3.
07
NATIONAL NUTRITION PROGRAM
Groups 1&2 – 3A
Department of Family and Community Medicine
MALNUTRITION
 Encompasses both under-nutrition and over-nutrition,
 Defined as the cellular imbalance between the supply of the
nutrients and energy and the body‘s demand for them to
ensure growth, maintenance, and specific functions.
 It is a multifactorial condition, most often related to poor
diet or severe and severe and repeated infections,
particularly in underprivileged populations
 Under-nutrition is defined as the result of insufficient
intake and repeated infectious diseases affecting nutritional
absorption which includes being underweight for age, short
for age (stunted), thin (wasted), and deficient in specific
vitamins and minerals (micronutrient malnutrition).
 Over-nutrition refers to oversupply of nutrients relative to
required amounts for normal growth, development, and
metabolism.
GLOBAL DATA AND TRENDS
 Out of a world population of seven billion
o About two billion people suffer from micronutrient
malnutrition
o Nearly 800 million people suffer from calorie
deficiency
 Out of five billion adults worldwide
o Nearly two billion are overweight or obese
o One in twelve has type 2 diabetes
 Out of 667 million children under age 5 worldwide
o 159 million are too short for their age
o 50 million do not weigh enough for their height
o 41 million are overweight
 Out of the 129 countries with data, 57 countries have serious
levels of both under-nutrition and adult overweight
(including obesity)
FORMS OF MALNUTRITION
 The various forms of malnutrition include undernutrition,
inadequate vitamins or minerals, overweight, obesity, and
resulting diet-related non-communicable diseases.
 Undernutrition is subdivided into wasting, stunting,
underweight, and deficiencies in vitamins and minerals
 Wasting refers to low weight-for-height which is an
indication of recent and severe weight loss due to
inadequate dietary intake or infectious disease
 Stunting refers to low height-for-age which indicates
chronic or recurrent undernutrition, usually linked with
poor socioeconomic conditions, poor maternal health and
nutrition
 Underweight refers to low weight-for-age wherein
stunting, wasting, or both may be present
 Micronutrient-related malnutrition involves inadequacies
in the intake of vitamins and minerals, collectively known as
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micronutrients, which enable production of enzymes,
hormones, and other substances essential for proper growth
and development.
o Globally, the most important micronutrients include
iodine, vitamin A, and iron (most common)
 Overweight and obesity occurs when the weight-for-
height is increased due to abnormal or excessive fat
accumulation.
o Classification requires the computation of the body
mass index (BMI) which is the person’s weight in
kilograms divided by the square of his/her height
inmeters (kg/m2).
o Overweight is defined as a BMI of > 25 while obesity is
a BMI of > 30.
CAUSES OF MALNUTRITION
 Causes of malnutrition can also be subdivided into primary
and secondary causes.
 Primary causes include situation wherein there is
inadequate or poor-quality food intake.
 Secondary causes include diseases that alter food intake or
nutrient requirements, metabolism, or absorption.
ASSESSMENT OF MALNUTRITION
 The nutritional assessment is done to:
o Obtain information about the prevalence and
geographic distribution of nutritional disorders within
a community or a specified population group.
o It can also be used to identify high-risk groups and to
assess the role of different epidemiological factors in
nutritional deficiencies.
 Two methods: Direct and Indirect
 Direct deals with individuals and measures the objective
criteria) and indirect (uses community health indices
reflecting nutritional influences.
o anthropometric, biochemical, clinical, dietary,
emotional, and functional measurements to cover all the
phases of the disease.
 Indirect generally uses community indices that reflect the
community nutritional status or needs (e.g. dietary
assessment and vital health statistics).
o It also includes ecological variables including crop
production, economic factors e.g. per capita income,
population density & social habits, and vital health
statistics particularly infant & under 5 mortality &
fertility indices.
DIETARY ASSESSMENT
 24-Hour Dietary Recall
o A trained interviewer asks the subject to recall all food
& drink taken in the previous 24 hours. It is quick, easy,

& depends on short-term memory, but may not be
truly representative of the person‘s usual intake.
 Food Frequency Questionnaire
o In this method the subject is given a list of around 100
food items to indicate his or her intake (frequency &
quantity) per day, per week & per month.
 Dietary history since early life
 Food diary technique
o Food intake (types & amounts) should be recorded by
the subject at the time of consumption. The length of
the collection period range between 1-7 days.
 Observed food consumption
o The most unused method in clinical practice, but it is
recommended for research purposes. The meal eaten
by the individual is weighed and contents are exactly
calculated.
DIETARY DATA
 Qualitative Method
o Uses the food pyramid & the basic food groups method.
o Different nutrients are classified into 5 groups (fat &
oils, bread & cereals, milk products, meatfish-poultry,
vegetables & fruits)
 Quantitative Method
o The amount of energy & specific nutrients in each food
consumed can be calculated using food composition
tables & then compare it with the recommended daily
intake.
 Estimated Average Requirement (EAR)
o daily nutrient intake level that meets the median or
average requirement of healthy individuals in
particular life stage and sex group, corrected for
incomplete utilization or dietary nutrient
bioavailability
 Recommended Energy/Nutrient Intake (REI/RNI
o level of intake of energy or nutrient which is
considered adequate for the maintenance of health and
wellbeing of healthy persons in the population.
(presented in the graph as +2sd)
 Adequate Intake (AI)
o daily nutrient intake level that is based on observed or
experimentally-determined approximation of the
average nutrient intake by a group (groups) of
apparently healthy people that are assumed to sustain
a defined nutritional state.
 Tolerable Upper Intake Level or Upper Limit (UL)
o Highest average daily nutrient intake level likely to
pose no adverse health effects to almost all individuals
in the general population.
CLINICAL ASSESSMENT
 Physical signs and symptoms of malnutrition can be valuable
aids in detecting nutritional deficiencies.
 It is an essential feature of all nutritional surveys
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 It is the simplest & most practical method of ascertaining the
nutritional status of a group of individuals
 It utilizes several physical signs, (specific & non-specific),
that are known to be associated with malnutrition and
deficiency of vitamins & micronutrients.
 Good nutritional history should be obtained
 Group One Signs
o Often associated with nutritional deficiency status.
Signs of malnutrition may often be mixed and may be
due to the deficiency of two or more micronutrients.
 Group Two Signs
o Need further investigation. They may be related to
malnutrition, perhaps of a chronic type, but are often
found in populations of developing countries where
other health and environmental problems, such as
poverty and illiteracy, are co-existent.
 Group Three
o These include physical signs that have no relation to
malnutrition, although they may be similar to physical
signs found in persons with malnutrition and must be
carefully delineated from them.
ANTHROPOMETRIC ASSESSMENT AND INDICATORS
 Weight
o Most widely used, most sensitive, and simplest
reproducible anthropometric measurement for the
evaluation of nutritional status in young children.
o Indicate body mass and is a composite of all body
constituents such as water, mineral, fat, protein, and
bone.
 Height/Length
o Good indicator of the chronicity of any debilitating
illness
 Mid-Upper Arm Circumference
o Usually measured at the midpoint between the
acromion and the olecranon with the left arm hanging
by the side of the body.
o It is relatively stable up to the age of five, and used to
assess 0-59 months of age as age-independent criteria
for assessing malnutrition.
 Skin Fold Thickness
o Measurement of subcutaneous fat using a skinfold
caliper which exerts a constant pressure on a fold of
skin.
o Representative of the total amount of body fat.
o Roughly for children, a skin fold thickness of more than
10 mm is normal and a skin fold thickness of less than
6 mm is considered having malnutrition.
 Body mass index (BMI)
o A measure to define overweight and thinness.
o BMI is defined as the weight in kilos divided by the
square of height in meters.
o Primarily used to identify chronic energy deficiencies
(or obesity) in adults.
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 Impairs several functions of the body and can lead to various

health consequences to which infants, young children, and
pregnant women appear to be at greatest risk.
 Xerophthalmia is the most specific VADD and is the leading
preventable cause of blindness in children throughout the
world.

Epidemiology
 The Philippines is considered as an endemic region for
Vitamin A Deficiency (VAD).
 National Nutrition Survey (1993): Sub-clinical VAD (serum
Retinol < 0.7 umol/L) was present in the up to 35% of pre-
school children.
 1998 follow-up: revealed a more alarming condition
o prevalence of maternal night blindness is 10.5%
 Weight-for-age compared to the WHO cut-off point which is 1%.
o Evaluates health and nutritional status in children
based on the child's weight compared with the weight
of reference children of the same age and sex.
o Useful in serial measurements of children under 5
years of age in clinic settings and particularly useful in
regard to infants under one year of age.
 Height-for-Age (Stunting)
o Measures the linear growth which is based on the
child's height compared with the height of reference
children of the same age and sex.
o It is considered as an indicator of long-term nutritional
adequacy
 Weight-for-Height (Wasting)
o Relates body mass to stature and is based on the
child's weight compared with the weight of reference
children of the same height and sex.
o It is generally interpreted as an indicator of present
nutritional status.

