CORAZON VC. BARBA, Ph.D.

Professor Emeritus
Institute of Human Nutrition and Food
University of the Philippines Los Baños
 UNICEF Conceptual Framework of Malnutrition

Child malnutrition,
Outcomes
Outcomes death and disability

Immediate
Immediate causes Inadequate
dietary intake
Disease
causes

Underlying
Underlying causes at Insufficient Inadequate Poor wat/san &
household/
causes at family access maternal & child- inadequate health
level to food care practices services
household
level
Quantity & quality of actual
resources - human, economic,
organizational - and the
Basic causes at way they are controlled
Basic causes at
societalsocietal
level level
Potential resources:
environment, technology,
people
Nutrition intervention is defined as a purposively
planned activity, program, policy, or other action that is
designed with the intent of changing a behavior, risk
factor, enrivonmental condition, or aspect of health
status for an individual, target group, community, or the
population at large.

The objective of nutrition intervention is to improve the

nutritional status of the individual, target group,
community or the population.
The specification of nutrition’s role in the country’s
general development strategy

An explicit nutrition planning process

The systematic identification and analysis of the key

design dimensions of the nutrition interventions, and

An integrative perspective
Five Basic Areas To Be Considered
Problem Diagnosis

Goal Specification/ Objective Setting

Intervention Design and Selection

Program Implementation

Evaluation
5 Areas To Be Considered

Problem Diagnosis
Who is malnourished?

What type of nutritional deficiency exists?

How severe is the deficiency?

Where is the target group located?

What are the causes of malnutrition?

Goal Specification/Objective Setting

What are the nutritional improvement goals of the

country’s development program and the specific
objectives of direct nutrition interventions?

Are the objectives quantifiable in terms of groups

and deficiency reductions?

Over what period will the impact be achieved?

Intervention Design and Selection
What types of intervention would most effectively
alleviate the deficiency in the short and longer run?

How should the intervention be designed to fit best the

local conditions and to overcome local administrative,
social, political and economic barriers?

How much will the intervention cost relative to its

nutritional impact?

How should different types of interventions best fit with

other types of development activities?

How can other development policies and programs be

oriented to improve the consumption effects on needy
groups?
 STAGE
Production Processing Distribution Consumption Utilization

INTERVENTION
Supplemen- Credit Nutrition Integrated Micronutrient
Agricultural Fortification Formulated Price
tary Feeding Assistance Education Programs Supplemen-
Production Foods Subsidy
/IGP tation

CAUSAL
FACTOR
Infections
Food Food Purchasing Habits Sanitation
Quantity Quality Power Population
The complexity of nutrition and how it affects
health

The diverse kinds of intervention efforts and the

decision structure involved

The constraints in delivering nutritional care

 Factors Affecting Nutrition Intervention
Local State National

Economy Politics Ecology Agricultural Meteorology Health Status

Systems

NUTRITION INTERVENTION

Health Legislation Environmen- Food Water Supply Health Status

Code and Health tal Services Availability Clinic Systems
Budget Codes & Marketing Attendance

Local Health Care Provider – Facility, Agency,

Hospital, Clinic
 Relevance to the defined nutritional problem
Feasibility
Integration with similar existing programmes
Effectiveness
Ease in targeting
Cost effectiveness
Ease in evaluation

Likelihood of becoming a long-term, ongoing

programme

Source: FAO
 Criteria Interventions
Relevance
Feasibility
Integration with Existing
Programmes
Effectiveness
Nutritional impact
Reduction of in equalities
Stimulation of participation
and self-reliance
Strengthening of other
project components
Other development effects
Ease in Targetting
Cost-Effectiveness
Eases in Evaluation
Sustainability TOTAL
Source : FAO MEAN
Identification of Solutions

Based on the problem that have been identified,

one or more solutions for each problem are identified
and are listed down.

