Unit – XI- Role of Nurse in Nutrition Programme

Unit – XI- Role of Nurse in Nutrition Programme

 National programmes related to nutrition

(ICDS, Vitamin A deficiency programme, NIDDP and Midday meal
programme)
 National and international agencies
(NIPCCD,CARE, FAO,CFTRI etc)
 Assessment of nutritional status.
 Nutrition education and role of nurse.
 Introduction

• Government of India has initiated several large scale supplementary

feeding program.
• Programmes aimed at over coming specific deficiency disease through
various ministers to eliminate malnutrition.
Aims :
To provide additional nutrients to target groups to fulfill the gap
between food intake and requirement .

Beneficiaries :
1) Pre-school children
2) school children
3) pregnant women
4) lactating mother
 MAJOR NUTRITIONAL PROGRAMME

 ICDS Programme
 Mid–day Meal Programme (School lunch Programme)
Mid-day meal scheme
 Special Nutritional Programme (SNP)
 Balwadi Nutrition Programme
 National Prophylaxis Program against Nutrition Blindness (NPPNB)
 National Nutritional Anemia Prophylaxis Programme
 National Iodine Deficiency Disorder Control Programme (NIDDCP)
I. INTEGRATED CHILD DEVELOPMENT SERVICES(ICDS)

INTRODUCTION-
a) Blue print of scheme was prepared by department of social
welfare in 1975.
b) The experiment project was conducted in year
1975-1976.
c) It was conducted in 4 urban,19 rural and 10 tribal areas.
Spread over 22 states and the union territory of Delhi.
d) The population norms for setting up of anganwadi centres and
mini anganwadi centres has been revised to cover all
habitations by SC,ST and minorities.
e) For the anganwadi centres in rural and urban project
population range from 400-800.
 OBJECTIVES OF ICDS;
 To improve the nutritional health status of children.(0-
6yrs)
 To lay foundation for proper psychological, physical and social
development of children.
 To reduce the mortality and morbidly malnutrition school drop
out.
 To achieve an effective coordination of policy and
implementation among various departments.
 To enhance the capacity of mother and nutritional oral needs of
children through proper nutrition and health education.
 SERVICES CONSIST OF;
 Supplementary Nutrition.
 Immunization.

 Health Check Up.

 Medical Referral Services.

 Nutrition And Health Education for Women.

 Non-formal Education for Children upto age of 6 Yrs.

 1. Supplementary Nutrition
 The aim of this scheme is to supplement nutritional intake as
follows;
A)Each child 6months to 6yrs – 500 kcal, 12- 15 grams of
protein.
 Financial norms of Rs. 4.00 per child per day.

B)Severe malnutrition child 6months to 6yrs – 800kal, and 20-25

grams proteins.
 Financial norms Rs.6 per child day.
C)Each pregnant and nursing women- 600 kcal and 18-20 grams
of proteins.
 Financial norms rs.5 per day.
Services Target Group Service provided by

(i)Supplementary Nutrition Children below 6 years, Pregnant & Anganwadi Worker and
Lactating Mothers Anganwadi Helper
Children below 6 years, Pregnant & ANM/MO
(ii) Immunization* Lactating Mothers
Children below 6 years, Pregnant & ANM/MO/AWW
(iii) Health Check-up* Lactating Mothers
Children below 6 years, Pregnant &
Lactating Mothers AWW/ANM/MO
(iv) Referral Services

AWW* AWW assists ANM

in identifying the target
(v) Pre-School Education Children 3-6 years group.

(vi) Nutrition & Health Education Women (15-45 years) AWW/ANM/MO

 2) Immunization
 Immunization against 6 vaccine preventable diseases is been done
including Hepatitis B and Hib vaccines)
 Mothers are immunized against tetanus.
 This supplementary nutrition is given for 300 days in year
 Finance provided is by state plan.

 Weight of children is checked every monthly.