OTHER ASSESSMENT TOOLS

 Vital Health Statistics
 Ecological Factors
 Environmental Factors Signs and Symptoms
 Biochemical/Laboratory Assessment  Vitamin A is one of the most essential vitamins in child and
 Radiologic Analysis maternal survival programs.
 The role of this vitamin is unquestionable especially in the
VITAMIN A DEFICIENCY maintenance of vision and eye health as well as in the
immune system and growth.
 A major nutritional concern in poor societies, especially in
low income countries.  A problem therefore in Vitamin A stores can be manifested
as vision defects and problems in epithelial integrity and
 Its presence as a public health problem is assessed by
function which can be seen as mucosal or skin
measuring the prevalence of deficiency in the population,
manifestations (immune system is defective) and corneal
represented by specific biochemical and clinical indicators of
problems.
status.
 Vitamin A also helps in the regulation and expression of over
 Main underlying cause of VAD as a public health problem is a
300 genes hence it greatly affects growth and development.
diet that is chronically insufficient in vitamin A that can lead
to lower body stores and fail to meet physiologic needs (e.g.
support tissue growth, normal metabolism, resistance to
infection).

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Table 2. Classification of Xerophthalmia  Iron equilibrium in the body is regulated carefully so as to

CLASSIFICATION ensure that enough iron is absorbed to compensate for the
XN Night blindness body’s daily iron losses.
 Iron deficiency is defined as a decrease in total iron content
X1A Conjunctival xerosis
in the body.
X1B Bitot’s spot  Iron deficiency anemia (IDA) develops when the body’s iron
X2 Corneal xerosis stores drop too low to support normal red blood cell
X3A Corneal ulcerations/keratomalacia (<1/2 corneal production.
surface)  It is said to be the most prevalent single deficiency state on a
X3B Corneal ulcerations/keratomalacia (>1/2 corneal worldwide basis.
surface)  Possible causes include inadequate dietary iron intake,
XS Corneal scar impaired iron absorption, bleeding, or loss of body iron in
the urine.
XF Xerophthalmia fundus

Epidemiology
Listed are important manifestations of VAD:
Global
A. Night Blindness (XN): This is described as difficulty seeing
 WHO estimates that the number of anemic people
in the dark and children usually refuse to play after dusk,
worldwide is a staggering two billion, and that
stumbles on furniture, and difficulty identifying things.
approximately 50% of these cases can be attributed to iron
B. Conjunctival Xerosis (X1A): The conjunctiva losses its deficiency.
usual luster due to hyposecretion of goblet cells which
 Iron deficiency is the most common and widespread
causes dryness of epithelium
nutritional disorder in the world.
C. Bitot’s Spots (X1B): An effect of long standing VAD
o The only nutrient deficiency that is also significantly
characterized as foamy and whitish patches seen in the
prevalent in industrialized countries.
sclera.
D. Corneal Xerosis (X2): Cornea becomes cloudy with orange-
peel appearance. It may manifest like fish scale over the
eyes.
E. Corneal Ulcer/Keratomalacia (X3A): Cornea becomes soft
and prone to perforation. This can lead to permanent
blindness. Children with prolonged diarrhea and measles
may develop this condition.
F. Corneal Scar (XS): Extensive fibrosis at the pupils can cause
total blindness

Diagnosis
 The diagnosis is mainly based on the complete history with
special attention to the nutritional aspect.
 Findings may be correlated to the physical findings, which
are usually mucosal, dermatologic, visual, and
developmental. Serum retinol can be tested as well.
 The WHO serum retinol threshold of < 0.7 mmol was used to
classify those at risk for biochemical VAD.
IRON DEFICIENCY ANEMIA
 Anemia is a condition wherein the number of red blood cells
or their oxygen-carrying capacity is insufficient to meet
physiologic needs, which vary by age, sex, altitude, smoking
habits, and pregnancy status. It is an indicator of both poor
nutrition and poor health.
 Iron is a micronutrient which is vital for all living organisms
because of its involvement in many metabolic processes,
including oxygen transport, synthesis of DNA, and electron
transport to produce energy.
Global prevalence of anemia in preschool-age children
 IDA affects 1.62 billion people globally
o preschool-age children are most at risk at 47.4%
o Men presented the lowest prevalence at 12.7%
 Developing countries
o every second pregnant woman and about 40% of
preschool children are estimated to be anemic
 aggravated by worm infections, malaria, and other
infectious diseases such as HIV and tuberculosis
 Anemia affects 293 million preschool-age children globally
o Africa – highest prevalence (67.6%)
o Southeast Asia (65.5%)
o Americas, Europe, and Western Pacific (20%)

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 The prevalence of anemia is slightly lower in pregnant  Iron deficiency affects more people than any other condition,
women constituting a public health condition of epidemic
o the distribution by region follows what is observed in proportions.
preschool-age children.  IDA reduces the work capacity of individuals and
o Africa – highest prevalence (57.1%) populations, leading to serious economic consequences and
o Southeast Asia (48.2%) obstacles to development and nations.
o European region (25%)  The most vulnerable of populations, those in the lowest
o Americas (24.1%) socioeconomic status, are those that are disproportionately
 Overall, 56.4 million pregnant women in the world are affected by iron deficiency, and it is they who gain the most
anemic (41.8% global prevalence). by its reduction.

Philippines
 According to the 8th National Nutrition Survey by the Food
and Nutrition Research Institute, Department of Science and
Technology (FNRI-DOST) in 2013, wherein they tested
hemoglobin levels of 33,852 participants including infants,
school children, adolescents, adults, elderly, pregnant
women, and lactating women
o Infants aged 6 months to 1 year old – highest
prevalence (39.4%)
o Pregnant women (25.2%)
o Males aged 20-39 years old – lowest prevalence (4.1%)
 According to region
o Cagaya has highest prevalence in all age groups except
children aged 6-12 years old
o ARMM

Global prevalence of anemia in pregnant women

 In non-pregnant women, the prevalence of anemia is slightly

lower at 30.2% global prevalence.
o Africa – highest prevalence (47.5%)
o Southeast Asia (35.7%)
o The European region (19%)
o Americas (17.8%)

Global prevalence of anemia in non-pregnant women of

reproductive age

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Regions with the highest and lowest prevalence of anemia by
age group, Philippines (FNRI-DOST, 2013)
Trend in the overall prevalence of anemia in the Philippines
 Children are one of the groups most affected by anemia.
 The trend the prevalence of anemia among Filipino children.
 In infants aged 6 months to 1 year old, there is an
inconsistency in the trend, as the prevalence progressively
increased until 2003 and decreased thereafter to the 2013
prevalence of 39.4%.
 Prevalence for children 1-5 years old and 6-12 years old
show a generally downward trend. In quintile index, it is
observed that the anemia prevalence is highest among
infants aged 6 months to 1 year old, regardless of
socioeconomic status, but it must be noted that a higher
prevalence is observed in those of low socioeconomic status.
 Another population component that is commonly affected by
anemia is that of pregnant women.
 In the figure above, it is observed that prevalence of anemia
among pregnant and lactating women has been decreasing
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since 1993, but with the former having a higher prevalence
than the latter.
Signs and Symptoms
 Generally, patients with IDA may report the following signs
and symptoms:
o Fatigue
o Diminished capability to perform hard labor
o Poor scholastic performance
o Cold intolerance
o Dysphagia with solid food
o Leg cramps during tedious activities
o Impaired growth
o Pallor of the mucous membranes
o Increased susceptibility to infections
o Mouth fissures
o Splenomegaly in severe and untreated cases
 IDA during pregnancy increases perinatal risks for mothers
and neonates increases overall infant mortality.
 In summary, the major health consequences include
o poor pregnancy outcome anemia contributes to 20% of
all maternal deaths
o impaired physical and cognitive development
o increased risk of morbidity in children
o reduced work productivity in adults due to lack of
energy
Diagnosis
 The primary tool in diagnosing anemia is to determine the
blood hemoglobin level.
 Useful tests also include the following:
o complete blood count
o peripheral blood smear
o determination of serum iron
o total iron-binding capacity
o serum ferritin
o hemoglobin electrophoresis
o reticulocyte hemoglobin content.
 Complete blood count results that may lead to diagnosis of
IDA include:
o low mean corpuscular volume
o low mean corpuscular hemoglobin concentration
o elevated platelet count in many cases
o normal or quite elevated white blood cell count.
 In IDA, red blood cells are microcytic and hypochromic in
the peripheral blood smears.
 Low serum iron and ferritin levels, with an elevated TIBS are
also diagnostic of iron deficiency.
IODINE DEFICIENCY
 Iodine is a trace element essential for the synthesis of
thyroid hormones such as triodothyronine (T3) and
thyroxine (T4), which regulate the metabolic pattern of most
 National Nutrition Program

