Public Health Nutrition

NUTRITION POLICIES AND PROGRAMMERS

NUTRITION ASSESSMENT
 Nutrition assessment is the systematic process of collecting and evaluating data to
determine an individual's or population's nutritional status.
Nutrition assessment covers many topics, including the collection, harmonization and sharing of dietary
data, dietary recommendations on nutrition requirements, food composition, and the analysis of dietary
data including the use of diet quality and diversity indicators.
Nutrition assessment provides timely, high-quality, and evidence-based information for setting targets,
design, planning, monitoring, and evaluating programs aiming at eradicating hunger and reducing the
burden of malnutrition in all its forms.
Global and free access to country-level information on diet and nutrition informs decision making to
achieve better nutrition for all.
Goals of nutrition assessment:
 Identify individuals or populations at risk for malnutrition.
 Determine nutritional needs and develop appropriate interventions.
 Evaluate the effectiveness of nutrition interventions.
Steps in Nutrition Assessment
Step 1: Screening
 Identify high-risk individuals or populations.
 Use validated screening tools to identify potential nutrition problems.
 Common screening methods: anthropometric measurements, dietary assessments, medical
history, and biochemical tests.
Step 2: Anthropometric Assessment
 Measurements of body size, shape, and composition.
 Key anthropometric indicators: weight, height, body mass index (BMI), mid-upper arm
circumference (MUAC), and skinfold thickness.
 Interpretation of anthropometric data using growth charts, reference standards, and z-scores.
Step 3: Dietary Assessment
 Evaluation of dietary intake and patterns.
 Methods of dietary assessment: food records, 24-hour recalls, food frequency questionnaires,
and direct observation.
 Interpretation of dietary data considering nutrient adequacy, energy intake, and dietary patterns.
Step 4: Clinical Assessment
 Examination of physical signs and symptoms related to nutrition.
 Assessment of medical history, medications, and underlying health conditions.
 Clinical signs of malnutrition: edema, muscle wasting, skin changes, and nutrient deficiencies.
Step 5: Biochemical Assessment
 Laboratory tests to measure nutrient biomarkers.
 Examples of biochemical markers: hemoglobin, serum albumin, vitamin D levels, and electrolyte
status.
 Interpretation of biochemical data in the context of specific nutrient deficiencies or excesses.
Step 6: Environmental Assessment

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 Evaluation of social, economic, and cultural factors influencing nutrition.

 Assessment of food security, access to clean water, and sanitation.
 Identification of environmental determinants of malnutrition.
Data Collection and Analysis
Data Collection:
 Selection of appropriate assessment tools and methods based on the target population and
available resources.
 Standardization of data collection procedures to ensure consistency and accuracy.
Data Analysis:
 Compilation and organization of collected data.
 Comparison of collected data with established reference values, guidelines, or standards.
 Identification of deviations or discrepancies from the norm.
 Integration of multiple assessment results to form a comprehensive picture of nutritional status.
Interpretation and Diagnosis:
 Interpretation of assessment findings to identify nutritional problems or deficiencies.
 Formulation of a nutrition diagnosis or problem list.
 Consideration of individual factors, such as age, gender, physiological conditions, and lifestyle.
Application of Nutrition Assessment Findings
A. Nutrition Intervention Planning:
 Development of individualized or population-level nutrition interventions.
 Setting realistic goals and objectives based on identified nutritional needs.
 Collaborating with healthcare professionals to integrate nutrition interventions into overall care
plans.
B. Monitoring and Evaluation:
 Regular monitoring of nutritional progress and outcomes.
 Adjustments of interventions based on ongoing assessment and feedback.
 Evaluation of the effectiveness and impact of nutrition interventions.

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A: Anthropometry
Anthropometry allows for an assessment of the different component parts of the human body. Body
composition refers to the anatomical makeup of the body in terms of bone, muscle, water, and fat. A
single measure will not provide a comprehensive overview of the patients’ condition and so a number
of measurements are required to form a more reasoned assessment. In malnutrition, changes in body
composition lead to Introduction to Malnutrition.
Anthropometric measurements that can be used to assess body composition.

Measurement Equation/ method Interpretation of results

A patient is indicated for nutrition support if they

have:

 BMI <18.5kg/m2
Weight and % % weight change = (previous weight - current  Unintentional weight loss of >10% in the
weight change weight / previous weight) x 100 previous 3-6 months
 BMI <20kg/m2 and unintentional weight loss
>5% in the previous 3-6 months.