 Nutritional health education is given to mother and children

suffering from 1st degree of malnutritonal.
 supplementary nutrition is given to 2nd and 3rd degree
malnutrition.
 4th degree malnutrition are advised for hospitalization.
 3) Nutrition and health education for women

 Nutrition and health education is given to all woman in age group

15-45 yrs.
 Priority is given to nursing expectant mother.
 4)Health checkup
 This includes;
a)Antenatal care of expectant mothers .
b)Postnatal care of nursing mother and care of newborn.
c)Care of children under 6 yrs of age.
d)Minimum 3 physical examination are done.
e)High risk mothers refer to appropriate institution for special
care.
 Prophylaxis against vitamin A deficiency and anaemia.
 Refer of serious cases to hospital.

 A card containing health record of child is given to mother.

 Health care of children under 6 year.

 Record of weight & hight of children at periodic interval.

 Watch over the miles stones.

 Immunization

 General check up every 3 to 6 months to detect diseases

& malnutrition.
 Treatment of disease like diarrhoea, RTI.

 Deworming.
 Non formal pre-school education

Children of 3 to 5 years are imparted non formal and pre school

education in an anganwadi in each village in about 1000
population.
 II. MID DAY MEAL PROGRAM

• Also called as School Lunch Programme.

• In operation since 1961
• Tamilnadu – first started this Programme
• Also called as National Support to Primary Education
Objectives:
 To attract more children for admission to school.
 Literacy improvement of children.
 Eating habits & nutrition education.
 AIMS

a) To fulfill one third nutritional requirement of school children.

b) To create interest about school and education.
c) To reduce absenteeism in school.
d) To provide relief to parents of poor children.
 PRINCIPLES
a) One third energy and half of protein req of the child must
be met.
b) Food should be free and at minimum cost.
c) Food should be prepared in school itself.
d) Locally available food should be used in
preparing the meal.
e) The menu should be change to avoid boredom among the
children.
 III. Midday Meal Scheme

• Started in 15 August 1995 and revised in 2004. Also known as National

Programme of nutritional support to primary education.
• This programme cover all primary school (govt. and govt. aided)
children of class 1 - 5.
• A cooked mid day meal with minimum 300 calories of energy and 8-12
gms of protein per day for a minimum of 200 days is given.
• In October 2007, the Scheme was extended to cover children of upper
primary classes (i.e. class VI to VIII)
• Educationally Backwards Blocks (EBBs) and the name of the Scheme
was changed from to ‘National Programme of Mid Day Meal in
Schools’.
• The nutritional norm for upper primary stage was fixed at 700
Calories and 20 grams of protein.
• The Scheme was extended to all areas across the country from
1.4.2008.
 IV. Special Nutrition Programme

• Started in 1970
• Operated by Ministry of social welfare.
• For nutritional benefit
* preschool children
* pregnant women
* lactating mother

And in operation in urban slums, tribal & drought prone

rural areas.
 Activities

1) Supplementary nutrition for 300 days per year

Child : 300 kcal & protein 10-12 gm/day
Women: 500 kcal & protein 25 gm/day
2) Provide health service
- supply vitamin A solution
- Iron & folic acid
Now SNP is merged with ICDS Programme
 V.Balwadi Nutrition Programme

• Implemented through Balwadis who provide pre-primary

education to 3-6yr children

• Provides 300 kcal energy & 10 gm protein per day for 270 days/
year.

• Balwadis are being phased out because of universalization

of ICDS.
 VI.National Prophylaxis Program against Nutrition
Blindness (NPPNB)
• National Prophylaxis Program against Nutrition Blindness due
to Vit A Deficiency (NPPNB) :
• Launched in 1970.
• Started as 100 percent centrally sponsored program
• Was 1st initiated in 11 states
• Subsequent years: program extended to whole of the country.
• Objective is for reduction of blindness & prevention of
blindness due to vit-A.
• Children are given a massive dose of vit A i.e 1 lakh IU at 6-12
month & subsequently 2 lakhs IU at 6 month interval till the child
is 5 yrs old.
• For treatment : one dose 2 lakhs IU vit-A followed by
similar dose after 4 wks.
• Vitamin A Supplementation is bundled with Albendazole
Suspension
• Biannual Approach.
• In the month of August and February.
• Currently implemented through existing PHCs and subcenters
• Female MPW and other paramedics administer Vitamin A at the
health centres.
 VII. National Nutritional Anemia Prophylaxis Programme

• The programme was launched during 4th 5 year plan in1970 by the
ministry of health and family welfare

• Prevention of nutritional anaemia in mother and children.