Grouping of Solutions

Identified Solutions with commonalities are grouped

together.
ssessmentohe Solutions
 determining number of problems solved per identified
solutions

 validating the prioritized solutions:

Based on criteria that have been identified, each of the

solutions are assigned scores.

For example, if the criteria is affordability, the scores

assigned on the characteristics of the particular
solution:

if the is: low cost (very affordable) = 3

moderate cost =2
expensive (not affordable) = 1
Ranking/Prioritization of the Solutions Identified

After all the solutions have each been assigned

certain scores based on the set criteria, all the scores
are tallied and the solutions with the highest scores are
considered high priority.
 Criteria Weight Interventions
The identified alternative Garden Food Forti Micro Supp Nutr Ed
solution must be
Relevant 1.0
1.0
Affordable
1.0
1.0
Simple
1.0
Sustainable 1.0
1.0
Effective
TOTAL
MEAN
Easy to evaluate
Level of achievement:

3- High 2- Moderate 1- Low 0-No Effect

Can be
Program Implementation
Which organizations and individuals will have what
responsibilities in managing the various
intervention?

How will organizations interrelate?

What will be the funding mechanisms?

What will be the timing of implementation?

Program/Intervention Implementation
 Advocacy
 Social Mobilization
 Orientation and Training
 Community Participation

Success in implementation rests on the political will

of leadership and availability of capable
manpower and resources.

Key management processes include organizing,

staffing, coordinating, training, directing and
technical backstopping.
 Operational Plan for Nutrition Interventions
Operational Strategy Resources Need
Intervention Objectives Target Activity to Agency/Person Clientele/ Place for Duration to Type of
and Undertake to be Involved Group Activity Undertake Resources
Description Lead Support Activity

the identified expressed as the group whom the tasks or the agency/ the agency/ the person the place the time The inputs
relevant results objec- the intervention activities person to person to whom the (barangay duration to necessary for the
intervention tive of interven- will affect (stated in lead the assist the activity is to agency, do the tasks intervention such
(activity/project/ tions applying considering general terms) major task/ mentioned be under- office) where and activities as:
program) with the following qualification or which will be activity task/activity taken the task/ (in no. of a) Human/Tech-
itsdescription; format or criteria prefer- done or activity will be weeks, of nical the time,
thesequence sequence by ably from the undertaken in undertaken, months, year) efforts, expertise
willbeby areas stating: nutritionally at relation to the indicate time duration to the line agency
ofconcern: a. target group risk families for intervention asterisk foot- can be stated people/commu-
within areas of as the selection of note at the per sub- nity that will be
concern, inter- subject beneficiaries end of the last activity needed for the
ventions are b. desired indicating how line for the intervention.
arranged results to detect them, names of b) Financial - the
according to c. behavioral where to locate barangays estimated cost
priority problem change them, and the to be requested
d. time frame estimated c) Material - will
potential include the
coverage. quantity and type,
and the equivalent
cost of materials
needed
Program guidelines
Participation of matters/families

Community awareness and decision making

Targeting
Worker and workload
Training and supervision of workers

Detailed operational planning & documentation

Logistics and control

Monitoring and evaluation
Monitoring and Evaluation
What are the purpose of the evaluation?

Who are the users?

What are their specific needs?

What is the appropriate data collection, analysis,

and dissemination system?

How well was the intervention delivering the

intended goods or services?

What behavioral and physiological impact on the

target group was achieved?

What are the causes for lack of impact?

 Monitoring and Evaluation
Monitoring refers to the regular collection,
processing and reporting of information about
the project which are useful in decision making
during implementation.