(NICE, 2006)
 If BMI <18.5kg/m2 patient is underweight
 If BMI 18.5-25kg/m2 patient is in normal BMI
Body mass index range
BMI (kg/m2) = weight (kg) / height 2 (m2)
(BMI)  If BMI >25kg/m2 patient is overweight

(WHO, 2016)

Involves measuring the circumference of the

 If MUAC is >23.5cm the patient is likely to have
mid-point on upper arm using a tape measure.
a healthy BMI and is at low risk of malnutrition.
This is a surrogate measure of both fat mass and
Mid upper arm  If MUAC is <23.5cm the patient is likely to have
fat free mass. It is a useful measure when a
circumference a BMI <20kg/m2 and may be at risk of
person cannot be weighed or if their weight is
(MUAC) malnutrition.
not likely to be a true reflection of the persons’
actual weight, e.g. if the patient has oedema or
ascites. (BAPEN, 2011)

Measurement requires a trained person using

skin fold callipers which have been calibrated.
Skin fold measurements can be taken at 4
different sites: suprailliac, subscapular, biceps,
Skin fold triceps (TSF; most commonly used). Centile tables can be used to interpret skin fold
thickness Measurement should be repeated 3 times and thickness measurements.
the mean result recorded. This is a surrogate
measure of total fat mass. Longitudinal
measurements can be used to identify any
changes in fat mass.

Mid arm muscle MAMC is a surrogate measure of fat free mass

Centile tables allow assessment of changes in total
circumference and is calculated using MUAC and TSF.
body muscle mass over time.
(MAMC) MAMC (cm) = MUAC (cm) – 3.14 x TSF (cm)

Other visual signs may indicate recent weight loss such as loose jewellery, baggy clothes, extra
notch in belt, ill-fitting dentures, loose or thin looking skin, and prominent bony features.

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B Biochemistry
The blood tests conducted within a nutrition assessment are interpreted in conjunction with a clinical
examination; previous medical history; and current medications. Biochemistry tests measure levels of
chemical substances present in the blood. Functional tests measure the function of vital organs such as
the kidneys or liver.
Normal range (note
that different
Measurement Rationale laboratories may use
different reference
ranges)

Women = 12.0 to 15.5

Haemoglobin (Hb) Assess for iron status or indicate anaemia. g/dl
Men = 13.5 to 17.5 g/dl

A low level may indicate inflammation or

35 - 50 g/L (3.5 - 5.0
Albumin (Alb) infection is present, therefore should not be
g/dL)
used to determine nutritional status.

This is an inflammatory marker which is

C-Reactive Protein (CRP) raised when infection or inflammation is Ideally <10 mg/L
present.

4-11 x109/L (4000-

Immune system marker is raised if infection
White cell count (WCC) 11,000 per cubic
is present.
millimetre of blood)

Glycated Haemoglobin Indicates an average blood sugar level over Ideally <48 mmol/mol
(HbA1c) a period of months. or <6.5% (Diabetes UK)

This is an indication of hydration status and

Sodium (Na) kidney function. A raised sodium level may 135-145 mmol/L
indicate dehydration.

Used to assess kidney function. High urea

Urea (Ur) and other markers levels in combination 2.5-7.1 mmol/L
may indicate dehydration.

Adjusted Ca 2.0-2.6
Used as a baseline when assessing risk of
mmol/l
Calcium and Phosphate refeeding syndrome Calcium is adjusted for
Phosphate 0.7-1.4
albumin level
mmol/l

Magnesium Likely to be low if there are large GI losses 0.7-1.0 mmol/l

Include vitamins and trace elements. These

are affected by the acute phase response if
Micronutrients
inflammation or infection is present and so
best measured when CRP is low

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C Clinical
A person’s disease state may increase the risk of malnutrition due to increased energy requirements;
reduced energy intake; or increased nutritional losses. Examples of diseases/conditions where this may
occur include:
 Cancer
 Chronic Obstructive Pulmonary Disease
 Heart failure
 Gastrointestinal disorders such as Crohn’s disease, liver disease, coeliac disease
 Neurological conditions such as stroke, Motor Neurone Disease, Parkinsons Disease, multiple
sclerosis, dementia
 Burns, surgery, or trauma
 Mental health conditions (such as depression)
Symptoms that may impact on a person’s nutritional status either through reducing nutritional intake
or increasing nutritional losses include:
 Altered bowel movements e.g. Diarrhoea, constipation.
 Upper gastrointestinal upset e.g. Reflux, bloating, nausea, and vomiting.
 Early satiety
 Dysphagia
 Lethargy
Energy requirements
1. Estimate Basal Metabolic Rate (BMR) using Henry Equations (2005) based on age, gender,
and weight (Henry, 2005) or estimate requirements for stable patients using 25-35kcal/kg
(NICE 2006).
2. Add factor when patient is metabolically stressed.
3. Add factor for activity and diet induced thermogenesis.
4. If aiming for weight gain, add 400-600 kcal/day. Only add this for patients who are
metabolically stable (i.e. not acutely unwell).
5. There are a number of alternative methods to calculate energy requirements in patients who
are obese, with care required not to over-estimate requirements.
(Weekes and Soulsby, 2011)
Fluid requirements:
 Aged >60 years = 30ml/kg body weight
 Aged <60 years = 35ml/kg body weight (Todorovic and Micklewright, 2011)