Rational
 Supplementary iron on daily basis is considered necessary in developing
countries because approaches like food fortification and dietary
modification are long term options.
 Majority of girls are anaemic even in their adolescence
 Prevent neural tube defects due to folic acid deficiency
 Requirements during 2nd and 3 rd trimester cant be made by daily intake
Beneficiaries:
Children between 1-5 years of age
Expecting and lactacting mothers
Family planning (IUD) acceptors
Policy:
Expecting, lactating mothers and IUD acceptors- 60 mg of elemental iron
and 0.5 mg folate everyday for 100 days.
Children 1-5 years –20 mg of elemental iron and 0.1 mg of folate everyday
for 100 days.
VIII. National Iodine Deficiency Disorder Control Programme
(NIDDCP)
• National Goitre control Programme (1962) is changed to
IDDCP in 1992. 100% centrally sponsored.

• Entire edible salt is replaced by Iodised salt.

• A national Reference Laboratory is present in Biochemistry dept.

of NICD, Delhi –to monitor iodine content of salt & urine
 Goal

1. To bring the prevalence of IDD to below 5% in the country

2. To ensure 100% consumption of adequately iodated salt

(15ppm) at the household level
 Objectives
1. Surveys to assess the magnitude of the iodine deficiency
disorders.
2. Supply of iodised salt in place of common salt.
3. Resurvey after every 5 years to assess the extent of iodine
deficiency disorders and the impact of iodised salt.
4. Laboratory monitoring of iodised salt and urinary iodine
excretion.
5. Health education & publicity
 Activities:

1. Iodisation
2. Survey
3. Monitoring and Reporting
4. Information Education Communication activities
 1. Iodisation Salt
USI- Universal Salt Iodisation- Policy
•Adequate iodisation of salt consumed by human and
animals.
•Universal Salt Iodization (USI) is key strategy for control of IDD.
• According to PFA Act, iodine content of salt at manufacture
level –not <30 PPM and at consumer level-not <15 PPM
 2. Surveys:

• Data collected- Goitre rate, Salt iodisation level, adequacy

and mUIE (age, sex wise)

• Frequency- Once in 5 years

3. Monitoring and Reporting:

Lab monitoring of NIDDCP- 3 level

• Primary- estimation of iodine in salt

•Secondary- Estimation of urinary iodine content (for bio-

availability of iodine)

•Tertiary- Neonatal monitoring for TSH

 4. IEC activities:

• October 21 World IDD day

• TV/Radio broadcasts
• 10 minutes video clip on IDD
• Pamphlets
• Posters depicting manifestations of IDDs
• Art of song and drama are also employed in collaboration with
Doordarshan and All India Radio
Assessment Of Nutritional Status.
 INTRODUCTION

• The nutritional status of an individual is often the result of many inter-

related factors.
• It is influenced by food intake, quantity & quality, & physical health.
• The spectrum of nutritional status spread from obesity to severe
malnutrition
 The Purpose of Nutritional Assessment

The purpose of nutritional assessment is to:

• Identify individuals or population groups at risk of becoming
malnourished
• Identify individuals or population groups who are malnourished
• To develop health care programs that meet the community needs which
are defined by the assessment
• To measure the effectiveness of the nutritional programs & intervention
once initiated.
• 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
 Methods of Nutritional Assessment

Nutrition is assessed by two types of methods;

• Direct
• Indirect.
The direct methods deal with the individual and measure objective criteria,
while indirect methods use community health indices that reflects
nutritional influences.
Direct Methods of Nutritional Assessment
These are summarized as ABCD
 Anthropometric methods
 Biochemical, laboratory methods
 Clinical methods
 Dietary evaluation methods
Indirect Methods of Nutritional Assessment
These include three categories:
• Ecological variables including crop production
• Economic factors e.g. per capita income, population density & social
habits
• Vital health statistics particularly infant & under 5 mortality & fertility
index
 CLINICAL ASSESSMENT
• It is an essential features of all nutritional surveys
• It 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.
• 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
Did not detect early cases
 Clinical signs of Nutritional Deficiency

