Global Nutrition Public Health And Policy

The target population

The less developed country chosen is Uganada. The acute malnutrition in Uganada remains seemingly and extensively an embedded problem. In 2011, a Demographic and Health Survey was conducted in the country the result of which has shown that 10 percent of the under five years old children had acute malnutrition. Out of this children having acute malnutrition, 70 percent have Moderate acute malnutrition (MAM) (Central Statistical Agency, 2012). Uganda’s current strategy is restricting the SFPs for the MAM treatment in the country’s selected districts that have been defined as chronically food insecure. The areas that are without the consideration of being chronically food insecure are devoid of food supplementation programmes. These areas rely on the existing strategies such as EOS (Enhanced Outreach Strategy) delivering vitamin A deworming and supplementation, nutrition counseling, improved sanitation and water treatment. However, there is increased recognition that the district level relative food security cannot be equated necessarily in all households to nutritional security (Getahun et al., 2011). Moreover, the children having MAM have requirement of food of sufficient nutrient and energy density for recovering. A recent survey conducted, although unpublished, in 19 districts of Uganda that are food secured indicated an average 4.9 percent MAM prevalence. This is a representation of alarming concern at a national scale. There is data paucity in Uganda that describes children with MAM with respect to short-term outcomes in food secure areas without any programs on food supplementation. Alongside this is the need for recommendations related to policy that are evidence based. This has prompted observational study’s designing.

RUTF energy dense vitamin/mineral enriched food has the designing of treating SAM without any complications. According to the weight of the body, RUTF shall be provided. In the other intervention, other Care Children will be enrolled and will be transferred to or referred to the care as appropriate following the discharge for the monitoring of the continual growth promotion (Briend, 2003). While, the children who are deteriorating or not showing any sign of improvement will be transferred to TFC (inpatient care). The enrolled children and the caregivers, during the follow up, will be the recipient of the comprehensive child health care that includes immunization, counseling and Nutrition education, HIV/AIDS care services and other community support groups that are available in the country.

The identification of the children during a bilateral pitting oedema screening and house-to-house MUAC will be carried out for 10 days (5 days per district) and will be implemented by 90 CHVs (community health volunteers). Cohorts in 3 districts will be starting within a couple of weeks of each other. 950 children will be identified during the initial screening as eligible following the meeting the MUAC of the child with the definition of MAM without any medical complications or bilateral pitting oedema (Briend et al., 1999). The bilateral pitting oedema will then be collected by 40 data collectors within the week following and weekly home visits will be performed for 28 weeks subsequently.

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RUTF and its application in the target country via CMAM

The malnutrition treatment along with its prevention amongst children below the age of five years has the requirement of nutritious food consumption that includes the breastfeed exclusively for first 6 months. This would be followed by the breastfeeding in conjunction with foods that are complementary till 24 months of age to the least (Dewey and Adu-Afarwuah, 2008). The other requirements are access of preventive (vitamin A supplementation, immunization etc) and along with it curative health service, hygienic environment (sanitary facilities, clean drinking water) and good prenatal care.

Albeit, the requirements of the nutrient density has been proposed by Golden (2009) for the children that are moderately malnourished, the proposed complementary food supplements and recommendations to improve dietary quality have relevance to 6 to 23 months young children at the risk to develop moderate malnutrition. This is in relation to be amongst the population of high shunting prevalence amongst the 2 to 5 years children and wasting amongst the age group of 6 to 59 months.

Amongst the food-secure population, the approach that will be primarily taken in preventing and treating malnutrition is with the provision of dietary advice related to the food to be consumed. The advices of such have the characteristics of emphasis on all food groups’ consumption. There has been distinguishing of 4-8 groups. The advices will also entail the change of food types that would be selected from these food groups, responsive and frequent feeding, and to ensure good energy density (Ashworth, 2009). The children who are moderately malnourished can meet their nutrient requirements with the selection of foods available locally and examining the impact’s evidence related to diet and the programs will be on the basis of promotion of foods available locally.

Tables 1 have shown active compounds and the nutrient groups that are necessary for good child development and growth along with these nutrients’ main dietary sources and these foods’ consumption. In a nutshell, there is requirement of wide range of foods that includes fruits and vegetables (Vitamin C, minerals and vitamins in enhancing nonheme iron’s absorption), animal source foods (good sources of some vitamins, minerals, and protein), lentils or legumes (especially for protein), breast milk, staples (for certain micronutrients and energy), oil (for essential fatty acids and energy) and iodine sources like salts (however high intake of sodium is not desirable for the moderately malnourished children) (Hotz and Gibson, 2007).