cells and play a vital role in the process of early growth and US Institute of
development of most organs, especially the brain. Age Group WHO
Medicine
 The body contains 15-20 mg of iodine and majority of which Adults and
are located in the thyroid glands for an adequate supply of 150 μg/day
Adolescents
T3 and T4.
Pregnant Women 220 μg/day 250 μg/day
 Inadequate levels of iodine intake leads to insufficient
thyroid hormone production, which in turn, causes Lactating Women 290 μg/day
aberrations in the body which are greatly affected by the (1-11 years old) 90-120 (6-12 years old)
Children
hormone such as the muscle, heart, liver, kidney and brain. μg/day 120 μg/day
 Disease states because of this are collectively known as Infants 110-130 μg/day 90 μg/day
iodine deficiency disorders (IDD).
o there is stimulation of increased TSH production which  Sources of dietary iodine
results in the hypertrophy of the thyroid gland: endemic o saltwater fish
goiter. o seaweed
o When severe and prolonged, the deficient production of o grains
thyroid hormones is called hypothyroidism. o egg yolks
o Causes are summarized into two things: demand and o milk and milk products (from iodine supplementation
supply (DOH). in chickens and cattles, and addition of iodophores in
o Firstly, lack of iodine-rich foods in the diet and the dairy products)
presence of goitrogen.  The upper limit for daily iodine intake is 1100 μg/day for
o Dietary goitrogens are those which interfere with iodine adults and lower in children.
absorption in the body can cause a decreased iodine  Increased demands in iodine levels such as those seen in
supply to the body. adolescents, pregnant women, and lactating women can also
o The following shows the different goitrogens and their cause iodine deficiency if not met with adequate supply.
mechanism:
Diagnosis
 The kidneys excrete around 90% of iodine intake, which has
been a reliable biomarker of recent iodine intake for
population as a whole.
 Best diagnostic test to identify iodine deficiency is a median
24-hour iodine urine collection.
 The absolute minimum daily iodine requirement is around
50 μg.
 If a population is found to have a mean daily urinary iodine
excretion of less than 25 μg, cretinism will be frequent in
that population.
 Because it is almost impossible to obtain urine samples
throughout the 24 hours, examiners rely on casual urine
samples instead.
 However not best, relating the urinary iodine to urinary
creatinine by expressing the ratio can be used practically.
 Another approach is simply to measure the concentration of
iodine in the urine as μg of iodine per 100 mL of urine.
 Laboratory tests may also be done by subjecting the urine to
a colorimeter to measure the amount of iodide by its
reaction with ceric ammonium sulfate and arsenious acid.
 The rate of color change of the chemicals depends on the
amount of iodine present in the sample.
 Another test such as blood test is simple and accurate
although more time consuming.
 Iodine patch test is a method where doctors paint a patch of
iodine on the skin and observes the extent of fading of the
 The recommended dietary iodine intake by the US Institute patch after 24 hours.
of Medicine and WHO is as follows:

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 Iodine deficient patient will likely present with more faded

patches as the skin absorbs the iodine more quickly.
 However, this is not as accurate as the two previous tests.

Epidemiology
 Over the past 20 years, the iodine nutritional status
worldwide has improved.
 The International Council for Control of Iodine Deficiency
Disorders (ICCIDD) has stated that there was a decrease in
countries with iodine deficiency from 54 to 32 from 2003-
2011.
 In the Philippines, the Food and Nutrition Research Institute
conducted the 8th National Nutrition Survey (2013) wherein
the severity of IDD was measured based on Median Urinary
Iodine Levels. Figure 1. Iodine nutrition based on UIE levels of children
aged 6-12 years old throughout the Philippines (Luzon,
Visayas, Mindanao and Philippines in toto)
Table 3. Epidemiological criteria for IDD severity based on
median urinary iodine levels.
 The highest percentage of iodine nutrition status is in the
Mean Urinary
adequate classification for all areas except Luzon:
Iodine Level Severity of IDD
o Excessive iodine intake level – highest percentage
(μg/L)
o Insufficient level (<20 μg/L UIE) for all areas – lowest
< 20 Severe percentage
20-49 Moderate
50-99 Mild
> 100 No deficiency

 As for the school-age children (≥ 6 years old), the criteria for

assessing iodine nutrition is stated in table 4.

Table 4. Epidemiological criteria for iodine nutrition based

on median urinary iodine levels.

Figure 2. Median UIE and proportion of UIE values <50 μg/L

Median and percent distribution of urinary iodine
evaluation levels among children aged 6-12 years old
(2013).
 FNRI
o 26.6% of the Philippine population of children aged 6-
12 years old have adequate intake of iodine
o 23.2% have excessive intake.
o 33.3% have insufficient levels of iodine intake.
among 6-12 year old children by region on 1998, 2008 and
2013
 Iodine nutritional status in the Philippines have been
improving for the last 15 years;
o a marked reduction in the percentage of the population
with UIE values <50 μg/L from 35.8% to 16.4%.
 Zamboanga Peninsula – highest percentage of
undernourished children in terms of iodine nutrition in 2013
o Followed by CAR and Davao.
 CALABARZON – lowest percentage in 2013
o followed by NCR and Cagayan.

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Act for Salt Iodization Nationwide (ASIN) Law

 Progress in the Philippines towards elimination of IDD has
been appreciable for the last 2 decades because of the
implementation of the ASIN law since 1995.
 This law was passed in response to the increasing goiter
rates in the country.
 The purposes of the act are to:
a) contribute to the elimination of micronutrient
malnutrition in the country, particularly iodine
deficiency disorders, through the cost-effective
preventive measure of salt iodization
b) require all producers manufacturers of food-grade salt
to iodize the salt that they produce, manufacture,
import, trade or distribute
c) require the Department of Health (DOH) to undertake
the salt iodization program and for its Bureau of Food
and Drugs (BFAD), to set and enforce standards for
food-grade iodized salt and to monitor compliance
thereof by the food-grade salt manufacturers
d) require the local government units (LGUs), through
their health officers and nutritionists/dietitians, or in
their absence through their sanitary inspectors, to
check and monitor the quality of food-grade salt being  Table 5 shows that since 1998, the Philippines have been
sold in their market in order to ascertain that such salt improving in iodine nutrition, as evaluated through the 3
is properly iodized indicators.
e) require the Department of Trade and Industry (DTI) to  There was a >90% goal on the proportion of households
regulate and monitor trading of iodized salt using iodized salt indicator.
f) direct the Department of Science and Technology  Starting from 25%, the goal is still to be achieved in 2013
(DOST), in collaboration with the Technology and (no data available yet) but has significantly increased to
Livelihood Resource Center (TLRC), to initiate, promote, 81.1% in 2008.
and cause the transfer of technology for salt iodization  On the other hand, both the median urinary iodine and the
g) authorize the National Nutrition Council (NNC), the proportion < 50 μg/L indicators have been achieved in 6-12
policy-making and coordinating body on nutrition, to year olds, lactating women, and pregnant women, and in 6-
serve as the advisory board on salt iodization 12 year olds, respectively.
h) provide mechanisms and incentives for the local salt
industry in the production, marketing and distribution Consequences of Iodine Deficiency
of iodized salt  Iodine deficiency has been identified by WHO to be the
i) ensure the sustainability of the salt iodization program world’s single most important preventable cause of mental
retardation.
Indicators for the Elimination of Iodine Deficiency Disorders  The severity is a spectrum from mild intellectual blunting to
 There are 3 indicators used to assess the progress of the frank cretinism.
Philippines with regards to IDD status.  Since iodine is needed for thyroid hormone production and
 These are proportion of households using iodized salt, the said hormone is needed for several developmental
median urinary iodine and proportion of the population with processes, pregnant women with iodine deficiency possess
UIE <50 μg/L. the risk of fetal death or fetal growth retardation.
 With this, it is also the leading cause of preventable mental
retardation and impaired psychomotor function in young
children; associated with lower IQ of ~13.5 points compared
to those without IDD.
a) Endemic Cretinism
- the extreme clinical manifestation of severe
hypothyroidism during fetal, neonatal and
childhood developmental stages.

