National Nutrition Policy and Strategy

National Nutrition Policy and Strategy 24thDecember 2004 Nutrition Section, CHD, DoHS, MoH&P 1 Table of contents ACRONYMS……………………………………………………………………………………….... 2 PREAMBLE…………………………………………………………………………………………. 5 1. Background………………………………………………………………………………………. 7 1.1 Causes and consequences of malnutrition …………………………………………………... 8 1.2 Current nutritional situation in Nepal……………………………….…….……………….... 9 1.3 Government actions in nutrition sector………………………..…………………………… 12 2. Overall goal and objectives and targets of each strategic approach………………….……..…… 13 3. Basis of nutrition policy……………………………………………….………………………… 15 4. Guiding principles…………………………………………………………………………….… 16 5. Strategic approaches for nutritional improvement……………………..………………………. 17 5.1 Protein-energy Malnutrition Control……………………………………………………… 17 5.2 Iron Deficiency Anemia Control……………………………………………………...…… 20 5.3 Iodine Deficiency Disorder Control…………………………………..…………...……… 22 5.4 Vitamin A Deficiency Control…………………………………………………….……..... 24 5.5 Intestinal Worm Infestation Control…………………………….………………..……..… 26 5.6 Low Birth Weight Control………………..…………………………………………….…. 27 5.7 Household Food 2 Security……………………………….……………………….…...……. 28 5.8 Improved Dietary Habit……………………….…………..…………………….……….... 29 5.9 Infectious Diseases Control……………………………………………………….………. 31 5.10 Life-style Related Diseases Control…………………………………….……….…..……. 32 5.11 School Health and Nutrition…………………….………………………………………… 34 5.12 Nutrition in Exceptionally Difficult Circumstances……………………………….……… 35 5.13 Analyzing, Monitoring and Evaluating Nutrition Situation…..………………………...… 36 6. ANNEXES……………………………………………………………………………………. … 37 Annex 1: Cut-off points for the assessment of nutritional status……………………………... 37 Annex 2: WHO standard for parameters of life-style diseases……………….………………. 39 Annex 3: Indicators and targets for reducing malnutrition………………………………...…. 39 Annex 4: Guidelines for complementary feeding……………………………..……………… 42 Annex 5: National protocol on iron supplementation and guidelines to treat severe anemia… 43 Annex 6: Guidelines for distribution of deworming tablets………………………….…….… 43 Annex 7: List of iron rich foods………………………………………………………………. 44 Annex 8: Guidelines for VA capsule supplementation and treatment protocol……………..... 44 Annex 9: List of Vitamin A rich foods…………………………………………………..……. 45 Annex 10: Associations between selected dietary components and cancer……………………. 46 Annex 11: Dietary guidelines for life-style diseases…………………………………………… 46 REFERENCES……………………………………………………………………………….…… … 47 3 LIST OF MEMBERS……………………………………………………………………………..…. 48 ACRONYMS AIDS Acquired Immune–Deficiency Syndrome ANC Antenatal Care API Annual Parasitic Incidence AR Annual Report ARI Acute Respiratory Infections BCC Behavior Change Communication BCHIMES Between Census Household Information Monitoring and Evaluation Survey BF Breast Feeding BFHI Baby Friendly Hospital Initiative BMI Body Mass Index BPP Birth Preparedness Package CBOs Community Based Organizations CDC Curriculum Development Center CF Complementary Feeding CHD Child Health Division DALYs Disability–Adjusted Life Years DFTQC Department of Food Technology and Quality Control DHO District Health Office(r) DHS Demographic and Health Survey DoHS Department of Health Services DOTS Directly Observed Treatment Short Course DPHO District Public Health Office(r) EDCD Epidemiology and Disease Control Division EPI Expanded Program of Immunization EPP Emergency Preparedness Plan Ex. BF Exclusively Breast Feeding FAO Food and Agriculture Organization FCHVs Female Community Health Volunteers FHD Family Health Division GM Growth Monitoring GMP Growth Monitoring Practice Hb Hemoglobin HIV Human Immuno–Deficiency Virus 4 HMG His Majesty’s Government HMIS Health Management and Information System HPs Health Posts HWs Health Workers IDA Iron Deficiency Anemia IDD Iodine Deficiency Disorder IEC Information, Education and Communication IMCI Integrated Management of Childhood Illness INGOs International Non Governmental Organizations IOM Institute of Medicine ISA Iodized Salt Act IU International Unit IYCF Infant and Young Child Feeding JICA Japan International Cooperation Agency KABP Knowledge, Attitude, Behavior and Practice LBW Low Birth Weight LMD Logistic Management Division LMIS Logistic Management Information System MD Management Division MDGs Millennium Development Goals MoAC Ministry of Agriculture and Cooperatives MoE Ministry of Education MoH Ministry of Health MoHAPP Ministry of Housing and Physical Planning MoIC Ministry of Industries and Commerce MoLD Ministry of Local Development MoWCSW Ministry of Women, Children and Social Welfare NCASC National Center for AIDS and STDs Control NCHS National Center for Health Statistics NFHS Nepal Family Health Survey NGOs Non Government Organizations NHEICC National Health Education, Information and Communication Center NHRC Nepal Health Research Council NHTC National Health Training Center NNIPS National Nutrition Interventions Project-Sarlahi NMSS Nepal Micro–nutrient Status Survey NPC National Planning Commission NS Nutrition Section ORCs Outreach Clinics 5 PAHO Pan American Health Organization PEM Protein Energy Malnutrition PHCC Primary Health Care Center PNC Postnatal Care RDA Recommended Dietary Allowances RHCC Reproductive Health Coordination Committee SHN School Health and Nutrition SHPs Sub–Health Posts SLTHP Second Long-Term Health Plan SMC School Management Committee STC Salt Trading Corporation UIE Urinary Iodine Excretion UNICEF United Nations Children’s Fund VA Vitamin A VAD Vitamin A Deficiency WFP World Food Program WHO World Health Organization 6 PREAMBLE Improving the nutritional status of people is one of the prime duties of the government and is an essential factor in improving their health status and the quality of life. There are already many nutrition-related programs. It is, therefore, important to clarify the strategies and the types of activities really necessary for each program. The development and the proposition of nutrition policies and strategies as well as activities to be carried out are thus very important. This is also expected to be useful in systematic and efficient implementation of various nutrition programs. This paper introduces the causes and the consequences of various types of malnutrition commonly seen in Nepal; the current nutritional situation in Nepal; and the current government actions in the nutrition sector. Then it introduces the overall goal and objectives and targets of each strategic approach. Basis of nutrition policy and guiding principles were explained which are very important and indispensable for the implementation of all the nutrition activities and for the development of nutrition programs. Furthermore, the general strategies for all the nutrition programs are profiled to explain the concepts. Additionally, individual strategic approaches are illustrated with objectives, specific objectives, activities, and indicators. Specific objectives are induced as prerequisite condition to solve the cause of each nutritional problem. Strategies are set to accomplish each specific objective, and activities are set as components for supporting corresponding strategies. Responsible bodies for the implementation of these activities are also listed. Indicators are identified for monitoring and evaluating the achievement of the specific objectives. Finally, annexes are attached with important guidelines and standards as useful information for program implementation. This paper introduces 13 strategic nutrition approaches, some currently being implemented by the nutrition sector and others not yet implemented but certainly necessary in the current situation. Except for ‘the strategy for monitoring,’ 12 other strategic approaches are categorized into the types of short and long term objectives according to the duration between programmatic input and their expected impacts. The programs that are categorized as ones with short term objectives are Protein-energy Malnutrition (PEM), Iron Deficiency Anemia (IDA), Iodine Deficiency Disorder (IDD), Vitamin A Deficiency (VAD), Intestinal Worm infestation, Low Birth Weight (LBW), Infectious Diseases and Nutrition in Exceptionally Difficult Circumstance. The programs categorized as those with long term objectives are Household Food Security, Dietary Habit, Life-style Related Diseases and School Health 7 and Nutrition.’ PEM, including LBW, is a very challenging issue, because the prevalence is associated strongly with various socio- economic factors. Therefore, PEM can also be categorized as a long-term approach. All the programs with short-term objectives, beside for ‘nutrition in exceptional circumstances’ have been conducted in the nutrition sector and other sectors, such as the family health and the public health sectors. However, the development or the improvement of the strategies is very urgent in order to strengthen the management of the programs. In addition, challenging programs, such as PEM and anemia control, need some collaboration with other programs with long-term approaches, such as food security, dietary habits and school health and nutrition. To have effective and efficient achievement of program, we must consider expanding the target groups from those already at critical risk, to groups who are expected to be influence in the future. School children have great potential to contribute to increasing the knowledge about health and nutrition among their family and community members and to improve the health and nutrition standard as a result of education and practice of health and nutrition at schools. Since the school health and nutrition programs must be effective in this long term view-point, the school health and nutrition strategies are also included in this policy and strategy paper. Malnutrition during childhood can lead to a risk of life-style diseases in the future as well as immediate risks of morbidity/mortality, according to a recent study1. We must recognize that the causes of life-style diseases are not necessarily the current life style, but can also reflect the nutritional status of childhood. Yet, current life-style, including food habits, has a great influence on life-style diseases, and people’s life style is gradually changing in Nepal. Several studies alarmed to pay attention to these types of diseases even in developing countries. The paper summarizes the strategies for such diseases, considering that the program implementation of life-style disease control is now necessary in this country. Due to the political conflict and natural disasters, Nepal is facing the problem of migration and displaced people. Natural disasters such as flood and landslides occur seasonally, increasing the number of displaced people who suffer from lack of food. In addition, special attention has to be paid to HIV positive mothers who breastfeed their babies, because these babies have a high risk of transmission of HIV through breast milk. To reduce the risk of malnutrition and the death from HIV, possible interventions must be conducted to protect children and mothers from this critical situation. Considering the current situations of Nepal, the strategies for nutrition in exceptionally difficult circumstances are proposed and incorporated in this paper. We expect that this paper will contribute to the recognition, measurement and sharing of nutritional concerns held in common by any stakeholders planning to take action. 