D Dietary Assessment
Dietary assessment is the process of collecting information about what a person eats and drinks
over a period of time. In other words, it is a record of the foods one eats in an attempt to calculate
their potential nutrient intake.
During a dietary assessment, the health practitioner analyses the energy, nutrients, and other dietary
constituents using food composition tables.
The goal of dietary assessment is to identify appropriate and actionable areas of change in the patient’s
diet and lifestyle and to improve the overall wellbeing of the patient. For a detailed analysis, the health
practitioner can deploy one or more of these methods:
 Diet Record
 24-hour recall
 Food Frequency Questionnaire
Advantages of Dietary Assessment
 It provides contextual information about a person’s nutritional intake.
 Results from the dietary assessment are largely accurate due to more detailed descriptions of
foods and portion sizes.
Disadvantages of Dietary Assessment
 It relies on accurate recall of dietary intake over a long period of time.

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 It is prone to misreporting, especially when the health practitioner adopts food frequency
questionnaires for data gathering.
An estimation of the total daily calorie intake, as well as overall quality of diet should be assessed.
Asking the patient (or their family/carer if patient unable) about their daily dietary intake will help
understand patterns of eating, portion sizes, cooking methods and types of food and drink taken.
Consider asking the following questions to help form a better understanding of the patients’ overall diet:
 What are the patients’ typical food and fluid intake? This can be recorded using food record
charts; 24-hour recall; 3-day food diary; or typical day diet history.
 Is the patient eating 3 meals a day?
 Do they have pudding after at least one meal per day?
 Are they eating snacks in between meals?
 Are they eating smaller meals than they used to when they were feeling well?
 Are they having regular drinks, at least 6-8 glasses of fluid/ day?
 Are they having nutritious drinks such as milky tea/coffee, fruit juice, milky drinks?
 Are they having carbohydrate foods (bread, potatoes, pasta, rice, breakfast cereals etc) and
protein foods (meat, cheese, beans, egg, fish, milk, yoghurt, cream) at each mealtime? Portion
sizes should be at least the size of the patient’s fist and amount to 1/3 each on the plate
(carbohydrate, protein, vegetables).
 Are they eating at least one portion of fruit or vegetable each day?
 If food is being blended, are they adding nutritious liquids such as milk, cream, or gravy to
aid blending, rather than water?
 Are they able to cook for themselves?
 Do they have access to essentials such as bread, milk, and cheese on a daily basis?
 Do they have a hot/cooked meal each day?
 Are they taking any nutritional supplements? Do they take them as recommended? Do they
like them?
Nutritional Assessment Tools
Food Frequency Questionnaire
 A food frequency questionnaire is a tool that helps to record how often person eats certain foods
on a regular basis. It also asks questions about eating habits. This information can then be
compared to national guidelines or standards.
 A food frequency questionnaire will help keep track of what a person eats regularly. A
person/patient can fill it out at home or take it to doctor’s office. The answers provided will help
doctor make the right decisions about nutritional health of the individual.
 When filling out a food questionnaire, everything ate during the past 24 hours is noted down,
including all beverages, including water, milk, juice, soda, tea, coffee, alcohol, and any other
drinks. Also, skipped meals are also mentioned. If not sure whether something was eaten, just
put an “X” next to the item.
Calorie Calculator
A calorie calculator allows you to fill in the number of calories you consume in a day. Then, based on
your weight, age, gender, height, and activity level, it determines the number of calories you need each
day for a healthy life.
A calorie calculator is only as good as the measurements you input. For instance, some people might
forget to include snacks, such as cookies, crackers, chips, etc., when they count calories. And they might
underestimate the calories they burn while exercising. These inaccurate measurements affect the
quality of information you get from the calculator in the end.

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E Environment
Social
Ability to shop, cook, assistance with eating and
drinking, mobility, budget restraints, limited storage
facilities, meal timings, family support.
Physical
Appetite, dentures, dexterity, use of cutlery, sight,
taste changes, nausea, vomiting, heart burn, bloating,
early satiety, diarrhoea, constipation, pain, breathing
difficulties, dysphagia (swallowing problems), food
intolerances, special diets, diminished thirst, taste
preferences.