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- Its features include severe and irreversible mental
retardation, short stature, deaf-mutism, spastic
dysplegia and squints.
b) Cretinoids
- presents almost like endemic cretinism, however,
is less severe.
- It has lesser degrees of mental retardation, is
associated with speech and hearing defects,
psychomotor retardation and gait defects.
- This also has greater prevalence in severely
endemic regions compared to the fully manifested
cretinism.
c) Adult Hypothyroidism
- mainly presents with goiter can manifest with
varying degrees of symptomatologies and
complications related to the hypometabolic state.
- This can severely hamper human energy and work
capacity which, on a large scale, can affect the
economic performance of the endemic region.
 The manifestations of IDD, as previously said is a spectrum
that varies in presentation depending on the severity of the
deficiency as well as the age group.
 The following figure shows the spectrum of IDD across
different age groups:
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UNDERWEIGHT, STUNTING, WASTING, AND OVERWEIGHT
 These are indicators used to measure nutritional imbalance
resulting in undernutrition (assessed from underweight,
wasting and stunting) and overweight.
 Child growth is the primary and internationally recognized
indicator of nutritional status and health in populations.
 The percentage of children with a low height for age
(stunting) reflects the cumulative effects of undernutrition
and infections since and even before birth.
 This measure can therefore be interpreted as an indication
of poor environmental conditions or long-term restriction of
a child's growth potential.
 The percentage of children who have low weight for age
(underweight), on the other hand, can reflect ‘wasting’ (i.e.
low weight for height), indicating acute weight loss,
‘stunting’, or both.
 Thus, 'underweight' is a composite indicator and may
therefore be difficult to interpret. The said indicators are
defined by the World Health Organization as follows:
o Underweight: weight for age < –2 standard deviations
(SD) of the WHO Child Growth Standards median.
o Stunting: height for age < –2 SD of the WHO Child
Growth Standards median.
o Wasting: weight for height < –2 SD of the WHO Child
Growth Standards median.
o Overweight: weight for height > +2 SD of the WHO
Child Growth Standards median.
Underweight
 Undernutrition, as measured by underweight status, has
been associated with substantially increased risk of
childhood mortality worldwide.
 Defined for children aged 0–4 years as low weight for-age
relative to the National Center for Health Statistics/World
Health Organization (NCHS/WHO) reference median.
 Underweight for women of reproductive age, on the other
hand, was defined as pre-pregnant body mass index (BMI)
below 20kg/m2.
 According to the 2017 UNICEF Joint Child Malnutrition
Estimates,
o 21.5% of children ages 0-59 months are below minus
two standard deviations from median weight-for-age of
the World Health Organization (WHO) Child Growth
Standards.
 National Nutrition Program

old) had the sharpest increases in underweight (4.9

percentage points higher than the 6-11 month old).

Trends in the prevalence of malnutrition among children

less than 5 years old in the Philippines (1989- 2013)

 Using weight for age as index, underweight prevalence has

gone down to 19.9%, a slight reduction from 20.2% in 2011.
 This reflects a relatively unchanged status for the past 10
years (from 20.7% in 2003, to 20.0% in 2005, and 20.6% in
 As shown in the figure above, underweight status among
2008), making it unlikely that the Philippines will achieve
children 0-5 years old are more commonly seen in rural
the MDG goal of a 50% reduction in underweight prevalence
areas and in the poorest and most depressed communities.
from the baseline of 27.3% in 1989.
 Top 3 with the highest underweight prevalences:
 Wasting/thinness increased to 7.9% from 7.3% in 2011, this
o MIMAROPA (27.5%)
contributes to a consistent upward trend from 5.8% in 2005,
o W. Visayas (25.9%)
and 6.9% in 2008.
o Bicol (24.6%).
 Stunting has gone down to 30.3% from 33.6% in 2011 the
 Urban areas and those in the richest quantiles have the
first substantial drop in this indicator since 2003.
lowest prevalances of underweight children.
 The prevalence of overweight among the population has
 The top 3 with the lowest underweight prevalences:
increased from 4.3% to 5.0%.
o NCR (12.9%)
o CAR (16.5%)
o Central Luzon (17.7%)
 This finding can be attributed to the number of possible
causes of low weight for age such as
o Poverty
o Poor health practices
o Improper nutrition
o Unsanitary environmental conditions

Stunting

Prevalence of underweight among children less than 5 years

old in the Philippines (2013)

 Based on the 8th Food and Nutrition Institute (FNRI)

National Nutrition Survey (2013), as shown in Figure 4,
o underweight prevalence has gone down to 19.9%, a
slight reduction from 20.2% in 2011. Prevalence of stunting among children less than 5 years old
o Also, similar to findings from the 6th and 7th NNS, in the Philippines (2013)
children in the first to second year of life (12-23 months

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 Stunting prevalence has gone down to 32.7%, a slight
reduction from 30.3% in 2011.
 Children in the first to second year of life (12-23 months old)
had the sharpest increases in stunting (15.3 percentage
points
 Stunting prevalence generally decreased in most of the
regions except Central Luzon and Bicol.
 A dramatic decrease in wasting was observed in the regions
of Cagayan Valley, ARMM, and Caraga.
Wasting
Prevalence of wasting among children less than 5 years old
in the Philippines (2013)
 Wasting/thinness continued to increase compared to 2011
(by 0.6 percentage points)
 Wasting prevalence still at a level of public health
significance.
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 Highest prevalence of underweight, stunting and wasting
were among those in the rural areas (22.6%, 35.0%, and
8.1% respectively) and in the poorest quintile.
Overweight
Prevalence of overweight among children less than 5 years
old in the Philippines (2013)
 The overweight prevalence rate is going up
 More males were overweight at 5.4 percent than females at
4.6percent.
 Overweight rates were highest among the 0-5 month olds
(9.9%), those in the highest wealth quintile (10.7%) and
those from regions IV-A (6.6%), CAR (6.1%), NCR (6.5%)
and Central Luzon (6.2%).
PROTEIN ENERGY MALNUTRITION
 Condition arising from inadequate intake of food rich in
energy and protein
 Characterized by marked weight loss and failure to grow.
 Currently the most important nutritional problem in most
countries in young children
 Energy deficiency is the major cause
 The annual mortality rate per 100,000 people from protein-
energy malnutrition in Philippines has decreased by 53.1%
since 1990, an average of 2.3% a year.
 Two forms of PEM are termed marasmus and
kwashiorkor.
Marasmus
 Marasmus describes a condition in which weight loss and
wasting of muscle and fat are the predominant signs.
 It occurs when intake of energy nutrients is inadequate to
meet the person’s needs, such as under conditions of famine.
 The main deficiency is one of food in general, and
therefore also of energy.
 Clinical features of nutritional marasmus
o Poor growth
o Wasting
o Alertness
o Appetite
o Anorexia
 National Nutrition Program

o Diarrhea  Divided into two parts: Part 1 consists of a summary of the

o Anemia situation analysis of nutrition in the country in 2016; and Part
o Skin sores 2 presents the plan.
o Hair changes  Part 2 is divided into section describing the rational for the
o Dehydration PPAN, followed by a brief description of the PPAN, a
 Most important precipitating causes of marasmus are description of the 11 programs and their classification, the
infectious and parasitic diseases of childhood. projects included in each program, the program structure
and results framework, PPAN strategy, the organization for
Kwashiorkor its overall management and coordination, the monitoring
 Kwashiorkor is one of the serious forms of PEM. and evaluation framework, and the plan’s budget estimates
section including a resource framework and resource
 It is seen most frequently in children one to three years of
mobilization strategy.
age
 It is found in children who have a diet that is usually
insufficient in protein PART I
 Kwashiorkor is often associated with, or even precipitated Nutritional Problems to be Addressed
by infectious diseases.  High levels of stunting and wasting among children under-
 Clinical features of kwashiorkor five years of age
o Edema  The prevalence of stunting remains high for the older
o Poor growth children.
o Wasting.  Deficiencies in vitamin A, iron, and iodine particularly
o Mental changes among groups for which the problem is of public health
o Hair changes (Flag sign or signa bandera – reddish significance
hair)  Hunger and food insecurity with 68.3% of Filipino
o Skin changes (Dermatoses) households not meeting their caloric requirements
o Anemia  overweight and obesity among various population groups
o Diarrhea should be addressed, especially among adults
o Moonface  Maternal Nutrition
 Poor infant and young child feeding in the first two years of
Marasmic Kwashiorkor life
 Children with features of both nutritional marasmus and  Exclusive breastfeeding (EBF) in the first six months of life
kwashiorkor continues to be a challenge
 Child with severe malnutrition who is found to have both  Problem for achieving optimum complementary feeding
edema and a weight for age below 60 percent of that
expected for his or her age Causality of Malnutrition

