Nutrition Care in package of service

Dr. May Khin Than Deputy Director

( Nutrition)Department of Health

Goal Role of nutrition

Goal 1: Eradicate extreme poverty & hunger

Hunger – undernutrition – undermines economic growth and perpetuates poverty. Malnutrition erodes human capital through irreversible and inter-generational effects on cognitive and physical development

Goal 3: Promote gender equality and empower women

Under nutrition in women (e.g., moderate and severe anemia) is often a reflection of gender inequality.

Goal 4: Reduce child mortality Malnutrition is directly or indirectly associated with more than 50% of all child deaths, and it is the main contributor to the burden of disease in the developing world.

Goal 5: Improve maternal health Maternal health is compromised by malnutrition, which is associated with most major risk factors for maternal mortality. Maternal stunting and iron and iodine deficiencies particularly pose serious problems.

Goal 6: Combat HIV/AIDS, malaria and other diseases.

Malnutrition may increase risk of HIV transmission, compromise antiretroviral therapy and hasten the onset of full-blown AIDS and premature death. It increases the chances of and prolongs tuberculosis infection even while being treated, resulting in spread of disease, and it reduces malaria survival rates.

Nutrition and the MDGs

16

17

5

45

8

27

Pneumonia *

Diarrhoea *

Malaria *

Neonatal

Injuries

Others

Vaccine-preventablediseases*

Causes of children U5 deaths in UNICEF East Asia Pacific region

Ref: WHO causes of death database & Undernutrition as an underlying cause of child deaths associated with diarrhoea, pneumonia, malaria and measles, Caulfield et al, 2004

Total number of deaths: 1.265 million

Undernutrition 53%

“Childhood underweight is the leading cause of the

global burden of disease”

Reduction of U5MR according to intervention

3%

3%

4%

4%

5%

6%

7%

13%

0% 2% 4% 6% 8% 10% 12% 14%

Antenatal steroids

Water, sanitation,hygiene

Clean delivery

Hib vaccine

Zinc

Continued BF withComplementary feeding

Insecticide treatedmaterials

Exclusive Breastfeeding

Source: Lancet Child Survival Series 2003

Infants not breastfed have 6-fold increased chance of dying in first two months;

Aim of Nutrition promotion

"Attainment of nutritional well-being of all citizens as part of the overall social-economic development by means of health and nutrition activities together with the cooperative efforts by the food production sector

General objective

To ensure that all citizens enjoy the nutritional state conducive to longevity and health

Specific objectives

To control/eliminate all forms of nutritional deficiency

To promote healthy dietary habits and lifestyles among people

To prevent over-nutrition and diet-related chronic diseases

Objectives towards achievement of MDG

To reduce underweight among under 5 children

To increase exclusively breast fed rate

To increase receiving high potency vitamin A supplementation among 6 months to 5 years old children

To reduce IDA prevalence among pregnant women and under five children

Public Health Nutrition Problems

1. Protein Energy Malnutrition (PEM)

2. Micronutrient Deficiencies

- Iron Deficiency Anemia (IDA)

- Iodine Deficiency Disorders (IDD)

- Vitamin A Deficiency (VAD)

- Vitamin B1 Deficienciy ( VB1D)

Strategies

Community involvement in nutrition activities

Nutrient supplementation (VA,B1,iron)

Supplementary feeding

Nutrition education

Integrated deworming

National Nutrition Surveillance System

Intersectoral cooperation

Food fortification (IS, Home fortification)

PEM Control activities

by health staff

1. Growth Monitoring and Promotion (GM/P)

2. Community Nutrition Centres (CNCs)

3. Hospital Nutrition Units (HNUs)

Community

based

1. Growth Monitoring and Promotion (GM/P)

2. Community Nutrition Centres (CNCs)

3. Village Food Banks (VFBs)

I. Protein Energy Malnutrition Control Project

1. Growth Monitoring /Promotion by BHS

Started in 1982 Each midwife monitors the

growth of about 100 under-3 children

Coverage -33% of all under-3 Community Nutrition Centres (CNCs)