8 Human beings need to have adequate nutrition to attain normal physical growth (in children) and for a healthy life. Adequate nutrition is a fundamental right for every human being. If people fail to consume sufficient quality and quantity of nutrients, they will suffer from hunger or malnutrition. Malnutrition takes a variety of forms. The main types of malnutrition seen in Nepal are protein-energy malnutrition, iodine deficiency disorders, iron deficiency anemia and vitamin A deficiency2. In particular malnutrition places an enormous burden on children and women. Even mildly or moderately malnourished children and women are more likely to be at high risk of death due to lack of resistance against common infectious diseases. The above types of malnutrition not only affect people’s health but also affect the quality of life and the development of the socio-economic situation in the country. The World Health Report 2002 clearly describes how childhood and maternal underweight are the greatest risk factor among several main factors that affect people’s health and disease status in the world, particularly in Asia3. In the Millennium Development Goals (MDGs), underweight has been adopted as a key indicator of poverty and hunger4. In addition, improved nutrition can help in reaching the MDGs by contributing to the achievement of universal primary education, reducing child mortality, improving maternal health, reducing the burden of HIV/AIDS and other infectious diseases as well as reducing poverty and hunger5. From these points of view, it is recognized that policies, programs and processes for nutrition improvement have a great role to play in promoting healthy lives and development across the globe. 1. Background 9 1.1 Causes and consequences of 0 1000 2000 3000 4000 5000 Lack of contraception High BMI Occupational risk factors for injury Unsafe health care injections Physical inactivity Vitamin A deficiency Alcohol Fruit and vegetable intake Zinc deficiency Cholesterol Iron deficiency Tobacco Blood pressure Indoor smoke from solid fuels Unsafe sex Unsafe water, sanitation, and hygiene Underweight SOUTH-EAST ASIA Disease burden (DALYs) in 2000 attributable to selected leading risk factors Number of Disability-Adjusted Life Years (000s) Source: WHR 2002 DALYs: Disability-adjusted life years (DALYs) for a disease or health condition are calculated as the sum of the years of life lost due to premature mortality (YLL) in the population and the years lost due to disability (YLD) for incident cases of the health condition. The burden of disease study (SLTHP, 1997-2017) has shown that group 1st category that includes pre-transition disorders such as infectious diseases, maternal and perinatal disorders and nutrition deficiency in Nepal are responsible for more than two-thirds of the disease burden i.e. 68%. Therefore nutrition intervention has been recommended as a priority element of essential health care services. Main interventions included are nutritional supplementation, enrichment, nutrition education and rehabilitation. Similarly, Nepal Health Sector strategy 2004, and Nepal Health Sector Implementation Plan have recognized the nutritional problems of mother and children and have recommended adopting a specific implementation strategy with regards to nutrition. Considering the nutritional situation in Nepal the government needs to take more intensified action to reduce the risk of malnutrition for all the Nepali people and to contribute to creating better lives and development in Nepal. Causes Consequences 10 Protein-energy Malnutrition (PEM) (Children) • Inappropriate breastfeeding • Inadequate complementary feeding practices • Insufficient health services (Growth monitoring and counseling) • Low birth weight. • Infectious diseases • Inadequate energy intake • Failing to grow (underweight, stunted, and wasted) • Reduced learning ability • Reduced resistance and immunity against infection • Reduced productivity in the future (Women) • Inadequate energy intake • Inadequate knowledge and practice of maternal feeding • Heavy physical workload • Lack of extra food intake during pregnancy and lactation • Low birth weight • Increased risk of maternal mortality and morbidity • Reduced productivity Iron Deficiency Anemia (IDA) • Inadequate intake of iron from daily diets • Inadequate absorption of dietary iron • Infestations such as hookworms and malaria • High requirements of iron particularly during growth and pregnancy • Blood loss (menstruation, and injury) • Vitamin A deficiency • Impaired human function at all stages of life • Impaired work performances, endurance and productivity • Increased risk of maternal morbidity and mortality • Increased risk of sickness and death for the baby Iodine Deficiency Disorders (IDD) • Lack of iodine in food • Cretinism • Goiter • Impaired cognitive function • Increased prenatal morbidity and mortality • Reduced productivity Vitamin A deficiency (VAD) • Low intake of Vitamin A from daily diets • Restricted Vitamin A (VA) absorption • Worm infestation • Increased VA requirement resulting from infectious diseases • Xerophthalmia (Night blindness, Bitot’s spot, corneal ulcer, Keratomalacia, xerosis) • Increased risk of morbidity and mortality • Increased risk of anemia Intestinal worms • Poor hygienic manner and environment • Inadequate opportunities for taking deworming tablets • Anemia and malnutrition Low birth weight (LBW) • Small maternal size at conception (low weight and short stature) • Low gestational weight gain • Maternal anemia • Maternal malnutrition • Premature delivery • Early pregnancy • Increased mortality and morbidity • Increased risk of stunting • Poor neurodevelopment • Reduced strength and work capacity • Increased risk of chronic diseases Household food insecurity • Low food production • Food loss during storage and preservation • Poor food processing skills • Poor management in food allocation • Low income for purchasing foods • Malnutrition • Reduced productivities • Increased risk of mortality and morbidity Infectious diseases • Lack of knowledge, attitude and practice of good hygiene manner • Insufficient access to public health services and medical treatment • Poor nutritional status • Poor hygienic environment • Increased mortality • Increased malnutrition Life-style • Unbalanced food intake • Increase mortality 11 Current status of Protein Energy Malnutrition (PEM) among children below 5 years of age 50.5 48.3 9.6 0 10 20 30 40 50 60 Stunted Underweight Wasted % Source: Nepal Demographic and Health Survey, 2001 Breastfeeding status by age 0 20 40 60 80 100 <2 2-3 4-5 6-7 8-9 10-11 12-15 A g e in m o n th s Exclusively breastfed (%) related diseases • Insufficient practice of healthy life style (tobacco use, alcohol, lack of exercise, etc) • Childhood malnutrition and obesity • Mental stress • Reduced quality of life • Reduced productivity Protein-energy Malnutrition (PEM) • 51% of children below 5 years of age are affected by stunting (short for their age), which can be a sign of early chronic under-nutrition6. • 48% of the children are underweight (low weight for age)6. • 10 % of the children are wasted (thin for their age), which can be an indicator of acute under-nutrition6. • Stunting is more common in the Mountain areas than in the Terai, but underweight and wasting are more common in the Terai areas. • 27% of women fall below the cut-off point of BMI (<18.5) • Prevalence of stunting, underweight and wasting tended to increase after 6 months of age indicating that the practice of complementary feeding was not appropriate for their growth. Breast feeding (BF) • Percentage of exclusively breastfed children <6 months is 68.3, however this coverage is still low. Only about half of the children continue to be exclusively breastfed by the time they are 4-5 months old6. • Nearly one in three children are breastfed within one hour of birth. • Initiation of breastfeeding is delayed for more than 24 hours for one in three neonates6. • 40% of neonates received a prelactal feed 6. 1.2 Current nutritional situation in 12 Prevalence of low urinary iodine (<100µg/l) in school-aged children 46.7 25.3 21.1 35.1 0 10 20 30 40 50 60 70 80 Terai Hills Mountains National % Prevalence of anemia in infants, children and women 90 78 67 0 10 20 30 40 50 60 70 80 90 100 6-11 months infants Preschool children Women % Foods consumed by children 0 10 20 30 40 50 60 70 80 90 100 <2 2-3 4-5 6-7 8-9 10-11 12-15 16-19 20-23 24-27 28-31 32-35 Age in months % Other milk/cheese/yogurt Food made from grains Fruits/vegetables Meat/fish/liver/poultry/eggs Complementary feeding (CF) • 65% of children aged 6-9 months receive foods made from grains as complementary food6. • The consumption rate of vegetables and fruits is relatively low, with only about 50% even in children aged one year6. • Only around 20% of children aged one year consume meat products6. • The frequency of meal was about 3 times per day in children aged one year6. This is quite low compared with the recommended frequency of 4 to 6 times including snacks, according to WHO complementary feeding guideline10. Iron Deficiency Anemia (IDA) • Prevalence of anemia was higher in preschool children (78%) than in women (67%). An astonishingly high rate of 90% was found in infants, 6-11 months old 7. • Among women, there is distinct variation between ecological zones, with highest levels in the Terai, followed by the Mountains7. • Only 32% of pre-school children and 29% of pregnant women consumed an adequate amount of iron to fulfill their daily requirements7. • Prevalence of anemia was also high (64%)in high school adolescents who attended the Government Girl’s high school in Kathmandu valley8. Iodine Deficiency Disorder (IDD) • Currently only 63% of households in Nepal are using adequately iodized salt2. • The proportion of low UIE values (<100µg/l) was 39.1% (adult women and school-aged children) 7. • The prevalence of low UIE is highest among women in the Terai zone. It is still high as a public health problem in that group7. • Only 35% of the respondents had heard educational messages about iodized salt and very few of the respondents (19%) knew about the importance of iodized salt for health7. Vitamin A deficiency (VAD) • The overall prevalence of night blindness in reproductive aged women and pregnant women was 4.7% and 6.0% respectively, while 16.7% of women reported having night blindness during their last pregnancy7. • The prevalence of night blindness was 0.27% among 12-59 months children, and that of Bito’s spot was 0.33 % among 6-59 months children7. (These prevalence are below WHO-Cut points for public health problems) • In school-aged children, the prevalence of night blindness was 1.2%, and Bito’s spot was 1.9%7. • Serum retinol levels revealed 16.6% of women and 32.2% of preschool children had sub-clinical VAD7. • Only 42% of pre-school children and 37% of women consumed an adequate amount of vitamin A7. 13 Prevalence of night blindness among women 4.7 6.0 0 1 2 3 4 5 6 7 8 9 10 Reproductive age women Pregnant women % Intestinal worms infestations • Since there was no national data on worm infestation it is estimated that more than 50% of the children and adolescents are suffering from intestinal worms from the following studies. Studies Districts studied Roundworm prevalence Whipworm prevalance Hookworm prevalence Total 1996 NNIPS study 292 pregnant women Sarlahi 56% 8% 79% 1996 WHO/WFP study 711 school children Parsa, Surkhet and Dailekh 22% 19% 65% 74% 1998 JICA study 1905 school children Kavrepalanchowk 43% 5% 9% 48% 1998 NNIPS study 129 infants Sarlahi 0.8% 0 0.8% 2004 NS/JICA study 536 adolescent girls Kathmandu, Bhaktapur and Lalitpur 45.1% 35.1% 40% Low birth weight (LBW) • Percentage of infant with low birth-weight is 21% in Nepal9. Life-style related diseases • The morbidity and mortality of life-style related diseases are likely to be increased according to the data based on the hospital source 1997/1998 2002/2003 Life-style related disease Hospital Inpatient Morbidity Death Hospital Inpatient Morbidity Death Cancer Hypertension Diabetes Cardiovascular disease 572 311 91 1867 28 12 5 140 1360 1022 308 4878 37 30 14 283 Source: DHS Annual Report 1997/1998 & DHS Annual Report 2002/2003 Admitted cases Life-style related disease 2001 2003 Coronary Artery Disease Hypertension Diabetes 572 311 91 28 12 5 Note: 14 Cut-off points for assessment of nutritional status: see Annex 1 Adjustment of Hb-cut-offs for populations living at higher altitudes: see Annex 1 WHO standards for parameters of life-style related disease: See annex 2 Current government actions for reducing various nutrition problems PEM • Growth monitoring and nutrition counseling at Primary Health Care Center (PHCC), Health Posts (HPs), Sub-Health Posts (SHPs) and Outreach Clinics (ORCs). • Promotion of exclusive breastfeeding through mass media • Implementation of Breast Milk Substitute Act 2049 and Regulation 2051. • Promotion of complementary feeding after 6 months. • Seven hospitals certified as Baby Friendly Hospital Initiatives (BFHI) in various parts of country. IDA • Distribution of iron/folate tablets to pregnant women and lactating mothers through hospitals, PHCC, HPs, SHPs and ORCs. • Intensification program of maternal iron supplementation through Female Community Health Volunteers (FCHVs) in 12 districts. IDD • Universal salt iodization as sole strategy to address IDD. • Distribution of iodized salt in remote districts at subsidized rates. • Implementation of Iodized Salt Social marketing Campaign. • Monitoring of iodized salt at the entry points, regional and national levels. • Evaluation of IDD status through National Survey and integrated mini- surveys for Vitamin A, iodized salt and deworming. • Iodized salt warehouse constructions in various parts of country. • Development of Iodized Salt Act in 1998. 