues behind performance monitoring data; and
for project pre-design assessment
Limitations – When Rapid Appraisals Are Not Appropriate
Findings from rapid appraisals may have limited reliability and validity, and cannot
be generalized to the larger population. Accordingly rapid appraisal should not be
the sole basis for summative or impact evaluations. Data can be biased and
inaccurate unless multiple methods are used to strengthen the validity of findings
and careful preparation is undertaken prior to beginning field work.
When are Rapid Appraisal Methods appropriate
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Choosing between rapid appraisals methods for an assessment or more timeconsuming methods, such as sample surveys, should depend on balancing several
factors, listed below.
Purpose of the study. The importance and nature of the decision depending
on it.
Confidence in results. The accuracy, reliability, and validity of findings
needed for management decisions.
• Time frame. When a decision must be made.
• Resource constraints (budget).
• Evaluation questions to be answered
Rapid assessment
Definition: It’s a procedure intended to provide a qualitative, cross sectional
snapshot through observation, key informant interviews, focus group discussion
and secondary sources.
The aim is to describe the current situation, outline the public health needs and
plan priority interventions
In a rapid assessment, anthropometric data are measured to obtain
information on the type of nutritional problems using quantitative methods.
However, the sampling selection and sampling coverage do not allow quantitative
conclusions to be made concerning the prevalence of nutritional problems that can
be generalized for a broader population.
The objectives of rapid assessment is to
 Identify the problem and determine its extent
 To identify groups at the highest risk eg the nomads, displaced groups,
specific age groups
 Estimate the number of people that require an assistance
 Act as a baseline to monitor the impact of interventions or the
responses to an improving or worsening situation.
NB/ The duration of a rapid assessment depends on the size and geographical
distribution of the population affected, the security situation, access to the
population, transport and logistics, the human resources available and the methods
used.
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A more thorough assessment, with detailed qualitative and quantitative data
and interventions plans, should be completed as soon as possible after the rapid
assessment based on the recommendation of the rapid assessment.
The findings from the rapid assessment need to drive the program priorities
and interventions.
Disseminate findings of the rapid assessment immediately to facilitate
concept paper writing, to seek fund, guide deployment of personnel
What are my objectives as an expert
 Assess the extent of the emergency, identify the principal needs and gaps,
and identify potential health threats to the population.
 Define and prioritize the type and size of interventions and priority activities
and provide information needed to plan the implementation of interventions.
 Broadly share information with the international community, donors and the
press in order to mobilize human and financial resources
How is data collected during rapid assessment
 Review of existing information – begin prior to field trip (UN website –
WHO, OCHA, WFP)
 Visual inspection of the affected area – cross-sectoral walks
 Interviews with key informants in the affect areas – affected community,
camp leaders, health workers
 Rapid surveys – sometimes convenient sampling to assess malnutrition
level, or number of cases with diarrhea
What information is essential to collect?
This is an example of essential information needed, depending on the context
you might need to add more, and sometimes not all information is available:
 Background of the emergency
 Estimate size of affected population and population movements into and
out of the area
 Map of the site – usually done by OCHA, if not hand drawn
 Environmental conditions
 Security conditions and access (roads, bridges, ports, airfields etc)
 Health and nutritional status of the population affected by the emergency
 Major health threats – communicable and non-communicable diseases
 Diseases of epidemic potential
 Existing health facilities and staff – capacity to deal with the affected
population
 Estimation of recent mortality rates
 Surveillance system in place prior to the emergency
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 Availability of food, water and shelter
 Extent of involvement of the local authorities, especially the Ministry of
Health
Presence and activities of international or local organizations
The indicator used during Rapid assessment of nutritional status is weight for
height. In addition, the presence or absence of oedema should be noted as oedema
adds to a childs weight hence might be a confounding factor. Oedema is the
presence of abnormally large amounts of fluids in the intracellular tissues. It is the
key clinical sign of severe form of protein energy malnutrition causing a very high
mortality rate in young children.
It is diagnosed by pressing moderate thumb pressure on the back of the feet or the
ankle for a few seconds . If there is oedema, the impression will remain for some
times where the oedema fluid has been pressed out of the tissue. Only if the two
feet show oedema, this is recorded. Oedema is a sign of severe malnutrition.
Dehydration: In some circumstances recording of dehydration may be indicated.
Such may be important where diarrheal diseases play a major role and may
especially affect children with evidence of wasting and weight for height below
-2z scores. The physical signs include loose skin, easy tenting of skin and very dry
mucous membrane. These children require an immediate attention.
Weight for height is recommended because
 It is independent of age for children
 It has international accepted reference population
 Its interpretation is based on wide experience in many parts of the world
Both types of surveys are suitable for a pre-feasibility study for the
assessment of the nutritional situation. One of these two types of surveys should be
used for identification of the project during the planning phase.
4.4: Baseline Survey
The baseline survey (for further information, see section 3.1.3.1) gathers
information concerning the type, prevalence, reasons and causes of nutritional
problems (see chapter 1.2).
Complete nutritional baseline and follow-up surveys cover the following areas:
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Felt needs by the community
- Demographic data of the households
- Socioeconomic factors
- Anthropometry
- Signs of malnutrition and disease
- Nutrition and health practices.
A. Follow up surveys
A follow-up survey (or multi-round survey or multi- phase survey) is a type of
survey in which households, a given population included in it are repeatedly
interviewed in the second, third, fourth or more visits, to obtain information on
vital events by noting the changes in composition of the households, or the
population under study that have taken place between successful visits.
The follow-up survey assesses the impact of the project or individual project
measures on the nutritional condition of a community (for further information, see
section 3.1.3.2).
Complete nutritional baseline and follow-up surveys cover the following areas:
Felt needs by the community
- Demographic data of the households
- Socioeconomic factors
- Anthropometry
- Signs of malnutrition and disease
- Nutrition and health practices.
Complete nutritional baseline and follow-up surveys should only be considered
for a self-standing nutrition project in which the objective of the project is the
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improvement of the nutritional situation of a community. In nutrition-related
projects that are expected to have a positive impact on the nutritional situation or
projects with potential negative side effects resulting in the worsening of the
nutritional situation, only specific nutritional indicators should be assessed. Data
on other aspects, in particular socioeconomic data, should then be taken from a
project-specific baseline survey.
Application of Nutrition Surveys
Pregnancy Monitoring and Operational Assessment
It involves collecting information on dietary history and intake data, biochemical
data, clinical examination and health history, anthropometric data, psychosocial
data.
.
To obtain adequate information ensure you:
• Identify nutrition-related problems, make nutrition diagnoses and take
appropriate action.
• Evaluate the pregnant woman’s knowledge, readiness to learn, and potential for
changing.
Nutrition assessment
The process of estimating the nutritional position of an individual or group, at a
given point in time, by using Proxy measurements of nutritional adequacy. It
provides an indication of the adequacy of the balance between dietary intake and
metabolic requirements
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Maternal nutrition assessment
A woman’s nutritional status should be assessed pre-conceptionally with the goal
of
optimizing maternal, fetal, and infant health. Pregnancy-related dietary changes
should
begin prior to conception, with appropriate modifications across pregnancy and
during
lactation.
Physical Assessment
Anthropometric measurements for pregnant women include weight gain during
pregnancy
and Mid-upper-arm circumference:
Weight gain during pregnancy
 Counsel mothers on adequate weight gain during pregnancy
 Monitor weight gain of all mothers attending ANC throughout pregnancy.
Pregnant women need to gain an average of 1 kg per month, a minimum of
0.5kgs per month for the first trimester and there after a minimum of 11.5kgs per month for the last six months.
 Provide the counseling and support to pregnant women with inadequate or
excessweight gain.
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Recommended
weight
gain
in
Pregnancy
MUAC (Mid-upper-arm circumference)
Pregnant and lactating mothers with indicates nutrition risk and should be provided
nutrition counseling and support
Body Mass Index (BMI)
The Body Mass Index (BMI) for adult women is a proxy measure for human body
fat based on
an individual’s weight and height, and is calculated by dividing one’s weight in
kilograms by
height squared in meters. BMI provides a reliable indicator of body fatness for
most people
and is an easy to perform and inexpensive method used to screen for weight
categories that
may lead to health problems.
The formula is:
The formula is: BMI = Weight (kg)
Height (m) 2
Example: An adult weighing 80kg, and with a height of 165cm (1.65m)
BMI calculation: 80 ÷ (1.65)2 = 29.38Kg/m2
Waist Hip Ratio (waist circumference divided by the hip circumference)
Is an indicator used to complement the measurement of BMI, to identify
individuals at
increased risk of obesity-related morbidity due to accumulation of abdominal fat
(WHO,
2000a). The larger the waist hip ratio, the higher the risk of onset of noncommunicable
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diseases. The hip circumference measurement should be taken around the widest
portion
of the buttocks
Dietary Assessment for pregnant and lactating women
Assess on the following for effective counseling of the mother on her nutrition:
 Eating patterns: foods regularly consumed, frequency of meals
 Foods that are available and affordable
 Food intolerance and aversions
 Dietary problems
 Hygiene and food preparation and handling practices.
 Psychosocial factors contributing to inadequacy of intake, such as social
isolation, depression, stigma.
 Fatigue and physical activity.
 Use of vitamin and mineral supplements and alternative practices.
 Living environment and functional status (income, housing, amenities to
cook, access to food, attitude regarding nutrition and food preparation)
• Medical History
 GI problems (e.g., diarrhea, abdominal pain, nausea, vomiting)
 Pattern of bowel movements (constipation)
 Presence of opportunistic infections
 Concurrent medical problems (e.g. diabetes, hypertension, malaria)
 Physical condition (examination)
• Medication Profile
Medication taken
Side effects of medications: Negative effects of food intake or
malabsorption of nutrients
• Biochemical profile (where available): the following tests will help you assess
the nutritional status of a pregnant woman
 Serum albumin
 Evaluation of anemia (iron, B12, and folate status)
 Urinalysis ( for the proteinuria).
• Indicators of good nutritional status during pregnancy include:
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 Weight gain: within 11.5 –16 kg
 Hemoglobin level ≥ 11g/dl
 Absence of clinical signs of micronutrient deficiencies
• Indicators of malnutrition in pregnant women include:
 Weight gain ≤ 11.5 kg
 Weight gain ≤ 1kg/month in the last trimester of the pregnancy
 Mid-upper arm circumference (MUAC) < 23 cm
 Hemoglobin level < 11g/dl
 Presence of goiter
 Presence of clinical signs of micronutrient deficiencies
5.2: Lactation
Assess if the mother is on and practice optimal breastfeeding practices by:
1. It they place infant skin-to-skin with mother immediately after birth since
 Skin-to-skin with mother keeps the newborn warm and helps stimulate
bonding or closeness, and brain development this is done by assisting the
mother to place the baby on her tummy immediately after delivery.
 Skin-to-skin helps the “let down” of the milk/colostrum (Colostrum is
the first thick, yellowish milk that contains antibodies which protects
baby from illness).
 There may be no visible milk in the first hours. For some women it even
takes a day or two to experience the “let down”. It is important to
continue putting the baby to the breast to stimulate milk production and
let down.
2. If they Initiate breastfeeding within the first hour of birth
 Ensure there is rooming in: Keep the baby with the mother in the same
bed for unlimited breastfeeding
 Assess if the mother gives newborn infants no food or drink-- no
water, no infant formula (pre-lacteal feeds) other than breast milk
unless medically indicated. Support the mother to attach and position
the baby to initiate breastfeeding immediately within 1 hour after
delivery.
 Ensure you assist the mother to breastfeed frequently from birth as it
helps the baby to learn to attach and also helps to prevent engorgement
and other complications.
 In the first few days, the baby may feed only 2 to 3 times /day. If the
baby is still sleepy on day 2, the mother may express some colostrum
and give it from a cup.
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5.3: Complementary feeding
Complementary feeding is defined as the process starting when breast milk
alone is no longer sufficient to meet the nutritional requirements of infants, and
therefore other foods and liquids are needed, along with breast milk. The transition
from exclusive breastfeeding to family foods – referred to as complementary
feeding – typically covers the period from 6 - 24 months of age, even though
breastfeeding may continue to two years of age and beyond. This is a critical
period of growth during which nutrient deficiencies and illnesses contribute
globally to higher rates of under nutrition among children under five years of age.
A number of successful strategies have been developed to improve
complementary feeding practices in low- and middle-income countries, where
practical difficulties can limit adherence to complementary feeding guidelines
S A F E P R E PARATION AND S T O R A G E OF COMPLEMENTARY
FOODS
Guideline: Practice good hygiene and proper food handling by a) washing
caregivers’ and children’s hands before food preparation and eating, b) storing
foods safely and serving foods immediately after preparation, c) using clean
utensils to prepare and serve food, d) using clean cups and bowls when feeding
children, and e) avoiding the use of feeding bottles, which are difficult to keep
clean.
AMOUNT O F COMPLEMENTARY FOOD NEEDED
Guideline: Start at six months of age with small amounts of food and
increase the quantity as the child gets older, while maintaining frequent
breastfeeding. The energy needs from complementary foods for infants with
“average” breast milk intake in developing countries are approximately 200 kcal
per day at 6-8 months of age, 300 kcal per day
at 9-11 months of age, and 550 kcal per day at 12-23 months of age. In
industrialized countries these estimates differ somewhat (130, 310 and 580 kcal/d
at 6-8, 9-11 and 12-23 months, respectively) because of differences in average
breast milk intake.
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FOOD C O N S I S T E N C Y
Guideline: Gradually increase food consistency and variety as the infant gets
older, adapting to the infant’s requirements and abilities. Infants can eat pureed,
mashed and semi-solid foods beginning at six months. By 8 months most infants
can also eat “finger foods” (snacks that can be eaten by children alone). By 12
months, most children can eat the same types of foods as consumed by the rest of
the family (keeping in mind the need for nutrient-dense foods. Avoid foods that
may cause choking (i.e., items that have a shape
and/or consistency that may cause them to become lodged in the trachea, such as
nuts, grapes, raw carrots).
MEAL FREQUENCY AND E N E R G Y D E N S I T Y
Guideline: Increase the number of times that the child is fed complementary
foods as he/she gets older. The appropriate number of feedings depends on the
energy density of the local foods and the usual amounts consumed at each feeding.
For the average healthy breastfed infant, meals of complementary foods should be
provided 2-3 times per day at 6-8 months of age and 3-4 times per day at 9-11 and
12-24 months of age. Additional nutritious snacks (such as a piece of fruit or bread
or chapatti with nut paste) may be offered 1-2 times per day, as desired. Snacks are
defined as foods eaten between meals-usually self-fed, convenient and easy to
prepare. If energy density or amount of food per meal is low, or the child is no
longer breastfed, more frequent meals may be required.
NUTRIENT CONTENT O F COMPLEMENTARY FOODS
Guideline: Feed a variety of foods to ensure that nutrient needs are met.
Meat, poultry, fish or eggs should be eaten daily, or as often as possible. Vegetarian
diets cannot meet nutrient needs at this age unless nutrient supplements or fortified
products are used (see #9 below). Vitamin A-rich fruits and vegetables should be
eaten daily. Provide diets with adequate fat content. Avoid giving drinks with low
nutrient value, such as tea, coffee and sugary drinks such as soda. Limit the amount
of juice offered so as to avoid displacing more nutrient rich foods.
FEEDING DURING A N D A F T E R I L L N E S S
Guideline: Increase fluid intake during illness, including more frequent
breastfeeding, and encourage the child to eat soft, varied, appetizing, favorite
foods. After illness, give food more often than usual and encourage the child to eat
more.
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5.4: Growth Monitoring and Promotion
Basic growth assessment, for children 0 to 59 months, involves regular
measuring a child’s weight and length or height, recording on the mother-child
booklet and interpretation through comparing these measurements to growth
standards. The purpose is to determine whether a child is growing “normally” or
has a growth problem or trend towards a growth problem that should be addressed
through counseling and follow-up with the purpose of promoting child health,
development and quality of life.
Weighing a child
It is recommended to weigh children using a scale with the following features:
• Solidly built and durable
• Measures up to 15 kg for baby scale and 150 kg weighing both the mother and
the baby
• Measures to a precision of 0.1 kg (100g)
Examples of such scales are electronic baby scale, pediatric beam balance, tare
weighing
scale. Other weighing scales available include the Salter scale and the bathroom
scale.
Prepare for weighing
1. Explain to the mother the reasons for weighing the child, e.g,
 see how the child is growing
 how the child is recovering from a previous illness
 how the child is responding to changes on feeding or care
2. Have the mother undress the child. Babies should be weighed naked; keep
them warm until weighing. Older children should remain with minimal
clothing, such as their underclothes.
N.B. A wet diaper, or shoes and jeans, can weigh more than 0.5 kg.
If it is too cold to undress a child, or if the child resists being undressed and
becomes agitated, you may weigh the clothed child, but note in the records that the
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child was clothed. It is important to avoid upsetting the child so that the
length/height measurements can also be taken.
When weighing a child using tared scale
“Tared weighing” means that the scale can be re-set to zero (“tared”) with the
person just weighed still on it. Thus, a mother can stand on the scale, be weighed,
and the scale tared. While remaining on the scale, if she is given her child to hold,
the child’s weight alone appears on the scale. Tared weighing has two clear
advantages:
1. There is no need to subtract weights to determine the child’s weight alone
(reducing the risk of error).
2. The child is likely to remain calm when held in the mother’s arms for
weighing.
Measure length or height
Equipment needed to measure length is a length board (sometimes called an
infantometer) which should be placed on a flat, stable surface such as a table.
To measure height, use a height board (sometimes called a stadiometer) mounted at
a right angle between a level floor and against a straight, vertical surface such as a
wall or pillar.
Depending on a child’s age and ability to stand, measure the child’s length or
height. A child’s length is measured lying down (recumbent). Height is measured
standing upright.
i. If a child is less than 2 years old, measure recumbent length.
ii. If the child is aged 2 years or older and able to stand, measure standing
height.
Note: In general, standing height is about 0.7 cm less than recumbent length. This
difference was taken into account in developing the WHO growth standards used
to make the charts in the growth record.
i. If a child less than 2 years old will not lie down for measurement of
length, measure standing height and add 0.7cm to convert it to length.
ii. If a child aged 2 years or older cannot stand, measure recumbent length
and subtract 0.7 cm to convert it to height.
Prepare to measure length or height
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i.
Be prepared to measure length/height immediately after weighing, while
the child’s clothes are off. Check that the child’s shoes, socks, and hair
ornaments have been removed.
ii. Whether measuring length or height, the mother is needed to help with
measurement and to soothe and comfort the child.
iii. Explain to the mother the reasons for the measurement and the steps in the
procedure.
iv. Answer any questions that she may have.
v. Show and tell her how she can help you.
vi. Explain that it is important to keep the child still and calm to obtain a
good measurement.
Measure length
i. Cover the length board with a thin cloth or soft paper for hygiene and for
the baby’s comfort.
ii. Ask the mother to place the baby on the length board herself and then help
to hold the baby’s head in place while you take the measurement. Show
her where to stand when placing the baby down, i.e. opposite you, on the
side of the length board away from the tape.
iii. Show her where to place the baby’s head (against the fixed headboard) so
that she can move quickly and surely without distressing the baby.
Example
Following is a picture of part of a measuring tape. The numbers and longer lines
indicate centimetre markings. The shorter lines indicate millimetres. The shaded
box shows the position of the footboard when a length measurement is taken.
Measure standing height
Ensure that the height board is on level ground. Check that shoes, socks and hair
ornaments
have been removed.
Working with the mother, and kneeling in order to get down to the level of the
child:
 Help the child to stand on the baseboard with feet slightly apart. The back
of the head, shoulder blades, buttocks, calves, and heels should all touch
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




