Nutrition Intervention
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Nutrition Intervention
Nutrition care process steps
1.
Nutrition assessment
2.
Nutrition diagnosis
3.
Nutrition intervention
4.
Nutrition monitoring and evaluation
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Definition
Nutrition Intervention:

Is purposely-planned actions designed with the intent
of changing a nutrition-related behavior, risk factor,
environmental condition, or aspect of health status
for an individual, a target group, or population at
large.
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When to intervene?
Critical periods in life span

The critical window opens during pregnancy and closes
at about two years of age.

These “1,000 days” offer the best opportunity to lock-in
future human capital.

Interventions during this period can potentially reduce
under nutrition-related mortality and morbidity by 25% if
implemented at scale.
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Selection of intervention
Some of the major considerations while choosing an
intervention strategy are:
The prevalence and severity of deficiency
The government commitment to address the problem
The existing health resources and service coverage
Level of consumption of factory products
The cost effectiveness of intervention
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Selection cont.
The recommended approach for combating serious
micronutrient deficiencies is to start with
supplementation and to shift to food fortification and
finally dietary diversification.
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UNICEF Conceptual framework: Etiology of
malnutrition
Micronutrient
malnutrition
Poor dietary
intake
Household food
insecurity
Disease
Inadequate care
Poverty
UNICEF 2001
Outcome
Poor sanitation,
& access to health
services
Immediate
causes
Underlying
causes
Basic
cause
Approaches to Nutrition Intervention
1.
Causal model based approach (CMBA)
2.
Food based approach
3.
Economic approach
4.
Life cycle approach
5.
Integrated approach
6.
Multi-sectoral approach
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Causal model based approach (CMBA)
Major intervention categories based on CMBA
1.
Supplementary & therapeutic feeding program (OTP, SC,
TSF, Deworming, Micronutrient supplementation, MND
treatment)
Targets immediate cause of malnutrition
2.
Behavior change communications + Water and Sanitation
+ Safety net programs + ITN
Targets Underlying cause of Malnutrition
3.
Increasing access to food and money to buy foods (Asset
building, Microcredit…)
Targets Basic causes of Malnutrition
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Food based approaches
 Focus on increasing nutrient content of food through
diversification or dietary modification
 Improving quality of foods
 Increase in the nutrient density of foods
 Increased production of diversified diet
 Increase consumption of diversified diet
 Bio fortification
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Economic approach
Food for work program
o Productive safety net
Income generating scheme(IGS)
Food stamp
o Giving a coupon/Stamped ticket for buying food for the
poorest of the poor.
 Food subsidy
o
Can be given to: producers or consumers
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Life cycle approach
Improving nutrition around the life-course
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WHO, 2013
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Integrated approach
 Integrating nutrition into various interventions
Therapeutic VS preventive
Emergency VS non Emergency
Nutrition VS health
Using different contacts as an opportunity for nutrition
intervention
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Integration of different services
Critical contacts for infant feeding, women’s nutrition
and PMTCT
PREGNANCY : TT,
antenatal visits, iron/folic
acid, de-worming, antimalarial, diet, risk signs,
FP, STI prevention, safe
delivery, iodized salt,
VCT, Infant Feeding
Options, Safe Sex, ARVs
DELIVERY: safe delivery,
vitamin A, iron/folic acid,
diet, FP, STI prevention,
Optimal delivery, VCT,
ARVs, Infant Feeding
Options
IMMUNIZATION:
vaccinations, vitamin A,
de-worming, assess
and treat infant’s
anemia, FP, and STI
referral, VCT, Safe Sex,
Support IF options
POSTNATAL AND
FAMILY PLANNING: ,
diet, iron/folic acid,
diet, FP, STI
prevention, child’s
vaccination, VCT,
Support IF options,
Safe Sex
SICK CHILD: monitor
growth, assess and treat
per IMCI, counsel on infant
feeding, assess and treat
for anemia, check and
complete vitamin A
/immunization/ de-worming,
VCT, Support IF options
WELL CHILD AND GMP:
monitor growth, assess
and counsel on infant
feeding, iodized salt,
check and complete
vaccination, VCT, Safe Sex
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Multi-sectoral approach
Key Principles in multi-sectoral approach
1.
Common vision and effective communication
2.
Defined Roles/Responsibilities and Continuity
3.
Accountability and joint decision-making
4.
Supportive environment and feedback mechanisms
5.
Innovation and knowledge-share
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Direct and indirect interventions