1.3 Government actions in nutrition 15 VAD • Mass supplementation of high-dose VA capsules to children aged 6 and 59 months of age in 75 districts. • Nutrition education activities through Behavior Change Communication (BCC) and mass media, community-level health workers and agricultural extension workers. • Initiation of VA capsules supplementation for postpartum mothers through FCHVs and health facilities. • Treatment of night-blind pregnant women with low dose VA capsules in the selected districts. • Case treatment for measles, severe malnutrition, chronic diarrhea and eye problems related to VAD. Intestinal worms • Biannual deworming of children aged 1-5 years during vitamin A capsule supplementation in all 75 districts. • Deworming of all pregnant women after completing the first trimester of pregnancy. LBW • Advocacy for antenatal check up and counseling at least 4 times during prenatal period according to MoH policy. • Nutrition education through health institutions for the general population with special focus on adolescents and expectant mothers. Infectious Disease Control (in other sectors) • Standard case management of diarrhea, ARI, measles, malnutrition and malaria among under 5 children through community based Integrated Management of Childhood Illness (IMCI) program. • Vaccine preventable disease control through regular immunization and periodic campaigns. • DOTS program for TB patient Life-style related diseases (in other sectors) • Tobacco advertisement have been banned in the electronic mass media • Establishment of a focal point in MoH to deal with problems related to non communicable diseases (coronary heart diseases, cancer etc) • The money collected from the tax of tobacco products is being diverted for the treatment of cancer and heart disease patients. 2. Overall goal and objectives and targets of each strategic h: 16 Overall goal: Achieving nutritional well being of all people in Nepal so that they can maintain a healthy life and contribute to the socio-economic development of the country, through improved nutrition-program implementation in collaboration with relevant sectors. In order to achieve the overall goal, the following conditions are indispensable: 1. The measures in this document have to be implemented and sustained to reduce the burden of nutritional problems such as protein-energy malnutrition, iron deficiency anemia, iodine deficiency disorder, vitamin A deficiency, low birth weight, diet-related diseases (life-style related diseases) and other nutritional disorders. 2. The measures for improved dietary habits, household food security and ‘school health and nutrition’ should be implemented as long-term strategies to modify nutritional status of the people and to reduce the prevalence of the nutritional disorders. 3. The control of infectious diseases including intestinal worm infestation has to be strengthened to help reduce the risk of malnutrition as well. 4. It is urgently necessary to address or promote the measures regarding nutrition in exceptionally difficult circumstances such as breastfeeding of HIV positive mothers and food shortages in crisis situation. 5. In order to promote the above mention measures efficiently and effectively, the monitoring, assessment and supervision of program implementation must be conducted regularly. In order to accomplish the above conditions, the area of approach with objectives and targets have been set up as following: Objectives and targets: Categories Objectives and targets Objective 1 To reduce protein-energy malnutrition in children under 5 years of age and reproductive aged women Target 1 To reduce the prevalence of PEM among children to half of the 2000 level by the year 2017 PEM Target 2 To reduce the prevalence of low BMI in women to half of the 2000 level by the year 2017 Objective 2 To reduce the prevalence of anemia among women and children IDA Target 1 To reduce the prevalence of iron deficiency anemia to less than 40% by the year 2017 Objective 3 To virtually eliminate iodine deficiency disorders and sustain the elimination IDD Target 1 To virtually eliminate iodine deficiency disorders by the year 2017 Objective 4 To virtually eliminate vitamin A deficiency and sustain the elimination VAD Target 1 To virtually eliminate vitamin A deficiency by the year 2017 Intestinal worm infestation Objective 5 To reduce the infestation of intestinal worms among children and pregnant women 17 Target 1 To reduce infestation of intestinal worms to less than 10% by the year 2017 Objective 6 To reduce the prevalence of low birth weight LBW Target 1 To reduce the prevalence of low birth weight to 12% by the year 2017 Objective 7 To improve household food security to ensure that all people can have adequate access, availability and utilization of food needed for healthy life Household food security Target 1 To reduce the percentage of people with inadequate energy intake to 25% by the year 2017 Objective 8 To promote the practice of good dietary habits to improve the nutritional status of all people Dietary Habit Target 1 To reduce the prevalence of undernutrition (underweight) and low BMI to half of the2000 level by the year 2017 Infectious disease Objective 9 To prevent and control infectious diseases to improve nutritional status and reduce child mortality Objective 10 Life-style related diseases To control the incidence of life-style related diseases (coronary artery disease, hypertension, tobacco and smoke related diseases, cancer, diabetes, dyslipidemia, etc) School health and nutrition Objective 11 To improve health and nutritional status of school children Nutrition in exceptionally difficult circumstances Objectives 12 To reduce the critical risk of malnutrition and life during exceptionally difficult circumstances Monitoring Objective 13 To strengthen the system for analyzing, monitoring and evaluating the nutrition situation Note: Indicators and targets for reducing malnutrition: see Annex 3 The Government of Nepal is concerned about the serious problem of malnutrition that persistently exists in large sections of the population in different forms, degrees and magnitudes and hence is strongly committed to improving the situation and ensuring the nutritional well being of all the people. In order to reduce/control nutritional problems, the Government of Nepal needs to take various measures based on the following important principles: Human rights Hunger and malnutrition are unacceptable in a world that has both the knowledge and the resources to end this human catastrophe. We recognize that accesses to nutritionally adequate and safe food and services for nutrition education are the rights of each individual. Pre-condition for development Nutritional well being of all people is a pre-condition for the development of societies and it should be a key objective for progress in human development. It must be at the centre of our social-economic development plans and strategies. Healthy Life Malnutrition is directly or indirectly associated with more than 50% of 3. Basis of Nutrition Policy 18 all child mortality and is associated with most of the major risk factors for maternal mortality. Malnutrition is the main contributor of the burden of diseases in the developing world. Nutritional improvement has to be enhanced to ensure the healthy life of all people. Universal primary education Under nutrition in infancy and early childhood affects school enrolment rates and on cognitive and behavioral development. Iodine and iron deficiencies lead to impaired cognitive development and thus effects educational attainments. Nutrition is therefore one of the key elements not only for normal physical development but also for improved intellectual resources. Prioritized groups Infants, young children, pregnant and nursing women, disabled people and the elderly within poor households are the most nutritionally vulnerable groups. Priority must be given to them for the protection and promotion of their nutritional well-being. People’s participation People-focused policies for nutritional improvement must acknowledge the fact that people’s own knowledge, practices and creativity are important driving forces for social change. Local community involvement, including that of families and households, is a prerequisite for improving food production and sustaining access to food and for instituting nutrition improvement programs and projects. Gender Women play a key role in socio-economic development and in many societies they are also the main producers of food. Special attention should be given to the nutrition of women during pregnancy and lactation. All forms of gender discrimination including traditional practices detrimental to women must be eliminated in accordance with the 1979 Convention on Elimination of All Forms of Discrimination against Women. The following general strategies have been pursued to improve the nutritional situation in Nepal. Community Participation Promote, facilitate and utilize community participation and involvement for all nutrition activities; Coordination among Intra Sectors Develop understanding and effective co-ordination between the various sections and divisions in the Department of Health Services, i.e., Family Health Division (FHD), Logistics Management Division (LMD), National Health Training Centre (NHTC) and the National Health Education, Information and Communication Centre (NHEICC). Coordination Maintain and strengthen co-ordination among other agencies 4. Guiding 19 among Inter Sectors involved in nutrition activities, i.e., the Ministry of Agriculture and Cooperatives (MoAC), Ministry of Education (MoE), Ministry of Women, Children and Social Welfare (MoWCSW), Ministry of Local Development (MoLD) and the National Planning Commission (NPC), as well as with other programs, International Development agencies, NGOs, INGOs and private sectors. Decentralization Decentralize authority to the region, district, Health Post, Sub Health Post and community for assessment, planning, implementation, and monitoring of nutrition activities. Advocacy Conduct National Advocacy and Social Mobilization Campaigns. Communication Develop behavior change communication strategies to implement nutrition programs with adequate messages and media use. Strengthen effective use of interpersonal communication and mass media for synergistic effect Integration Integrate/incorporate nutrition plans in activities such as the Expanded Programmes on Immunization (EPI), Integrated Management of Childhood Illness (IMCI), Maternal and Child Health, Family Planning programs, etc. Monitoring and evaluation Monitor and evaluate the situations of nutritional status and program implementation to strengthen nutrition policy and strategy and to modify programs as necessary Research Carry out research and feasibility study to analyze the current nutritional situation to identify the major factors of nutritional problems and to clarify the possibility of new approaches. Capacity Building Develop the capacity of all health workers so they can effectively transfer