PHILIPPINE PLAN FOR ACTION FOR NUTRITION
 Integral part of the Philippine Development Plan 2017-2022.
 It is consistent with the Duterte Administration 10-
 point Economic Agenda, the Health for All Agenda of the
Department of Health
 Considers country commitments to the global community as
embodied in the 2030 Sustainable Development Goals,
 It consists of 12 programs and 46 projects serving as a
framework for actions
 Of these 12 programs, 8 are nutrition-specific, one is
nutrition-sensitive and three are enabling support
programs.
 The PPAN 2017-2022 comes with a budget estimate for the
entire period of six years.
 The plan has a monitoring and evaluation framework
showing the plan for progress monitoring and evaluation
through the six-year period.
 The National Nutrition Council Secretariat led and
coordinated plan formulation.

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 Undernutrition is thought to arise from the immediate
causes of inadequate dietary intake and disease.
 These immediate causes are, in turn, linked with underlying
causes that include food insecurity, poor caring and
feeding practices, and poor home environmental
conditions and inadequate health services.
 These immediate and underlying causes are further linked to
basic causes at the society level that covers among others,
low access and control of resources
 For the ASEAN region, another conceptual framework was
done
PART II
Goals
 To improve the nutrition situation of the country as a
contribution to:
o The achievement of Ambisyon 20402 by improving the
quality of the human resource base of the country
o Reducing inequality in human development outcomes
o Reducing child and maternal mortality
Objectives
 PPAN 2017-2022 has two layers of outcome objectives: the
outcome targets and the suboutcome or intermediate
targets.
 Outcome targets refers to final outcomes against which
plan success will be measured
 Sub-outcome or intermediate target refers to outcomes
that will contribute to the achievement of the final outcomes
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National Nutrition Program
Outcome Targets
 To reduce levels of child stunting to 21.4% and wasting to
<5%
 To reduce micronutrient deficiencies to levels below
public health significance
 No increase in overweight among children
 To reduce overweight among adolescents (from 8.3% to
<5%) and adults (from 31.1% to 28%)
Sub-Outcome Targets
 To reduce the proportion of nutritionally-at-risk
pregnant women from 24.8% to 20% by 2022
 To reduce the prevalence of low birthweight from 21.4% in
2013 to 16.6% by 2022
 To increase the prevalence of exclusive breastfeeding
among infants 5 months old from 24.7% in 2015 to 33.3 by
2022
 To increase the percentage of children 6-23 months old
meeting the minimum acceptable diet from 18.6% in
2015 to 22.5% by 2022
 To increase the proportion of households with diets that
meet the energy requirements from 31.7% in 2013 to 37.1
by 2022
Strategic Thrusts
 Focus on the first 1000 days of life
 Complementation of nutrition-specific and nutrition-
sensitive programs
 Intensified mobilization of local government units
 Reaching geographically isolated and disadvantaged
areas (GIDAs) and communities of indigenous peoples
 Complementation of actions of national and local
governments

Priority Areas for PPAN
Nutrition-Sensitive Program
 development projects to produce nutritional outcomes
 done by:
o targeting households with undernourished children or
nutritionally-vulnerable groups
o targeting areas with high levels of malnutrition
o being a channel for delivering nutrition-specific
interventions
 Table 5 shows a list of development programs and projects
that will be tweaked to produce nutritional outcomes in
addition to their original objectives. This list in this program
is an initial one and will be updated in the course of plan
implementation.
Enabling Programs
 Mobilization of local government units for nutrition
outcomes
o Mobilization of Local Government Units for Delivery of
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Nutritional Outcomes through the NNC Sub-Regional
Network
o Enabling Policy and Legal Framework for LGU
Mobilization
o Development of Continuing Opportunities for LGU
Excellence in Nutrition Programming
o Mobilization of Rural Improvement Clubs and other
community-based organizations for nutrition action
 Policy development for food and nutrition
o Securing policy support for improving nutrition,
specifically along the priority legislative measures
o Public advocacy for improved support to nutrition
 Strengthened management support to the PPAN 2017-2022
o Securing vital nutrition infrastructure and resource
requirements for PPAN
o b. Strengthening coordination, monitoring, evaluation
and management of PPAN across NNC including member
agencies and NNC Secretariat
SERVICE TARGETS
 percent of the target group that should be reached by a
service
 targeted at about 90% of the population group
 based on estimates of the Lancet Series on Maternal and
Child Malnutrition, a 90% coverage of key services can result
to reduced mortality and stunting at significant levels
 the target for obesity is 50% of the target population
IMPLEMENTATION AND MANAGEMENT MECHANISM
 Formulation of the National PPAN Implementation Plan
o cover specific activities to be undertaken for each
program for each year
o updated annually to respond to the evolving situation
o include a resource framework with explicit estimates of
funded and unfunded budgets and a resource
mobilization strategy
o This strategy will endeavor to ensure that needed
resources will eventually be available within the plan
period.
 Regional Nutrition Action Plan (RNAP)
o regional level
o formulated to capture initiatives of regional offices of
member agencies of the Regional Nutrition Committee
along the PPAN programs for 2017-2022
o updated annually
 local nutrition committees will formulate or reformulate
their respective nutrition action plans (LNAPs)
o formulated along the PPAN programs
o consider the locality’s nutrition problems and causes
o Per guidelines these LNAPs should cover the three-year
term of the local chief executive, and relevant items
integrated in the annual investment plan of the local
government unit.
 The National Nutrition Council Governing Board will
continue to be the policy-making body for PPAN 2017-
2022.
o Assisted by the NNC Technical Committee and technical

working groups that will be established or re-organized
for each program
 Monitoring will involve the generation of reports on physical
and financial accomplishments from various stakeholders.
Duterte’s Administration Health Agenda on Nutrition: ALL
FOR HEALTH TOWARDS HEALTH FOR ALL – Philippines
Health Agenda 2016-2011
 Philippine Plan of Action for Nutrition (PPAN) 2017-2022
o essential part of the Philippine Development Plan 2017-
2022
o consistent with
 Duterte Administration 10-point Economic Agenda
 the Health for All Agenda of the Department of
Health (DOH)
 the development pillars of malasakit (protective
concern), pagbabago (change or transformation),
and kaunlaran (development)
 the vision of Ambisyon 2040
o a guarantee of the administration to provide and ensure
quality health care to all life stages and give services for
both the well and the sick while taking into account the
triple burden of disease which includes communicable
diseases, non-commmunicable diseases and
malnutrition, and diseases of rapid urbanization and
industrialization
o considers country commitments to the global
community as embodied in the 2030 Sustainable
Development Goals, the 2025 Global Targets for
Maternal, Infant and Young Child Nutrition, and the
2014 International Conference on Nutrition
 long term-vision for the Philippines stated in Ambisyon 2040
is for Filipinos to live a long and healthy life
o allow people to realize their full potential and to enjoy
the attainment of their ambitions for many years
o healthy lifestyle choices must be considered and new
products and process that are safer, environment-
friendly, and promote good health should be employed
o Ensuring the quality of health care and health-related
products and the safety of the other products is the
responsibility of the government.
o policies that promote work-life balance must be
advanced
 President Duterte vowed to include improvements in
healthcare access
 Issues and concerns on health:
o health services and health worker distribution
o healthcare financing - more patients utilize private
facilities, government funding that previously went to
public facilities gets shifted into reimbursements to
private providers
o hospital corporatization and privatization
 Aquino administration had directed more funding to
PhilHealth and less to direct service provision at public
hospitals
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 Kalusugan Pangkalahatan (or Universal Health Coverage) of
the Aquino Health Agenda was intended to transform
healthcare financing such that public institutions are forced
to compete with private institutions
 under the Aquino administration, a number of hospitals that
were formerly government owned and run have been
corporatized or privatized in public-private partnerships
(PPP)
o includes the Philippine Heart Center, National Kidney
and Transplant Institute
PHILIPPINE FOOD FORTIFICATION PROGRAM
 5 impact programs of PPAN:
o food security
o micronutrient supplementation and food fortification
o credit assistance for livelihood
o nutrition education
o food assistance
Definition of Food Fortification
 Codex Alimentarius Commission of the United Nations
defined it as “the addition of one or more essential nutrients
to a food, whether or not it is normally contained in the food,
for the purpose of preventing or correcting a demonstrated
deficiency of one or more nutrients in the population or
specific population groups.”
 to address the possible nutrient loss during food
transformation, nutrient fortification has become an
important aspect in food processing
Objectives of the Food Fortification Program (DOH)
1. To provide the basis for the need for a food fortification
program in the Philippines: The Micronutrient Malnutrition
Problem
2. To discuss various types of food fortification strategies
3. To provide an update on the current situation of food
fortification in the Philippines
 level of fortification must contribute significantly to the
nutritional requirements but must not exceed the safe upper
limit
 fortificant must not alter the organoleptic properties,
physical structure, or shelf life of the vehicle
 Control and monitoring procedures must be built into the
manufacturing procedures to ensure that fortification levels
are adequate.
Policies on Food Fortification
Act for Salt Iodinization Nationwide (ASIN) – RA 8172
 signed into law by Former President Fidel V. Ramos on
December 20, 1995
 requires all producers, importers, and manufacturers of
food-grade salt to iodize the salt they produce, manufacture,
trade, or distribute
 sets standards, regulations, and incentives as well as
sanctions and fines to violators
 Include the ff. activities:
o distribution of iodization machines
 National Nutrition Program