the vertical board. This alignment may be impossible for an obese child, in
which case, help the child to stand on the board with one or more contact
points touching the board. The trunk should be balanced over the waist,
i.e., not leaning back or forward.
Ask the mother to hold the child’s knees and ankles to help keep the legs
straight and feet flat, with heels and calves touching the vertical board.
Ask her to focus the child’s attention, soothe the child as needed, and
inform you if the child moves out of position.
Position the child’s head so that a horizontal line from the ear canal to the
lower border of the eye socket runs parallel to the baseboard. To keep the
head in this position, hold the bridge between your thumb and forefinger
over the child’s chin.
If necessary, push gently on the tummy to help the child stand to full
height.
Still keeping the head in position use your other hand to pull down the
headboard to rest firmly on top of the head and compress the hair.
Read the measurement of the child’s height in centimetres to the last
completed 0.1 cm This is the last line that you can actually see. Plot this
height in the child’s growth chart (mother & child health booklet).
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Plot points for growth indicators
In order to plot points, one needs to understand the following
 The horizontal reference line at the bottom of the graph which indicates the
age of the child.
 The vertical reference line at the far left of the graph which indicates weight
or length/ height.
Plotted point – the point on a graph where a line extended from a measurement on
the
horizontal line intersects with a line extended from a measurement on the vertical
line.
Plotting weight for Age
a. Plot completed weeks, months and years on a vertical line (not between the
vertical
lines) on the mother and child health booklet.
b. For horizontal line, Plot weight for age on or between the horizontal line as
precisely as
possible.
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c. When points are plotted for 2 or more visits join / connect the adjacent points
with a straight line to better observe the trend.
Example 1
On the graph below, age (in weeks or months) is on the x axis; weight in kilograms
is on the
y axis. The horizontal lines represent 0.1 kg (100 g) increments. A point has been
plotted
for an infant boy who is 6 weeks old and weighs 5 kg. The curved lines on the
graph are
reference lines that will help you interpret the plotted points and trends; you will
learn more
about them in later sections of this module.
Figure 18: plotting weight for age
Example 2
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The following graph shows weight-for-age at three visits of a boy. The horizontal
lines
represent 0.1 kg (100 g) increments.
Plot length/height-for-age
Length/height-for-age reflects attained growth in length or height at the child’s age
at a
given visit.
This indicator can help identify children who are stunted (short) due to prolonged
under-nutrition or repeated illness. Children who are tall for their age can also be
identified, but tallness is rarely a problem unless it is excessive and may reflect
uncommon endocrine disorders.
Age is plotted in completed weeks from birth until age 3 months; in completed
months from
3 to 12 months; and then in completed years and months.
To plot length/height-for-age:
 Plot completed weeks, months, or years and months on a vertical line (not
between vertical lines). For example, if a child is 5 ½ months old, the point
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will be plotted on the line for 5 months (not between the lines for 5 and 6
months).
 Plot length or height on or between the horizontal lines as precisely as
possible. For example, if the measurement is 60.5 cm, plot the point in the
middle of the space between horizontal lines.
 When points are plotted for two or more visits, connect adjacent points with
a straight line to better observe the trend.
Judge whether a plotted point seems sensible, and if necessary, re-measure the
child. For example, a baby’s length should not be shorter than at the previous visit.
If it is, one of the measurements was wrong.
Example 3 – Anna
The following graph shows Anna’s height-for-age at three visits. The horizontal
lines represent 1 cm increments. At the first visit, Anna was 2 years and 4 months
of age and was 92 cm in height.
Figure 19: Plotting length/height for age
Note:
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• Plot measurements (weight/height) once per month on the child’s growth chart
• If the measurements are taken more than once in a period of 4 weeks, the
subsequent measurements should be recorded on the clinical notes and not plotted
Interpretation of weight /height for age
Z-score lines on the growth charts are numbered positively (1, 2, 3) or negatively
(−1, −2, −3).
In general, a plotted point that is far from the median in either direction (for
example, close
to the 3 or −3 z-score line) may represent a growth problem, although other factors
must
be considered, such as the growth trend, the health condition of the child and the
height of
the parents.
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Program Monitoring and Evaluation
Meaning of terms
Programme planning
Stages in programme planning
Programme planning involve the following phases.
Analyse the present situation.
Set objectives for the extension programme.
Develop the programme by identifying what needs to be done to achieve the
objectives, and then prepare a work plan.
Implement the programme by putting the work plan into effect.
Evaluate the programme and its achievements as a basis for planning future
programmes.
Situation analysis
This involves an identification of the problems. Nutritional problems, health
problems must be understood and the natural, human and other resources of the
area identified. This stage involves three activities.
Collecting facts
There is a good deal of information that the agent will need about the people in the
area, their nutritional problems, natural resources and the facilities available for
local development. The agent will need information in order to have a good
understanding of the situation with which he is dealing, for example, on social
structure and local culture, farming systems, education and literacy levels,
household size, health facilities, local channels of communication, transport
facilities, local credit systems, marketing, health and nutrition levels, and crops and
livestock.
These facts can be collected from a variety of sources such as in the health centers,
focus group discussion with key informant, observation. .
Analyzing facts
Facts do not speak for themselves. It is necessary to ask why things happen in the
way they do. If if household members report that they have been experiencing
drought in the recent year the researcher must look for other information that
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would suggest an explanation. Is it because of low rainfall, declining soil fertility?
The experts must also separate fact from opinion and guesswork. They may obtain
conflicting information from two different sources, and must judge which is the
more reliable.
Identifying problems and potential
It should now be possible to decide what the main problems facing the community
in the area are, and what potential there is for health and nutrition improvement.
This is where the expertise technical knowledge becomes important. The
community may know what their problems are, but the experts can bring their own
perception of local problem. They will be able to explain problems more fully and
relate them to processes which the community may not realize are in any way
connected..
Throughout the situation analysis, the experts should avoid either, relying totally
on their own expertise when interpreting facts and identifying problems, or leaving
it entirely up to community to define local needs and possibilities for change. It
should be a joint effort, with experts and community bringing their own experience
and knowledge together to reach a full understanding. If the community is not fully
involved in these activities, the experts runs the risk of misinterpreting facts,
wasting time in analysis and, almost certainly, of failing to gain the full support of
the community for the program.
Setting objectives
Once the existing situation has been analysed, decisions can be made about the
changes that should be brought about through a nutrition or health program. The
key questions are how will local problems be solved and how will local potential
be developed. Solutions will require clear, realistic objectives which should be set
in three stages.
Finding solutions
In looking for solutions to local problems, the agent should distinguish between
technical solutions, involving, solutions which involve institutional changes.
Solutions involving institutional changes may require action by other agencies and
at higher levels. While the agent should certainly suggest such solutions to those
responsible, there may be little that can be done locally in isolation.
Selecting solutions
It is important to ensure that proposed solutions are:
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Acceptable to the community in the area
Technically sound and tested by research and experience elsewhere.
Consistent with national policy, and with the local activities of other agencies.
Feasible within the time and with the resources available to the community.
Within the scope of the agent's ability
Programme implementation
This involves the implementation of the identified interventions
Monitoring: what is it?
It is the ongoing collection and review of information on project implementation,
coverage and utilization that is reported and acted on, on on-going basis
Why do monitoring?
 To improve intervention programmes by identifying aspects that are
working as planned and those that
need correction.
 To modify Programme as per identified need.
 To ensure that all needy cases are reached: eg, General food ration reaches
all targeted persons by maximizing on inclusion of deserving cases and
exclusion of undeserving cases in special targeting I.e. severely
malnourished
 To track (and demonstrate) results at the program or population level.
Nb: Thus monitoring is used to determine how well a Programme is being
implemented
 At different levels
 At what cost
 Also tracks the changes occurring due to
implemented
(positive or negative)
interventions being
Evaluation: What is it?
 A process of data collection designed to assess the effectiveness of the
project in attaining its originally stated objectives and the extent to which
observed changes are attributable to the project.
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 Done at the end of the project but could be planned at strategic periods
during the life of the projects; inform of reviews e.g. mid- term reviews, or
biennial
reviews.
Evaluation can use rigorous study designs e.g., experimental design or
quasi-experimental-involving control groups
 M&E happens only after the decision to implement a certain intervention has
been made
 Both monitoring and evaluation need clearly stated goals clearly stated
objectives
Evaluation Basics
 Evaluation should be considered early; prior to program development
 Purpose: to determine the extent to which a program or intervention is
effective, i.e., to determine if it is successful or how well it meets its
objective
 It should be conducted throughout program development
Types of Evaluation
Formative
 Strengthen or improve the program being evaluated
 Needs Assessment, Implementation & Process
Summative
Examine the effects or outcomes of the program
Outcome, Impact & Cost-Benefit Analysis
Characteristics of Good Evaluation
• It is objective.
– Self-assessments and subjective judgments of those responsible for a
program have low credibility.
• It is replicable.
– Someone else should be able to re-do your evaluation and get the
same results.
• It is methodologically strong.
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– Confidence in the evaluation's findings; evaluation is able to resist
criticism and attack.
• Its results are generalizable.
– The results should apply to the broad range of individuals, and
situations to which the program is aimed.
What can be evaluated?
 Demographics
 Knowledge
 Attitudes
 Behavior
 Change
 Intentions
 Predictors
Components of M&E
Usually four components are considered
 Inputs
 Processes
 Outputs
 Outcomes
Inputs are the set of resources dedicated to a Programme: They include
 human and financial resources,
 physical facilities, equipment and operational
 policies that enable services to be delivered ,I.e.,
– Personnel
– Facilities
– Space: storage, room for admitting children on TFP, for conducting
SFP and space for guardians.
– Equipment
– Supplies
Process refers to the set of activities in which Program inputs are utilized in
pursuit of the results from the Program
Process refer to multiple activities that are carried out to achieve the
objectives of the projects
 Service delivery operations (food distribution)
 Management oriented activities
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 Training, IES, research, etc
Outputs are the results obtained at the Programme level through execution
of activities using its resources (inputs):
Outputs
 Could be staff performing better as a result of having been trained
 As a result of clear policy environment
 Staff better informed about policies- better in taking decisions.
Outputs classified into three levels:
• Functional outputs: number of nutrition IEC talks, food preparation
demonstration, people trained
• Service outputs:e.g, number benefiting/accessing TFP,SFP, quality of
service, acceptability/ image
• Service utilization: number using the service(collecting rations, visiting
ANC clinics for supplements)
• Outcome: the set of results expected to occur at the population level due to
Programme activities and generation of Programme outputs. The
intermediate effects are often behavioral and result directly from project
outputs. They may be necessary to achieve a desired impact.
• Outcomes
may
be
divided
into
two
components:
Intermediate outcomes and long-term outcomes.
• Immediate outcomes: are set of results at the population level that are
closely and clearly linked to the Programme activities.
• Long-term outcomes: refer to set of results at the population level that are
long- term in nature and are produced through action of immediate
outcomes.
• There is generally a considerable time lag 5-10 years between inception and
change in long range outcomes. Good health, reduced mortality rates.
Components
• Outcomes- two levels
• Intermediate outcomes Occur at population level and are closely associated
with Programme inputs(drop in prevalence of severe cases of malnutrition,
anemia).
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• Long range outcomes Refer to results at population level that are long term
in nature and come through action of intermediate outcomes (drop in overall
prevalence of malnutrition, deaths, better health)
• Six key outcomes for nutrition
– Exclusive breastfeeding
– Appropriate complementary feeding,
– Adequate iron intake
– Adequate vitamin A intake
– Adequate iodine intake
– Adequate nutritional care during illness and severe malnutrition
Elements of M&E
Indicators
 Indicators are variables that measure the different aspects of a given
Programme
 The inputs, processes, outputs and outcomes.
 An indicator can be assigned a numeric value, a percentage, a mean value, a
ranking, an absolute number of yes/ no score e.g., presence verses absence
 Selection of indicators
Indicators must be selected to provide evidence that defines the extent to which
project interventions are successful in achieving the set objectives.
Criteria for selection of indicators
• Validity: It measures what it is intended to
• Sensitivity: its changes reflect desired changes
• Reliable: It produces the same results when repeated
• Uni-dimensional: it measures only one phenomenon
• Operational: it is measurable
• Objective: it is not subject to Measurer’s biases
• Practical: its data collection is reasonably feasible
• Comparability (from time to time/ place to place)
Policy environment (indicators)
• Existence of a policy development plan
• Number of appropriately disseminated policy analysis
• Number of policy awareness raising events targeted at leaders
• Quality of Programme leadership
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• Extent of commercial sector participation
Components of M&E plan
• Introduction: The country region and background of what the project is
addressing
• Conceptual framework-maps the linkages inputs-processes-outputsoutcomes
Theory and methodologies of program and system planning
Theoretical method
A Method is a general process for influencing changes in the determinants of
behavior and environmental conditions
Practical Strategy:
A strategy is a practical technique for the application of methods in ways that fit
with the intervention group and the context in which the intervention will be
conducted
Emerging issues and Trends
7.1: Emerging issues
7.2: Challenges
Sustainability
One of the biggest challenges facing nutrition surveillance systems is the issue of
sustainability and continued effectiveness of the system. There are many examples
of information systems that have ‘withered’ away as donor interest has waned
(either because the area served by the information system has not experienced
crisis for a number of years or because internal donor funding priorities have
changed). Continuation of adequate financial resourcing is therefore crucial.
The continued availability of adequately trained staff who are committed is also
essential. All too often staff are expected to take on other roles and do not have
sufficient time to support the system to the required standard. Competing activities
such as immunization campaigns, child health days and capacity building
workshops often prevent the surveillance activities from being conducted. In
addition to competing activities and overambitious workloads, turnover of ministry
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staff can also exacerbate this problem as by the time the staff have been trained and
become familiar and competent in their activities, they are moved to a different
area or division.
Ideally if a system proves to be effective and sensitive to monitoring change over
time, this should justify the additional resources. With the current renewed interest
in nutrition surveillance systems, and improved quality of data collection tools and
analysis, the availability of resources to establish sustainable surveillance systems
is increasing with more interest and experience in establishing nutrition
surveillance systems as a component of early warning at national level.
Institutional issues
Issues, such as where the system should be housed and how it links with existing
early warning systems or health information systems, also need to be considered,
in terms of who ultimately makes the decision in terms of the analysis of the
information and determines the appropriate response. The challenge for many
information systems is that they rely on a range of information sources that cut
across several government ministries including health, agriculture and education.
This means that no one ministry takes responsibility for the management of the
system. Over time it may be abandoned.
One option is to establish a separate Ministry with specific responsibility for
disaster management and response, which manages the system and takes
responsibility for the information generated
Linking information to action
Data collected which is not linked to action is pointless and unethical. Nutrition
surveillance systems should be designed in such a way as to maximize the
likelihood that information will elicit an appropriate response if one is needed.
There are two main reasons many surveillance systems fail to produce the desired
response:
Firstly, there can be a lack of confidence in the data. This is very common when
data is based on trends and not on prevalence data. Sometimes, data indicating a
deteriorating nutritional trend from the surveillance systems is only accepted if it is
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confirmed by providing prevalence estimates from representative surveys. The lack
of international agreement on standards for sentinel site surveillance or rapid
assessments is problematic
There are political reasons for failing to react to surveillance information. Issues of
credibility and political inertia can both to some degree be addressed by involving
decision-makers (in government or at international level) in the design of the
system. Joint prior decisions about thresholds, institutional location of system and
role of data and process of data use in decision making can all help address these
potential impediments to effective response. Credibility of systems is also
enhanced by transparency and honesty with regard to short-comings and failures
where these occur.
7.3: Coping Strategies
To turn a weak surveillance system into a stronger one:
• Make the appropriate systemic improvements, including the aspects of
improvement identified in the evaluation phase;
• Build ownership for all improvements at every level;
• Train personnel in order to develop skilled workers;
• Ensure availability of resources.
Transformation by definition means change. If no change is made, the surveillance
system will continue to function poorly, with the associated nutrition and health
risks and detrimental effect on the economy. The transformation or the
improvement has to be sustainable. There are many factors influencing the
sustainability of a surveillance system, for example local capability and resource
availability.
To enable sustainability of an improved surveillance system, capacity, motivation
and resources are essential. If transformations are made but not sustained,
improvements will be
lost and the system will either revert to its prior state or perhaps get worse or even
collapse.
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Therefore, the focus should be on building ownership through empowerment in
order to sustain the improvements.
National ownership motivates stakeholders to maintain the improvements over
time.
Ownership should:
• result when people know and care enough about their surveillance system to fund
interventions to implement improvements;
• be built at each level of the system: national, regional and local;
• be built by all parties: data recorders, data analysers and decision-makers.
Building ownership should be ongoing, helping to increase commitment and
strengthen capacity to improve the surveillance system at each step of the process.
6.3 Practical steps to transform a weak surveillance system into a stronger one
(8)
The following practical steps can be taken to improve a surveillance system:
1. Assess the current food and nutrition surveillance activities. The first step is to
look at the current nutrition surveillance activities and how they are being
performed.
2. Determine specific conditions. In what context is the food and nutrition
surveillance system working?
3. Identify strengths, interactions, opportunities, weaknesses and gaps. Is there an
overlap with other interventions/activities? What are the challenges?
4. Develop a plan of action. Set out the priorities, strategies and time schedule for
the implementation of various action steps to transform the system into a better
one.
5. Implement the plan of action. The best plan of action needs monitoring over
time.
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NUTRITIONAL ASSESSMENT
a) Nutritional surveys
A survey is any activity that collects information in an organised and methodical manner about
characteristics of interest from some or all units of a population using well-defined concepts,
methods and procedures, and compiles such information into a useful summary form. It involves
collection of information at one point in time.
A survey usually begins with the need for information where no data – or insufficient data –
exist. Sometimes this need arises from within the statistical agency itself, and sometimes it
results from a request from an external client, which could be another government agency or
department, or a private organisation.
A survey can be thought to consist of several interconnected steps which include: defining the
objectives, selecting a survey frame, determining the sample design, designing the questionnaire,
collecting and processing the data, analysing and disseminating the data and documenting the
survey. The life of a survey can be broken down into several phases. The first is the planning
phase, which is followed by the design and development phase, and then the implementation
phase. Finally, the entire survey process is reviewed and evaluated.
The steps of a survey are:
1. Formulation of the Statement of Objectives
2. Selection of a survey frame
3. Determination of the sample design
4. Questionnaire design
5. Data collection
6. Data capture and coding
7. Editing and imputation
8. Estimation
9. Data analysis
10. Data dissemination
11. Documentation
A Nutrition survey is the collection of nutrition related data from a selected population from
one point on time. It establishes the baseline nutritional status of the population and describes the
population at risk of chronic malnutrition. E.g. cross sectional survey that is commonly used. The
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information obtained can be used to allocate resources to much needy population and also to
formulate policies to improve the overall nutrition.
Factors that influence choice of a dietary survey method
The purpose of the survey
The foods and nutrients of interest
The number of subjects to be surveyed
The likely response rate
Accuracy of the method
Cost of the method per subject
The age, sex and literacy of the subjects
Methods of assessing food security in the household
 The World Food Summit of 1996 defined food security as existing “when all people at all
times have access to sufficient, safe, nutritious food to maintain a healthy and active life”
 Food Security means that all people at all times have physical & economic access to
adequate amounts of nutritious, safe, and culturally appropriate foods.
1. Dietary diversity questionnaire
Obtaining detailed data on household food access or individual consumption can be time
consuming, expensive, and requires a high level of technical skill both in data collection
and analysis.
The dietary diversity questionnaire is a tool providing a more rapid, user-friendly and
cost-effective approach to measure changes in dietary quality at the household and
individual level.
Administration and scoring/analysis of the tools are straightforward and quick
Dietary diversity is a qualitative measure of food consumption that reflects
household access to a wide variety of foods, and is also a proxy of the nutrient
adequacy of the diet for individuals.
It is also called dietary diversity score (DDS).
Household dietary diversity score (HDDS) reflects the household’s economic ability to
consume a variety of foods.
Individual dietary diversity score (IDDS) aims at capturing nutrient adequacy.
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The Coping Strategies Index (CSI)
Brief Description: The Coping Strategies Index (CSI) is a tool that measures what people do
when they cannot access enough food. It is a series of questions about how households manage
to cope with a shortfall in food for consumption, and results in a simple numeric score. The CSI
is based on the many possible answers to a single question: “What do you do when you don’t
have adequate food and don’t have the money to buy any?”
Uses: The CSI measures the frequency and severity of coping behaviors. The CSI is an
appropriate tool for emergency situations when other methods are not practical or timely. It can
be used for a variety of purposes, including to:





Provide a quick, current status indicator of the extent of food insecurity.
Measure or monitor the impact of food assistance programs.
Act as an early warning indicator of an impending food crisis.
Identify areas and population groups where needs are greatest.
Shed light on the causes of malnutrition
1. Limit portion size at mealtimes
2. Reduce number of meals/day
3. Borrow food or rely on others
4. Use less expensive/preferred foods
5. Purchase food on credit
6. Gather wild food
7. Send HH members to eat elsewhere
8. Reduce adult consumption
9. Rely on casual labor for food
10. Limit portion size at mealtimes
11. Reduce number of meals/day
12. Borrow food or rely on others
13. Use less expensive/preferred foods
14. Purchase food on credit
15. Gather wild food
16. Send HH members to eat elsewhere
17. Reduce adult consumption
18. Rely on casual labor for food
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1. State 3 importance of conducting baseline studies
(6 marks)
1. It is a starting point for a project: Through its results, a baseline serves as a benchmark
for all future activities, where project managers can refer to for the purposes of making
project management decisions.
2. Establishing priority areas/planning: Baseline studies are important in establishing
priority areas for a project. This is especially true when a project has several objectives.
The results of a baseline study can show some aspects of a project need more focus than
other while others may only need to be given little focus. Take for example a project on
HIV and AIDS in Dhaka. A baseline study may show that while there is generally high
public information on awareness of risk and prevention strategies, these strategies are
either non-existent or inaccessible. In this case, project output would focus more on
improving access to prevention strategies and little on doing media campaigns and
community mobilization.
Attribution: Without a baseline, it is not possible to know the impact of a project. A
baseline study serves the purpose of informing decision makers what impact the project
has had on the target community. Accordingly, along with other strategies such as use
of control groups, it also helps in attributing change in the target population to the project.
4. Baseline tools are used for evaluation: the tools used during a baseline study are
normally the same tools used during evaluation. This is important for ensuring that
management compares “apples to apples”. As such, conducting a baseline means that
time and other resources for designing evaluation tools are minimized or even eliminated
altogether.
5. Donor requirement: In most cases, it is a donor requirement that a baseline study is
carried out as part of the program process. Since M&E is integral for any donor to
establish future project success, they might, and always do compel implementing
organizations to carry out baseline studies.
b) Surveillance
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The term surveillance is reserved to refer to a system of data collection and application (WHO,
1976). Such systems are based upon routinely compiled data and monitor changes in relevant
variables over time, give warning of impending crises or monitor the effectiveness or
ineffectiveness of existing programmes and policies. Surveillance may draw upon several types
of data but the essential features are that the data are collected across time, as in repeated crosssectional surveys or repeated reporting of the prevalence of underweight children from growth
monitoring, and that the data collection and analysis are linked to decision-making.
Nutritional surveillance is a systematic approach used to detect malnutrition and identify
populations at risk of suffering from it. The concept of nutritional surveillance is derived from
disease surveillance, and means “to watch over nutrition, in order to make decisions that lead to
improvements in nutrition in populations”.
Nutrition surveillance utilizes a diverse range of information sources on nutrition. Examples
include detailed nutrition assessments, health facility information, rapid assessments, sentinel
site surveillance and intervention data. Information on the wide range of factors affecting
nutrition is also collected from partners in other sectors of health, food security, water and
security. Most recently, methods and tools for the monitoring of dietary intake and coping
strategies have been developed.
c) Screening
Nutritional screening is the process of identifying characteristics known to be associated
with nutrition problems. Its purpose is to identify populations, sub-groups or individuals who
are malnourished or at nutritional risk. Four different methods are used to collect data used in
assessing nutritional status:
1. Anthropometric
2. Biochemical or Laboratory
3. Clinical (physical exam)
4. Dietary: Nutritional History Current Intake
(Commonly read ABCD)
Purpose of nutrition assessment
iv.
v.
vi.
To accurately determine nutritional status
To identify current and potential nutritional and medical problems
To monitor changes in nutritional status during national policy changes, fortification
programs, nutrition intervention or the course of a chronic or acute illness
Nutrition assessment is important because acute and chronic malnutrition can be identified.
The methods for nutrition assessment will be covered in detail in topic three.
COPING STATEGY INDEX
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Brief Description: The Coping Strategies Index (CSI) is a tool that measures what people do
when they cannot access enough food. It is a series of questions about how households manage
to cope with a shortfall in food for consumption, and results in a simple numeric score. The CSI
is based on the many possible answers to a single question: “What do you do when you don’t
have adequate food and don’t have the money to buy any?”
Uses: The CSI measures the frequency and severity of coping behaviors. The CSI is an
appropriate tool for emergency situations when other methods are not practical or timely. It can
be used for a variety of purposes, including to:





Provide a quick, current status indicator of the extent of food insecurity.
Measure or monitor the impact of food assistance programs.
Act as an early warning indicator of an impending food crisis.
Identify areas and population groups where needs are greatest.
Shed light on the causes of malnutrition
NUTRITIONAL ASSESSMENT INDICES
Indices are a plural of index. An Index is something used or serving to point out a sign or
indication. Nutritional assessment indices therefore points out a sign or indication of nutrition
status of an individual or population i.e. normal nutritional status or malnourished
(undernourished or undernourished).
When body measurements are compared to a reference value, they are called nutrition indices.
Three commonly used nutrition indices are WFH which is used to assess wasting, height-for-age
(HFA) which is used to assess stunting, and weight-for-age (WFA) which is used to assess
underweight.
Nutrition indicators are an interpretation of nutrition indices based on cut off points. Nutrition
indicators measure the clinical phenomena of malnutrition and are used for making a judgement
or assessment. A good nutrition indicator detects as many people at risk as possible (sensitivity)
without including too many people who are not at risk (specificity). A good nutrition indicator
should also be functionally meaningful (i.e., related to the risk of morbidity and mortality), and
be sensitive to change.
a) Reference distribution
The reference distribution is essentially a theoretical sampling distribution, given the value of
your standard error.
In most research, we find that the standard error equals 0.05, or 5 percent. In probability theory,
the standard error is a valuable piece of information because it indicates the extent to which the
sample estimates will be distributed around the population.
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When data are analysed to decide whether conditions are as they should be, or whether the level
of some variable has changed, the fundamental strategy is to compare the current condition or
level with an appropriate reference distribution. The reference distribution shows how things
should be, or how they used to be. Sometimes an external reference distribution should be
created, instead of simply using one of the well-known and nicely tabulated statistical reference
distributions, such as normal or t distribution. Most statistical methods that rely upon these
distributions assume that the data are random, normally distributed, and independent. Many sets
of environmental data violate these requirements.
A specially constructed reference distribution will not be based on assumptions about properties
of the data that may not be true. It will be based on the data themselves, whatever their
properties. If serial correlation or connormality affects the data, it will be incorporated into the
external reference distribution.
The standard definition of a reference range for a particular measurement is defined as the
prediction interval between which 95% of values of a reference group fall into, in such a way
that 2.5% of the time a sample value will be less than the lower limit of this interval, and 2.5% of
the time it will be larger than the upper limit of this interval, whatever the distribution of these
values.
Reference ranges that are given by this definition are sometimes referred as standard ranges.
Regarding the target population, if not otherwise specified, a standard reference range generally
denotes the one in healthy individuals, or without any known condition that directly affects the
ranges being established. These are likewise established using reference groups from the healthy
population, and are sometimes termed normal ranges or normal values (and sometimes "usual"
ranges/values). However, using the term normal may not be appropriate as not everyone outside
the interval is abnormal, and people who have a particular condition may still fall within this
interval.
However, reference ranges may also be established by taking samples from the whole
population, with or without diseases and conditions. In some cases, diseased individuals are
taken as the population, establishing reference ranges among those having a disease or condition.
Preferably, there should be specific reference ranges for each subgroup of the population that has
any factor that affects the measurement, such as, for example, specific ranges for each sex, age
group, race or any other general determinant.
Methods for establishing reference ranges are mainly based on assuming a normal distribution,
or a log-normal distribution, or directly from percentages of interest, as detailed respectively in
following sections.
Normal distribution
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When assuming a normal distribution, the reference range is obtained by measuring the values in
a reference group and taking two standard deviations either side of the mean. This encompasses
~95 % of the total population. (34.1 + 34.1 +13.6 +13.6 = 95.4%)
The 95% prediction interval, is often estimated by assuming a normal distribution of the
measured parameter, in which case it can alternatively be defined as the interval limited by 1.96
(often rounded up to 2) population standard deviations from either side of the population mean
(also called the expected value). However, in the real world, neither the population mean nor the
population standard deviation are known. They both need to be estimated from a sample, whose
size can be designated n. The population standard deviation is estimated by the sample standard
deviation and the population mean is estimated by the sample mean (also called mean or
arithmetic mean).
In nutrition assessment, reference distribution is applied in identifying the level of malnutrition
e.g. under nutrition; -3 SD for severe acute malnutrition, -2SD for moderate acute malnutrition
etc.
b) Reference limits
Normal range or reference interval
In this section we ask what values measurements on normal, healthy people are likely to have.
There are difficulties in doing this. Who is `normal' anyway? In the UK population almost
everyone has hard fatty deposits in their coronary arteries, which result in death for many of
them. Very few Africans have this; they die from other causes. So it is normal in the UK to have
an abnormality. We usually say that normal people are the apparently healthy members of the
local population..
The next problem is to estimate the set of values. If we use the range of the observations, the
difference between the two most extreme values, we can be fairly confident that if we carry on
sampling we will eventually find observations outside it, and the range will get bigger and
bigger. To avoid this we use a range between two quantiles, usually the 2.5 centile and the 97.5
centile, which is called the normal range, 95% reference range, or 95% reference interval.
This leaves 5% of normals outside the `normal range', which is the set of values within which
95% of measurements from apparently healthy individuals will lie.
A third difficulty comes from confusion between `normal' as used in medicine and `Normal
distribution' as used in statistics. This has led some people to develop approaches which say that
all data which do not fit under a Normal curve are abnormal! Such methods are simply absurd;
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there is no reason to suppose that all variables follow a Normal distribution. The term `reference
interval', which is becoming widely used, has the advantage of avoiding this confusion.
However, the most commonly used method of calculation rests on the assumption that the
variable follows a Normal distribution.
We have already seen that in general most observations fall within two standard deviations of the
mean, and that for a Normal distribution 95% are within these limits with 2.5% below and 2.5%
above. If we estimate the mean, m, and standard deviation, s, of data from a Normal population
we can estimate the reference interval as m - 2s to m + 2s.
(Refer to statistics module on normal distribution).
c) Cut off points
A nutrition cut-off or a cut-off point is the level or limit at which you decide the level of
nutritional status of an individual or population.
There are different cut off points based on the methods of nutrition assessment (e.g. MUAC,
BMI), age (e.g. children, adults), sex (male and female) etc.
Example;
i.
Indices, indicators and indicator cut-offs for children aged 6 – 59 Months
Standard cut-off points are used internationally to define under-nutrition in children ages 6-59
months. The cut-off points for nutrition indicators are derived from the WHO child growth
standard population (WHO standards) or NCHS reference population (NCHS references).
Note that Cut-offs may vary according to the context, agency and national guidelines
A. Bilateral Pitting Oedema
Bilateral pitting oedema is a clinical manifestation of acute malnutrition caused by an abnormal
infiltration and excess accumulation of serous fluid in connective tissue or in a serous cavity.
Bilateral pitting oedema (also called kwashiorkor) is verified when thumb pressure applied on
top of both feet for three seconds leaves a pit (indentation) in the foot after the thumb is lifted.
B. MUAC indicator
Low MUAC is an indicator for wasting, to be used for a child age 6-59 months. The indicator
is relatively easy to measure; it involves measuring the circumference of a child’s left midupper arm. MUAC < 110 mm for children ages 6-59 months indicates SAM (cut-off).
MUAC ≥ 110 mm and < 125 mm for children ages 6-59 months indicates MAM. MUAC is a
better indicator of mortality risk associated with acute malnutrition than WFH z-score
(WHO) or WFH as a percentage of the median (NCHS).
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C. WFH indicator
Low WFH is an indicator for wasting. A WFH standard deviation (SD) below -2 z-score of
the median (WFH < -2 z-score) of the WHO standards or a WFH < 80% of the median (WFH
< 80%) of the NCHS references indicate wasting. Severe wasting is indicated by a WFH < -3
z-score (WHO standards) or a WFH < 70% of the median (NCHS references). Moderate
wasting is indicated by a WFH ≥ -3 and < -2 z-score (WHO standards) or a WFH ≥ 70% and
< 80% (NCHS references).
SUMMARY TABLE: INDICATORS OF ACUTE MALNUTRITION WITH CUTOFF FOR
SAM AND MAM
Bilateral Pitting MUAC
Oedema
WFH
z-score
(WHO standards
or
NCHS
references)
WFH
as
a
percentage of the
median
(NCHS
references)
SAM
Present
< 110 mm* or red
< -3
< 70%
MAM
Not present
> 110 mm* and < ≥ -3 and < -2
125
mm*
or
yellow
≥ 70% and < 80%
Note that on the WHO child growth standards and NCHS child growth references: The NCHS
child growth references were developed in 1978 from a cohort of American children and used as
an international reference until 2006. The WHO 2006 Child Growth Standards were developed
from a multicentre growth reference study that followed optimal child growth of a cohort of
children in Oman, Norway, Ghana, India and the United States.
Z-score
A Z- score is a statistical measure of the distance in standard deviations of a value from the
median value of the reference population.
OR
It’s a standardized value computed by subtracting the median from the data value X and then
dividing the results by the standard deviation of the reference population.
Actual height - Median height for the reference child
Z-score=_________________________________________________
Absolute value for Standard Deviation
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Absolute value of standard Deviation= Median Height-Height at -1 Standard deviation
To give an example
ii.
Indices, indicators and indicator cut-offs for children aged 6 – 17 years
BMI for Age
Body Mass Index (BMI) is a person's weight in kilograms divided by the square of height in
meters. For children and teens, BMI is age and sex specific and is often referred to as BMI-forage. In children, a high amount of body fat can lead to weight-related diseases and other health
issues and being underweight can also put one at risk for health issues.
A high BMI can be an indicator of high body fatness. BMI does not measure body fat directly,
but research has shown that BMI is correlated with more direct measures of body fat, such as
skinfold thickness measurements. BMI can be considered an alternative to direct measures of
body fat. In general, BMI is an inexpensive and easy-to-perform method of screening for weight
categories that may lead to health problems.
After BMI is calculated for children and teens, it is expressed as a percentile which can be
obtained from either a graph or a percentile calculator. Because weight and height change during
growth and development, as does their relation to body fatness, a child’s BMI must be
interpreted relative to other children of the same sex and age.
The BMI-for-age percentile growth charts are the most commonly used indicator to measure the
size and growth patterns of children and teens.
BMI is interpreted differently for children and teens even though it is calculated as weight ÷
height2. Because there are changes in weight and height with age, as well as their relation to body
fatness, BMI levels among children and teens need to be expressed relative to other children of
the same sex and age.
Childhood obesity can have a harmful effect on the body in a variety of ways.


o High blood pressure and high cholesterol, which are risk factors for
cardiovascular disease (CVD).
o Increased risk of impaired glucose tolerance, insulin resistance and type 2
diabetes.
o Breathing problems, such as sleep apnea, and asthma.
o Joint problems and musculoskeletal discomfort.
o Fatty liver disease, gallstones, and gastro-esophageal reflux (i.e., heartburn).
o Psychological stress such as depression, behavioral problems, and issues in
school.
o Low self-esteem and low self-reported quality of life.
o Impaired social, physical, and emotional functioning.
Obese children are more likely to become obese adults. Adult obesity is associated with a
number of serious health conditions including heart disease, diabetes, and some cancers.
If children are overweight, obesity in adulthood is likely to be more severe.
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iii.
Indices, indicators and indicator cut-offs for adults
 BMI
Body Mass Index is a useful clinical calculation to diagnose obesity because it is correlated with
total body fat and is relatively unaffected by height. It is most often used to diagnose obesity, but
it is equally applicable to defining those who are underweight. This makes it more useful across
heights and gender. It should be remembered that the typical body weight tables are based on
mortality outcomes but do not predict morbidity. There are some limitations to the BMI since it
will overestimate body fat in persons who are very muscular and underestimate body fat in
persons who have lost muscle mass, such as the elderly.
BMI = weight (kg)
height2 (m 2)
Table showing the International Classification of adult underweight, overweight and obesity
according to BMI.
Classification
Principal cut-off points
Underweight
<18.50
Severe thinness
<16.00
Moderate thinness
16.00 - 16.99
Mild thinness
17.00 - 18.49
Normal range
18.50 - 24.99
Overweight
≥25.00
Pre-obese
25.00 - 29.99
Obese
≥30.00
Obese class I
30.00 - 34.99
Obese class II
35.00 – 34.99
Obese class III
≥40.00
Anthropometric indicators for children
The three indices commonly used in assessing nutrition status of children are;
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 Height/length for age
 Weight for age
 Weight for length/height
The indices used to identify three nutritional conditions for children:
•
•
•
Underweight: low weight for age
Stunting: low height for age
Wasting: low weight for height
TOPIC 3; METHODS OF NUTRITIONAL ASSESSMENT
1. ANTHROPOMETRIC
Anthropometric are physical measurements that reflect body composition and development.
They serve three main purposes;
A. To evaluate the progress of growth in pregnant women, infants, children and adolescents
B. To detect under-nutrition and over-nutrition in all age groups
C. To measure changes in body after some times
Anthropometric measurements are a
an
of
as
at
of
by
The most basic of anthropometric measurements are weight and height. Anthropometric
measurements are used to determine a human being’s nutritional and general health status.
Measuring weight and height of infants and children is an international health practice that
provides a readily accessible, inexpensive, objective method to ascertain the health history and
health status of a child.
A weight measurement along with a height measurement is a powerful tool; with them a clinician
has a direct record of the prior health status and dietary intake of a child and his/her future risk
status for poor health. Weight and height measurements are essential to Children’s health watch
in order to:
 Identify malnourished infants and children.
 Identify infants and children at-risk for malnutrition.
 Link at-risk children to medical and social services.
 Evaluate the overall health status of children
Anthropometric Measures
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i.
Height (cm)
The subject stands erect & bare footed on a stadiometer with a movable head piece. The
head piece is leveled with skull vault & height is recorded to the nearest 0.5 cm.
ii.
Weight (kg)
Use a regularly calibrated electronic or balanced-beam scale. Spring scales are less reliable.
Weigh in light clothes, no shoes. Read to the nearest 100 gm (0.1kg)
iii.
iv.
v.
vi.
Mid Upper Arm Circumference; it measures the muscle as and subcutaneous fat. MUAC
should be measured on the left upper arm while the arm is hanging down the side of the
body and relaxed. The tape should be placed at the midpoint between the shoulder and
the tip of the elbow. It is recommended to use a string instead of the MUAC tape to find
the midpoint.
Head circumference; it reflects the brain growth and development in infants and children
under two year
% body fat (BIA: Bioelectrical Impedance Analysis)
 Widely used method for estimating body composition.
 Relatively simple, quick, and noninvasive.
 Determines the electrical impedance of body tissues, which provides an estimate of
total body water (TBW).
 Using values of TBW derived from BIA, one can then estimate fat-free mass (FFM)
and body fat (adiposity).
Skinfold thickness measurements
These measurements provide an estimate of the size of the subcutaneous fat depot, which
in turn, provides an estimate of total body fat. Skinfold thickness and arm circumference
are two measurements that indirectly assess fat and fat-free mass.
Skinfolds:
The following skin folds thickness are taken;