appropriate knowledge and implement nutrition programs with good skills. Develop the system to educate dieticians. Nutrition institution building is essential to strengthen all the nutrition programs. Objective 1: To reduce Protein-energy malnutrition in children under 5 years of age and 5. Strategic approaches for nutritional i t 5.1 Protein-energy Malnutrition 20 reproductive aged women Appropriate breastfeeding practice Appropriate complementary feeding practice Reduced infectious disease Growth monitoring practice and counseling Reduced Low Birth Weight Improved maternal nutrition Increased awareness about the nutritive value of food Reduced PEM Reduced mortality Reduced morbidity Improved physical and mental development Measures and Impact of PEM Control Nutrition Rehabilitation Fortified food supplementation in food deficient areas (for children) Specific objective Strategy Activities Responsibility Indicator Ensure early initiation of BF within one hour of birth, avoidance of prelactal feed and promotion of Ex. BF for the first 6 months. Ensure continuation of BF for at least 2 years and introduction of appropriate CF after 6 months • Campaign through mass media • Counsel the mother regarding BF • Mobilize women’s group • Develop school curriculum NS/CHD, DHO/DPHO, MoE Strengthen the capacity of HWs/ medical professionals for nutrition/BF management • Train HWs/medical professionals, community level service providers and volunteers • Reactivate BFHI NS/CHD, DHO/DPHO, CBOs Protect from commercial promotional practices which undermine optimal BF practices • Implement, strengthen and monitor the Breast-milk Substitute Marketing Control Act • Appoint Inspector for monitoring NS/CHD, DHO/DPHO, MoH To protect, promote and support optimal feeding practice for infants and young childrena Empower all mothers, families and care-givers to make and carry out fully informed decisions about feeding • Provide nutrition counseling and education for mothers and caregivers DHO/DPHO, MoH, Health institutions Coverage of Ex. BF Coverage of appropriate CF 21 Support community based programs • Create and support the network of mother to mother support group • Integrate community-based programs with other health programs. • Collectively assess, analyze and take action for optimal feeding practice DHO/DPHO, Health institutions Promote mother and child friendly working environment • Establish crèches • Promote BF breaks for working mothers • Advocate for extended maternity leave • Advocate for paternity leave NS/CHD, DHO/PHO Promote the use of appropriate and adequate locally available complementary foods like Jaulo and Sarvottam Pitho • Develop guidelines on safe IYCFb • Explore innovative approaches through fortification • Develop mandatory standards on commercial production of CF, fortification and marketing practices • Nutrition education for mothers/care takers NS/CHD DFTQC Strengthen the system of GM and supervision/monitoring for GM • Update guidelines on GM • Explain the guidelines of GM to all health workers through training • Regular implementation and monitoring of GM • Training and workshop for DHO/PHO/NFP NS/CHD, DHO/DPHO, Health institutions Improve skills and knowledge regarding GM and nutrition counseling among health workers. • Training and orientation • Monitoring and supervision NFP, DHO/DPHO, NS/CHD To increase the coverage of Growth Monitoring (GM) Provide PHC/HP/SHP with necessary equipment and material for GM • Distribution of weighing scales, growth charts, and IEC materials LMD GM coverage 22 Create awareness regarding the importance of appropriate and adequate nutrition for children, pregnant and lactating mothers • Nutrition education and counseling practice through ANC/PNC services, GM and mass media DHO/DPHO, NS/CHD To improve nutrition knowledge, attitudes and practices of parents and community people Change culturally acceptable nutrition behavior to improve intake of nutritious foods and diversification of diet • Nutrition education and counseling practice through ANC/PNC services, GM and mass media • School Health and Nutrition Programs DHO/DPHO NS/CHD Health institutions Improved KABP Facilitate the function of nutrition rehabilitation at hospital level • Establish a rehabilitation center at each zonal hospital NS/CHD, Zonal hospitals, NGOs/INGOs To facilitate the building of nutrition rehabilitation institutions for severe malnutrition Strengthen the ability of health personnel in dietary and clinical management of severely malnourished children • Train health personnel in the treatment of severe malnutrition NS/CHD No. of rehabilitatio n centers No. of malnourishe d cases treated To reduce the No. of children who suffer from inadequate energy intake Distribute fortified foods to children aged 6 to 36 months (and expectant and nursing mothers) in food deficient areas • Develop guidelines for food supplementation • Collaborate with donor agencies for effective distribution to target areas. NS/CHD, Donor agencies To reduce low birth weight See objective 6 To reduce the risk of infectious diseases See objective 9 To improve maternal nutrition See the next strategy for women Note: a. Concept of objectives and strategies in this part were based on the IYCF Strategy paper (draft) b. Guideline for complementary foods should be developed following WHO guideline: see Annex 4 (For women) Specific Objective Strategy Activities Responsibility Indicators To reduce the risk factors for under-nutrition in women, particularly pregnant and lactating women Create awareness of the importance of additional dietary intake during pregnancy and lactation • National campaign by mass media (National nutrition week) • Use local media (FM) • Implement BCC and BPP • Intra-sectoral collaboration NS/CHD, FHD, MoWCSW, MoE Weight gain during pregnancy BMI for non-pregnan t women 23 Strengthen the activities of nutrition education and counseling • Train HWs and other initiators on nutrition • Activate nutrition education and counseling at health facilities • Use local media (FM) NS/CHD, FHD Promote social (community and family) support for maintaining good heath care and dietary habit • Implement BCC and BPP NS/CHD, FHD Reduce heavy work load of pregnant and lactating women • Implement BCC and BPP NS/CHD, FHD Prevent early pregnancy and ensure adequate birth spacing • Implement BCC and BPP NS/CHD, FHD Improve iron status of pregnant and lactating women See Objective 2 Objective 2: To reduce the prevalence of anemia among women (reproductive aged) and children (preschool) Increased coverage and compliance of iron supplementation Reduced burden of parasitic infestations Improved maternal nutrition and care Dietary modification Reduced anemia Increased learning capacity Increased productivity Reduced maternal morbidity/mortality Reduced infant morbidity/mortality Reduced LBW Measures and Impact of IDA Control Iron fortification Control vitamin A deficiency Specific objectives Strategy Activities Responsibility Indicators 5.2 Iron Deficiency Anemia 24 Create awareness of anemia and importance of iron supplementation • IEC campaigns through mass media • Nutrition education at community level NS/CHD, DHO/DPHO, NHTC, NHEICC Ensure availability of iron/folate supplements at all health facilities and ORC • Strengthen logistic system and monitoring for delivery of iron/folate tablets NS/CHD, DHO/DPHO, LMD, To increase coverage and compliance of iron/folate supplementation for pregnant and postpartum womena Increase accessibility of iron/folate at the family and community level • Involvement of FCHVs • Activation of the role of PHCC/ORC DHO/DPHO Anemia prevalence Coverage and compliance of iron supplementati on Strengthen parasitic infestation control programs (intestinal helminthes, malaria and kalazar) • Biannual Deworming activities for preschool children • Deworming of pregnant women during second trimester of pregnancy • Appropriate use of insecticide spray • Distribution of impregnated mosquito nets NS/CHD DHO/DPHO EDCD To reduce burden of parasitic infestationsb (helminthes, kalazar and malaria) Create awareness about improving living conditions including sanitation and hygiene • National campaign through mass media • Health education • Collaboration with related sectors NHEICC, DHO/DPHO, EDCD, MoHAPP Prevalence of parasitic infestation Coverage of deworming tablets Reduction in API To control vitamin A deficiency in children, pregnant and postpartum mothers Promote vitamin A deficiency control program for children, pregnant and postpartum mothers See objective 4 (strategy for VAD control) Identify suitable food vehicles for iron fortification • Feasibility study of iron fortification Devise necessary policies to successfully implement fortification • Revise food regulations • Develop a systematic plan for production and distribution • Establish monitoring system to ensure quality of fortification To effectively implement food fortification to increase dietary iron intake Fortify commercially produced wheat flour with iron • Encourage private sectors and NGOs in iron fortification of wheat flour NS/CHD DFTQC MoAC Production and consumption of iron fortified foods 25 Increase awareness about iron rich foodsc, both animal and vegetables sources Promote dietary practices that improve the content and bioavailability of iron in diet To promote locally appropriate dietary modifications to improve the quality and diversity of food consumed Advocate for equity among genders in access and control over household foods • National campaign • Nutrition education • Develop IEC materials • National campaign for gender equity NFP/DHO, NS/CHD, NHEICC, MoWCSW Improved KABP Create awareness of the importance of increased food intake and reduced work load during pregnancy • IEC campaign • Nutrition education • Coordination with existing gender programs Promote advocacy campaigns against teen age pregnancy, early marriage and short birth spacing • IEC campaign • Coordination with existing gender programs To promote maternal care practices to improve health and nutritional status of mothers and their babies Develop a scheme for screening and diagnosing high risk women for severe anemia • Develop guidelines for screening and diagnosis of high risk groups DHO/DPHO, NS/CHD, MoWCSW, NHEICC, NGOs/INGOs Improved KABP Maternal morbidity/ mortality Incidence of LBW babies Conduct operational research regarding anemia To identify effective modalities to address iron deficiency in children, adolescents and non-pregnant reproductive aged women Review the possibility of extending iron/folate supplementation to other groups at risk as well as to find out alternative approaches to supplementation • Operational research • Collect information and review other possibilities NS/CHD Operation research Strengthen HMIS and LMIS to routinely monitor, supervise and report on program implementation • Review existing HMIS/LMIS • Strengthen reporting and recording systems at all levels Evaluate the impact of the program through periodic surveys and identify `hot spots’ which need to be prioritized • Design and carry out the evaluation surveys To develop a systematic approach to monitoring and evaluation of anemia control program activities Develop capacity in screening for anemia by measuring hemoglobin with field testing tools • Training for health workers in screening for anemia NS/CHD, DHO/DPHO, LMD, MD Monitoring and evaluation report Note: a. National Protocol on Iron Supplementation and guidelines for treating severe anemia: see Annex 5 b. Guidelines for the distribution of deworming tablets: see Annex 6 26 c. List of iron rich foods: see Annex 7 Objective 3: To virtually eliminate iodine deficiency and sustain the elimination Iodization of salt Increased accessibility of iodized salt Promote use of iodized salt Reduced IDD Reduced perinatal mortality Improved productivity Improved cognitive function Measures and Impact of IDD Control Specific objectives Strategy Activity Responsibility Indicator Strengthen implementation of Iodized Salt Act • Implement Iodized Salt Regulations • Develop operational guidelines for iodized salt trading • Strengthen monitoring and regulating bodiesa of iodized salt trading NS/CHD, DFTQC, IDD committee To ensure all edible salt is iodized Encourage better storage practices to prevent iodine loss • Advocacy for importer/trader, dealer, retailer and community people MoH, STC Prepared Guidelines Iodine level at entry, dealer and household levels % of households consuming adequately iodized salt 5.3 Iodine Deficiency Disorder 27 Ensure systematic monitoring of iodized salt • Internal monitoring at entry points • External monitoring at the entry sites and depot sites • Monitoring at community level STC, Salt traders NS/CHD, DFTQC. DHO/DPHO (>15 ppm) To increase the accessibility of iodized packet salt with quality assurance logob Increase the market share of the iodized packet salt • Advocate among dealers/traders • Monitore the market share of iodized packet salt with quality assurance logo in salt business • Distribution of iodized salt in inaccessible districts at subsidized costs • Coordinate with different government bodies to restrict infiltration of non iodized salt or inadequately iodized salt NS/CHD Coverage of the market share of iodized packet salt To increase the use of iodized packet salt Create awareness of the importance of iodized salt • Implement social marketing campaign • Initiate school based promotion campaign • Training/orientation to health workers and volunteers NS/CHD, DHO/DPHO, NGOs/INGOs Coverage of the use of iodized packet salt To monitor IDD prevalence at national level Develop IDD monitoring system and implement the monitoring survey at national level • Collaborations with external and internal partners to practice NS, IOM, Prevalence of IDD based on UIE examination and coverage of iodized saltc Note: a. Regulation bodies: 1. Ministry of Health 2. IDD elimination committee and 3.DFTQC b. Quality assurance logo: IDD technical Committee under Ministry of Health issued a two child logo for the quality assurance of iodized packet salt at 50 ppm level (minimum) in 1998. c. WHO/UNICEF/ICCIDD has recommended two main indicators to assess the status of IDD. These are urinary iodine excretion (bio-chemical indicator) and salt iodine (process indicator). Criteria based on both of the indicators should be met in order to declare elimination of IDD from a particular area. 28 Objective 4: To virtually eliminate vitamin A deficiency and sustain the elimination Supplementation with VA capsules Dietary modification Prevent VAD Reduced child morbidity and mortality Reduced maternal morbidity and mortality Reduced xerophthalmia Measures and Impact of VAD Control Treatment of night blind pregnant women Vitamin A fortification Specific objectives Strategy Activities Responsibility Indicator Ensure availability of VA capsules at health facilities • Strengthen logistic system of VA capsules distribution LMD, DHO, CHD Increase awareness of importance of VA capsules supplementation • Distribution of VA capsule through FCHVs • Supervision by Health post workers • Training to newly appointed HWs and newly recruited FCHVs DHO/DPHO, NS/CHD To sustain the existing high coverage of supplementation of high-dose VA capsules to children aged 6-59monthsa Promote biannual VA capsules supplementation through FCHV at VA days • National campaign through mass media • Mobilization of community leaders DHO/DPHO, NS/CHD Coverage of VA supplementati on 5.4 Vitamin A Deficiency 29 Increase awareness of benefits of VA capsules supplementation • Campaign and education DHO/DPHO, NS/CHD Promote VA capsules supplementation within 6 weeks of delivery DHO/DPHO, NS/CHD To increase coverage of supplementation of high-dose VA capsule to postpartum mothersb • Distribution of VA capsule through FCHVs and HP staffs • Supervision by Health post workers • Training to newly appointed HWs and newly recruited FCHVs • Supplementation of VA capsule at the time of BCG vaccination Coverage of VA supplementati on To reduce the risk of VA deficiency for night blind pregnant mothersc Promote treatment of night-blind pregnant women with low-dose VA capsules after first trimester. • Advocate for low-dose VA capsules • Low-dose treatment through health institutions DHO/DPHO, NS/CHD, Health institutions Coverage of LDVAC dose Prevalence of night blindness Strengthen implementation of the activity for treatment • Training to health workers at health institutes • Disseminate and distribute case treatment protocol card NS/CHD To ensure treatment of clinical conditions such as xerophthalmia, measles, severe malnutrition and prolonged diarrhea by the recommended dose of VA capsules Ensure availability of VA capsules • Supply VA capsules to all health facilities LMD, NS/CHD Coverage of cases treated Advocate for increased home production, consumption and preservation of VA rich foods • National campaign • Nutrition education • Promote home gardening and animal husbandry To promote dietary modification to improve the quality and diversity of foods Promote the consumption of VA rich foodsd and balanced diet through nutrition education • Campaign by mass-media • Promote home gardening and animal husbandry • Nutrition education NS/CHD, MoAC, DFTQC, MoE Improved KABP 30 To promote the use of VA fortified food Strengthen implementation of fortification activity • Create awareness about fortified food • Identify appropriate food vehicle for VA fortification • Establish fortification policy • Encourage industrial partners and NGOs/INGOs in fortification NS/CHD, MoIC, DFTQC Increased use of fortified food Note: a. Guidelines for VA Capsule supplementation and treatment protocol: see annex 8 b. Postpartum supplementation is aimed to correct VAD in infants from birth to 6 months. c. Currently practicing in three districts only. d. List of vitamin A rich foods: see Annex 9 Objective 5: To reduce the infestation of intestinal worms among children and pregnant women 5.5 Intestinal Worm 31 Good hygiene practices Deworming tablets Reduced Intestinal worms infestations Prevention of anemia Prevention of malnutrition Measures and Impact of Intestinal Worms Control Hygiene environment Specific objectives Strategy Activities Responsibility Indicator To sustain the existing high coverage of deworming tablets among children aged 1-5 yearsa. Distribute the deworming tablets to target groups during vitamin A capsule supplementation in all districts. • Training to FCHVs • Logistics management of deworming tablets • Distribution of deworming tablets by FCHVs • Advocacy for deworming LMD, DHO/DPHO NS/CHD, Health institutions Coverage of deworming tablets Prevalence of intestinal worm infestation To increase the coverage of deworming tablets to pregnant womenb Strengthen deworming program for pregnant women through health facilities • Training to Health workers • Logistic management of deworming tablets • Distribution by health workers • Advocacy for deworming LMD, DHO/DPHO NS/CHD, Health institutions Coverage of deworming tablets Prevalence of intestinal worm infestation To promote the improvement of hygiene practices to reduce contamination with intestinal worms/ova Advocate for people to improve their hygiene practices. • Campaign • Health education DHO/DPHO, NS/CHD, NHEICC Coverage of deworming tablets Prevalence of intestinal worm infestation Note: a. Guidelines for distribution of deworming tablets: see annex 6 b. Single dose of deworming tablets (Albendazole 400 mg) from 2nd trimester (4months) of pregnancy. Objective 6: To reduce the prevalence of low birth weight 5.6 Low Birth Weight 32 Improved maternal nutrition Reduced physical burden of mother Reduced LBW Reduced prevalence of malnutrition Reduced infant mortality/mortality Reduced risk of chronic disease at adulthood Measures and Impact of LBW Control Reduced habits of smoking tobacco and drinking alcohol by pregnant women Reduced early pregnancy Increased nutrition monitoring and counseling services at antenatal checkup Specific objectives Strategy Activities Responsibility Indicator Reduce maternal PEM • Nutrition education counseling • National campaign • Monitoring nutritional status at antenatal clinic Reduce maternal IDD • Campaign to promote use of iodized salt Reduce maternal VAD • Treatment of night blind pregnant women with low dose VA capsules Reduce maternal anemia • Provide iron tablets and de- worm medicine To improve maternal nutritional status Reduce workload of pregnant women • Collaboration with gender sector DHO/DPHO, NS/CHD, MoWCSW, NHEICC, Health institutions Weight gain of pregnant mother Coverage of iodized salt Anemia prevalence VAD prevalence Improved KABP To reduce number of pregnant women who have the habits of smoking tobacco and drinking alcohol Increase awareness of risks of smoking and alcohol to LBW • National campaign through mass media • Nutrition/health education • Enforce respective legislation FHD, Health institutions No. of pregnant women with the habits of smoking and drinking alcohol To reduce cases of early pregnancy Increase awareness of risks of teen-age pregnancy to infant and maternal health • Establish and strengthen adolescent clinic • Develop school curriculum on reproductive health • Counseling and education • Improve family planning FHD, Health institutions Cases of Teen age pregnancy 33 To increase % of pregnant women who access services for nutrition monitoring and counseling at antenatal clinic Strengthen activities for nutrition monitoring /counseling at antenatal clinics • Monitor body weight gain • Develop guideline/manual for nutrition counseling • Implement nutrition counseling by trained HWs • Collaboration with safe motherhood program or Family Health Division Family health sector Coverage of ANC visits Objective 7: To improve household food security to ensure that all people have adequate access, availability and utilization of food needed for a healthy life. Improved nutritious food production Good management of food allocation Income generation Improved food storage and preservation Improved household food security Reduced malnutrition Improved productivity Reduced risk of morbidity/mortality Measures and Impact of Household Food Security Improved food processing Specific objectives Strategy Activities Responsibility Indicator Promote kitchen gardening Improve agricultural skills To improve nutritious food production at household level Promote raising of poultry, fish and livestock for household consumption • Collaboration with agricultural sector MoAC, MoH Energy availability/ Capita 5.7 Household Food 34 To improve food storage and preservation skills Advocate among community people as to how to store and preserve their foods at home • Develop IEC materials • Training to community people • Collaboration with agricultural sector MoAC, DFTQC Improved KABP To diversify utilization of various food items Improve technical knowledge of food processing • Establish cooperatives • Establish community processing unit MoAC, DFTQC Quantity of production and consumptio n of processed foods To improve food allocation throughout the year within the household Advocate among community people as to how to manage their food allocation • Develop IEC materials • Campaign and education • Training MoAC, MoE, NS/CHD Food deficit data To increase income generating opportunities for sustained purchasing power of foods Promote activities of women’s groups which are interested in income generation • Introduction of appropriate income generation activities MoAC, MoWCSW, Local development offices, NGOs/INGOs Increased household income Objective 8: To promote the practice of good dietary habits to improve the nutritional status of all people 5.8 Improved Dietary 35 Identify nutritional problems Reduced food taboos Ensure the decision making power of women Increase awareness of good food habits Improved dietary habits Improved nutritional status Improved productivity Reduced risk of Morbidity/mortality Reduced incidence of life-style related diseases Measures and Impact of Improved Dietary Habits Behavior change Increased the availability of foods Specific objectives Strategy Activities Responsibility Indicator To identify nutritional problems due to culturally