2. CNC by BHS

Started in 1982 Funds: community donations Each centre takes care of 20-

30 mal-nourished children 100 CNCs all over One meal a day Cooking demonstration

I. Protein Energy Malnutrition Control Project(cont)

3. Hospital Nutrition Unit (HNU) )

Started in 1982

20 HNUs all over the country

Management of severely

malnourished children

Therapeutic feeding (WHO guideline),

Treatment of infections, Nut

Education

4. Village Food Banks ( VFB) Community based-, started in 1999 Management for severely

malnourished children in remote villages

205 VFBs in 34 tsps all over the country

Take care of moderately malnourished children as well

Supplementary feeding/ therapeutic feeding , Nut. education

II. IDD Elimination project

Goal – IDDEStrategy – Universal salt iodisation ( USI)

Visible Goitre Rate Among 6-11 Year Children(by year)

34.4832.48

21.84

7.58

33.08

25.1

12.7 12

5.5

1.01

0

5

10

15

20

25

30

35

40

1994 1997 1999 2001 2003-04 2006

Year

%

TGR

VGR

စ�မ�အ��ငအ��ဒငဆ- ထ�တလ�ပမ�အဆင�- 40-60 ppm လကကအဆင�- > 30 ppm လကလ�အဆင� - 15 မ� 30 ppm အ�မထေထငစ�အဆင�- 15 ppm

III. Vit A deficiency control project High potency vitamin A capsule

- every 6 months for 6-59 m children- once within 1 m after delivery

Coverage;

> 90 % of < 5 children 60 % of lactating women

Prevalence of Bitot's Spot Among Under-5 Children

0.6

0.38

0.23

0.03

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

1991 1994 1997 2000

Year

%

IV. Nutritional Anemia Anemia status of women

as follow.

Non pregnant women (NNC 2001) 45%

Adolescent school girls (NNC 2002) 26%

Pregnant women (NNC 2005) 71%

Under five children (NNC2005) 76%

Prevalence of Anaemia Among Non-pregnant Women by Region (2001)

31

43.4

48.2

55.6

0 10 20 30 40 50 60

Hilly

Plain

Coastal

Delta

Reg

ion

Prevalence (%)

Prevalence of Anaemia Among Adolescent Schoolgirls by Region (2002)

7.6

28.3

31.7

38

0 5 10 15 20 25 30 35 40

Hilly

Coastal

Plain

Delta

Reg

ion

Prevalence (%)

IV. Anaemia Control Project (cont)

4.1. Iron supplementation

for pregnant women (all tsp) for adolescent schoolgirls ( 20 tsp) under five children (with GMP) – iron syrup, Initial trial on iron sprinkles ( also known as

Home fortification) Coverage ; 95% of adolescent school girls received full

dose 70 % PW

4.2. Nutrition education

4.3. Integated Mass Deworming campaign

Since Jan 2006 Coverage > 60 % of 2-9 y children > 70 % of pregnant women

5.1. Vitamin B1 supplementation:

for pregnant – 9 month till 3 month after delivery ( 1/2tab (50mgtab), alternate day* 4 m)

5.2.Effective treatment provided for babies with infantile beriberi

5.3.Nutrition education - Dietary diversification - Proper cooking methods

VI. Nutrition Promotion Month campaignNPW since 2003 – 2008 in September Since 2009 – Breast feeding week & NPWs

in August

V. Infantile Beriberi project

VII. Nutrition in Emergency 4 key areas 1. Comprehensive

information on the nutrition status of children through rapid assessment, surveillance and survey

2. Management of acute Malnutrition

3. Prevention of micronutrient deficiencies

4. Infant feeding in Emergencies

Nut. Situation & targetSituation Target

2015-16

Underweight among

< 5 children

35.3% (2000 MICS) 31.5%(2003MICS)

28.0% (2009MICS) 19.3% by 2015

Vit A last (6) month > 90 % by tsp rep.65% (2003 MICS)

55.9% ( 2009 MICS)

>90%

Bitot’s spot < 5 0.23% in 1997 0.03% in 2000 <0.05%

Iron Deficiency

Anemia

45% NPW (01)

26.4% adol (2002)

71% PW and

75 % <5 children (2003).