F Assessment of risk of re-feeding syndrome:

Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in
malnourished patients on refeeding following a period of starvation (NICE, 2006). This is particularly common in
patients receiving artificial refeeding but is possible with oral refeeding (particularly if oral nutritional supplements
are prescribed). The patient should be considered at risk of refeeding syndrome if they meet the following criteria
(NICE 2006).
If the patient has one or more of the following:
 Body mass index <16 kg/m2
 Unintentional weight loss >15% in the past three to six months
 Little or no nutritional intake for >10 days
 Low levels of potassium, phosphate, or magnesium before feeding
Or the patient has two or more of the following:
 Body mass index <18.5 kg/m2
 Unintentional weight loss >10% in the past three to six months
 Little or no nutritional intake for >5 days
 History of alcohol misuse or drugs, including insulin, chemotherapy, antacids, or diuretics
If the patient is considered to be at high risk of refeeding syndrome, the following steps are advised by:
 Start nutrition support at a maximum of 10 kcal/kg/day, increasing levels slowly to meet or exceed
full needs by 4–7 days.
 Restore circulatory volume and monitoring fluid balance and overall clinical status closely.
 Provide immediately before and during the first 10 days of feeding: oral thiamine 200–300 mg daily,
vitamin B co strong 1 or 2 tablets, three times a day (or full dose daily intravenous vitamin B
preparation, if necessary) and a balanced multivitamin/ trace element supplement once daily
 Provide oral, enteral, or intravenous supplements of potassium (likely requirement 2–4
mmol/kg/day), phosphate (likely requirement 0.3–0.6 mmol/kg/day) and magnesium (likely
requirement 0.2 mmol/kg/day intravenous, 0.4 mmol/kg/day oral) unless pre-feeding plasma levels
are high. Pre-feeding correction of low plasma levels is unnecessary.

Nutritional/Dietetic Diagnosis (BDA, 2012)

The information gathered as part of the assessment should be reviewed and synthesised and from this a nutritional diagnosis
should be determined.
Problem
The alterations in the client/group/populations' nutritional status.
Aetiology
The related factors contributing to the existence of, or maintenance of pathophysiological, psychosocial, situational,
developmental, cultural, and/or environmental problems.
Signs and Symptoms
The defining characteristics are a cluster of subjective and objective signs and symptoms established for each nutritional
diagnosis. The defining characteristics are gathered during the assessment phase and provide evidence that nutrition related
problem exist.
The next phase of the care process is the intervention, which is divided into the plan and implementation.
Plan
Aim Identify the overall aim of treatment. It may be minimising further losses, prevent further weight loss, maintain nutritional
status, increase weight, or improve nutritional status.
Dietetic Goals Identify several short-term goals/ action points that will be changed as a result of the assessment.
These should be written as SMART goals (Specific, measurable, achievable, realistic, and timely). The goals should be
negotiated and agreed between the health care professional and the patient or carer.
A timeframe for follow up and review should be agreed upon.

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NUTRITION ANALYSIS
Definition: Nutrition analysis involves the interpretation and evaluation of collected nutrition data to identify
nutritional problems and develop appropriate interventions.
Key components of nutrition analysis:
 Comparing assessment data against reference values and standards.
 Identifying discrepancies or deviations from the norm.
 Formulating a diagnosis or nutrition-related problem list.
 Prioritizing and setting goals for interventions.
Objectives of nutrition analysis:
 Evaluate the adequacy of nutrient intake.
 Identify nutrient deficiencies or excesses.
 Assess dietary patterns and food choices.
 Provide recommendations for improving nutrition and preventing diseases.
Methods of Nutrition Analysis
1. Dietary Assessment Methods:
 Food Records: Individuals record all food and beverages consumed over a specific period.
 24-hour Recalls: Individuals recall their intake from the previous day in detail.
 Food Frequency Questionnaires: Individuals report the frequency of consuming specific foods or food groups.
 Direct Observation: Trained observers record food intake in real-time.
 Automated Dietary Assessment Tools: Software applications or online platforms that analyze dietary intake based
on entered data.
2. Nutrient Database and Software:
 Nutrient Databases: Comprehensive collections of nutrient composition data for various foods and beverages.
 Software Programs: Analytical tools that match food consumption data with nutrient composition data to calculate
nutrient intake.
Steps in Nutrition Analysis
a) Data Collection:
 Obtain accurate and detailed information on food consumption.
 Ensure representative and reliable data collection methods.
 Consider the limitations and challenges associated with each assessment method.
b) Data Processing:
 Convert food consumption data into a format suitable for analysis.
 Aggregate and organize data for each individual or group.
 Validate data for completeness and accuracy.
c) Nutrient Calculation:
 Match food consumption data with nutrient composition data from the database.
 Calculate nutrient intake based on portion sizes, cooking methods, and nutrient content of consumed foods.
 Consider variations in nutrient availability due to cooking or processing methods.
d) Data Interpretation:
 Compare nutrient intake against recommended dietary guidelines or reference values.
 Identify inadequacies, excesses, or imbalances in nutrient intake.
 Assess nutrient density and variety in the diet.
 Analyze dietary patterns and identify potential risks or protective factors.
e) Reporting and Recommendations:
 Summarize and present the findings of the analysis.
 Provide personalized or population-level recommendations for improving nutrition.
 Consider cultural, socioeconomic, and individual factors when formulating recommendations.
Challenges and Limitations of Nutrition Analysis
1. Accuracy of Dietary Assessment:
 Relying on self-reported data can cause errors and biases.
 Memory lapses or inaccurate portion estimation can affect data quality.
2. Nutrient Database Limitations:
 Variability in nutrient composition within food items.
 Outdated or incomplete nutrient data for certain foods.
3. Interpretation Challenges:
 Interactions between nutrients and the impact on health outcomes.
 Individual variations in nutrient requirements and bioavailability.
4. Other Factors:
 Limited access to culturally appropriate nutrient databases.
 Ethical considerations in collecting sensitive dietary information.