related dietary habits Conduct a study to clarify the problems of culturally-related dietary habits • Collect information about dietary habits and food intake • Review and analyze the culturally-related dietary habits NS/CHD DFTQC Nutritional status (Prevalence of underweight and Prevalence of low BMI) To increase the awareness and knowledge of balanced diets, nutritious foods, and good dietary habits Promote nutrition education activities and advocate for good diets and dietary habits • Update and disseminate existing guidelines on good diets and dietary habits • Develop IEC materials for good dietary habits • Coordinate with curriculum development center to update the curriculum • Implement nutrition education /advocacy at various levels NS/CHD DFTQC CDC/MoE DHO/DPHO Improved knowledge To promote behavior change to improve dietary habits Develop and strengthen programs that focus on behavior change as the means of improving dietary habits • Develop tools which promote behavior change for improved dietary habits • Train health workers in the use of behavior change tools • Utilize local people and resources in programs aimed at NS/CHD, NHTC, DHO/DPHO Improved behavior change 36 behavior change To reduce the risk of nutritional problems due to food taboos Strengthen the activities of nutrition education/advocacy which seek to eliminate the food taboos affecting nutritional status • Identify food taboos which are still commonly practiced • Advocate using behavior change tool at the community level • Advocate among traditional healers NS/CHD, NHTC, DHO/DPHO Identified food taboos To increase the availability of various types of food at the household level Promote the program of household food security • See objective 7 NS/CHD MoAC Nutritional status Number of different types of foods in households To encourage women in the decision making for preparation of family foods Promote empowerment of women/gender equity • Social mobilization • Support women’s groups MoWCSW % of women having decision making power for food preparation Objective 9: To prevent and control infectious diseases to improve nutritional status and reduce child mortality 5.9 Infectious Diseases 37 Increased accessibility to better health system Improved nutritional status Health education Improved food hygiene Reduced risk of Infectious diseases Reduced malnutrition Reduced morbidity/ mortality Measures and Impact of Infectious Diseases Control Improved environment (food safety, housing, Safe water and sanitation) Specific objectives Strategy Activities Responsibility Indicator Promote knowledge, attitudes and practices which will prevent infectious diseases • Campaign through mass media • Education on health and hygiene MoE, MoLD, MoE • Immunization services • Measles control EPI section/CHD • Diarrheal disease control • ARI control IMCI section/CHD, MoHAPP • HIV prevention NCASC • Tuberculosis control TB Center • Vector born disease control (malaria, kala-azar etc) Epidemiology division/EDCD Ensure access to appropriate health services • Improve referral system DHO/DPHO To reduce the risk of morbidity and mortality by infectious diseases Improve nutritional status to raise resistance against infectious disease • Implement PEM program (see objective 1) • Sustain vitamin A supplementation (see objective 4) • Promote IYCF practices (see objective 1) CHD, FHD Morbidity and mortality of infectious diseases Severity and incidence of diarrhea and pneumonia Immunizati on coverage Access to safe drinking water Percentage of malnourishe d children 38 Improve safe water supply, sanitation and housing • Increase access to safe drinking water • Improve sanitation system • Increase the availability of public and private toilets • Advocate about the importance of better housing MoHAPP, MoH (Environment health focal point), NHEICC Improve food hygiene • Health education through BCC for improved food hygiene • Campaign amongst food handlers for food hygiene • Advocacy for appropriate food safety legislation and regulations MoE, NHEICC, DFTQC Objective 10: To control the incidence of life-style related diseases (coronary heart disease, hypertension, tobacco and smoke related diseases, cancer, diabetes, dyslipidemia, etc) Dietary modification Reduced LBW and childhood malnutrition and obesity Reduced life-style related diseases Increased Quality of life Increased productivity Measures and Impact of Life-style Related Diseases Practice of healthy life style (cessation of tobacco use, Regular physical exercise, Stress management techniques) Reduced mortality 5.10 Life-style Related Diseases 39 Specific objectives Strategy Activities Responsibility Indicator Create awareness among adults about the importance of maintaining good food habits for lifea • Develop IEC materials • Develop systematic networking system to distribute IEC materials • Campaign through media • School health and nutrition education To promote good food habits Develop capacity for counseling at health facilities • Develop IEC counseling materials • Training to health workers NS/CHD, DHO/DPHO KABP Create awareness about the importance for adolescents and adults to control smoking and body weight To promote better lifestyle for improved health Create awareness to increase physical activity and improve stress management techniques • Develop IEC materials • Develop RDA for Nepali people • Revise nutritive value of foods • Campaign through media • Nutrition and health education NS/CHD, FHD, Schools, Universities, Hospitals, NGOs/INGOs Incidence of life style related diseases To reduce inadequate intrauterine development and malnutrition and obesity during childhoodb See objective 6 and objective 1 Note: Association between selected dietary components and cancer: see annex 10 a. Dietary guidelines for Life-style related diseases: See annex 11 b. Recent data demonstrated that malnutrition in childhood and during the gestational period could increase risk of the above non-communicable diseases in adulthood 40 Objective 11: To improve health and nutritional status of school children Increased use of school health and nutrition services Improved healthful school environment Improved community support system and policy Reduced malnutrition among school children Increased enrolment and attendance Contributions to future socio-economic developments Measures and Impact of Improved Health and Nutrition in School Children Improved health and nutrition behavior Improved physical growth Increased learning ability Specific objectives Strategy Activities Responsibility Indicator Build capacity of the policy and working level stakeholders • Training of teachers, Child clubs, SMCs and SHN Committees on anthropometric measurements, iron and Vitamin A supplementation and deworming To Increase use of SHN services by school children Increase SHN Services • Assessment of nutritional status, development of dietary guidelines, mass deworming, iron tablet distribution and school feeding program MoE, NS/CHD, SMC/SHN Committee % in enrolment and attendance rates Prevalence of anemia, VAD and worm infestation Proportion of malnourishe d children 5.11 School Health and 41 Formulate policies and standards by MoE and MoH • Incorporate school programs aiming SHN services into the School Improvement Plan Minimize environmental risks • Provide safe and hygienic food service To improve healthful school environment Provide adequate and safe water supply and sanitary facilities • Build separate latrines for boys and girls • Maintain hand-washing facilities at schools MoE, MoLD, MoAC, SMC, MoH, MoHAPP % of schools with separate latrines for girls and boys Reduced incidence of diarrhea and worm infestations Enhance knowledge, skills and learning ability • Conduct behavior-centered sessions on personal hygiene and nutrition • Promote kitchen gardens at schools To improve health and nutrition behavior Introduce child to child and child-to-parent approach • Develop and disseminate IEC materials and SHN facilitation reference manuals Schools, MoE, Curriculum Development Center, NHEICC % of children who report at least two nutritional measures % of schools having a kitchen garden Strengthen linkage, networking and partnership between MoE and MoH at various levels • Form a national level SHN Advisory and Steering Committee, Integrate school based health and nutrition services To improve and strengthen community support systems and policy environment Improve policy environment • Formulate school policy and protocols on healthy food, helminthes control and prepare SHN implementation guidelines MoE, MoH, SMC/SHN committee, Child clubs, MoWCSW % of schools with partners active in and supportive of SHN program Objective 12: To reduce the critical risk of death and/or malnutrition during exceptionally difficult circumstances 5.12 Nutrition in exceptionally difficult 42 Specific objective Strategy Activities Responsibility Indicator Increase awareness of BF in relation to HIV positive mothers at all levels • Develop evidence-based guidelines on HIV and infant feeding • National campaign through mass-media • Health education at various levels (health facilities, community, school, etc) To reduce the risk of malnutrition and morbidity/mortality by HIV transmission through BF of infants Provide support to HIV-positive mothers to successfully carry out their infant feeding decision • Develop counseling system for HIV-positive women • Build capacity of counselors/health workers for counseling • Implement counseling services for HIV-positive mothers NS/CHD, NCASC, DHO/DPHO, Health institutes, schools Nutritional status of HIV-positive infants % of infants who contracted HIV through BF % of HIV-positive mothers who have access to counseling services Ensure that nutrition is integrated as a key component of Emergency Preparedness Plan (EPP) • Advocate importance of nutrition in EPP To Reduce the risk of malnutrition and morbidity/mortality of people who suffer through complex emergencies including natural or human-induced disasters (flood, drought, earthquake, war, civil unrest, severe political and economical living conditions) Ensure that affected people have access to minimal nutritional requirements, particularly young children and women • Develop an implementation plan and guidelines for different situations • Collaborate with relief agencies for effective delivery of food • Monitor nutritional status, and availability /accessibility of foods NS/CHD, UN Agencies, Red Cross, Human right’s group, Ministry of Home Affairs and other concerned Ministries Prevalence of malnutrition % of target populations who access minimal nutritional requirements Objective 13: To strengthen the system for analyzing, monitoring and evaluating nutrition situations Specific objectives Strategy Activity Responsibility Indicator 5.13 Analyzing, Monitoring and Evaluating Nutrition 43 To strengthen existing institutional capacities and capabilities at various levels Increase knowledge and skills of key actors at all levels • Seminar • Workshop • Nutrition education at academic institutions NS/CHD University Situational analysis Strengthen collaboration amongst relevant institutions • Establish committee • Establish nutrition association To improve coordination of data collection, analysis and reporting Develop networks for data collection, processing and databank • Network NS/CHD University Data collection To standardize tools for monitoring and evaluation of the nutrition situation Acquire necessary tools and facilities required for data collection, processing and reporting • Create nutritional RDAs for Nepali people • Identify standard values of anthropometric measurements for Nepali people NS/CHD University Nepal RDAs and Anthropome t-ric standards To implement national survey to assess nutritional status in Nepal Strengthen capacity building for national nutrition survey • Training • Implementation of national nutrition survey NS/CHD National survey ANNEXES Annex 1: Cut-off points for the assessment of nutritional status Type Level Target Cut-off point Clinical examination Low Birth-weight Neonate <2500 g Moderate-Severe < 5 yrs <-2SD W/Aa, <3 