Evaluation refers to the process of determining

systematically and objectively the relevance,
efficiency, effectiveness, and effects and/or
impact of projects in relation to objectives.
Approaches to/kinds of evaluation
a. Informal
 No statistical methods
 Conducted by a review team who visits the site one
or more times; interviews managers, field staff and
beneficiaries; reviews project materials, records and
accounts; and writes an evaluation report
 Used in recently started pilot projects with varied
objectives

b. Formal
 Utilizes statistical methods
 Comprehensive and is appropriate for projects that
serve a large group of beneficiaries that render
similar goods and services.
c. Process
 No statistical methods
 Conducted by a review team who visits the site one or
more times; interviews managers, field staff and clients;
reviews project materials, records and accounts; and
writes an evaluation report
 Determines how and how well processes function;
how the program does/does not work

d. Summative
 Seeks to find out if the program is effective or not
 Insufficient to be used for planning since data on how
programs can be further improved are often lacking.
…cont. Approaches to/kinds of evaluation

e. Formative

 Small-scale experiment conducted to further develop a

program design that is more effective, efficient or
acceptable.

f. Comprehensive Survey
 Involves the collection and analysis of a set of data
formulated to answer both summative and formative
questions.
 Sociological and econometric methods are used.

f. Small sample
 Used for pretest of materials or products making use of
a small sample size, around 5-30.
 Evaluation and Indicators
INTERVENTION COMPONENTS
INPUTS OUTPUTS OUTCOMES BENEFITS/
IMPACT
INDICATORS

Cost % TG Behavior Productivity

Quality % TG reached IMR Earning
Design % Deficit > 5 MR power
covered Morbidity Health
% Leakages Anthropometry savings
Clinical Signs Well being
Biochemical
indicators
TG = Target Group
IMR = Infant Mortality Rate
Revision/replanning

The information generated by monitoring and

evaluation provides the basis for making the
needed changes for implementation of current
program/intervention(s) in order to improve
efficiency and effectiveness.
Interventions Across the Life Cycle (Bhutta, Lancet 2013)
List of modelling effects on mortality for 34 high burden
countries: revised model (Bhutta, Lancet 2013)
 Packages of Nutrition Interventions
Optimal maternal nutrition during pregnancy
•Maternal multiple micronutrient supplements to all
• Calcium supplementation to mothers at-risk of low intake
• Maternal balanced energy protein supplements as needed
• Universal salt iodization
Infant and young child feeding
• Promotion of early, exclusive breastfeeding for 6 months; continued breastfeeding
until 24 months
• Appropriate complementary feeding education in food secure populations and
additional complementary food supplements in food insecure populations
Micronutrient supplementation in children at risk
• Vitamin A supplementation between 6-59 months age
• Preventive zinc supplements between 12-59 months of age
Management of acute malnutrition
• Supplementary feeding for moderate acute malnutrition
• Management of severe acute malnutrition

Source: Bhutta, Lancet 2013

 IMPACTS
Mortality in children younger than 5 years could be reduced by
15% (range 9-19%)
• 35% (19-43) reduction in diarrhoea-specific mortality
• 29% (16-37) reduction in pneumonia-specific mortality
• 39% (23-47) reduction in measles-specific mortality
• Reduced deaths due to asphyxia and congenital anomalies
• Little effect on maternal mortality

Stunting overall reduced by at least 20.3% (range 11.1-28.9%)

Severe wasting reduced overall by 61.4% (range 35.7-72%)
Source: Bhutta, Lancet 2013
 Key Messages (Bhutta, Lancet 2013)
Interventions exist to improve maternal nutrition and reduce
fetal growth restriction and small-for-gestational age (SGA)
births in appropriate settings in developing countries, if
scaled up

A set of 10 evidence-based interventions if implemented at

scale can save at least 15% of under 5 child deaths (i.e. 1
million lives saved) and avert a fifth of all stunting

Delivery strategies exist to especially target undernutrition

and impact child mortality among the poorest

The costs for scaling up these nutrition specific interventions

globally is $9.6 billion, affordable given the gains

A clear need exists to introduce promising evidence-based

interventions in the preconception period and adolescents
and also address the impact on long-term
neurodevelopmental outcomes
2013