Triceps skinfold: Measured at the midpoint of the back of the upper arm
Biceps skinfold: Measured as the thickness of a vertical fold on the front of the upper
arm, directly above the center of the cubital fossa, as the same level as the triceps
skinfold.
 Subscapular skinfold; measured below and laterally to the angle of the shoulder
blade, with the shoulder and arm relaxed. Placing the subjects arm behind the back
may assist in identification of the site. The skin fold should angle 45 degree from
horizontal, in the same direction as the inner border of the scapula.
 Suprailiac skinfold; Measured in the mid axillary line immediately superior to the
illiaccrest. The skinfold is picked up obliquely just posterior to the mid axillary line
and parallel to the cleavage lines of the skin.
Other measurements include
i.
Waist circumference
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ii.
iii.
Hip circumference
Etc
Advantages of Anthropometry
 Objective with high specificity & sensitivity
 Measures many variables of nutritional significance (Ht, Wt, MAC, HC, skin fold
thickness, waist & hip ratio & BMI).
 Readings are numerical & gradable on standard growth charts
 Readings are reproducible.
 Non-expensive & need minimal training
Limitations of Anthropometry
 Inter-observers errors in measurement
 Limited nutritional diagnosis
 Problems with reference standards, i.e. local versus international standards
 Arbitrary statistical cut-off levels for what considered as abnormal values
Practices;
Students to practice on taking anthropometric measurements
2. BIOCHEMICAL ASSESSMENT
Biochemical assessment also known as laboratory assessment measures a nutrient or its
metabolite in one or more body fluids such as blood and urine, or feces to indicate infection or
disease. For example estimation of the concentration of serum albumin is an indicator of protein
status of the body. Biochemical measurements of a nutrient or its metabolites, storage or
transport compound, or an enzyme that depend s upon some vitamin or mineral, are functional
measures. These are better indicators of nutritional status than directly measuring the blood
levels of a nutrient such as vitamin A or calcium.
Types of biochemical (chemical) techniques used in nutritional assessment
i.
ii.
iii.
iv.
v.
vi.
vii.
Measurement of nutrient concentration in the blood.
Measurement of the urinary excretion of a nutrient.
Measurement of the urinary metabolites of a nutrient.
Detection of abnormal metabolites in urine or blood resulting from a nutrient deficiency.
Measurement of changes in blood constituents or enzyme activities which are dependent
upon the nutrient intake.
Measurement of ‘tissue specific’ chemical markers.
Saturation, loading and isotope tests.
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Different biochemical methods of assessment of nutrition status can provide data that may reflect
a person's recent dietary intake or long-term intake, or it may not reflect intake at all.
Many variables can affect nutrient levels in body fluids. These include activity level, stress, age,
gender, and the status of other nutrients.
A table showing biochemical tests useful for assessing nutrition status
Nutrients
Assessment test
Protein
Urinary creatine excretion, serum albumin, serum prealbumin, serum
transferrin, retinol-binding protein, total lymphocyte count, nitrogen
balance
Vitamin A
Retinol-binding protein, serum carotene
Thiamine
Erythrocyte (red blood cell) transketolase activity, urinary thiamine
Riboflavin
Erythrocyte glutathione reducrase activity, urinary riboflavin
Vitamin B6
Urinary xanthurenic acid ecretion after tryptophan load test, urinary
vitamin B 6 , erythrocyte transaminase activity
Niacin
Urinary metabolites NMN (N-methyl nicotinamide) or 2-pyridone
Vitamin B12
Serum vitamin B12, erythrocyte vitamin B12
Biotin
Serum biotin, urinary biotin
Vitamin C
Serum or plasma vitamin C, urinary vitamin C
Vitamin D
Serum alkaline phosphatase
Vitamin E
Serum tocopherol, erythrocyte hemolysis
Vitamin K
Blood clotting time (prothrombin time)
Minerals
Potassium
Serum potassium
Magnesium
Serum magnesium
Iron
Haemoglobin, haematocrit, serum ferritin, total iron binding capacity,
transferrin saturation, erythrocyte protoporphyrin, mean corpuscular
volume, serum iron
Iodine
Serum protein-bound iodine, radioiodine uptake
Zinc
Plasma zinc, hair zinc
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Advantages of Biochemical Method
 It is useful in detecting early changes in body metabolism & nutrition before the appearance
of overt clinical signs.
 It is precise, accurate and reproducible.
 Useful to validate data obtained from dietary methods e.g. comparing salt intake with 24hour urinary excretion
Limitations of Biochemical Method




Time consuming
Expensive
They cannot be applied on large scale
Needs trained personnel & facilities
3. CLINICAL ASSESSMENT OF NUTRITION STATUS
Nutritional assessment begins with a detailed nutritional history that includes clinical, dietary,
socioeconomic, and family issues.
Clinical assessment;
1. Is an essential features of all nutritional surveys
 Is the simplest & most practical method of ascertaining the nutritional status of a group of
individuals
 It utilizes a number of physical signs, (specific & non specific), that are known to be
associated with malnutrition and deficiency of vitamins & micronutrients
In clinical assessment;

Good nutritional history should be obtained
General clinical examination, with special attention to organs like hair, angles of the
mouth, gums, nails, skin, eyes, tongue, muscles, bones, & thyroid gland.
 Detection of relevant signs helps in establishing the nutritional diagnosis
Advantages
 Fast & Easy to perform
 Inexpensive
 Non-invasive
Limitations

Does not detect early cases
A table showing clinical signs of nutrients deficiencies
Clinical signs
Possible deficiencies
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HAIR:
Spare & thin
Easy to pull out
Protein, zinc, biotin deficiency
Protein deficiency
Corkscrew coiled hair
Mouth
Glossitis
Bleeding & spongy gums
Angular stomatitis, cheilosis &
fissured tongue
Leukoplakia
Sore mouth & tongue
Eyes
Vit C & Vit A deficiency
Riboflavin, niacin, folic acid, B12 , pr.
Vit. C,A, K, folic acid & niacin
B 2,6,& niacin
Vit.A,B12, B-complex, folic acid & niacin
Vit B12,6,c, niacin ,folic acid & iron
Night blindness, exophthalmia
Photophobia-blurring,
conjunctival inflammation
Nails
Vitamin A deficiency
Vit B2 & vit A
Deficiencies
Spooning
Transverse lines
Skin
Iron deficiency
Protein deficiency
Pallor
Follicular hyperkeratosis
Flaking dermatitis
Pigmentation, desquamation
Bruising, purpura
Goiter
Folic acid, iron, B12
Vitamin B & Vitamin C
PEM, Vit B2, Vitamin A, Zinc & Niacin
Niacin & PEM
Vit K ,Vit C & folic acid
Iodine deficiency
Another example on clinical manifestations of acute malnutrition
Acute malnutrition is defined by the presence of bilateral pitting oedema and wasting (defined by
low mid-upper arm circumference [MUAC] or weight-for-height [WFH]). Acute malnutrition is
caused by a decrease in food consumption and/or illness.
 The following terms are used to describe the clinical manifestations of severe acute
malnutrition (SAM):
-Marasmus (severe wasting)
-Kwashiorkor (bilateral pitting oedema)
-Marasmic kwashiorkor (bilateral pitting oedema and severe wasting)
 Familiarity with these clinical signs will help health care providers triage cases efficiently –
even before measurements are made.
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 In most cases the anthropometric measurements will confirm these clinical diagnoses, but in
a few cases there might be clinical but no anthropometric confirmation (e.g., observing that
the skin on the buttocks has a “baggy pants” look.)
Clinical signs of marasmus
A child with marasmus might have these characteristics:
 Thin appearance, “old man” face
 Apathy: the child is very quiet and does not cry
 The ribs and bones are easily seen
 The skin under the upper arms appears loose
 On the back, the ribs and shoulder bones are easily seen
 In extreme cases of wasting, the skin on the buttocks has a “baggy pants” look
 No bilateral pitting oedema
These children have lost fat and muscle and will weigh less than other children of similar height.
Indicator:
Picture;




Severe wasting :
MUAC < 110 mm
Z-score < -3 (WHO)
WFH < 70% of median (NCHS)
Clinical signs of kwashiorkor (bilateral pitting oedema)
A child with kwashiorkor (bilateral pitting oedema) might have these characteristics:
o
o
o
o
o
o
o
“Moon face”
Dermatosis: flaky skin or patches of abnormally light or dark skin (in
severe cases)
Apathy, little energy
Loss of appetite
Hair changes
Irritable, cries easily