centile of W/A Underweight1,2 Severe < 5 yrs <-3SD W/Aa, <60% of W/A Moderate-Severe < 5 yrs <-2SD H/Ab Stunting1 Severe < 5 yrs <-3SD H/Ab Moderate-Severe < 5 yrs <-2SD W/Hc Wasting1 Severe < 5 yrs <-3SD W/Hc Undernourished <16 BMId Probably undernourished 16 – 18.5 BMI Normal 18.5 – 25 BMI Probably obese 25 – 30 BMI Adult malnutrition (Based on BMI)3 Obese Adult >30 BMI Vitamin A deficiency4,5 Sub-clinical Serum retinol <0.70 µmol /Le 44 Clinical Serum retinol <0.35 µmol /Lf Night blindness, Bitot’s spot Conjunctive xerosis, Keratomalacia Active corneal lesions Mild 50-99 µg/L UIEg Moderate 20-49µg/L UIE Iodine deficiency Based on urinary iodine excretion6 Severe <20µg/L UIE Grade 0 No goiter Grade 1 Not visible with the neck in normal position. The mass moves upward when the subject swallows. Nodular alternations can occur even when the thyroid is not visibly enlarged. Based on palpation7 Grade 2 A swelling in the neck that is visible when the neck is in a normal position and is consistent with an enlarged thyroid by palpation 6-59 months <110 g/L Hbh 5-11 years <115 g/L Hb 12-14 years <120 g/ L Hb Adult woman <120 g/L Hb Pregnant woman <110 g/L Hb Adult man <130 g/L Hb Mild For all <10.0 g/L Hb cut-off point Moderate For all 7.0 - <10.0 g/L Hb Anemia8,9 *WHO adjustment of Hb cut-off points for population living at higher altitude) Severe For all <7.0 g/L Hb 45 a: weight for age in NCHS/WHO standard b: height for age in NCHS/WHO standard c: weight for height in NCHS/WHO standard d: Body Mass Index =Weight in kg / (Height in meters)2 e: less than 5% with serum values ≤0.70 µmol/l is characteristic of affluent societies and children with adequate vitamin A status f: A prevalence of >5% of serum levels <0.35 µmol/l is strong corroborative evidence of any clinical criteria met to identify an urgent public health problem. g: The benchmark for monitoring progress towards elimination of IDD as a public health problem is 50% of the target group with urinary iodine below 100 µg/l and less than 20% with levels below 50µg/l h: A classification of countries with respect to the degree of public-health significance of anemia has been proposed by WHO (1996) in which countries or population groups with anemia prevalence of at least 40% are categorized as “high”, 15-40% as “medium” and under 15% as “low”. References: 1. WHO. Measuring Change in Nutritional Status: Guideline for Assessing the Nutritional Impact of Supplementary Feeding Programs for Vulnerable Groups, WHO, Geneva, 1983 2. FS. King and A. Burgess. Nutrition for Developing Countries, Oxford University Press, 1993 3. G. Beaton, A. Kelly, J. Kevany, R. Martorell and J. Mason. Appropriate uses of anthropometric indices on children, ACC/SCN Nutrition Policy Discussion Paper, No. 7, ACC/SCN, Geneva, 1990 4. ACC/SCN. Micronutrients, Third Report on the World Nutrition Situation, ACC/SCN, Geneva, 1997 5. WHO. Indicators for accessing Vitamin A Deficiency and their application in monitoring and evaluating intervention programs, World Health Organization, 1998 6. ACC/SCN. Micronutrients Update, 4th Report on The World Nutrition Situation, ACC/SCN2000 7. UNICEF. Indicators for assessing Iodine Deficiency Disorders and Their Control Through Salt Iodization, NewYork, 1994 8. ACC/SCN. Controlling iron deficiency, Nutrition Policy Discussion Paper, No. 9. ACC/SCN, Geneva 9. CP. Howson, TE. Kennedy and A. Horwitz, Prevention of Micronutrient Deficiencies: Tools for Policymakers and Public Health Workers, Institute of Medicine, National Academy Press, Washington, D.C. 1998 Adjustment of Hb cut-offs for populations living at higher altitudes Normal increases in hemoglobin related to long term altitude exposure Altitude (meters) Increase in Hb (g/dl) <1000 1000 1500 2000 2500 3000 3500 4000 4500+ 0 + 0.2 + 0.5 + 0.8 + 1.3 + 1.9 + 2.7 + 3.5 + 4.5 Source: Nepal Micronutrient Status Survey, 1998 46 Annex 2: WHO standard for parameters of life-style disease Definitions of the characteristics of the metabolic syndrome (WHO standard for reference) Desirable Borderline Risk Cholesterol Total Cholesterol HDL-Cholesterol1 LDL-cholesterol2 Triglycerides <200 mg/dl >60 <130 <200 200-239 mg/dl 35-59 130-159 200-400 >240 mg/dl <35 >160 >400 Blood glucose stage/ Diabetes FPG Test3 OGT Test4 <6.1 mmol/L (<110 mg/dl) <7.8 mmol/L (<140 mg/dl) ≥7.0 mmol/L (≥126 mg/dl) ≥11.1 mmol/L (≥ 200 mg/dl) Uric acid level Male Female 2-7 mg/dl 2.5-6 mg/dl >7 mg/dl >6 mg/dl Blood Pressure/ Hypertension Systolic Diastolic <120 mmHg 80 mmHg 120-140 mmHg 80-90 mmHg ≥140 mmHg ≥90 mmHg Note: 1. HDL-Cholesterol: High Density Lipoprotein-Cholesterol 2. LDL-Cholesterol: Low Density Lipoprotein-Cholesterol 3. FPG Test: Fasting Plasma Glucose Test. Fasting is defined as no caloric intake for at least eight hours. OGT Test: Oral Glucose Tolerance Test. It is defined as 2 hour blood glucose Annex 3: Indicators and targets for reducing malnutrition Indicators and targets for reducing the prevalence of PEM in children under three years Indicators 1990’s 2000’s Target 10th Plan (2007) Target 11th Plan (2012) Target MDGs (2015) Target SLTHP (2017) Reference Prevalence of underweighta (<5yrs) 46.9b 48.3 39 32 27 24 NFHS1996 DHS2001 Prevalence of stuntinga 48.4 b 50.5 41 33 28 25 NFHS1996 DHS2001 Prevalence of wastinga 11.2 b 9.6 8 6 5 5 NFHS1996 DHS2001 Rate of exclusive 74.0 68.3 77 84 88 >90 NFHS1996 47 breastfeeding (<6 months)c DHS2001 Rate of optimal complementary feeding (6-9 months) 65 75 83 88 >90 DHS 2001 Coverage of growth monitoring d (<3yrs) 12-17 30 45 55 >60 DoHS AR 20002/03 a. <-2SD of NCHS/WHO standard b. Average data for children under 3 years c. The average rate of exclusive breastfeeding among all the groups from 0 to 5 months old d. Coverage of growth monitoring = (number of visits ÷ number of targets) × 100 Number of targets is calculated as follows: 1/3 × target population × 6 visits + 2/3 target population × 4 visits, where target population is all children 0-36 months of age. Indicators and target for reducing the prevalence of PEM in women Indicator 1990’s 2000’s Target 10th Plan (2007) Target 11th Plan (2012) Target MDGs (2015) Target SLTHP (2017) Reference Prevalence of Low BMIa 28.3 26.7 22 18 15 13 DHS 1996 DHS 2001 (Prevalence of poor weight gain during pregnancy) No data a. Low BMI: less than 18.5kg/m2 Indicators and targets for reducing the prevalence of anemia Indicator 1990’s 2000’s Target 10th Plan (2007) Target 11th Plan (2012) Target MDGs (2015) Targets SLTHP (2017) Reference Prevalence of anemia among children 78.0 60 49 43 <40 NMSS 1998 Prevalence of anemia among all women 67.7 54 47 42 <40 NMSS 1998 Prevalence of anemia among pregnant women 74.6 58 48 43 <40 NMSS 1998 Coverage of iron distribution 54-68 72 76 79 >80 DoHS AR 2000/03 Compliance of iron supplementation No data Indicators and targets for eliminating IDD Indicators 1990’s 2000’s Target 10th Plan (2007) Target 11th Plan (2012) Target MDGs (2015) Target SLTHP (2017) Reference Median Urinary 144µg/l >100µg/l NMSS 48 Iodine Excretion 1998 Coverage of iodized salt use (≥15 ppm) 55 63 75 83 88 >90 NMSS 1998 BCHIMES 2000 Indicators and targets for eliminating Vitamin A deficiency Indicators 1990’s 2000’s Target 10th Plan (2007) Target 11th Plan (2012) Target MDGs (2015) Target SLTHP (2017) Reference Prevalence of VAD (sub-clinical) 32.3 19 11 7 <5 NMSS1998 Prevalence of night blindness in pregnant women 6.1 3 2 1 <1 NMSS1998 Coverage of VA supplementation for children aged 6-59 months 97 >90 >90 >90 >90 DoHS AR 2002/03 Coverage of VA supplementation for postpartum mothers 47 57 74 84 >90 HMIS Report 2003/04 Coverage of cases treated No data Indicators and target for reducing low birth weight (LBW) Indicators 1990’s 2000’s Target 10th Plan (2007) Target 11th Plan (2012) Target MDGs (2015) Target SLTHP (2017) Reference Prevalence of LBW 21 19 15 13 12 UNICEF 2004 Rate of poor weight gain during pregnancy No data Indicators and target for improving household food security Indicators 1990’s 2000’s Target 10th Plan (2007) Target 11th Plan (2012) Target MDGs (2015) Target SLTHP (2017) Reference Rate of people with inadequate energy intake 50 38 32 28 25 CBS 1998 49 Indicators and target for intestinal worms control Indicators 1990’s 2000’s Target 10th Plan (2007) Target 11th Plan (2012) Target MDGs (2015) Target SLTHP (2017) Reference Rate of infestation of intestinal worms among children 74 45 27 16 <10 WHO/WFP 1999 Coverage of deworming tablets among children aged 2 to 5 yearsa 90 >90 >90 >90 >90 DoHS AR 2002/03 a. Only since October 2004 children aged 1 years have been included Annex 4: Guidelines for complementary feeding 1. Duration of exclusive breastfeeding and age of introduction of complementary foods: Practice exclusive breastfeeding from birth to six months of age, and introduce complementary foods at six months of age (180 days) while continuing to breastfeed. 2. Maintenance of breastfeeding: Continue frequent, on-demand breastfeeding until two years of age or beyond. 3. Responsive feeding: Practice responsive feeding, applying the principles of psychosocial care. Specifically: • feed infants directly and assist older children when they feed themselves, being sensitive to their hunger and satiety cues; • feed slowly and patiently, and encourage children to eat, but do not force them; • if children refuse many foods, experiment with different food combinations, tastes, textures and methods of encouragement; • minimize distractions during meals if the child loses interest easily; • remember that feeding times are periods of learning and love – talk to children during feeding, with eye-to-eye contact. 4. Safe preparation and storage of complementary foods: Practice good hygiene and proper food handling by: • washing caregivers’ and children’s hands before food preparation and eating; • storing food safely and serving foods immediately after preparation; • using clean utensils to prepare and serve food; • using clean cups and bowls when feeding children; • avoiding the use of feeding bottles, which are difficult to keep clean. 5. Amount of complementary food needed: 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. 6. Food consistency: Gradually increase food consistency and variety as the infant get older, adapting to infant’s requirements and abilities. Infants can eat pureed, mashed and semi-solid foods beginning at six months. By eight 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 the mind the need for nutrient-dense foods, as explained in 8. below). Avoid foods that may cause choking (i.e., items that have a 50 shape and /or consistency that may cause them to become lodged in the trachea, such as nuts, grapes, raw carrots). 7. Meal frequency and energy density: Increase the number of items that the child is fed complementary food, as he/she gets older. The appropriate number of feeding depends on the energy density of the local foods and the usual amounts consumed at each feeding. For the average healthy breastfed infants, 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 fruits or bread or chapatti with nuts 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. 8. Nutrients content of complementary foods: Feed a variety of foods to ensure the nutrients 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 nutrients 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. 9. Use of vitamin-mineral supplements or fortified products for infants and mother: Use fortified complementary foods or vitamin-mineral supplements for the infant, as needed. In some populations, breastfeeding mother may also need vitamin-mineral supplements or fortified products, both for their own health and to ensure normal concentrations of certain nutrients (particularly vitamins) in their breast milk. [Such products may also be beneficial for pre-pregnant and pregnant women]. 