Nutritional interventions are broadly divided in to
direct and indirect

Direct interventions
◦ Are nutrition specific interventions
◦ Address more immediate determinants of
malnutrition including quality diet and access to
individual health care
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Direct interventions

Commonly includes
Increasing intake of vitamin, mineral, and other
essential nutrients
Providing therapeutic and supplementary feedings
Promoting good nutritional practices (e.g. optimal
complementary and breastfeeding)
Deworming

Usually the duty of health care system
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Indirect interventions
Nutritional sensitive interventions
Address underlying determinants of malnutrition
Example: food availability, water and sanitation,
natural resource rehabilitation, women’s
empowerment, conditional cash transfer
Usually part of multi-sectorial programs
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Classical nutritional interventions for
control of micronutrient deficiencies
1.
Supplementation
2.
Fortification
3.
Dietary diversification
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Supplementation
Supplementation: is provision of relatively large doses of
micronutrients, usually in the form of capsules, syrups
and injections
 Sometimes it can be also applied in the context of
macronutrients (e.g. high calorie food supplementation)
 Administered as part of health care or specific nutrition
campaigns
 Examples:
Iron foliate supplementation during pregnancy
Multiple micronutrient supplementation
Vitamin A supplementation to children and lactating
women

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Fortification
The practice of deliberately increasing the content of
essential micronutrients in a food so as to improve
nutritional quality and to provide a PH benefit with
minimal risk to health
 In most cases, food vehicles that are widely distributed,
widely consumed and centrally processed are preferred
 Has long history of use in industrialized countries for the
successful control of VA,VD, several B vitamins (thiamine,
riboflavin and niacin), iodine and iron deficiencies
 It requires the support from the food industry or there
should be legal reinforcement
 Good example: iodization of salt, fortification of oils, sugar
and cereals with VA, fortification of cereals and sugars with
iron