o training on the technology of salt iodization and quality

assurance
b. wheat flour - fortified with Vitamin A and iron
Fortificant Minimum Maximum
Acceptable Level Tolerable Level Fortificant Minimum Maximum
Vitamin A 12.0 RE/L 23.0 RE/L Acceptable Level Tolerable Level
Retinol palmitate Levels set by BFAD Levels set by BFAD Vitamin A 5.0 mg/kg 30.0 mg/kg
Or others Retinol palmitate Levels set by BFAD Levels set by BFAD
approved by Or others
BFAD approved by
o dissemination of information on the law and its BFAD
implementing rules and regulations c. refined sugar- fortified with vitamin A
o installation of titration laboratories in all regions d. cooking oil - fortified with vitamin A except for export
o community-based monitoring of iodized salt
o multimedia campaign to promote the consumption of
iodized salt Implementation, Monitoring, and Review
Philippine Food Fortification Act of 2000
 supplement the ASIN law Fortificant Minimum Maximum
Acceptable Tolerable Level
 signed into law by former President Estrada on November,
2000 Level
Vitamin A 3.0 mg/kg as 6.5 mg/kg as
 cover all imported or locally processed foods or food
products for sale or distribution, for human consumption in Retinol retinol retinol
palmitate/acetate Or Levels set by Levels set by BFAD
the Philippines
others approved by BFAD
 exemptions include
BFAD
o Dietary supplements for which established standards
Or others approved
have already been prescribed by the DOH through BFAD
by BFAD
o Those intended for exports or for use in the production
Iron 70.0 mg Fe/kg 105 mg/kg as
of other processed food products, such as beverages
Elemental Iron retinol
where the fortified product used for food processing
(electrolytic, H
may affect the processed product by the fortificant.
reduced, particle size
Voluntary vs. Mandatory Food Fortification
should be ≤ 50
Voluntary Food Fortification
microns) 50.0 mg Fe/kg
 aims to encourage food processors to undertake food
Ferrous Sulfate or Levels set by 75.0 mg Fe/kg
fortification on their own volition
Ferrous Fumarate BFAD Levels set by BFAD
 to enhance the nutrition content of their food products
Others approved by
 Under the Sangkap Pinoy Seal Program (SPSP) the BFAD
Department of Health (DOH), shall encourage the
fortification of all processed foods or food products based on
 DOH through BFAD – lead agency for the implementation
the rules and regulations which the DOH through BFAD shall
and monitoring of th law
issue after the effectivity of RA 8976.
 NNC - the policy-making and coordinating body on nutrition
 Manufacturers who opt to fortify their processed food or
o the advisory board on food fortification
food products but do not apply for registration under the
o responsible for a periodic review of the micronutrients
Sangkap Pinoy Program, shall fortify their processed foods
added to food
or food products based on acceptable standards on food
fortification set by the DOH through BFAD.  DOH – responsible for the conduct of promotional and
advocacy activities on the use of fortified processed foods or
 There are 139 processed food products with Sangkap Pinoy
food products through the SPSP and/or other programs
Seal with 83% with vitamin A, 29% with iron and 14% with
designed to promote nutrition
iodine (2008).
Mandatory Food Fortification  Results of the review would be the basis for determining if
the mandatory fortification is still required or not.
 mandatory fortification of staple foods
 conduct the review at least every five years, to concur with
 based on standards set by the DOH through the BFAD
the national nutrition surveys of the FNRI and/or the
 Include the ff. food groups:
assessment of the Philippine Plan of Action for Nutrition
a. All rice, except brown rice and locally produced
glutinous rice - fortified with iron

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Status of the Food Fortification Program
Flour Fortification with Vitamin A and Iron
 Based on FDA monitoring all local flour millers are fortifying
with vitamin A and iron
 94% and 92% of all samples tested by FDA in 2009 were
fortified with vitamin A and iron respectively
 77% and 99% were fortified with vitamin A and iron
respectively
 In 2010 decrease in vitamin A due to non-fortified imported
and market samples flour.
 58% of samples from local mills for vitamin A and 67% of
imported flour for iron were fortified according to standard
Mandatory Fortification of Refined Sugar with Vitamin A
 Non-fortification by industry due to the unresolved issue of
who will bear the cost of fortification brought about by the
quedansystem of transferable certificates of sugar
ownership.
 Lack of premix production
 Fortification of refined sugar would benefit mainly those in
the high-income group.
Rice Fortification with Iron
 NFA is fortifying 50% of its rice in 2009 and 2010
 With the non – fortification of NFA rice, private sector has an
excuse for non – fortification of its rice.
 There is limited commercial/private sector iron rice premix
and iron fortified rice production and distribution mostly in
Mindanao (Region XII and XI)
 Gen San has the only commercial iron rice premix plant in
the Philippines and Davao City implementing mandatory rice
fortification in food outlets
 NFA conducted communications campaign for its iron
fortified rice thru the called “I-rice” campaign though issues
remain on the acceptability of its product
Cooking Oil Fortification with Vitamin A
 Based on the samples analyzed by FDA in 2009 and 2010,
more than 90% are fortified (91% in 2009 and 94% in 2010)
 Samples monitored were labeled and packed
 FDA is not monitoring "takal"
 UNDERFIVE AND MATERNAL DEATHS AND ADDRESS
Salt Iodization
 Based on the 2008 NNS, 81.1% of households were positive
for iodine using Rapid Test Kit (RTK)
 In the same survey for Region III, 55.7% were positive for
RTK but only 34.2% and 24.2% have iodine content >5ppm
and >15ppm respectively using WYD Tester
 For FDA monitoring in 2010, 88% were >5ppm while 44%
were >15ppm
 FDA started implementing localization of ASIN Law with
General Santos City as the 1st to have a MOA with FDA on
localization
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National Nutrition Program
Sangkap Pinoy Seal Program
 There are 139 processed food products with
SangkapPinoySeal with 83% with vitamin A, 29% with iron
and 14% with iodine (2008)
 37% of the products are snack foods
 Most of the products FDA analyzed are within the standard
 Based on 2003 NNS Households’ awareness of SPS- and FF-
products is 11% and 14%, respectively, in 2008 awareness
is 11.6%
 Although awareness is low, usage of SPS-products is 99.2%
POLICY ON MICRONUTRIENT SUPPLEMENTATION
 The three-pronged strategy identified by the government to
combat micronutrient deficiencies:
1. Micronutrient supplementation
2. Diet diversification
3. Food fortification
 Micronutrient supplementation
o the provision of pharmaceutically prepared vitamins
and minerals for treatment or prevention of specific
micronutrient deficiency
 Diet diversification
o the adoption of proper food and nutrition practices
through nutrition education, food production and
consumption
o promotes the consumption of a wide variety of foods
rich in micronutrients
 Food fortification
o the addition of essential micronutrients to widely
consumed food product at levels above its normal state
 The goal of Micronutrient Supplementation:
o “Achievement of better health outcomes, sustained health
financing and responsive health system by ensuring that
all Filipinos especially the disadvantaged group (lowest 2
income quantities) have equitable access to affordable
health care.”
ADMINISTRATIVE ORDER 2010-0010:
REVISED POLICY ON MICRONUTRIENT
SUPPLEMENTATION TO SUPPORT ACHIEVEMENT OF 2015
MILLENNIUM DEVELOPMENT GOAL TARGETS TO REDUCE
MICRONUTRIENT NEEDS OF OTHER POPULATION GROUPS
I. Objectives
 In general, this policy and guide aims to ensure the
appropriate provision of quality micronutrient
supplementation (MS) in the country. Specifically, it aims to:
1. Guide health workers and providers in administering
micronutrient supplements to identified population
groups and client needs;
2. Promote the compliance and adherence among DOH
offices, the LGUs and private sector to the revised policy
and guidelines; and
3. Generate the support of other stakeholders in
implementing the MS policy and guide throughout the
country.