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NUTRITION SURVEILLANCE
Definition:
Nutrition surveillance is the continuous and systematic monitoring of nutritional
indicators to detect changes in nutritional status and trends over time.
Principles of Food and Nutrition Surveillance System:
A food and nutrition surveillance system are a way to gather information about the nutritional
status of a population and use that data to make informed decisions and policies. It helps
understand how well a vulnerable population is doing in terms of their nutrition and well-being.
The system collects, analyzes, and interprets data about food consumption and nutritional status.
By closely monitoring these indicators, we can better understand the situation and take
appropriate actions.
The main goal of a food and nutrition surveillance system is to improve and prevent the
deterioration of the nutritional status of populations. It helps identify risk groups and assess
factors that affect food consumption patterns and nutrition. This information is crucial for making
decisions that can positively impact the well-being of the population.
The nutritional status of a population is influenced by various factors such as social and economic
conditions, health, environment, and food availability. Therefore, decisions based on nutrition
surveillance can cover a wide range of areas within the government.
Creating a nutrition surveillance system doesn't have to be complicated or require collecting a
vast amount of data regularly. The information needed depends on the specific problem and the
available resources. The key is to design an efficient system that makes the best use of existing
data sources.
Objectives of nutrition surveillance:
 Early detection of nutrition-related problems or emergencies.
 Assessment of the impact of interventions and programs.
 Evaluation of the effectiveness of nutrition policies.
 Describe the nutritional status of the population, including at-risk subgroups.
 Analyze causes and associated factors of nutrition problems and select preventive measures.
 Assist governments in decision-making, prioritizing resources, and addressing normal
development and emergencies.
 Predict the evolution of nutritional problems and aid in policy formulation.
 Monitor and evaluate the effectiveness of nutritional programs. In emergency settings:
 Serve as a warning system for evolving crises.
 Identify appropriate response strategies, including non-food assistance.
 Trigger in-depth assessments and responses based on trend analysis.
 Target areas at higher risk or in greater need of assistance.
 Identify acutely malnourished children.
EXPLANATION:
A food and nutrition surveillance system are a way of collecting and analyzing information about
nutrition-related issues. It helps governments, organizations, and communities make informed
decisions about how to address problems related to overnutrition and undernutrition. The
system gathers data on various aspects, such as agriculture, dietary habits, health, and socio-
economic factors. This data can be collected at different levels, such as national, regional, or
community based. To identify the specific nutritional problem, it's important to measure the
nutritional status of the targeted population. This involves assessing factors like body
measurements, blood tests, and overall health. By understanding the underlying causes of the
problem, decision-makers can choose the most appropriate interventions to improve nutrition.

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The triple-A cycle diagram for addressing nutrition-related