<30% NPW

<60% PW

Situation Target

2015-16

VGR among 6-11 year 12% in 2000 2 % in 2006 < 5%

iodated salt

consumption

86% HH in 2003. >90% HH

Median UIE 136ug/l in 2006 >100 ug/ l

BeriBeri 7.12% of death amg 1-11 m old children

<6 %

New HMIS

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န နနနနနနနနနနနနနနနနနနနနနန နနန နညပညပ��ငအရလမချငထေပပြချငပြ%စပသည။ န နနနနန နနနနနနန န နနနနနနနန နနနနနနနနနနလ�ပငနသ��ပစ'ညမ�၊မ�တတမမ�တတန��ငသမ)ပ��ပ��

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နနနနနနနနနနန နနန ထေဆငရ�ကသ�ရနရညမ�နပသည။

New HMIS အလ�ည��ကျ�ကျေကျ�ရ� /ရပ�ကျ�ကျ သတမ�တက ငန�စထေအက

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နနနနနနနနနနနနနနနနနနနနန က��လညထေကငထေ%ထ�တသ�ရ��န��ငမည (Nut. Surveillance) (၂)အ��ငအ��ဒငဆစစထေဆပြချင တဝန�ကျ�ကျေ�သ ရ�� (၅) နနနနနနနနနနနနန�စထေအကကထေလမ�အပ��မ�နက��ယ

န န နနန န နနနနနနန နနနန နန နန နန နနနန နန အထေလချ� �န၍ကထေလတစဦစ�အတ�ကအဟရအထေပြချအထေန နန နန နနနနနနနနနနနနနနနနနနနနနနနနနနနန နနနနနဆနစစပြချငန�င�အဟရထေစင�ထေရ�ကမ�ထေပပြချငတ�3ပဝင

နနန နန နန န နနနနနနနနနနနနနနန သည။ ကထေလတ��ငမချ� �နန��ငပကအဟရချ� �"တ$�သ,မ�၊ နနနနန န နနန နနနနနနန ချ� �"တ$�လ�ယသ,မ�က�� ေထေရ�ချ�ယ၍က��ယအထေလချ� �နက

အဟရထေစင�ထေရ�ကမ�ထေပမ�သ PEM နနနနနနန နနန ထေလ�က�မညပြ%စပသည။( Growth Monitoring and Promotion)

အလ�ည�က�ထေက�ရ�/ ရပက�ကတ�င - (၅)န�စထေအက နနနနနန နနန နနနနနန နနနနနနန ကထေလတ��ငအက��ယအထေလချ� �န၍ပြ%စထေစ၊ အလ�

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နနနနနနန နနနနနနနနနန န နနနနနနနနနနနနနနန လကထေမငလ��ပတတ��ငမြပ�လကထေမငလ��ပတ န နနနနနနနနန ထေလ�နညထေနပကထပမ�က��ယ အထေလချ� �န၍ပြ%စထေစ- နနနနနနနန ကြက�ထ�%5� ဖြမြ%��မ�က��တ��ငတ

နနနနနနနနန န နနနနနနမ�တတမ တင၍ အဟရချ� �"တ$�သ,မ�က��ဆနစစ ထေ%ထ�တရပမည။

နန နန နဆနစစထေ%ထ�တသ�ရ��မြပ�သည�အဟရချ� �"တ$ နန နန န�ကထေလ မ�န�င�အဟရ ချ� �"တ$�မ� ပြ%စန��င သည�ကထေလမ�အ( နနနန နနနနန %�န၊ဝမထေလ�၊

နနနနန နနန န နနန နနနနထေချ�ငဆ��ရငကြကပပြ%စသည�ကထေလမ�) နနနနနနနနနနနနနနန နနနနနနနနနန အဟရထေစင�ထေရ�ကမ�ထေပရပမည။

အဟရကျေ�င��ကျေ��ကျ�မ� န နနနထေပသညဆ��သညမ�ယင ကထေလ မ�အ

(က) နန နန န န နနနန နန က��ယအထေလချ� �န၍အဟရအထေပြချအထေန ပြပနလည ဆနစစပြချင၊

(ချ) မ�ချငမ�အအဟရပညထေပထေဆ�ထေန� ပြချင၊ လ��အပပကက�သပြချင/ည/နပ���ခြပြချင

(ဂ) အဟရ ပြ%ည�စ�ကထေက;ထေမ�န��ငထေရအတ�ကစ�စဉထေပပြချင နနနန နနန နနနနနန နနနနနနနနနန နနန၊တ�3 ထေဆငရ�ကပြချငပြ%စသည။

Measure the circumference of left upper arm at mid point

Locate tip of shoulder

(Arrow-1)

Tip of shoulder(Arrow-2)

Locate tip of elbow(Arrow-3)

Note: Elbow is bent 90°

Measure distance between tip of shoulder and tip of elbow

Note: The elbow is bent 90°

Mark mid point between tip of shoulder and tip of elbow (Arrow-6)

Note: The elbow is bent 90°

How do you measure MUAC?