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Fortification cont.
Classification of fortification
A. Mass fortification
Fortify food that are widely consumed by the general
population
The best option when the majority of the population is
at risk of the deficiency
B. Targeted fortification
Fortify food designed for specific population subgroups
Complementary foods for young children
Rations for severely malnourished children
Food developed for school feeding programs
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Fortification cont.
C.
Market driven fortification
Food manufacturer takes a business oriented
initiative to add specific amounts of one or
more micronutrients to processed foods
D.
Households and community level fortification
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Dietary diversification
The ideal long term goal that the society should strive to
Also called food based approach
Commonly involves change in the production and
consumption of foods
Logical steps
Identification of food items, with high micronutrient
content and bioavailability
When the supply of the foods is low, promotion of
production (e.g. cultivation, keeping livestock)
Should be linked with nutritional education in order to
produce better consumer behavior
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Dietary diversification cont.
Common dietary diversification programs
Production and promotion of animal source foods:
example animal husbandry, poultry production,
aquaculture
Backyard gardening for fruits and vegetable
Promotion of household level food processing
methods like germination, fermentation and soaking to
reduce the phytate content of cereals and legumes
Bio-fortification of staple food crops
Combating food taboos
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Essential Nutrition Actions (ENA)
Seven focus areas of (ENA)
1.
Optimal Breast feeding and its benefits
2.
Optimal complementary feeding from >6 months
3.
Sick child feeding
4.
Maternal nutrition during pregnancy & lactation
5.
Control of vitamin A deficiency,
6.
Iron deficiency anemia and
7.
Control of Iodine deficiency disorders
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ENA Key messages
1. For Optimal breast feeding
Initiate breast feeding within 1/2 hr after delivery
Give colostrums
Exclusive breastfeeding for the first 6 months
Breastfeeding day and night on demand at least 8-12
times a day
Let the baby finish one breast before switching
Position and attach the baby to breast correctly
Initiate complementary food at 6 months
Continue breast feeding up to 24 months
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ENA Key messages cont.
2. For optimal Complementary feeding
Give solid/ semi solid complementary food at 6 month
CF should fulfill “FADUA” criteria
◦ F= Frequency
◦ A= Amount
◦ D= Density
◦ U= Utilization (hygiene)
◦ A= Active feeding
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ENA Key messages cont.
Frequency of CF
• Increase frequency of feeding with age of the child
Age (mont) Meal frequency/day Meal frequency per day
for breast fed baby for non-breastfed baby
6-9
2-3 times
+
1-2 snacks
10-23
3-4 times
+
1-2 snacks
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4-5 times
+
1-2 snacks
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ENA Key messages cont.
Amount of CF
• Increases the amount of food the baby eats as the baby
grows older.
Age (mo)
Amount of Kcal for Amount of K cal for the
breast fed baby
non-breast fed baby
6-8
200 Kcal
600Kcal
9-11
300Kcal
700Kcal
550Kcal
900Kcal
12-23
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ENA Key messages cont.
Density of CF
Increases thickness (density) and variety of food
◦ As the child gets older, adapting to the child's nutritional
requirements and physical abilities
Give infant pureed, mashed, & semi-solid food at 6 month
Breastfeed the child at least until 2 years old
Add protein-rich foods
◦ Animal/plant : beans, soya, chick peas, groundnuts, eggs,
liver, meat, chicken, milk.
Diversify the child’s food
Improve bioavailability (fermentation, germination)
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ENA Key messages cont.
Utilization of CF
Practices good hygiene & safe food preparation.



Feeds liquids from a small cup or bowl.
 Avoid bottle feeding : difficult to keep clean
 Contaminated bottles can cause diarrhoea
Before feeding child,
 Wash hands with soap and water,
 Use clean utensils and bowls to avoid introducing
dirt and germs.
 May use fingers (after washing) to feed child
Serve the food immediately after preparation.
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ENA Key messages cont.
Active feeding
Responsive feeding (Interact with child during)
Feeds infant directly and helps older child to eat.
Experiments with food combinations, tastes, textures to
encourage child who refuses foods.
Minimizes distractions during meals if child loses interest
easily.
Feeding times are periods of learning and love, talk to
child during feeding with eye-to-eye contact
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ENA key messages cont.
3. For sick child feeding
Breast-feeding a sick child:
◦ During illness breastfeed more frequently
◦ After illness continue to breastfeed more frequently
for two weeks
◦ Express breast milk and give with a cup if the infant too
sick to suckle
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ENA Key messages cont.
4. For maternal nutrition
◦ Give at least 1 additional meal during pregnancy
(+200-285kcal/day)
◦ Give at least two additional meals (+500-650 kcal )
per day during lactation
5. For control and prevention of IDD
◦ Provide iodized salt to the whole family
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ENA key messages cont.
6. For control and prevention of IDA
Diversified diet (iron rich foods)
Ferrous Foliate supplementation
Deworming of children 2 – 5 years
Deworming of pregnant women in 3rd trimester
Use bed net
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ENA key messages cont.
7. For control & prevention of VAD
I.
Dietary diversification
II.
Supplementation
◦ Breast feeding (give colostrums)
◦ Preventive (lactating women during the first 6 weeks after
delivery)
◦ Disease targeted (child with diarrhea, Pneumonia
◦ Therapeutic dose (measles, exophthalmia, PEM)
III.
Fortification : Vitamin A friendly foods (eg. Orange flesh sweet
potato, rice…)
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