Bilateral pitting oedema
Indicator;
Picture;
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4. DIETARY ASSESSMENT
It is the process of evaluating what people eat by using one or several intake indicators. It is the
best approach for identifying nutrients that are likely to either be under-or over consumed by the
individual or groups of interest and it can be used to identify food patterns and preferences.
Dietary status is not necessarily reflective of nutrition status i.e eating well does not necessarily
translate to good nutrition status- it can be influenced by disease such as diarroea, malabsoption,
diabetes.
Dietary methods are an indirect way of assessing nutrition status. Dietary assessment can either
be:
1. Food intake-what is consumed in reference to RDA
2. Food consumption patterns.
Dietary assessment protocols consist of three stages:
1.
2.
3.
Measurement of food intakes using a method appropriate for the study objectives
Calculation of nutrient intakes.
an evaluation of nutrient adequacy which can involve
 assessment of dietary diversity (average number of different foods consumed
per day) and selected indices of dietary quality such as intakes of animal
source foods (g/d);
 Percentage of energy from protein, fat and animal protein;
 Selected nutrient densities; and
 dietary practices
Dietary assessment methods used can be take place using two major approaches/methods:
Accurate dietary approaches and rapid dietary pproaches.
ACCURATE DIETARY APPROACH
a) Duplicate
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 The duplicate method of dietary assessment is applicable when a duplicate portion of all
food and drink consumed throughout the day is retained.
 The identical portions are weighed, by the respondent (or fieldworker) and usually a
concurrent weighed diet diary is maintained.
 All food is chemically analyzed by bomb calorimetry.
 Sometimes, multiple days of assessment may be combined into a single composite, and
then homogenized before analysis; this does not provide data on within-person variation
Advantages
1. The method provides accurate nutrient intake data which is not subject to the errors
inherent in data processing including the limitations of food composition data
2. It is an objective measure of dietary assessment
Disadvantages
1.
2.
3.
4.
5.
The method is expensive
It imposes a high individual burden
Individuals must be literate, numerate and highly motivated
Unsuitable for large-scale studies
It is unlikely to capture habitual diet unless adequate days are assessed, but even then
there is a high chance of this method altering food intake to ease the burden
6. Relies on the respondent providing a complete duplicate of consumption
b) Weighed food diaries
 Weighed food diaries (diet diaries or food records) are a detailed prospective
dietary assessment method.
 An individual undertaking a weighed food diary, records details of food and drink
eaten at the time of consumption.
 Instructions and record sheets or booklets are provided, together with a set of
weighing scales for the food and drink
 Portions of food are weighed on to a plate and described in detail in the record
booklet
 Brand names, a complete description of the method of preparation, cooking and
recipes for composite dishes should be recorded.
 Plate waste is often weighed and recorded separately.
 A short questionnaire can be included to aid interpretation of the record and
provide details of core foods regularly eaten e.g. type of milk and to inquire about
non-food items such as dietary supplements.
 The food record may also be maintained either by digital audio recording or
electronically.
 Seven days of recording is historically most common, but longer or shorter
periods can be used depending on the aims of the dietary assessment
 Seven days of recording mean that the assessment is not biased towards certain
days of the week and this is important for infrequently eaten foods.
 Non-food items such as water, dietary supplements and alcohol are also recorded.
Advantages
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1. The method is still considered the gold-standard method for dietary assessment
2. It does not rely on individual memory and recall as the food/drink are recorded at the
point of consumption
3. Provides exact portion sizes and therefore does not rely on portion size estimation
4. Detailed descriptions of the foods consumed and all eating occasions are provided
5. Suitable to capture foods eaten on a regular basis
6. Excellent estimates for energy, nutrients, foods and food groups
Disadvantages
1. The method is time consuming and labour intensive for both study/survey participants
and researchers and is therefore very costly in staff time and equipment
2. Dietary data input and translation into nutrient data is complex
3. The weighed food diary imposes the biggest respondent burden of all methods and
individuals must be motivated and compliant
4. The individual must be numerate and literate
5. The individual may alter his/her diet to make it easier to record
6. Weighing food eaten away from home can be difficult for the individual
7. Several days of recording are necessary because of daily variations in most people’s diet
(minimum 3 days). Seven days are commonly recorded but recording can become less
accurate towards the end of the period because of study fatigue. The intake recorded may
not be ‘typical’ diet.
8. Foods eaten less than once or twice a week may not be captured
c) Estimated Food diaries
Estimated food diaries or records are a prospective dietary assessment method which
provide detailed data on food and nutrient intakes
Individuals record details of foods and beverages consumed at the time of
consumption
Brand names, cooking and preparation methods should be provided by respondents.
Portion sizes should be estimated and photographs, household measures or natural
unit sizes (e.g. slices of bread) are commonly used for this.
Foods can also be weighed and recorded if an individual chooses, but the main
purpose of using this method is to avoid the burden of weighing.
Traditionally the method is pen and paper based but the food diary may also be
completed either by digital recording or electronically.
Although not as complex as the weighed diary, the method requires a detailed
explanation of how to carry out the recording of diet that is best done face-to-face.
At the end of the assessment period, ideally a trained interviewer should go through
the record with the individual to clarify details – this could be done by telephone.
A short questionnaire can be included to aid interpretation of the record and provide
details of core foods regularly eaten e.g. type of milk and to inquire about non-food
items such as dietary supplements.
Parents/caregivers can complete diaries for young children or in addition to children
in older age groups.
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Individuals may record the time, location and whether the respondent was alone or
with others for each eating occasion, thus providing information on eating patterns
and the social context of eating.
Advantages
1. Recorded at point of consumption so there is no reliance on an individual’s memory
2. Portion size often well described so estimates are usually good and this reduces error
associated with quantification
3. Detailed description of foods consumed are provided which enhances the accuracy of diet
coding
4. All eating occasions are recorded in real time
5. Surrogates can be used for those not able to complete a written record, such as
parents/caregivers for young children and caregivers/adult children for the elderly
6. Meals can be photographed to aid interpretation of portion size and details of food items
consumed
7. Recordings can be made away from home relatively easily and the method is flexible and
suits people with erratic lifestyle habits
8. It is suitable for the assessment of foods eaten regularly
9. Provides good estimates of energy and most nutrients, foods and food groups
Disadvantages
1. It is time consuming and costly to turn the diaries into nutrient data
2. The individual must be literate and be motivated as the method imposes a large burden,
although much less than the weighed method
3. The individual may alter his/her diet to make it easier to record, or to cover up poor
eating habits
4. Subjects may forget to record food items or even meals consumed
5. The portion sizes of some foods may be difficult to estimate if the description given by
the individual is inadequate
6. The assessment of foods eaten less than once or twice a week may not be accurate
7. Several days of recording are necessary because of daily variations in what people eat
(minimum 3 days); seven days are commonly recorded but recording can become less
accurate towards the end of the period because of study fatigue.
8. For children foods eaten when not in the charge of parents may be missed or less
accurately recorded
RAPID METHODS OF DIETARY SURVEYS
1. 24 Hr Recall
 The 24-hour recall method is a way to take a snapshot of an individual’s usual eating
habits.
 As the name suggests, the aim is to detail everything one ate over the previous 24
hours.
 This is done in conversation with the nutritionist during consultation.
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 The nutritionist asks about the foods one ate, the mood at the time and the setting of
the meal – for example, were you out for dinner with friends, or standing on your own
in the kitchen.
 The nutritionist will ask about the portion size of each food, how the food was
prepared and how the food was served – did you add salt at the table, for example.
 It is quick, easy, & depends on short-term memory, but may not be truly
representative of the person’s usual intake
Home work; develop a 24 hour recall questionnaire
2. Dietary history
The method is a detailed retrospective dietary assessment used more often in clinical
practice than in research studies.
A diet history is used to describe usual food and/or nutrient intakes over a relatively
long period e.g. 6 months and typically one year
A dietary history is a structured interview method consisting of questions about
habitual intake of foods from the core (e.g. meat and alternatives, cereals, fruit and
vegetables, dairy and ‘extras’) food groups in the last seven days.
This is followed by a ‘cross check’ to clarify information about usual intake in the
past 3, 6, or 12 months, depending on the aims of the assessment.7
Advantages
1. Individuals need not be literate
2. Covers usual diet in detail so only one interview is necessary for the particular time under
consideration
3. Details of individual foods are obtained
4. Comprehensive information is obtained about foods eaten less regularly
5. Energy and most nutrients can be estimated reasonably accurately
Disadvantages
1. It is essential to have well trained interviewers with a good knowledge of local foods.
2. The resulting data depend heavily on the skill of the interviewer
3. Older individuals may become fatigued and unable to complete the interview in one
session; a typical session lasts 60-90 minutes
4. The individual may not remember everything they usually consume leading to recall bias
5. The method is difficult for those with erratic eating habits such as shift workers
6. Individuals may over-report ‘good’ foods and under-report intake of ‘bad’ foods
7. It may be difficult for the individual to assess portion sizes of past meals although the
interviewer can use photographs or food models to aid this
8. It is difficult to adapt for telephone interview, self-completion or computer completion by
individual and necessitates a home visit
9. Individual food coding is necessary - this is time consuming requiring trained staff and is
consequently expensive.
3. Food frequency
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Food frequency questionnaires (FFQ) are designed to assess habitual diet by asking about
the frequency with which food items or specific food groups are consumed over a
reference period (e.g. 6 months or a year).
FFQs may be based on an extensive list of food items or a relatively short list of specific
foods.
The foods listed should be:
a) Major sources of a group of nutrients of particular interest
b) Foods which contribute to the variability in intake between individuals in the
population
c) Commonly consumed in the study population.
The length of the list of foods can range from about 20 to 200 items.
Questionnaires can be self-administered using paper or wev-based formats, or interviewer
administered, either face-to-face or telephone interview.
The frequency of food consumption is assessed by a multiple response grid in which
respondents are asked to estimate how often a particular food or beverage is consumed.
Categories ranging from ‘never’ or ‘less than once a month’ to ‘6+ per day’ are used and
participants have to choose one of these options.
Advantages
1. Low respondent burden - typically take 10-20 minutes to complete
2. Assess habitual consumption over an extended period of time
3. Comparatively easy to administer and have a low cost compared to other dietary
assessment methods
4. May be self-administered via mail or the Internet
5. Used to assess habitual consumption over an extended period of time
6. More complete data may be collected if the FFQ is interviewer administered but
respondent bias may be less if self-administered
7. Can be used to gather information on a range of foods or designed to be shorter and focus
on foods rich in a specific nutrient or a particular group of foods e.g. fruit and vegetables
8. Portion size estimates can be used to obtain absolute nutrient intakes
9. Inclusion of an open section allows respondents to record consumption of foods not
included on the food list
10. Separate sections can be included that ask about consumption of seasonal items, cooking
and preparation methods and additions to foods, including sauces and condiments
11. The standardization of responses enables FFQs to be analyzed relatively quickly
12. Computer-readable forms can be scanned into computers reducing data-entry errors
13. Existing FFQs can be modified for use in new studies if the analysis package is available
Disadvantages
1. A comprehensive list of all foods eaten cannot be included and reported intake is limited
to the foods contained in the food list
2. Accurate reporting relies on respondent memory
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3. Bias may be introduced with respondents reporting eating ‘good’ foods more frequently
(over-estimation) or the consumption of ‘bad’ foods less often (under-estimation)
4. A relatively high degree of literacy and numeracy skills are required if self administered,
although less than other methods; interviewers can help overcome this problem
5. Estimating portion sizes may be difficult and the use of small, medium and large to
describe portion size may not have a commonly accepted meaning
6. Self-administered FFQs may not be completed fully; some respondents may only
complete the questionnaire for items they are familiar with
7. Problems with interpreting questions may arise with self-administered FFQs
8. FFQs developed in one country or for a specific subpopulation are unlikely to be
appropriate for use in another country unless dietary habits are very similar
9. The food list may not be reflective of the dietary patterns of the population to be studied;
ethnic differences in a population may not be captured for example.
10. Pre-prepared meals such as ready meals or take-away foods may not be easy for
respondents to classify if the food list is based on more basic food categories
11. Validity can vary widely between foods and nutrients from the same FFQ
12. Grouping of foods into individual items may make answering some questions
problematic
NB. Students to familiarize with a food frequency questionnaire
ASSESSMENT OF FOOD CONSUMPION AT THE NATIONAL LEVEL
Food balance sheets (FBS)
Food balance sheet shows a brief picture of the pattern of the food supply of a country during a
specified reference period. It shows the food items for human consumption, along with how it is
produced, used, imported/exported, and how it benefits the society (per capita supply).
The total quantity produced in a country added to the total quantity imported and adjusted to any
change in stocks that may have occurred since the beginning of the reference period gives the
supply available during that period.
On the utilization side a distinction is made between the quantities exported, fed to livestock +
used for seed, losses during storage and transportation, and food supplies available for human
consumption. The per capita supply of each such food item available for human consumption is
then obtained by dividing the respective quantity by the related data on the population actually
partaking in it.
Data on per capita food supplies are expressed in terms of quantity and by applying appropriate
food composition factors for all primary and processed products also in terms of dietary energy
value, protein and fat content. The food balance sheet covers production, trade, feed and seed,
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waste, other utilization, availability, quantities, calories, proteins, and fats. By combining these
elements, one is able to detect the food security of a country, how reliant it is on imported
crops/foodstuffs, and how it attributes to world exports.
Advantages
1. Annual FBS tabulated regularly over a period of years will show overall trends in the
national food supply, disclose changes that may have taken place in the types of food
consumed, i.e., the pattern of the diet, and reveal the extent to which the food supply of
the country as a whole is adequate in relation to nutritional requirements.
2. By bringing together the larger part of the food and agricultural data in each country, FBS
are useful in making a detailed examination and appraisal of the food and agricultural
situation in a country as well as comparisons of exports and imports.
3. Data on per capita food supplies are an important element for projecting food demand.
This data is the basis of projections into the future and are used with other information
such as income elasticity and national income forecasts to analyze various possible future
scenarios
4. They are often overlooked in the statistical system. Identification of important gaps in the
available data might also stimulate the improvement of national statistics at the source.are good source of information
5. The calorie values obtained as the mean in the FBS become proxies for the food
consumption mean intake and when combined with the variance in food consumption
data collected from household consumption - or expenditure surveys - are used to
estimate the distribution (function) of food intakes in the country.
Disadvantages
1. The accuracy of FBS depends on the reliability of the underlying basic statistics of
population, supply and utilization of foods and on the accuracy of the nutritive value data
of various foods which is usually the mandate of the national health and nutrition
authorities. The data vary a lot both in terms of coverage and accuracy.
2. FBS do not give any indication of the differences that may exist in the diet consumed by
different population groups, e.g., people of different socio-economic groups, ecological
zones or geographical areas within a country.
3. Do provide information on seasonal variations in the total food supply
2. Market Data Base
Commercial market databases report projected sales of packaged foods sold in grocery
stores. This information can be used to analyze trends in consumer purchases of foods,
food groups, or individual brands nation-wide.
NB. Formulate advantages and disadvantages together with students
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ASSESSMENT OF FOOD CONSUMPTION AT THE HOUSEHOLD LEVEL
Household food consumption is the amount of food available for consumption in a household,
not counting food eaten away from home unless it was taken from the home. Food consumption
per capita is calculated in terms of income level, family size, region, and other socio-economic
characteristics. Estimates can be made of nutrient intake per capita by multiplying average food
consumption data by nutrient values of foods from nutrient data tables.
1. Food account method
In this method, a person in the household keeps a daily record of all food entering the household
during a given time period, usually seven days. Food is not counted if it is consumed outside the
home, discarded as plate waste, or fed to pets. The method makes fairly little demand on the
household recorder, and is inexpensive to use for a large population. The resulting data provides
information on the mean food consumption and selection patterns of a population.
2. List recall method
In this method, an interviewer asks a person in the household to recall all food used by the
household on an as-purchased basis. Quantity and price of foods are noted for a certain period
of time, usually one to seven days
5. SOCIO-DEMOGRAPHIC ASSESSMENT
Socio demographics like the age, marital status, sex, religion etc may influence dietary practices
and therefore affect the nutrition status . Also socio-economic factors profoundly affect nutrition
status. Socioeconomic status is a major indicator of nutritional status (Keding & Krawinkel,
2008). The ethnic background and educational level of both the client and the other members of
the household influence food availability and food choices. An understanding of the community
environment is also important in assessing nutrition status. For example, the interviewer should
be familiar with the food habits of the major ethnic group within the locale, regional food
preferences, and nutritional resources and programs available in the community. Local health
department and social agencies often can provide such information.
Level of income also influence the diet. In general, the quality of the diets declines as income
falls. At some points, the ability to purchase the foods required to meet nutrients needs is lost; an
inadequate income puts an adequate diet out of reach. Agencies use poverty indexes to identify
people at risk for poor nutrition and to qualify people for government food assistance programs.
Low income affects not only the power to purchase food but also ability to shop for, store, and
cook them.
Culture, access, knowledge, disease and stress are major factors affecting diet and nutrition
status. When financial concerns are present, meals are often skipped and food that is purchased
may not provide a nutritionally adequate diet.
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Important information on socio demographic include access to grocery, education, ethnic
identities, income, kitchen facilities, number of people in a household etc.
TOPIC 4: TYPES OF NUTRITIONAL SURVEYS
1. Assessment of lactation
Maternal Infant and Young Child Nutrition (MIYCN) influence what, how and when the
infant or child is feed, with direct effect on nutrition status. It is important to collect this data
to help in understanding anthropometric indicators.
A semi-structured questionnaire used over a reference period, and, for different age groups,
observation, case studies, KAP study etc. is developed to collect the data.
Different MIYCN indicators can be collected in an assessment depending on the objective.
Data is analyzed and presented in a descriptive manner as well as linking it with nutrition
status.
INDICATOR
RECOMMENDATION
OTHER COMMENT
Initiation of breastfeeding
Within one hour of birth
For children born within 24 hours
Exclusive breast feeding
First 6 month of birth
Introduction
complementary feeding
of At the age of six months
Solid and non-solid foods
Dietary diversity
Variety e.g. 4 food group
Food
group
influences cut off
Meal frequency
Depends on the age of See meal frequency below for
child and breastfeeding complementary feeding
status
Duration of breastfeeding
Two years and above
Median duration is obtained in an
assessment
OTHERS
Consumption
foods
of
classification
certain e.g. iron rich/fortified
Breastfeeding up to 1 or 2 Depend on the objective
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years
Children ever breastfeed
Depend on the objective
Milk feeding frequency
At least two feedings for
non-breast fed
Bottle feeding
Not recommended
May be collected for intervention
2. Complementary feeding
On complementary feeding, the questionnaire is developed that assesses among others the
information in the table below.
Frequency and amounts of foods
Age
Frequency
Amount at each meal
7 – 9 months
3 times a day plus frequent breastfeeds
Increasing gradually to 2/3 of
250ml cup at each meal
9 – 11 moths
3 meals plus 1 snack between meals ¾ of a 250 ml cup/bowl
plus breastfeeds
12 – 24 moths
3 meals plus 2 snacks between meals A full of a 250 ml cup/bowl
plus breastfeeds
3. Other non-anthropometric data important in nutrition survey
 Other non-anthropometric data collected due to its linkage with health and ultimately
nutrition status include;
 Water – availability, access, quality and quality
 Sanitation – availability and utilization of sanitation facilities such as latrines,
waste disposal
 Health – availability and utilization of health facilities
 Methodology - information is collected at the household level using a semi-structured
questionnaire, observation, FGD
 Some of the indicators collected include;
Indicators
Recommended
Other
commended
Availability of safe water
Safe water (treated either at source or Proper source
storage)
and
system
maintained
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Distance to the water source
Maximum distance of 500 meters
Time taken to and from water Queuing an source not more than 15
source
minutes, takes more than three minutes
to fill a 20 liters container
Water collecting and storage Atleast two 10-20 L collecting container
containers
and enough for storage
Quantity of water
15 liters/person/day
Others
Depend on objective
For drinking,
cooking
and
hygiene
 Some of the indicators of sanitation collected include;
Excreta disposalAvailability of washing detergent e.g. soap
Maximum of 20 persons per toilet
Availability of male and female toilet
Toilets not more than 50 m from dwelling
Immediate and hygienic disposal of children faeces
Maintenance of toilet
 Some of the health data collected include
General morbidity
Common childhood illnesses, ARI, diarrhea, measles, malaria
Coverage/status for health-related programs; polioimmunisation, measles
vaccination, vitamin A supplementation
Access and utilization of health facilities
Admission to feeding facilities/coverage
Health seeking behavior – whether and how health assistance is/was sought
The data is triangulated in the analysis and classification of the nutrition situation is done.
4. Dietary intake
Nutritional intake of humans is assessed by five different methods. These are:
i.
ii.
iii.
iv.
v.
24 hours dietary recall
Food frequency questionnaire
Dietary history since early life
Food dairy technique
Observed food consumption
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A. 24 Hours Dietary Recall
o A trained interviewer asks the subject to recall all food & drink taken in the previous
24 hours.
o It is quick, easy, & depends on short-term memory, but may not be truly
representative of the person’s usual intake
B. Food Frequency Questionnaire
o In this method the subject is given a list of around 100 food items to indicate his or
her intake (frequency & quantity) per day, per week & per month.
o Inexpensive, more representative & easy to use.
C. Dietary History
o It is an accurate method for assessing the nutritional status.
o The information should be collected by a trained interviewer.
o Details about usual intake, types, amount, frequency & timing needs to be obtained.
o Cross-checking to verify data is important.
D. Food Dairy
o Food intake (types & amounts) should be recorded by the subject at the time of
consumption.
o The length of the collection period range between 1-7 days.
o Reliable but difficult to maintain.
E. Observed Food Consumption
o The most unused method in clinical practice, but it is recommended for research
purposes.
o The meal eaten by the individual is weighed and contents are exactly calculated.
o The method is characterized by having a high degree of accuracy but expensive &
needs time & efforts.
Interpretation of Dietary Data
1. Qualitative Method