HAIR
• Spare & thin - Protein, zinc, biotin deficiency
MOUTH
Glossitis - Riboflavin, niacin, folic acid, B12
Bleeding & spongy gums - Vit. C,A, K, folic acid & niacin
• Sore mouth & tongue - Vit B12,6,c, niacin ,folic acid & iron
EYES
Night blindness, exophthalmia -Vitamin A deficiency
NAILS
Spooning- Iron deficiency
Transverse lines -Protein deficiency
SKIN
Pallor - Folic acid, iron, B12
Thyroid gland
 In mountainous areas and far from sea places Goiter is a reliable sign of
iodine deficiency.
Enlarged Thyroid Gland
 Anthropometric Methods
• Anthropometry is the measurement of body height, weight &
proportions.
• It is an essential component of clinical examination of infants, children
& pregnant women.
• It is used to evaluate both under & over nutrition.
• The measured values reflects the current nutritional status & don’t
differentiate between acute & chronic changes
Other anthropometric Measurements

 Mid-arm circumference
 Skin fold thickness
 Head circumference
 Chest circumference
Height Measurement
Weight Measurement
Mid-arm circumference
Skin fold thickness
Head circumference
Chest circumference
Anthropometry for children
• Accurate measurement of height and weight is essential. The results can
then be used to evaluate the physical growth of the child.
• For growth monitoring the data are plotted on growth charts over a
period of time that is enough to calculate growth velocity, which can
then be compared to international standards
Measurements for adults
• Height: Height: 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.
• WEIGHT MEASUREMENT
• 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)
Nutritional Indices in Adults
• The international standard for assessing body size in adults is the body
mass index (BMI).
• BMI is computed using the following formula:
• BMI = Weight (kg)/ Height (m²)
• Evidence shows that high BMI (obesity level) is associated with type 2
diabetes & high risk of cardiovascular morbidity & mortality
BMI (WHO – Classification)
 BMI < 18.5 = Under Weight
 BMI 18.5-24.5= Healthy weight range
 BMI 25-30 = Overweight (grade 1 obesity)
 BMI >30 = Obese (grade 2 obesity)
 BMI >40 =Very obese (morbid or grade 3 obesity)
 DIETARY ASSESSMENT
Nutritional intake of humans is assessed by five different methods.
These are:
24 hours dietary recall
Food frequency questionnaire
Dietary history since early life
Food dairy technique
Observed food consumption
 24 Hours Dietary Recall

 A trained interviewer asks the subject to recall all food & drink taken in
the previous 24 hours.
 It is quick, easy, & depends on short-term memory, but may not be truly
representative of the person’s usual intake
 Food Frequency Questionnaire

• 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.
• Inexpensive, more representative & easy to use.
Limitations:
 long Questionnaire
 Errors with estimating serving size.
 Needs updating with new commercial food products to keep pace with
changing dietary habits.
 DIETARY HISTORY

• It is an accurate method for assessing the nutritional status.

• The information should be collected by a trained interviewer.
• Details about usual intake, types, amount, frequency & timing needs to
be obtained.
• Cross-checking to verify data is important
 FOOD DAIRY
Food intake (types & amounts) should be recorded by the subject at the
time of consumption.
The length of the collection period range between 1-7 days. Reliable but
difficult to maintain.

 OBSERVED FOOD CONSUMPTION

 The most unused method in clinical practice, but it is recommended for
research purposes.
 The meal eaten by the individual is weighed and contents are exactly
calculated.
 The method is characterized by having a high degree of accuracy but
expensive & needs time & efforts.
 Dietary Evaluation Methods

1. Qualitative Method
 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.
Food Pyramid
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.
 Biochemical, laboratory methods
• Hemoglobin estimation is the most important test, & useful index of the
overall state of nutrition. Beside anemia it also tells about protein & trace
element nutrition
• Stool examination for the presence of ova and/or intestinal parasites
• Urine dipstick & microscopy for albumin, sugar and blood
Specific Lab Tests
• Measurement of individual nutrient in body fluids (e.g. serum retinol,
serum iron, urinary iodine, vitamin D)
• Detection of abnormal amount of metabolites in the urine (e.g. urinary
creatinine / hydroxyproline ratio)
• Analysis of hair, nails & skin for micro-nutrients.
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 24-hour urinary excretion.
Limitations of Biochemical Method
• Time consuming
• Expensive
• They cannot be applied on large scale
• Needs trained personnel & facilities