II. Scope of Application
 applies to all national, regional, and local government offices,
public and private health facilities, NGOs, development
partners and other stakeholders whose functions and
activities contribute to the delivery and provision of MS
nationwide
III. General Guidelines
A. Micronutrient supplementation shall be adopted as an
intervention to address micronutrient deficiency given the
following conditions:
1. Population groups with micronutrient deficiency
prevalence that is at a level of public health importance
2. Micronutrient needs of population groups cannot be
met through regular diet and use of fortified foods
3. Use of MS is proven efficacious and safe, and
4. Administration of MS has significant effects on health
and welfare at each stage in the life cycle and on the
next generation.
B. Micronutrient supplementation is recommended for the
following priority age and physiological groups:
1. 0-59 months old children
2. pregnant and lactating women
3. non-pregnant and non-lactating women of reproductive
age (15-49 years old)
C. A package of micronutrient supplements in the right dosage,
timing, frequency and duration shall be provided to the
above priority groups according to their needs at various
stages of their life cycle.
D. Priority shall be given to population groups and individuals
in special situations or with particular conditions:
1. during emergencies
2. those residing in areas endemic with malaria and
schistosomiasis
3. individuals who are clinically diagnosed with
micronutrient deficiencies e.g. xeropthalmia
E. Therapeutic dosage may be given to individuals with
established deficiencies even if micronutrient
supplementation is not recommended for the following age
groups:
1. 5-9 years old children
2. adults, 50-60 years old
3. elderly, >60 years old
F. Delivery of the MS Packages shall be integrated into the
existing Maternal, Newborn and Child Health and Nutrition
(MNCHN) service delivery channels and through other
avenues that could best reach the targeted clients. These
may include non-traditional service settings such as the
schools, the workplace,etc, to widen reach and coverage.
G. LGU’s capacity to provide quality MS to priority population
groups shall be enhanced particularly in the area of MS
program management, diagnosis and MS administration,
counselling and information, and systems design and
establishment for client referral, recording and reporting,
follow-up and tracking.
H. Financing of essential MS must be sustained and secured.
I. MS information management shall be strengthened for
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better planning and implementation.
J. Promotion of MS shall be intensified to generate the desired
behaviors of targeted clients and other groups of
stakeholders. Promotion efforts shall be focused towards
improving the targeted clients’ awareness and appreciation
of MS benefits and its negative consequences if deficiencies
remained uncorrected, wider adoption by LGUs of the
recommended MS packages.
K. Continuous availability of MS supply shall be ascertained at
the local level.
L. Monitoring and evaluation of the MS program must be
improved by expanding the coverage of scope to be tracked,
integrating MS as part of the regular supervision visits at the
local level, and inclusion of the review of the MS intervention
in the regular Program Implementation Review (PIR).
SANGKAP PINOY SEAL PROGRAM (SPSP)
 established under Republic Act No. 8976 or the Philippine
Food Fortification Act of 2000 on November 7, 2000
 DOH and BFAD aim to encourage food manufacturers to
fortify all processed foods or food products with essential
nutrients at levels approved by the DOH
 an accompanying program to Food Fortification
 Nutrition Service (NS)-DOH
o the agency responsible for the implementation of the
program
 management is handled by a Technical Board composed of
Directors from NS-DOH, BFAD-DOH, National Nutrition
Council-Department of Agriculture (NNC-DA), Food and
Nutrition Research Institute-Department of Science and
Technology (FNRI-DOST), and Department of Trade and
Industry (DTI)
o regularly conduct quality assurance and control
monitoring of these products
 the Seal
o guide used by consumers in selecting nutritious foods
o awarded to manufacturers who are able to meet the
standards for fortifying products with Vitamin A, iron,
and iodine
o include food products such as sardines, instant noodles,
cheese, juice drinks, chocolate drinks, weaning foods,
biscuits, margarine, snack foods, condiments, hotdogs,
and hotcake
o makes the general public aware of the availability of
fortified foods with assurance of quality and thus
encourages them to consume such product
o provides a mechanism for the government to support
the private sector in marketing fortified foods and
o serves as a venue for regular consultation and dialogue
with the industry for public–private sector partnership
for food fortification
 Manufacturers who opt to fortify their processed foods of
food products but do not apply for Sangkap Pinoy Seal shall
fortify their processed food or food products based on
acceptable standards on food fortification set by the DOH

through the BFAD.
Status and Recommendations for the Sangkap Pinoy Seal
Program
 In 2008, there are 139 processed food products with
Sangkap Pinoy Seal:
o 83% with vitamin A
o 29% with iron
o 14% with iodine
o 37% of the products are snack foods
 In a 2003 NNS Households’ awareness, 11% and 14% of
households are aware of Sangkap Pinoy Seal and Fortified
Food products, respectively.
 usage of Sangkap Pinoy Seal products is 99.2%
Fortification Guidelines for Processed Foods
 Added nutrients shall supply at least 1/3 of the RDA ( now
referred to as Recommended Energy and Nutrient Intakes/
RENI ) of the target consumer
 Reference RENI will be those for Filipino adult male 30 to 49
years old, for those intended for children, reference RENI
will be for 4 – 6 years old
 Computation of the minimum fortification level:
Fortification level per 100 g = (A/B*C) x 100
Where A = 1/3 RDA of the target consumer
B = no. of servings like to be consumed per day
C = serving size (amount of food normally eaten at one
time
Growth Monitoring
Role in Child Survival
 Growth monitoring
o Defined as the regular measurement, recording and
interpretation of a child's growth change In order to
counsel, act and follow up results"
o targeted by child survival Initiatives such as those
undertaken by UNICEF and the U.S. Agency for
International Development as an important tool for
reducing infant mortality
 Growth promotion activities such as those focusing on
health education, counseling, referral and other actions to
follow up results are essential
 growth monitoring and promotion, to emphasize that action
based on the results of assessment is an essential component
of the intervention
 Advantages:
o It allows for the early identification of children at high
risk of malnutrition.
o It enhances the transfer of nutritional information by
providing the educator with data concerning children's
growth patterns that can be used in tailoring advice.
o It assists in focusing scarce resources such as supple-
mentary food commoditic.; recipients who most need
them.
o It provides a good opportunity for immunization and
other preventive and promotive services, as well as for
simple treatment and referral to other health services.
o When combined with nutrition surveillance, it assists in
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evaluating the impact of other health and development
 Problems that inhibit the implementation of effective
projects:
o Mothers often do not understand the significance of the
monitoring activities and are not involved in the
measurement of their children.
o Health workers many times have not been properly
trained to take accurate measurements, interpret them,
and provide the follow-up support needed.
o The community has often not been sensitized to the
importance of growth nor been mobilized to undertake
corrective actions.
o Measurement equipment is frequently inappropriately
designed, expensive, in poor repair or unavailable.
o Adequate systems for providing follow-up support are
often missing, with education sporadic and ill-designed,
on-site services poorly organized or nonexistent and
referral services weak.
Major Conclusions and Recommendations
1. Traditional methods for monitoring growth
o Helps sensitive indicators to be incorporated into
project procedures, and advice can be linked with what
mothers already know
o mothers may have a wide range of criteria for deciding
whether their children are growing well
o include physical changes common in nutritional
diseases and various traditional anthropometric
measures such as the fit of bead strings or clothes
o traditional indicators
 sufficiently sensitive to provide valuable early
warning signs even before weight changes can be
detected
2. Practices with particularly negative or positive effects
on growth
o adequate growth amidst poverty should be initiated by
projects wishing to strength their growth promotion
approach
o include introducing solid foods very late or leaving food
consumption decisions completely up to the child can
be quite damaging
o increased focus on learning from families that do
particularly well in adverse conditions
3. Attitudes toward weighing
o Project planners should determine whether there is any
resistance to weighing of young children
o Weighing is seen at times as degrading, as if the child is
a piece of meat
4. Health workers inadequacies and possible training
strategies
o Training in growth monitoring for both health
professionals and front line workers should be
strengthened
o many knowledge and attitude problems are common
both at the professional and auxiliary levels
5. Protocols and supervision