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


Using the food pyramid & the basic food groups method.
Different nutrients are classified into 5 groups (fat & oils, bread & cereals, milk
products, meat-fish-poultry, vegetables & fruits)
Determine the number of serving from each group & compare it with minimum
requirement.
2. Quantitative Method
The amount of energy & specific nutrients in each food consumed can be calculated
using food composition tables & then compare it with the recommended daily intake.
Evaluation by this method is expensive & time consuming, unless computing
facilities are available.
Computer programs e.g. Nutri survey may be used
5. Growth monitoring
Growth monitoring and promotion
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Growth monitoring can be defined as the regular recording of a child's weight, coupled with
some specified remedial actions if the weight is abnormal in some way. Growth promotion
includes growth monitoring of children (weighing and charting of weights), but goes beyond that
to identify growth problems (in partnership with mother or caregiver), formulate actions in
response to problems, and follow-up the effects of agreed-upon interventions. Although the
causes of growth faltering and the responses to it may be region specific, the process is the same,
and we consider here growth monitoring in both the deprived and richer populations of the
world.
Even if the behavior changes do not achieve the internationally accepted feeding guidelines, they
can maintain or improve the growth and nutrition status of a youngster; for example, feeding an
extra 2-3 spoonful’s of rice to each meal, or instituting exclusive breastfeeding can keep a child
from faltering and thus on an adequate growth trajectory
Roles/Objectives of GMP in Children
1. The main role is to identify growth disturbances or concerns. Necessary interventions can
be taken basing on the results of anthropometry.
2. Improving nutrition status of children and reducing mortality and morbidity
3. Delivering of promotional and educational nutrition messages to mothers and/or
caregivers. However, this is somewhat ineffectiveness in particular the growth chart is
poorly understood by mothers
4. To provide regular contact with primary health services.
Weight measurements

Weight measurement aim at determining the degree wasting, acute
malnutrition( SAM OR MAM)
 Growth charts are used to compare a child's height, weight, and head size against
children of the same age
 Growth charts were developed from information gained by measuring and weighing
thousands of children. From these numbers, the national average weight and height
for each age and sex were established.
 The scope of this subject confines us to weight only
 Weight is measured in ounces and pounds, or grams and kilograms.
 In Kenya, we use Kg and grams.
 Each of the weight measurements taken every time a child visits MCH is recorded in
their growth monitoring cards and compared to national standards.
 Average birth weight in Kenya is 2.5 Kg
 Low birth weight babies are newborns weighing less than 2,500 grams, with the
measurement taken within the first hours of life, before significant postnatal weight
loss has occurred.
Children at risk
 Those who live in families with food shortages
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

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

Interventions
Those with compromised immunity HIV/AIDS and T.B
Diseases such as diarrhea.
Low birth weight infants
Poor hygiene and sanitation
Refugees and displaced persons
A. Nutrition education
Combination of educational strategies, accompanied by environmental support, designed to
facilitate voluntary adoption of food choices and other food- and nutrition-related behaviors
conducive to health and well-being. Nutrition education is delivered through multiple venues and
involves activities at the individual, community, and policy levels
The work of nutrition educators take place in colleges, universities and schools, government
agencies, cooperative extensions, the food industry, voluntary and service organizations and with
other reliable places of nutrition and health education information.
B. Nutrition counseling
Process of identifying and labeling of a nutrition problem and having an extensive discussion it.
The nutrition counselor facilitates the sessions and transfers knowledge to the counselee.
Nutrition counseling goes beyond just knowledge transfer, the counselee is an active participant.
Nutrition counselors are change agents in dietary patterns.
Components of nutrition counseling
i.
Nutrition assessment and diagnosis- this helps identify and label the nutrition problem
in a Problem, Etiology and Symptoms (PES) format.
e.g Inappropriate feeding practices related (RT) to lack of knowledge as evidenced by
(AEB) infant receiving solid foods.
ii.
Goal setting
Once the problem has been identified, goals are set. Service provider and client have to
agree on expected outcomes
iii.
Planning and intervention
Planning involves identification of possible solutions, priotizing the solutions and
implementing the most viable solution
iv.
Follow up
At the end of counseling session, set date and time of the next appointment. Clients
should receive routine counseling sessions so that their progress towards achievement of
better nutrition standards can be revised as need may arise.
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C. Demonstrations
This is the action or process of showing the existence or truth of something by giving proof
or evidence. A nutritionist may demonstrate on best breast feeding practice, cooking of food
etc.
D. Supplementation
A supplement is something added to complete a thing, make up for a deficiency, or
extend or strengthen the whole.
A dietary supplement is intended to provide nutrients that may otherwise not be
consumed in sufficient quantities.
There are more than 50,000 dietary supplements available
Dietary supplements are unnecessary if one eats a balanced diet
Supplementation programmes common in Kenya
1. Vitamin A Supplementation
Vitamin A supplementation coverage rate (% of children ages 6-59 months) in
Kenya was last measured at 62 in 2010, according to the World Bank.
Vitamin A supplementation refers to the percentage of children ages 6-59 months
old who received at least one high-dose vitamin A capsule in the previous six
months
At six months, the child receives 100,000 iu, blue capsule
After every 6 months, the dosage increase to 200000 international units red
capsule until the age of 59 months
Mothers also receive 200000 international after delivery to recover depleted
maternal stores and pass on some to the new born
Deficiencies in Vit A are characterized by night blindness, xerophthalmia
(crowding of the cornea of the eye), impaired immune function and "Bitot's Spotscollection of keratin in the conjunctiva
Note, vit A supplementation is contraindicated in oedematous children.
2. Iron supplementation
 Done reverse iron deficiency in both children and women
3. Folic acid supplementation (vit B 9)
 For pregnant women to prevent neural tube defects such as spina bifida and
anencephaly(is a condition that prevents the normal development of the brain and
the bones of the skull)
 Supplementation before conception, and in the first few weeks of pregnancy,
significantly and substantially lower the risk of several different birth defects
 Neural tube defects are severe abnormalities of the central nervous system that
develop in babies during the first few weeks of pregnancy resulting in
malformations of the spine, skull, and brain
4. Zinc supplementation
 Zinc-supplementation is proven to reduce the duration and severity of childhood
diarrhea
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


Zinc is found in a variety of sources but high concentrations are found in animal
sources.
Zinc content is also high in nuts, legumes and wholegrain seeds.
Uptake of Zn is impaired by phytates and high dietary Ca levels.
Factors that affect child growth
1. Heredity is one thing that affects the children from the beginning. This deals with
the genes and characteristics that the parents passed down to their children.
2. Health- If a children is sick; their growth is likely to be slower than that of a
healthy child.
3. Eating Habits- If a parent constantly feeds the child junk food, there may be
complications then or even later on in life. A child with proper nourishment is
more likely to develop with fewer complications.
4. Exercise- The amount of laying around vs. play and exercise will affect their
development.
5. Rest- Right next to exercise, sleeping is essential to the body of a young child.
6. Disease- (similar to health) A sickly child is going to have trouble developing, and
might already be experiencing some of those troubles.
7. Family/Surroundings- A friendly and safe environment lends itself to helping the
child grow and develop. Negative surroundings are likely to carry with the
children for the rest of their lives.
Activities undertaken in growth monitoring and promotion






Growth monitoring of young children is recognized as an effective means of
detecting growth faltering early, providing a critical opportunity for taking the
preventive or curative actions needed.
Some of the activities engaged in to ensure this happens include: Anthropometry
(height, weight and MUAC), recording and plotting weights on the growths cards,
making comparisons with standard deviations to detect any growth disturbances,
finding solutions to any detected problems (nutrition counseling) and even
demonstrations on how to implement the agreed-upon interventions (say)
preparation of supplementary diet.
Referrals are also made for sick children.
Health/nutrition education
Facility planning education
Supplementation
Follow-up
TOOLS USED GROWTH MONITORING AND PROMOTION
1. SD in terms of Z-score charts
2. Percentiles
3. Road to health (RTH)/child health cards
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1. SD in terms of Z-scores.
Well distributed curves, the mean and median are usually at zero.
Y-Values
 >-1 SD Z-score is normal
 <- 1SD > -2 mild under-nutrition
 <- 2SD > -3 moderate under-nutrition
 <- 3SD severe under-nutrition
 <- 2SD global acute malnutrition
Some changes to your child's growth chart may worry your health care provider more
than others:
2. Percentiles
 When one of your child's measurements stays below the 10th percentile or above the 90th
percentile for his or her age.
 If the head is growing too slowly or too quickly when measured over time.
 When your child's measurement does not stay close to one line on the graph. For
example, a health care provider may worry if a 6-month-old was in the 75th percentile,
but then moved to the 25th percentile at 9 months, and dropped even lower at 12 months.
3. Road to health (RTH)/child health cards
 Many parents worry if they learn that their child's height, weight, or head size is smaller
than those of most other children the same age.
 They worry about whether their child will do well in school, or are able to keep up in
sports.
 Learning a few important facts can make it easier for parents to understand what different
measurements mean:
 Mistakes in measurement can happen, for example if the baby squirms on the scale.
 One measurement may not represent the big picture. For example, a toddler may lose
weight after a bout of diarrhea, but will likely regain the weight after the illness is gone.
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

There is a wide range for what is considered "normal." Just because your child is in the
15th percentile for weight (meaning 85 out of 100 children weigh more), this number
rarely means your child is sick, you're not feeding your child enough, or your breast milk
is not enough for your baby.
Your child's measurements do not predict whether he or she will be tall, short, fat, or
skinny as an adult.
PLOTTING INTERPRETATIONS
Let students plot graphs on photocopied growth monitoring cards.
WHO Child Growth Standards were developed using data collected in the WHO
Multicentre Growth Reference Study.
The site presents documentation on how the physical growth curves and motor milestone
windows of achievement were developed as well as application tools to support
implementation of the standards.
6. Pregnancy monitoring
As outlined in the MIYCN, maternal guidelines are used to monitor nutrition in pregnancy.
Some of the guidelines are as follows;
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POLICY GUIDELINES, RECOMMENDATIONS AND KEY MESSAGES

All Pregnant women and lactating mothers should have access to and should be
knowledgeable about the need for an adequate and nutritious diet.
Recommendations and key messages
Encourage and support mothers to:
Eat one extra small meal or “snack” each day in addition to 3 meals to provide
energy and nutrition for her and the growing baby.
Eat a diversified diet, to ensure variety in the food choices using the locally
available foods. Choose foods from at least 3-4 food groups at every meal (refer
to Annex 1: Healthy Food Guide Pyramid) e.g. Wholegrain and cereals, roots and
tubers, pulses and legumes, animal source foods (meat, fish, poultry, eggs),
sprouted pulses, green leafy vegetables, nuts and seeds, milk and milk products,
fresh fruits and vegetables, meat, fish, poultry, eggs).
Encourage daily consumption of fruits, vegetables, legumes, and whole grain
cereals to promote healthy weights.
Take plenty of fluids and water.
Avoid taking tea or coffee with meals as it inhibits iron absorption and it can
interfere with the body’s use of the foods.
Consume Iodized salt as a pregnant woman requires sufficient iodine for brain
development of the child in the womb.
Take small frequent meals
Engage in some form of physical activity to stay healthy
Review with the mother the factors that commonly affect nutrition intake and give
advice
Integrate nutritional health promotion into primary health care services to
encourage healthy lifestyles.