Measure the circumference

of the arm at mid point

with correct tape tension.

Note: The elbow is

extended.

tv,frSwfwGif vufarmif; vHk;ywfukd wkdif;yg/wdyfjudK;=ym;onf ravsmhvGef; rwif;vGef;ygapESifh/uav;.vufarmif;ukd qefhxm;onf/

How do you interpret MUAC?

Less than 11.5 cm: Severe acute malnutrition (SAM)

11.5 -12.4 cm: Moderate acute malnutrition (MAM)

12.5-13.4 cm: At-risk

13.5 cm and above: Well-nourished

Severe with complication=> refer to hospital

Severe without complication/ mod => locally available food

No AMW => NE, Cooking demonstration

G Growth chart န�င�ပတသက၍ ထေဆငရ�ကရန

juD;xGm;r_vrf;ajumif;

aumufcsuf aqG;aEG;7ef

yHkrSefwuf yHkrSefjuD;xGm;

csD;usL;yg

yxrtjudrf--wef; (odkh) us

juD;xGm;r_aES;=cif;pwif

IYCF aqG;aEG;7ef

oHk;judrfqufwdkuf ---wef; (odkh) us

juD;xGm;r_aES;=cif;

usef;rma7;Xmen$ef;ydkh7ef

wef;Iaxmifwuf tav;csdefwdk;e_ef;rsm;ae

formula milk rSefuefpGm a7mpyf=cif;&Sdr&SdESifh အ ေထေjumif; 7if; qef;ppf7ef

Situation

► Low birth wt prev.► 23.5% (NNC -1994) ► 12 % (HMIS -2000) ► 8.6 % (MICS -2009)

BF rate > 90% EBF = 23.6% (MICS 2009) Appropriate initiation of CF-

70%

Nutritional status among < 5 children

Prevalence of wasting among under five children in Myanmar

Vitamin A coverage was high > 90 % by tsp reportsVitamin A coverage was high > 90 % by tsp reports

TargetsSr Particular A/U 2006

/2011

2011-

2012

Target

1 Prevalence of PEMamong under-5 children (WFA < - 2SD, NCHS)WHO; GSTD

(%) 31 29 [ <25%]

2 Visible goitre rate among 6- 11 year children (%) 2 - [<5%]

3 Median Urinary Iodine excretion ug/dl 123 100-

200

>100 µg/dl

4 Proportion of households consuming effectively iodated salt

(%) 47 57 [>90%]

5 Prevalence of Bitot's spot among under-5 children (%) 0.03 .03 <0.03

6 Proportion of under-5 children with normal serum vitamin A status

(%) >95 >95 >95

7 Prevalence of anaemia among non-pregnant women (%) 45 40 [<30%]

8 Prevalence of anaemia among pregnant women (%) 71 67 [<60%]

9 Worm Infestation among under five children % 71 67 (<60%)

10

Vit. B1 deficiency among pregnant women and lactating women

%12.9

<12.9

<5%

11

Vitamin B1 deficiency among under one children % 7.1 <7.1

<6

Integration!!

Nutrition surveillance Growth monitoring

Nutrient supplementation (VA,B1,iron)

Nutrition education

Integrated deworming

Testing iodised salt

Micronutrient supplementation

State/Division Nutrition Teams (SDNT)

S/D Health Director

Nutrition Team Leader

Public Health Public Health Public Health

Nurse(1) Nurse (2) Nurse (3)

Nutritionist Statistician

Functions of

SDNTs

Training

Education

Supervisio

n Nutrition

surveillance

Nutrition surveys

Different way

ကချ�ငပြပညနယစ�ပ��စချနမ�တ�ငအဟရအထေပြချအထေနထေလ�လ

ကချ�ငပြပညနယစ�ပ��စချနတ�ငက�ငဆငထေလ�လ