o The use of protocols that provide trainees and workers
with specific guidelines on monitoring and promotional
tasks to be completed should be considered.
6. Strategies for involving mothers
o Approaches that are home-based or at least community-
centered, with outreach drives and well-designed
incentive programs, may increase involvement of those
most at risk.
o Mothers should keep their children's growth cards and
be taught how to accurately interpret them.
7. Approaches to community participation
o the community can do project plannging, outreach, and
monitoring
o Creative strategies include the use of graphs for
displaying community growth results.
8. Growth chart design
o Growth charts should be simple and clear, use
culturally-appropriate colors and language,
o have specific technical features to facilitate accurate
plotting and Interpretation
o emphasize weight gain rather than nutritional status
9. Weighing scale selection
o when selecting scales, consider the maintenance,
durability, portability, acceptability, accuracy, potential
for user error, simplicity and cost
o Bar scales, spring dial scales and tubular spring scales
are good choices
o electronic walk-on and hanging scales in the future
10. Choice of follow-up activities
o concentrate maximum effort on what is typically the
weakest link in the growth monitoring process
o include:
 Nutritional and health education
 Preventive and curative services
 Referral to other health and child care facilities
 Supplementary feeding
 Nutritional surveillance and assessment
11. The focus of educational activities
o Useful educational techniques for promoting growth
include:
 involving the mothers themselves in message
design
 developing counseling cards and action posters
that provide advice for specific conditions and age
levels
 using pictures, stories, games, plays, and slogans
 fostering effective mother-to-mother exchange
integrating mass media approaches with face-to-
face education.
12. Supplementary feeding strategies
o should be focused on high risk children under three
who can be assisted In resuming good growth through
short term assistance and effective parental education
o By concentrating on the earlier stages of malnutrition
among younger children, it was successful in gradually
lowering the prevalence of more severe and chronic
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malnutrition.
13. Expanding project activities
o consider strategies to enhance possibilities of success of
the project
o useful to:
 mobilize support from all sectors of society
 analyze the features of small scale projects that
have enabled them to have substantial impact, o
explore and, if possible, use systems other
expanded programs such as EPI have developed to
deal with financial, supervisory, and coordination
problems
 simplify technology, for example by improving
scale design, targeting educational messages more
accurately, and streamlining work flow, so wider
coverage can be obtained with little added cost
 integrate growth monitoring with other PHC
activities while strengthening referral services
14. Selecting effective research methods
o qualitative methods successfully used in the field:
 Community diagnosis and baseline studies
 Situation analysis
 Case studies of small and large scale projects
 Studies of "adequate growth amidst poverty"
 Systems analysis and use of observational guides
 Operations research
2012 NUTRITIONAL GUIDELINES FOR FILIPINOS
 set of dietary guidelines based on the eating pattern,
lifestyle, and health status of Filipinos
 contains all the nutrition messages to healthy living for all
age groups from infants to adults, pregnant and lactating
women, and the elderly
 first NGF released in 1990 composed of five messsges is
called “Dietary Guidelines for Filipinos”
 In 2000, a revised nutritional guidelines composed of ten
messages is released and called the Nutritional Guidelines
for Filipinos.
 2012 NGF includes the basis and justification for each of the
ten nutritional and health message
 NGF Goal: the improvement of the nutritional status,
productivity and quality of life of the population through
adoption of desirable dietary practices and healthy lifestyle
 Objectives of NGF
1. To promote a healthy well-balanced diet
2. To promote exclusive breastfeeding
3. To give appropriate complementary foods
4. To increase the food and dietary energy of the average
Filipino
5. To prevent nutritional defciency diseases and
lifestylerelated diseases
6. To encourage attainment of normal body weight
7. To promote food safety
 New Messages of 2012 NGF
1. Eat a variety of foods everyday to get the nutrients
 National Nutrition Program

needed by the body.

2. Breastfeed infants exclusively from birth up to six
months and then give appropriate complementary
foods while continuing breastfeeding for two years and
beyond for optimum growth and development.
3. Eat more vegetables and fruits to get the essential
vitamins, minerals, and fiber for regulation of body
processes.
4. Consume fish, lean meat, poultry, egg, dried beans or
nuts daily for growth and repair of body tissues.
5. Consume milk, milk products, and other calcium-rich
food such as small fish and shellfish, everyday for
healthy bones and teeth.
6. Consume safe foods and water to prevent diarrhea and
other food-and water-borne diseases.
7. Use iodized salt to prevent Iodine Deficiency Disorders.
8. Limit intake of salty, fried, fatty, and sugar-rich foods to
prevent cardiovascular diseases.
9. Attain normal body weight through proper diet and
moderate physical activity to maintain good health and
help prevent obesity.
10. Be physically active, make healthy food choices, manage
stress, avoid alcoholic beverage, and do not smoke to
help prevent lifestyle-related non-communicable
disease.
 target users of the guideline – general public
LET’S GO BATCH 2019! 100% PROMOTION!
#2019KAKAYANIN #ROADTOCLERKSHIP

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 3.07
January, 26, 2018
NATIONAL NUTRITION PROGRAM
Groups 1&2 – 3A
Department of Family and Community Medicine

NGF 2012
Message Action Points
1.  Plan and consume a balanced diet.
 Eat the recommended amount of food from each of the food groups.
 Pay particular attention to the increased needs during periods of growth and development (school children
and adolescents), pregnancy and lactation.
 Take care of the increased nutritional needs of adolescents by giving adequate and varied meals to get them
ready for adulthood.
 When planning to eat convenience foods, choose those with high nutritional value and observe the principle
of variety.
 Select fortified foods, whenever possible.
 Read food labels to make healthier food choices.
 Take nutritional supplements only upon expert advice
2.  Take nutritional supplements only upon expert advice
o Practice exclusive breastfeeding for the first six (6) months of life
o Continue breastfeeding for up to two (2) years
o Provide appropriate, adequate and safe complementary food in addition to breastmilk from 6 months
onwards
 Feeding should be supported and promoted by all members of the family, the community, the health-care
providers and the society
3.  To help meet nutrient requirements:
o Consume two to three servings of vegetables each day, one serving of which is a green leafy or yellow
vegetable.
o Take three servings of fruit daily, one serving of which is a vitamin C-rich fruit.
o Encourage vegetable and fruit home gardening.
4.  To improve the quality of the diet:
o Consume fish, lean meat, poultry and eggs.
o Include legumes such as dried beans in your diet
5.  To help meet requirements for calcium:
o Include milk and milk products and other calcium-rich foods in the diet everyday for stronger bones and
teeth.
o Consume natural foods high in vitamin D such as salmon, tuna, mackerel and fish liver oils; and foods
fortified with vitamin D like butter, margarine, milk, yogurt, cheese, and ready-to-eat cereals.
6.  Eat clean and safe food.
 Drink safe water.
 Practice good personal hygiene.
 Practice environmental hygiene and sanitation.
 Clean and sanitize food preparation area.
 Practice pest control.
 Practice safe food storage, handling, preparation and service
7.  Use iodized salt to prevent iodine deficiency disorders and avoid physical and mental underdevelopment.
 Consume foods rich in iodine like seafood and seaweeds and those fortified with iodine.
8.  Limit intake of salt and salty to prevent hypertension particularly among susceptible individuals.
 Limit intake of saturated fats and cholesterol-rich foods particularly among individuals with high risk to

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22
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chronic degenerative diseases. Use moderate amounts of polyunsaturated fats instead.

 Use coconut oil rather than saturated fats in cooking since it consists mainly of medium-chain triglycerides
that are easily digested, absorbed, transported, and utilized by the body as source of energy.
 If not overweight, stir-fry foods in vegetable oil or add fats and oils whenever possible in food preparation to
ensure adequate fat intake.
 Limit intake of hydrogenated fats such as margarine.
 Avoid excessive intake of sugar to prevent CVD risk, overweight and obesity, which may lead to other health
risk factors.
9.  Monitor weight regularly.
 Attain normal body weight.
 Monitor waist circumference and waist-hip-ratio among adults.
 Follow a balanced and nutritious diet in consonance with the level of physical activity.
 Avoid habits and behaviors that promote obesity.
10.  It is strongly advised to drink in moderation, if alcohol consumption cannot be avoided.
 Learn to manage or control stress.

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