problems.
This manual is a user reference guide for policymakers and program
managers who want to develop a food and nutrition surveillance
system. It focuses on practical application and offers a model for
creating such a system. The manual provides an overview of the
fundamental principles, essential steps, and important
considerations involved in the various activities of the surveillance
system.
The information in the manual is presented in a concise and easy-
to-understand format. Its goal is to offer the basic elements and framework for establishing a functional
surveillance system, especially for those who currently do not have such a system in place. Additionally,
it can assist in improving the output of existing surveillance systems, enhancing the impact of nutrition
programs through better targeting and timeliness.
This manual serves as a practical guide for developing a food and nutrition surveillance system. It
provides an overview of key principles and steps in a clear and accessible manner, helping policymakers
and program managers establish or upgrade their systems to support effective nutrition programs.
WHO’s Member States have endorsed global targets for improving maternal, infant, and young child
nutrition by 2025 and are committed to monitoring progress.
1. 40% reduction in the number of children under 5 who are stunted
2. 50% reduction of anemia in women reproductive age
3. 30% reduction in low birth weight
4. No increase in childhood overweight
5. Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50%
6. Reduce and maintain childhood wasting to less than 5%
Key Components of Nutrition Surveillance
1. Data Collection:
 Regular and consistent collection of nutrition-related data.
 Selection of appropriate indicators, such as anthropometric measurements, dietary intake,
biochemical markers, and food security.
 Selection of appropriate indicators based on the purpose and target population.
 Sources of data: surveys, routine health information systems, population-based studies, and
program monitoring.
2. Surveillance Systems:
 Establishment of structured surveillance systems at local, national, and global levels.
 Integration of nutrition surveillance into existing health information systems.
 Collaboration between various stakeholders, including government agencies, research
institutions, and non-governmental organizations.
3. Standardized Indicators:
 Adoption of standardized indicators and measurement methods.
 Common nutrition indicators include prevalence of underweight, stunting, wasting, anemia, and
overweight/obesity.
Use of age-specific growth charts and reference values for interpretation.
 Anthropometric Indicators: Height, weight, body mass index (BMI), mid-upper arm
circumference (MUAC), and other measures of body composition.
 Dietary Indicators: Food consumption, nutrient intake, dietary diversity, and quality.
 Clinical Indicators: Signs and symptoms of malnutrition, such as edema, muscle wasting, and
micronutrient deficiencies.
 Biochemical Indicators: Laboratory tests measuring nutrient biomarkers, such as
hemoglobin, serum albumin, and vitamin levels.

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4. Data Analysis and Interpretation:

 Compilation and analysis of collected data.
 Calculation of prevalence rates, trends, and distributions and changes in nutritional indicators.
 Comparison of surveillance data with established benchmarks, reference values, or targets.
 Identification of high-risk groups, geographical disparities, and emerging nutrition issues.
 Identification of vulnerable populations and disparities in nutritional status.
5. Reporting and Dissemination:
 Preparation of reports summarizing surveillance findings.
 Communication of results to policymakers, healthcare professionals, and the public.
 Utilization of data for evidence-based decision-making and policy development.
 Summarization and communication of surveillance findings to relevant stakeholders.
 Generation of reports, bulletins, or dashboards for dissemination.
 Presentation of data in a user-friendly format to facilitate understanding and decision-making.

Essential actions for conducting a food and nutrition surveillance survey.

Identify population groups at risk using standard case definitions. This information may be used by
Identify nutritional
integrated food and nutrition surveillance systems to identify priority nutritional disorders, nutrition-
indicators
related diseases,and conditions
Analyze and Compile the data and analyses for trends. Compare information with previous periods and
interpret data summarize the results

Report malnourished cases or conditions to the next level. If this is a diseasetargeted at elimination
Report
or eradication, investigate, and respond immediately

Respond Mobilize resources and personnel to implement the appropriate nutritional orpublic health response

Encourage future cooperation by communicating with levels that reported theproblems regarding the
Provide feedback
investigation outcome and the success of response efforts
Evaluate and Assess the effectiveness of the surveillance system in terms of timeliness,quality of information,
improve the preparedness, thresholds, case management.
system and overall performance. Take action to correct problems and make improvements

Methods of Nutrition Surveillance

A. Anthropometric Surveillance:
 Regular collection of anthropometric measurements, such as height, weight, and mid-upper arm
circumference.
 Monitoring growth patterns and prevalence of undernutrition (stunting, wasting) and
overnutrition (overweight/obesity).
B. Dietary Surveillance:
 Assessment of dietary intake and patterns at the population level.
 Use of methods like household surveys, 24-hour recalls, food balance sheets, and dietary
records.
C. Biochemical Surveillance:
 Collection and analysis of biological samples to assess nutrient status.
 Measurement of biomarkers such as hemoglobin, serum albumin, vitamin D levels, and iron
status.
D. Food Security Surveillance:
 Monitoring the availability, access, and utilization of food at the population level.
 Assessment of food prices, production, consumption, and distribution.
E. Health Facility-based Surveillance:
 Monitoring nutritional status and outcomes of patients in healthcare settings.
 Use of data from health records, hospital admissions, and outpatient visits.