10. Feeding during and after illness: 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. Source: Guiding Principles for Complementary Feeding of the Breastfed Child. Washington DC: PAHO, WHO, 2003 Annex 5: National Protocol on Iron Supplementation and Guidelines to treat severe anemia National protocol on Iron Supplementation for Pregnant and Postpartum Women Dose: 60 mg iron + 400µg folic acid, daily Duration: From the beginning of the second trimester in pregnancy (6 months) till 45 days postpartum (total 225 days) Note: It is also globally recommended that if 6 months duration cannot be achieved in pregnancy, continue to supplement during the postpartum for 6 months or increase the dose to 120 mg iron in pregnancy (Source: Rebecca J. Stoltzfus and Michele L. Dreyfus., Guidelines for the use of iron supplements to prevent and treat iron deficiency anemia, INACG, WHO and UNICEF., 1998) 51 Annex 6: Guidelines for distribution of deworming Tablets According to World Health Organization, if more than 20% of the population in a country (community) is suffering from worm infestation then, that country should provide the biannual deworming tablets to the community. Many studies carried out in Nepal show that almost one-third of pregnant women and children are suffering from worms (esp. hook worms). One tablet Albendazol (400 mg) or one tablet Mebendazol (500 mg) can kill the different types of intestinal worms. In Nepal, one tablet of Albendazol (400 mg) is being distributed according to the decision of HMG, MoH and WHO. This tablet can kill the roundworm, trichuris and hook worms and the eggs of these worms also come out mixing with the stool. There are no side effects when children take this tablet even if they are not suffering from worms. This tablet can be given to children above one year of age who are suffering from intestinal worms or suspected to be suffering. But, HMG, MoH is providing this tablet only to the targeted age groups. Target Dose Time Children (1-<2 years) 1/2 tablet of Albendazol (200 mg) Twice a year (integrated with vitamin A program) Children (2-5 years) 1 tablet of Albendazol (400 mg) Twice a year (integrated with vitamin A program) Pregnant women (after first trimester) 1 tablet of Albendazol (400 mg) Once (after completion of first trimester) Source: Guidelines for distribution of deworming tablets Nutrition Section, CHD, MoH Annex 7: List of iron rich foods Guidelines for oral and folate therapy to treat severe anemia Age group Dose Duration <2 years 25 mg iron + 100-400µg folic acid daily 3 months 2-12 years 60 mg iron + 400µg folic acid daily 3 months Adolescents and adults, including pregnant women 120 mg iron + 400µg folic acid daily 3 months • After completing 3 months of therapeutic supplementation, pregnant women and infants should continue preventive supplementation regimen. • Children with Kwashiorkor or marasmus should be assumed to be severely anemic. However, oral iron supplementation should be delayed until the child regains appetite and starts gaining weight, usually after 14 days Source: Rebecca J. Stoltzfus and Michele L. Dreyfuss, Guidelines for the use of Iron Supplements to Prevent and Treat Iron Deficiency Anemia, INACG, WHO and UNICEF, 1998 52 Iron content in selected foods 7.9 7.6 7.4 7.1 6.8 6.6 6.2 2.5 2.1 1.5 0.2 0.2 1-89.0 Iron content (mg/100 gm) 94.3 44.0 28.6 28.4 26.6 20.0 17.0 16.3 11.4 10.4 10.0 9.7 9.5 8.6 Iron content (mg/100 gm) Watermelon Lentil Onion stalk Peas, dry Horse gram Liver, goat Broad beans, sprouted Mutton Egg, hen Chicken Milk, buffalo’s Milk cow’s Fish, dried Name of the food Mustard leaf “gundrukh” “Masyaura” Garden cress Turnip greens Radish leaf “gundrukh” Rice, beaten Tamarind pulp Mustard leaves Sugar unrefined “sakkar” Soybean Colocasia leaves Liver, chicken Bengal gram, roasted Cow pea Name of the food Source: Ministry of Agriculture, Nutrient Content in Nepalese Foods Ramesh K. Adhikari, Miriam E. Krantz, Child Nutrition and Health Annex 8: Guidelines for VA Capsule supplementation and treatment protocol Guidelines for the implementation of the national vitamin A deficiency control program in Nepal Basic activities High dose supplementation of VA capsule to children 6-59 months in 75 districts through mass distribution twice a year according the following schedule: Baisakh (March- April) during the peri-measles season and before the beginning of the high risk season of xerophthalmia. Kartik (October/November) prior to the harvest season, to boost vitamin A stores for the acceleration in growth that often follows. • Children 6 to under 12 months of age – one oral vitamin A dose of 100,000 IU two times per year during the capsule distribution campaign. • Children 12 to 59 months of age – one oral vitamin A dose of 200,000 IU two times per year during the capsule distribution campaign. • Special emphasis will be given during the campaign for severely malnourished children in order to be sure they will receive one mega dose of vitamin A, and that their mothers will receive special attention from the FCHVs. • Women immediately following childbirth, or as soon as possible up to six weeks post-partum, can be given one oral dose of vitamin A 200,000 IU. (Postpartum supplementation is aimed to correct VAD in infants since birth to 6 months) • Nutrition education activities and promotion of home gardening, to be carried out utilizing various communication media, including community-level health workers, and agricultural extension workers. • The target population for the nutrition education activities will be all the mothers of children 6-59 months, as well as pregnant and lactating mothers. This population will also be the priority target for adult literacy and post-literacy activities. Case treatment in all 75 districts with vitamin A capsules for xerophthalmia, measles, severe malnutrition and prolonged diarrhea, in accordance with WHO/UINICEF/IVACG guideline. For treatment of children with these illnesses, the following 53 protocols for the use of vitamin A should be observed: Prevention and treatment protocol Targets Dose Children 6 to <12 months 100,000 IU of vitamin A, 2 times/year Children above 12 to 59 months 200,000 IU of vitamin A, 2 times/year Prevent Protocol Mothers (within 6 weeks of delivery) 200,000 IU of vitamin A, Xerophthalmia (Night blindness, Bitot’s Spot, Keratomalacia, etc.) Three dosesa: One dose upon diagnosis One dose the following day One dose one month later Measles Two doses One dose upon diagnosis One dose the following day Prolonged diarrhea (>14 days duration) One dose Immediately upon diagnosis Treatment Protocols (for children) Severe malnutrition (Undernutrition) One dose Immediately upon diagnosis (for women) Night blind pregnant mothers and others 25,000 IU weekly single dose, four doses a. one dose: 100,000 IU for children aged 6-<12 months; 200,000 IU for children more than 12 months Annex 9: List of Vitamin A rich foods Pre vitamin A content in selected foods 1930 1740 1520 1380 1160 666 595 426 420 270 120 Carotene (mcg/100 gm) 12857 12000 6918 5580 5520 5295 4275 3030 2743 2622 2340 1940 Carotene (mcg/100 gm) Liver chicken* Bethe leaves Mustard leaf “gundrukh” Rape leaves Pumpkin* Papaya, ripe Onion stalk Soybean Egg, hen Lentil Cabbage Name of the food Stinging nettle Colocasia leaves Coriander leaves Spinach Amaranth, tender Radish leaves Carrot Liver goat* Mango Mustard leaves Fenugreek leaves Pumpkin leaves Name of the food Source: Ministry of Agriculture, Nutrient Content in Nepalese Foods Ramesh K. Adhikari, Miriam E. Krantz, Child Nutrition and Health National Institute of Nutrition, Nutritive Value of Indian Foods *The value is equivalent to B-carotene 54 Annex 10: Associations between selected dietary components and cancer Associations between selected dietary components and cancer Site of cancer Fat Body weight Fiber Fruits and vegetables Alcohol Smoked, salted and pickled foods Lung − Breast + + +/− Colon ++ − − Prostrate ++ Bladder − Rectum + − + Endometrium ++ Oral cavity − +(a) Stomach − ++ Cervix − Oesophagus − ++(a) + Key: + = Positive association; increased intake with increased cancer. − = Negative association; increased intake with decrease cancer. a = Synergistic with smoking Source: Report of a WHO Study Group, WHO Technical Report Series 797 Annex 11: Dietary guidelines for life-style related diseases Dietary guidelines for life-style related diseases • Consume a variety of food. • Eat fruits and vegetables. • Include sufficient grains/cereals. • Eat more fiber. • Include calcium-rich foods and protein-rich foods in the diet. • Drink sufficient and clean fluids. • Restrict the use of fats and oils and be selective about the types of fats used. • Use less salt and eat less salty foods. • Cut down on sugar, and on drinks and foods that contain sugar. • Encourage exclusive breastfeeding combined with suitable complementary foods after six months. • Maintain a healthy body weight. • Encourage physical activity and exercise and suggest its minimum duration. • Control alcohol intake • Stop or avoid tobacco use. Source: Report of a Joint FAO/WHO Consultation, 1998 55 REFERENCES: 1. ACC/SCN. Ending Malnutrition by 2020: An Agenda for Change in the Millennium, Global Nutrition Challenges: a life cycle approach, ACC/SCN. 1999 2. Ministry of Health, Department of Health Services. Annual Report, 2002/2003, Kathmandu, Nepal. 3. WHO, The world Health Report 2002, Reducing Risks, Promoting Healthy Life, Geneva. 2002 4. United Nations, Millennium Development Goals, http://www.un.org/millenniumgoals 5. SCN: Nutrition trends and implication for attaining the MDGs, In SCN 5th Report on the World Nutrition Situation, pp5-24 (2004) UN System SCN, Geneva. 6. Ministry of Health/New ERA/ORC Macro. Nepal Demographic and Health Survey, 2001. 7. Ministry of Health/UNICEF/WHO/MI/New Era Ltd. Nepal Micro Nutrient Status Survey, 1998. 8. Rikimaru, Toru., Joshi, Nira., Pandey, Sharada. Prevalence of Anemia and it’s Relevant Factors among High School Girls of Kathmandu Valley-Nepal, 2003. 9. UNICEF. The State of the World’s Children, 2004. 10. PAHO, WHO. Guiding Principles for Complementary Feeding of the Breastfed Child. Washington DC, 2003. 56 Advisory Committee: 1. Dr. B.D.Chataut, Director General, Department of Health Services 2. Dr. B. P. Pandit, Chief Specialist, Ministry of Health 3. Dr. Y.V. Pradhan, Director, Child Health Division, DoHS 4. Dr. G.P. Ojha, Former Director, Child Health Division, DoHS 5. Dr. R.K. Adhikari, Dean, IOM, Maharajgunj 6. Mrs. Sharada Pandey, Chief, Nutrition Section, CHD 7. Mr. Muniswor Mool, Chief HMIS Section, Management Division, DoHS 8. Mr. K.M. Neupane, Under Secretary, MoH 9. Dr. Indira Sharma, Professor, P.K. Campus 10. Dr. Toru Rikimaru, JICA Nutrition Advisor, JICA/Nutrition Section, CHD 11. Dr. Madhu Dixit Devkota, MBBS Coordinator, IOM Group Sessions members: ProteinEnergy Malnutrition 1. Dr. Madhu Dixit Devkota 2. Dr. Prakash Sundar Shrestha 3. Dr. Bhim Acharya 4. Dr. Toru Rikimaru 5. Mrs. Roshani Shrestha 6. Ms. Nira Joshi Iron Deficiency Anemia 1. Dr. Bhim Acharya 2. Dr. Toru Rikimaru 3. Mrs. Munu Thapa 4. Dr. Kalpana Tiwari 5. Ms. Nira Joshi 6. Ms. Rina Tiwari Iodine Deficiency Disorders 1. Mr. M.R. Maharjan 2. Mr. Dilli Raman Adhikari 3. Dr. Toru Rikimaru 4. Mr. Naveen Paudyal Vitamin A Deficiency Disorders & Deworming 1. Mr. M.R. Maharjan 2. Dr. Bhim Acharya 3. Dr. Toru Rikimaru 4. Mrs. Sushila Risal 5. Ms. Nira Joshi 6. Mr. K.P. Acharya 7. Mr. Tuyu N. Paechhai Household Food Security 1. Mrs. Bidhya Manandhar 2. Dr. Bhim Acharya 3. Dr. Toru Rikimaru 4. Ms. Vicky Haines 5. Ms. Nira Joshi Improved dietary habit 1. Mrs. Bidhya Manandhar 2. Dr. Toru Rikimaru 3. Ms. Vicky Haines 4. Ms. Nira Joshi 5. Mr. Naveen Paudyal Infectionu diseases 1. Dr. Sun Lal Thapa 2. Dr. Tekendra Karki 3. Dr. Bhim Acharya 4. Dr. Toru Rikimaru 5. Ms. Nira Joshi Life-style related diseases 1. Dr. Prakash Regmi 2. Dr. Sushila Malla 3. Mrs. Mansha Thakurathi 4. Dr. Bhim Acharya 5. Dr. Toru Rikimaru 6. Ms. Nira Joshi 7. Ms. Nani Shova Shakya 8. Mrs. Sunita Shrestha Policy and planning 1. Dr. Y.V. Pradhan 2. Mrs. Sharada Pandey 3. Mr. Prem Kumar Shrestha 4. Mr. Bishwo Prashad Subedi 5. Mr. K.M Neupane 1 6. Dr. Prakash Raj Regmi 7. Mr. Ramji Dhakal 8. Mr. Dhurba Thapa 9. Dr. Toru Rikimaru 10. Dr. Karuna Onta 11. Ms. Nira Joshi 12. Mr. Naveen Paudyal Working group members: 1. Dr. Sailesh Upadhya 2. Mrs. Pramila Ghimire 3. Dr. B.K. Subedi 4. Mr. P.O. Blomquist 5. Mr. Pragyan Mathema