Hoppe et al Hope et al

Table 2 has shown the key traits of young malnourished children’s diets (Michaelsen et al., 2009) and the required foods’ considerations in realizing such diets’ consumption. The diet when is consisting plant foods largely with very little fortified foods and animal-source foods as has been the case for several families and the children in Uganda, there has been many issues needing addressing. From the table 1 and table 2, it can be concluded that plant foods, particularly staples (rice, wheat, maize), vegetables, lentils, and legumes have been containing considerable amount of antinutrients (such as α-amylase, inhibitors of protease, lentils, polyphenols, and phytate) reducing mineral bioavailability and interfering with specific compounds related digestion (Zimmermann, 2007).

Michaelsen et al

Thus, special processing in reducing the anti nutrients content must be used and the vitamin content must be augmented in compensating for the lower bioavailability, or both. Moreover, sugar or oil must be added in increasing the energy density.

Table 1 provides summary of the options to improve the quality of nutrients of a diet that is primarily plant-source based when the fortified foods and the animal source foods are added in sufficient amounts is cease to be feasible because of the issues of availability or cost. The options are divisible into procedures which are home based performances and the foods’ industrial processing performance. The home procedures comprises of preparation practices and processing with the use of unprocessed, locally available foods (fermenting, soaking, or germination in reducing antinutrient contents and increasing bioavailability, and plant-source foods will be preserved in increasing micronutrients intake) or these nutrients’ additions that lacks through the complementary food supplements’ usage (i.e. point-of-use fortification or home fortification) (Hoppe et al., 2008).

Before the introduction of RUTF, the of acute malnutrition management has had their limitations to hospitals that resulted in high mortality and low coverage rates as the cases of malnourishment are identified at later stages and frequently with complications. However, current RUTF availability has led to malnourishment of children subject to treatment at communities (Hurrell e al., 2003). The data obtained recently have indicated that CMAM has high degree of cost effectiveness and comparable to public health measures of high impact such as antibiotic treatment for respiratory infections of acute nature, vitamin A supplementation, and diarrheal diseases. In spite of CMAM programs’ efficacy, insufficient attention is drawn from CMAM for global implementation that suggests that CMAM programs must be integrated to the regional or local routine health system.

Evaluation and monitoring of the CMAM project

SAM (Severe acute malnutrition) has been most serious malnutrition form of acute childhood and it has the association of very high mortality and morbidity rates. Over half of childhood deaths are due to under-nutrition, although it not much been documented as the direct cause of it. The malnutrition’s relative mortality risk is 8.4 for SAM and for MAM (moderate acute malnutrition), it is 4.6 (UNICEF-WHO-The World Bank Joint Child Malnutrition, 2012). Globally, SAM affects around 19 million children under the age of five. The WHO (World Health Organization) recommends regimes of inpatient treatment of intensive nutritional and medical protocols for SAM management. However, availability of trained staff of low supply, high cost, and limited inpatient capacity in the hospital have resulted in high defaulting, high mortality, low recovery, and low coverage defaulting at the therapeutic programs at the inpatient. This resulted in community based management’s innovation of CMAM. CMAM can be considered as integrated public-health approach in addressing the acute malnutrition that emphasises the treatment of uncomplicated SAM patients only as outpatients while the inpatients are kept as the complicated SAM cases (Bryce et al., 2008). The CMAM’s effectiveness is well documented in emergencies in Uganda. In the contexts of non-emergency, for long term improvements and sustainability in the SAM management require the implementation of CMAM through health infrastructure’s existing ministry as a part of primary and standard health care package.

The districts of Uganda are operated by the ministry of family planning operating as the dual system of family and health planning services with help of district hospitals, specialized hospitals, and medical college hospitals complexes, community clinics, union sub centers, family welfare and union health centers, child and maternal welfare centers. The establishment of the community clinics is for the provision of integrated family and health planning services from a single primary health care centre (Savy et al., 2009). The field level workers such as family welfare assistants (FWA) and the health assistants (HA) provide domiciliary services. The community health care providers are run by the community clinics assisted by the FWAs and HAs.

The documents that pertain to nutrition services, child health services, and national health system will be reviewed and ongoing programs will be conducted at the district levels. The collection of documents have been from the official sources that includes local health administration offices, NGO offices, health care directorate that is community based, and institute of public health nutrition. The documents that will be reviewed are the ones that are included in the national nutrition policy, community based health care, national nutrition services’ national plans, population sector and nutrition development program document, CMAM related government guidelines, and NGOs’ CMAM implementation reports focusing Uganda (Deen et al., 2003).

There are 40 key informant interviews that will be conducted amongst the very important individuals having involvement in nutrition and child health program designing and implementation in Uganda (Vesikari et al., 2007). The participants’ selection will be purposive that depends on their involvement in nutrition and child health policy and related implementation of program in Uganda.