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Methods of Nutrition Surveillance

In normal situations:
1. Large-scale national surveys:
These surveys provide data on health, food, and nutrition at a national level. They help identify
nutritional indicators and provide information at subregional, district, and village levels.
2. Repeated small-scale surveys:
These population-based surveys collect data using standard methods. They assess the extent,
severity, and causes of malnutrition among a representative sample of the population. The data
helps policymakers prioritize interventions and areas at risk.
3. Clinic-based monitoring:
Health professionals monitor growth in children at maternal and child health clinics. This
continuous monitoring helps identify growth issues and allows for prompt intervention.
4. Sentinel site surveillance:
Surveillance is conducted in a limited number of sites or specific population groups to detect
trends in well-being. It monitors indicators such as nutritional status, morbidity, dietary issues,
coping strategies, and food security.
5. School census data:
Nutritional assessments are periodically conducted in schools, measuring first-grade children.
The data identifies high-risk children and informs school feeding programs and food-based
strategies. Monitoring obesity among school-aged children is also important.
In emergency situations, the following methods are used:
1. Rapid nutrition assessments:
These assessments provide quick data on the situation of at-risk populations and groups during
emergencies.
2. Rapid screening based on mid-upper arm circumference:
This screening method helps identify individuals at risk of malnutrition by measuring their mid-
upper arm circumference.
 There is no single prescribed method for establishing nutrition surveillance systems in emergencies.
Various sources of information are used based on the context, availability, and feasibility.
Representative data collected from the population is considered the best method.
Types of Nutrition Surveillance
A. Sentinel Surveillance:
 Monitoring a select group of representative sites or population subgroups.
 Allows for targeted data collection and in-depth analysis of specific populations.
 Provides detailed information but may not capture broader trends.
B. Population-Based Surveillance:
 Monitoring nutritional indicators in the general population or specific age groups.
 Provides a broader picture of nutritional status and trends.
 Enables comparisons between regions, countries, or population groups.
C. Program-Based Surveillance:
 Monitoring the impact of specific nutrition programs or interventions.
 Evaluating program performance and outcomes.
 Provides insights into the effectiveness of interventions.
D. Syndromic Surveillance:
 Monitoring indicators that serve as early warning signs of nutrition-related emergencies.
 Rapid detection of outbreaks or sudden changes in nutritional status.
 Enables timely response and intervention.

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 Public Health Nutrition

Challenges and Limitations of Nutrition Surveillance

A food and nutrition surveillance system faces several challenges.
 First, ensuring effective links between information and action is crucial. However, there are
difficulties in obtaining reliable data, timely reporting, efficient action management, and maintaining
sustainability.
 Another challenge is interpreting findings correctly because the significance of malnutrition levels
can vary depending on the context. Without understanding the underlying causes, an appropriate
response may not be provided.
 Sustainability is a major challenge as well. In the past, surveillance systems failed because
governments couldn't provide the necessary resources to maintain them. When establishing a
system, long-term sustainability should be considered, especially in areas prone to prolonged crises.
A system that proves effective in monitoring changes over time can justify long-term resource
provision and avoid the need for costly emergency responses.
 Institutionalization is another problem. Integrating the surveillance system with existing early-
warning or health information systems can be challenging. If multiple government ministries are
involved, no specific ministry may take responsibility for managing the system, leading to
uncontrolled operations.
 Linking information to action is vital. Collecting data without taking action based on it is
meaningless. A surveillance system should be designed to maximize the probability of a response
when necessary. This requires analyzing the ideal institutional locations for the system, considering
dissemination channels for information, and involving decision-makers in designing an analytical
framework. Involving decision-makers strengthens the credibility of the system and increases the
likelihood of a timely response.

Stakeholders of food and nutrition surveillance data

Stakeholder Purpose

Nutrition: national food and nutrition guidelines, nutrient reference values, nutrition
goals and targets, nutrition strategies (e.g. Healthy Eating – Healthy Action),
purchasing services
Health: health strategies (e.g. chronic disease, inequalities, population subgroups),
Government
purchasing services, health promotion, advice for higher healthauthority
Food: development, monitoring and enforcement of food regulations andstandards
(e.g. food safety, composition, and labelling), international food
standards (Codex), advice for Food Safety Authority
Programmes (e.g. nutrition education, health promotion, food safety) andservices,
Health sector
patient advice, and education
Nongovernmental
Policies and programmes, health promotion
organizations
Academic institutions Teaching, research direction, data for research