Provide and promote intake of iron/folate through antenatal care services and support
other strategies to address maternal anemia
Recommendations and key messages
Mothers should be encouraged to take iron/folate tablets to prevent anemia daily
during duration of pregnancy irrespective of their hemoglobin levels (60mg of
iron and 400 µg folic acid every day).
Encourage the mother to take 400ug of folic acid daily around the time of
conception to significantly reduce the incidence of neural tube defects. Folate
supplementation should be started in the first trimester of pregnancy to prevent
birth defects.
Provide information on possible side effects and how to avoid trouble-some sideeffects when giving iron/folate supplements.
Promote an adequate diet rich in iron. Rich sources of iron include liver, milk,
eggs, legumes, dark green leafy vegetables.
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Discourage consumption of tea and coffee with a meal or shortly after a meal as it
inhibits iron absorption.
Encourage use of Vitamin C rich fruits and vegetables such as tomato, guava,
mango, pineapple, orange and other citrus fruits as they enhance iron absorption.
Germination, fermentation and soaking of cereals and legumes improve the
bioavailability of iron by reducing the content of phytate, a substance in food that
inhibits iron absorption.
Provide de-worming tablets to help prevent anemia (Mebendazole given during
2nd trimester) as per the National Focused Antenatal Care (FANC) guidelines.
Provide Intermittent Presumptive Treatment (IPT) for malaria to all mothers in
malaria endemic areas according to the National FANC Guidelines.
Incase of folic acid more than 400µg, delay intake of folic acid supplementation
for two weeks (14 days) after taking SP (folic acid reduces the efficacy of SP).
Counsel the mother on how to prevent malaria by sleeping under an insecticidetreated mosquito net (ITN) and take anti-malarial tablets (IPT) as prescribed.
Promote and encourage early seeking of treatment for infections
Encourage and promote good hygiene practices.
 Support optimal maternal nutrition through healthy weight gain during pregnancy and
lactation.
Recommendations and key messages
Counsel mothers on adequate weight gain during pregnancy
Monitor weight gain of all mothers attending ANC throughout pregnancy. Pregnant
women need to gain an average of 1 kg per month, a minimum of 0.5kgs per month
for the first trimester and there after a minimum of 1-1.5kgs per month for the last six
months.
Provide the counseling and support to pregnant women with inadequate or excess
weight gain.
Recommended weight gain in pregnancy
BMI Index (BMI pre-conception
Appropriate weight to gain
Underweight( BMI<18.5)
12.5-18 kg
Normal weight ( BMI 18.5-24.9)
12-15 kg
Overweight ( BMI 25-29.9)
7-11.5 kg
Obes
6 kg
]e (BMI >30)
Twin pregnancy
16.0-20.5
Adolescent pregnancy
Upper end of recommended values
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

NB;
Pregnant and lactating women at risk, that is, adolescents, women with low weights, HIVpositive women, and women in emergency situations, should receive special attention to
support optimal care.
Promote utilization of family planning and other health services for all women during
antenatal and postnatal care to optimize MIYCN.
 Recommendations and key messages. Encourage the mother to attend ANC
services at least four times during pregnancy.
 Provide the Mother and Child Health booklet to all pregnant women in her first
ANC visit
 Encourage family planning by discussing with the mother on the available and
most appropriate family planning method for their individual situations.
 Immunize all pregnant women with Tetanus Toxoid (TT) according to the
National schedule.
 Provide education on the risks and harmful effects of alcohol and drug abuse.
-
Nutritional assessment is done based on such policies and guidelines
Familiarize with the a nutrition survey questionnaire and find questions related to
maternal nutrition
GROWTH MONITORING AND PROMOTION (GMP)
GMP is a practice that is usually carried out in young children's clinic and in the community. Its
purpose is to help parents keep their young children healthy and well nourished. Growth- means
getting bigger, it is specific body changes and increase in body size. The child gets bigger
because the bones, muscles and other body tissues are increasing in size. Parents understand that
a sign of health is the growth of their baby. Healthy newborns double their weight ~ 4-6 months
and triple it by one year. Growth reflects nutrition adequacy, health status, economic status and
other environmental influence on the family. Accurate assessment of growth and interpretations
of growth rates .are important components of health care for infants.
Child development is the biological, psychological and emotional changes that occur in human
beings being birth and end of adolescents as individuals' progress from dependency to increasing
autonomy. They changes may occur as a result of genetically controlled processes known as
maturation or as a result of environmental factors and learning but most commonly as a result of
the interaction between the two.
Development changes may also occur as a result of human nature and our ability to learn from
the environment.
Age development periods can be defined as intervals e.g.
•
Infants
4 weeks- I ~ear
•
Toddlers
1-3 years
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•
Pre-school
4-6 years
•
School age
6-13 years
•
Adolescents
13- 2_0 years
GROWTH MONITORING
It is watching over a child's growth i.e. the speed at which a child is growing which will tell
whether the child is well nourished or under nourished
It is done by plotting the weight of the child in a weight chart so as to compare the child's weight
gain to the weight gain of healthy children
• Growth monitoring involves the process of following the growth rate of a child in comparison
to a standard by periodic frequent anthropometric measurements in order to assess growth
adequacy and identify i.e. faltering early (GM is not infrequent or one-time anthropometric
measurement of a child to assess nutritional status without growth velocity over time i.e.
Nutritional surveillance/ nutrition assessment.
•Growth promotion is a means of helping healthy children to keep growing well and children to
keep growing well and children with growth failure to grow better.
•It is usually done the following information obtained from the child's weight chart
Conditions required in monitoring and promotion of growth
•Understanding on how growth and nutrition are linked
•Understanding of the weight charts
•Understanding of how GMP helps children to be well nourished
•Be able to carry out GMP activities
•Accuracy requires calibrated scales, recumbent length measurement board with an attached right
angle head piece and non-stretch tape for head circumference.
Purpose of assessing growth status times (monitoring)
•For assessing growth progress~
• Times a baby has been measured and the growth plotted, the more li~e growth trend will be
clear in spite of minor errors
It can identify a weight /length gain and the need for intervention
Growth is so fast it may be easier to determine growth problems during infancy than later.
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Warning signs of growth difficulties
1.
Lack of weight / height
11.
Plateau weight and length or head circumference for more than a month
m.
Drop in the weight without regain within a few weeks
N/B
Head increase as a result as a result of brain growth. A rapid increase in head circumference is
not a sign of nutrition but be signal that requires immediate attention to protect brain
development.
An infact that is gaining weight faster than expected than expected may be at greater risk for
overweight in the short term and needs intervention based on feeding assessment and
interventions with the parents.
FACTORS THAT INFLUENCE CHILD GROWTH
1.
Internal factors which are mainly biological
11.
Intrauterine development-placenta insufficiency
111.
Birth order (parity)
1v.
Birth weight
v.
Parental size and genetic constitution
v1.
Mothers age and maternal nutrition
EXTERNAL FACTORS
1.
Environmental
11.
Nutritional factors
111.
Economic level of family
1v.
Climatic conditions
Proximal environment- level of stimulation and the quality maternal-child interaction
Distal environment-parent education, culture, social, economic status of the households
Growth monitoring promotion
1.
It is a prevention activity comprised of growth monitoring and counselling that;
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11.
Increases awareness about child growth
111.
Improves caring practices
1v.
Increase demand for other services as needed and
v.
Serves as the core activity m an integrated child health nutrition program where
applicable.
Community based GMP is that concept that takes GMP further than individual and family level.
It takes the periodic (monthly) weighing of the child and classification of the child's progress. It
is used to not only make decisions regarding the child's care at home or the need for medical
attention, but also to stimulate activity in the community district or program to improve child's
growth in an enabling environment.
Activities of the GMP
i.
Preventive services of immunization
ii.
Vit. A supplementation
iii.
Regular growth monitoring and promoting
iv.
Nutrition education
v.
Counselling
vi.
Treatment of general illness
vii.
Adequate feeding
viii.
Proper breastfeeding practices
Growth monitoring and triple A approach
Triple A: this is Assessment, Analysis and Action. It is a UNICEF program since 1980's and it is
an effort to address health and nutrition at a family and community levels
At the family level- triple A is focused at an individual child. The link is clear between the
information on the child's growth that comes from GM activity and decision making process and
the action taken for that child. At the community level- individual child growth information can
be aggregated and serve as the foundation for triple A action at the community level and beyond
Nutrition education- is the key and important component of GMP because of the improvement of
child nutrition depends on changing feeding and caring practices in the home.
Individual nutrition counseling- is the cornerstone of effective and efficient GMP
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Regular weighing and assessing the growth of a child- provides the opportunity for
individualized nutrition education with targeted messages related to how well the child is
growing, how healthy he/she is and what how often the child eats and the care givers resources
and motivation.
GM- is the focal point for stimulating a decision a decision on growth, health and feeding for the
child.
Health follow - up and referrals - i.e. regular monitoring of the child growth is also very
important
Prevention and treatment- of common diseases like malaria and provision of food supplements
MONITORING A CHILD'S GROWTH USING ROAD TO GOOD HEALTH CHART Regular
monitoring of a child's weight plays an important role in ensuring optimal health and good
nutritional status and preventing growth faltering (too fast or too slow)
The weight is taken and plotted on a road to good health chart. The exact position of the child's
weight on the graph is more important than whether the line plotted follow the same general
direction as the curves in the growth curve.
NIB
Weighing is not an intervention but the data obtained from weighing should be used to advise the
mother according depending on whether the child is gaining or losing weight (how the child is
growing)
WARNING SIGNS OF SERIOUS UNDER NUTRITION
Signs that a child is under nourished/ likely to become (is at risk). The child's weight is below
60% of reference or at least 2 kgs below the 3rd centile”
i.
The child is losing weight
ii.
The child is gaining weight too slowly or is it ill
iii.
The child is under six months and has not gained weight for I month or
iv.
The child is under six months and has gained weight too slowly over several months
v.
The child is over 12 months and has not gained any weight for 3 months especicilay if the
weight is less than 3rd centile
vi.
The child is 6 months and has gained too slowly over several months
vii.
Then child is over 12 months and has not gained any weight for 3 months ( especially
serious if the weight is below 3rd centile)
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Advantages of growth monitoring (plotting of heights on growth charts)
1.
A family can compare the shape of their children's weight line with the reference line. If
the child is gaining weight at the same rates as the references line, then the parents knows they
are caring well for the child. If too slowly, they know the child need more food or care
2.
A family can see if their child stops gaining weight when the child is sick, they can check
that she/he is gaining lost weight quickly as the child recovers.
m.
Family and health workers can identify children with growth failure early when it is easy
to help them
1v.
Community workers can know which families have undernourished children and
therefore need help most
v.
GMP gives mothers a chance to meet regularly, deal with problems quickly and check
that the families have the information and resources that they need to help the children grow well
~ Advantages of GMP at the community levels
1.
The community has control over planning and organizing the GMP program and it can
adjust the required activities to suit their needs
2.
Since the community owns the program, they are likely to control it with ease
III.
Parents feel they have more control over their children's weight and they can check for
themselves if their children are overweight, underweight or normal or if an underweight, the
child is gaining weight.
1v.
There is reduced cost on the side of the parents and more so travel costs to the
hospital, clinics as well as medical fees, suitable cost to attend the clinic.
Limitations of community based GMP

It is less easy to supervise than clinic based

The supervisors have to learn new skills and the community members need special
training

Parents may lose interest unless they see that the program is helping their children

It may be difficult to help sick children

Growth promotions (interventions)

This is the most important and the most difficult party of GMP
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
GP is an important activity that must be done with the mother and if possible other
relatives (e.g. father) they are activities that help the healthy children grow well and the
underweight grow better.
Activities of growth promotion

Nutrition education

Nutrition counseling

Supplementation

Immunization

Follow-up
1. NUTRITION EDUCATION
This is the dissemination of information about nutrition. In nutrition education, what need to be
done on the following are discussed under GP.

When a child is gaining weight is gaining weight at a healthy rate

A child is not gaining weight at a healthy rate
Importance of nutrition education

It helps in protecting and promoting nutrition in crisis and recovery

It educates mothers on exclusive breastfeeding

It improves children and mothers health by promoting better health practices

It helps promote regular use of services when they are available

It helps mothers to know what they can do for themselves to improve their health
together with the health of their children (proper feeding practices, hygiene and general)

It helps improve women's education on planning, purchasing and preparation of
children's meal (basic information on child nutrition)
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
It creates awareness on causes, signs and symptoms and prevention of children's diseases
or disorders

It helps mothers to read and interpret growth chart
Areas where nutrition education is done

General wards - during ward rounds

Special nutrition wards-usually expensive to run, it can concentrate more on practical

Nutritional rehabilitation units- can be residential type where mothers stay with their
children for some weeks.

Nutrition clinics and maternity clinics- in some places there are special nutrition clinics
that conduct regular checks on nutritional status and follow up on children.
2. NUTRITION COUNSELING
This is face to face communication between two people where one person tries to help another to
make decisions or plan and act to solve a problem. It modifies an individual's existing habits. It is
important in that information can be controlled i.e. not too much information is given at a go,
thus not confusing. Moves from simple to complex
Steps in nutrition counseling
•
Great the client (to establish a rapport)
•
Ask the client (gather information)
•
Tell the client (provide information)
•
Explain to the client in a detailed form
•
Refer the client
Counseling guidelines
Use SOLER
•
Sit squarely
•
Open posture
•
Lean forward
•
Eye contact
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•
Relax and reassure
Importance of nutrition counseling
1.
It helps in discussing the outcomes of nutrition assessment on children which helps
mothers to understand what they ought to do to improve on nutrition of their children.
2.
Through nutrition counseling mothers are able to get better explanation on how the
diagnosis of their children was arrived at.
m.
Mothers/ care givers are involved in formulating the child's diet
1v.
It paves way for discussion of the factors that may affect the diseases (e.g. stress)
•
v.
Helps to identify knowledge capacity of mothers equipping them with better knowledge
3. Supplementation
It is the process of giving additional nutrients to a child with a deficiency to promote his or her
health growth. This helps to prevent widespread of acute malnutrition and reduce high mortality
rate among the vulnerable groups.
Importance of supplementation
It prevents nutrition health condition from worsening

Boasts the immune system of vulnerable children

Caters for inadequate nutrients intake in a child's diet

Increases growth among the affected children e.g. zinc supplement increases growth rate
in children

Reduces risks in occurrence of some conditions /defects e.g. folate supplements prevent
neural tube defects in newborns

Reduces the risk of chronic diseases
4. Immunization
Immunization against childhood disorders / diseases eg. Diptheria childhood, TT, influenza.
measles, whopping cough and hepatitis
5. Follow Up
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It is an activity where a child who is undernourished or at risk is followed especially to the
children who do not attend GMP clinics regularly, therefore visits to their home/ consult
community health workers (CHW’s), colleagues or neighbours if the child has been referred to a
senior health worker or a social worker, try to if the family has been helped. If the child goes out
to the hospital, find out what happen to him/her and monitor them carefully when discharged.
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