The related activities of the medical college hospitals, district health complexes, and community clinics selected will be subject to observation in collecting information on nutrition supply chain, available equipment and delivery (Ahmed et al., 1999). The observational reviews of such in each facility will be lasting for 4 h at least with the use of a set of checklist for 9 days consecutively.

The thematic analysis approach will be followed in organizing and interpreting responses. There will be development of the English transcripts on the basis of all audio-recorded interviews. The analysis of the transcripts will be done thematically that follows the conceptual framework (Boelaert et al., 1995). The themes that are pre-defined have been divided into transcripts and sub-themes which have been subject to review in developing code list for the WHO health system building blocks and the conceptual framework. The suitability of the health system is for the integration of CMAM and has been subject to consideration on the basis of provision of enabling adopting system, logistics, human resources and service centers at grass root level.

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References

  • Ashworth, A. (2009) ‘Ferguson E. Dietary counseling in the management of moderate malnourishment in children’, Food Nutr Bull, 30:S406–33.
  • Briend, A., Lacsala, R., Prudhon, C., Mounier, B., Grellety, Y. and Golden, M. H. (1999) ‘Ready-to-use therapeutic food for treatment of marasmus’, Lancet, 353:1767–1768.
  • Bryce, J., Coitinho, D., Darnton-Hill, I., Pelletier, D. and Pinstrup-Andersen, P. (2008) ‘Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: effective action at national level’, Lancet, 371:510–526.
  • Central Statistical Agency. (2012) Ethiopian Demographic and Health Survey 2011. Addis Ababa, Ethiopia and Calverton Maryland, USA.
  • Cook, R. (1971) ‘Is hospital the place for the treatment of malnourished children?’, J Trop Pediatr Environ Child Health, 17:15–25.
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  • Deen, J. L., et al. (2003) ‘Implementation of WHO guidelines on management of severe malnutrition in hospitals in Africa’, Bull World Health Organ., 81:237–243.
  • Getahun, Z., Urga, K., Genebo, T. and Nigatu, A. (2011) ‘Review of the status of malnutrition and trends in Ethiopia’, Ethiop J Heal Dev., 15: 55–74.
  • Golden, M. H. (2009) ‘Proposed recommended nutrient densities for moderately malnourished children’, Food Nutr Bull, 30:S267–343.
  • Hoppe, C., Jacobsen, S., Molgaard, C., Friis, H., Sangild, P. T. and Michaelsen, K. F. (2008) ‘The use of whey protein or skimmed milk powder in fortified blended foods for vulnerable groups; a literature review’, J Nutr, 138:145S–61S.
  • Michaelsen, K. F., Hoppe, C., Roos, N., Kaestel, P., Stougaard, M., Lauritzen, L., Molgaard, C., Girma, T. and Friis, H. (2009) ‘Choice of foods and ingredients for moderately malnourished children 6 months to 5 years of age’, Food Nutr Bull, 30:S344–405.
  • UNICEF-WHO-The World Bank Joint Child Malnutrition. (2012) Levels & Trends in Child Malnutrition [online] Available from [Nov 10, 2012].
  • Zimmermann, M. B. (2007) ‘Nutritional iron deficiency’, Lancet, 370:511–20.
  • Dewey, K. G. and Adu-Afarwuah, S. (2008) ‘Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries’. Maternal Child Nutr, 4:24–85.
  • Hotz, C. and Gibson, R. S. (2007) ‘Traditional food-processing and preparation practices to enhance the bioavailability of micronutrients in plant-based diets’, J Nutr, 137:1097–100.
  • Hurrell, R. F., Reddy, M. B., Juillerat, M. A. and Cook, J. D. (2003) ‘Degradation of phytic acid in cereal porridges improves iron absorption by human subjects’, Am J Clin Nutr, 77:1213–9.
  • Savy, M., Edmond, K., Fine, P. E., Hall, A., et al. (2009) ‘Landscape analysis of interactions between nutrition and vaccine responses in children’, J Nutr., 139:2154S–2218S.
  • Vesikari, T., Itzler, R., Matson, D. O., et al. (2007) ‘Efficacy of a pentavalent rotavirus vaccine in reducing rotavirus-associated health care utilization across three regions (11 countries)’, Int J Infect Dis., 11(Suppl 2):S29–S35.
  • Boelaert, M., Davis, A., Le, L. B., et al.(1995) ‘Nutrition guidelines’, 1st. Paris: Medecins sans Frontieres.
  • Ahmed, T., Ali, M., Ullah, M. M., et al. (1999) ‘Mortality in severely alnourished children with diarrhoea and use of a standardised management protocol’, Lancet., 353:1919–1922.
  • Briend, A. (2003) ‘Trial and error methods, “expert” guessing or linear programming? Formulating sound nutritional recommendations for complementary feeding’, SCN News, 7:36–9.

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