Lancet Series
Maternal & Child
Nutrition

e c i fi c
tion s p
nu t ri

nutri
tio n se
nsitiv
e
nutrition specific

Exclusive BF up to 6 months,
continued BF, appropriate Fortification of foods
and nutritious food, up to 2
years
The process of adding nutrients to food to
maintain or improve the quality of the diet of
a group, a community or population

CODEX ALIMENTARIUS the addition of one

or more essential nutrient to a food,
whether or not it 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 group
 Key Issues in Food Fortification

Nutrient needs
Fortificant quantity
Carrier selection
Cost
Legislation and policies
Effectiveness
Availability of the fortificant
Organoleptic quality
The place of fortification
Production or processing
Transport of fortificant
Transport of fortified food
Storage of fortified food
Stability and quality of fortified food
Quality control
Centralized processing
Simple, low cost technology
Good marketing qualities (dark color and strong
odor or vehicle to mask slight changes to original
color/odor)
High stability and bioavailability of added
micronutrient in final product
Minimal segregation of the fortificant and vehicle
Good stability during storage
No micronutrient interaction
 Nutrient Type of food
Ascorbic acid Canned, frozen, and dried fruit
drinks, canned and dried milk
products, dry cereal products
Thiamin, Dry cereals, flour, bread, pasta, milk
riboflavin, niacin products
Vitamin A (or - Dry cereal products, flour, bread,
carotene) pasta, milk products, margarine,
vegetable oils, sugar, monosodium
glutamate
Vitamin D Milk products, margarine, dry cereal
products, vegetable oils, fruit drinks
nutrition specific

Micronutrient Photo credit: ACF

supplementation Treatment of severe malnutrition

 NUTRIENT
SUPPLEMENTATION
Provision of nutrient supplements, particularly vitamin
and/or mineral supplements, to meet the nutrient needs;
or fill in the dietary gaps of individuals, groups, or the
population; or to treat a diagnosed deficiency disease.

Nutrient supplements are intended to be taken by

mouth, and can be in many forms, including tablets,
capsules, liquids, powders, etc. as long as they are not
represented for use as a conventional food or as a sole
item of a meal or diet.
 NUTRIENT
SUPPLEMENTATION
Key Issues in Nutrient Supplementation
Total nutrient intakes
 Genetics/genomics
 Contraindications
 Nutrient excess
 Nutrient interactions
 Supplement forms and dosages
 Adverse effects
 Cost
 Legislation and policies
 NUTRIENT
SUPPLEMENTATION
Examples:
Target Group Nutrient(s)
Women of childbearing age
who may become pregnant Folic acid
Young Children, 6-59 months,
at risk of VAD Vitamin A
Mothers at low risk of Ca intake Calcium
Infants, Children, Women who
are anemic Iron
 (Dietary Supplementation)
Supplementing or adding to the normal diets of
vulnerable groups with the types of food needed to
alleviate undernutrition / deficiency thru ducing the
gap between actual consumption and
requirements. The type of food given and the focus
on the vulnerable group is aimed, along with
nutrition education, at overcoming certain habits
or beliefs that restrict the consumption of available
nutrients. Supplementary feeding can also improve
household food security thru food or income
transfer effect.
 Key Issues in Supplementary Feeding

Community involvement
Participant selection
Food supplement size
Food supplement nutrient content
Time dimension of the program
Site location of feeding site or
distribution point
Site facilities, access to water supply
Logistics and control
Cost effectiveness
 CHALLENGES

ADDRESSING COMMON BARRIERS

• Supplies and other logistics

• Manpower
• Providers’ motivation and tools
• Nutrition promotion materials
• Consumer behavior
• Adherence by clients to complete protocol

Underlying lack of perceived

urgency at all levels
 CHALLENGES

• Country ownership
• Metrics, commitments results, improved nutritional status, public
health impact, economic impact
• Leverage the benefits of multilateral organizations and
partnerships
• Evidence-based and scalable
• Cost-effective interventions/ package of intervention to produce
impact
• Focus on gender, and vulnerable age groups

Will we reach our goals?

Thank you !