Food industry Food labelling, food marketing

General public Information, advice, education

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 Public Health Nutrition

Sources of data
Sources of food and nutrition surveillance data can be primary or secondary.
Primary data are collected through surveys specifically designed to monitor food and nutrition.
National nutrition surveys are the major source of primary data. They provide detailed and specific
information on food and nutrient intakes, nutritional status, and nutrition-related health status. Ideally,
food and nutrition surveillance data should be collected continuously. However, this is not a practical
option for most countries, as nutrition surveys are expensive to undertake. Most countries undertake
national nutrition surveys on a periodic basis, approximately from every three to five years up to 10
years, which is considered sufficient to keep up with changes in dietary patterns and new food
technologies.
Secondary data are derived from data collected for purposes other than food and nutrition
surveillance. Potential sources of secondary data include routinely collected health statistics, household
budget surveys, market research surveys, industry surveys and research studies. Issues to be
considered when evaluating the value of secondary data sources include the:
• periodicity of data collection (ad hoc, periodic, continuous).
• frequency of data collection (weekly, monthly, yearly).
• level of aggregation (individual, household, national).
• sample size and sampling strategy.
• format in which the data is stored (computer, paper).
• availability and cost of data.

Food and nutrition monitoring domains and data sources

Sector Data source Comments
Health economic survey (household) Includes national and household food
Food supply Food balance sheet (national) supply
Adult and child nutrition surveys Limited All foods and beverages, including
Food consumption data on selected food groups (e.g. fortified or functional foods, dietary
vegetables and fruit) from health surveys supplements, and breast milk
Factor analysis or diet quality score (e.g.
Dietary patterns Nutrition survey data Healthy Eating Index)
Derived from nutrition surveys usingfood Requires maintenance of up-to-date
Nutrient intake composition tables food composition database
Nutritional Adult and child nutrition and health Includes anthropometric
and biochemical
status surveys measurements
Includes incidence and prevalence of
Nutrition-related health ischemic heart disease, diabetes,
Health and nutrition surveys obesity, blood pressure, blood lipid
status
profile
Nutrition surveys
Healthy food basket pricing Includes various dimensions of
Food security
Food bank surveys household food security
Benefit statistics
Includes food preferences, food
Nutrition surveys preparation practices, social settings for
Food culture Survey of foods consumed away fromhome. eating, portion sizes, consumer
Surveys of advertising and marketing knowledge, attitudes and behaviors,
marketing, and advertising practices
Includes intention and attempts to
Stage of change Nutrition surveys change diet; perceived barriers or
facilitators of dietary change
Links to other risk or Includes drug use (especially alcohol
Health and health behavior survey and tobacco), physical activity, infant
protective factors care practices (i.e. breastfeeding)

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 Public Health Nutrition

INCORPORATING NUTRITION OBJECTIVES INTO DEVELOPMENT

POLICIES IN PAKISTAN
I. Understanding the Nutrition Challenges in Pakistan:
A. Malnutrition and its consequences:
 Prevalence of malnutrition in Pakistan.
 Impact on health, economy, and human capital development.
B. Key nutritional issues in Pakistan:
 Undernutrition: stunting, wasting, and underweight.
 Micronutrient deficiencies: iron, vitamin A, iodine, zinc.
 Overnutrition: rising rates of obesity and non-communicable diseases.
II. Rationale for Incorporating Nutrition Objectives into Development Policies:
A. Linkages between nutrition and development:
 Improved nutrition as a catalyst for sustainable development.
 Interconnectedness between nutrition, health, education, and poverty reduction.
B. Economic costs of malnutrition:
 Impact on productivity and human capital.
 The burden on healthcare systems.
III. Strategies for Incorporating Nutrition Objectives into Development Policies:
A. National level:
 Policy coherence: aligning nutrition objectives with national development goals.
 Institutional arrangements: establishing dedicated bodies for nutrition governance.
 Multi-sectoral collaboration: involving various sectors such as health, agriculture, education, and
social welfare.
 Legislation and regulations: implementing policies to address nutrition-related issues.
B. Local level:
 Decentralization and devolution: empowering local governments to prioritize nutrition.
 Capacity building: training and education for local policymakers and officials.
 Community engagement: involving communities in nutrition planning and decision-making.
 Resource mobilization: allocating funds for local nutrition programs and interventions.
IV. Examples of Successful Nutrition Integration in Development Policies:
A. National level:
 National Food Security and Nutrition Policy of Pakistan.
 Scaling Up Nutrition (SUN) Movement in Pakistan.
B. Local level:
 District Nutrition Strategies and Action Plans.
 Community-based nutrition programs.
V. Challenges and the Way Forward:
 Political will and commitment.
 Limited financial resources and budget allocations.
 Data and monitoring systems.
 Capacity gaps and training needs.
 Advocacy and awareness.
Conclusion:
 Importance of incorporating nutrition objectives into development policies.
 Call for collective action and commitment from all stakeholders to address malnutrition in
Pakistan.
 Emphasis on the potential for improved health, education, and economic outcomes through
integrated nutrition interventions.

Instructor: Ms. Bushra Kainat Page | 67