Nutritional Assessment and Analysis

Session No: Time: 90 mins

Objective:
• NGO partners understand the concept of various degree of
malnutrition.
• NGO partners are able to recognize the micro nutrient deficiencies
among children.
• NGO partners are proactive to reduce malnutrition among children

Handout:

Key learning:
• Concept of malnutrition
• Low birth weight and mile stones of development
• Growth monitoring
• Micro nutrient deficiencies
• Role of stakeholders in reducing the malnutrition in the community
• Analysis- pitfalls of single survey, Household Economic Analysis and
Nutrition Survey

Concept of malnutrition:
The term malnutrition indicates a bad nutritional status. Nutritional
status is the physiological state of an individual, which results from:
• Relationship between nutrient intake and requirements, and from
deficiency or excess of specific nutrient. Wrong kinds of food such
undiversified diet (not mixed food).
• Body’s ability to digest, absorb and use these nutrients. If child is
having any infectious disease or water sanitation condition is poor or poor
household hygienic condition. In such situation nutritious food will not be
digested and absorbed in a proper manner.
Low birth weight:
We need to have some discussion about Low birth weight and reason for
low birth weight in India. This is an indicator to represent the health status of
mother and babies. This is also an early indication of the growth of babies.

1. According to WHO study around 67.8%- 69.3% adolescent girls are under
weight (BMI < 18.5) and around 41% adolescents are anaemic in India.
Malnutrition and repeated infection of malaria or other infectious diseases
make the situation worse. According to Indian culture early marriage among
young girls is common (NFHS-3 around 53% girls get married before the 18
years of age in rural areas). Therefore these girls will be pregnant in early
age and give birth to a small baby or low birth weight babies.
 Nutritional Status of mother

Low birth weight

The young mother with BMI less than 18.5 should be considered as “at risk
mother”. These mother should be identified early and attention should given
to provide regular health check up, Iron and Folic Acid tablets and counseling
on locally nutritious food.

MDG no 5 aim to improve maternal health:

In households where basic needs are hardly met, the pressure of post-
disaster impact can eliminate the possibility of adequate maternal care as
stretched resources can only cover immediate survival requirements.
Additionally, in many cases, gender inequity gives women less access to
household income and assets. Disaster risk reduction efforts that include
gender issues at the outset have proven necessary in addressing the
improvement of maternal health.

Nutritional requirements for Adults (SPHERE): the following estimates

for average population requirements should be used, with the figures
adjusted for each population as described in Appendix 7.

- 2,100 kcals per person per day

- 10-12% of total energy provided by protein

- 17% of total energy provided by fat

- adequate micronutrient intake through fresh or fortified foods.

Methods of Nutrition Assessment-

• Weight for Age,
• Weight for Height,
• Height for Age
• Mid Upper Arm Circumference,
• BMI (Body Mass Index kg/m2)
Anthropometric Measurement
For children, anthropometric indicators are typically based on age, height and
weight. Three standard indicators are “height for age”, “weight for height”,
and “weight for age”. Low heightfor-age is often referred to as “stunting”, low
weight-for-height as “wasting”, and low weightfor-age as “underweight”.
Existing sources of nutrition information/ data
• Monthly Progress Report for Block ICDS
• NFHS
• NNMB
National Nutrition Monitoring Bureau (NNMB) at the National Institute of
Nutrition, Hyderabad, and the National Family Health Survey (NFHS).
Considering the former first, the NNMB surveys go back to the 1970s, but are
available for nine states only: Andhra Pradesh, Gujarat, Karnataka, Kerala,
Madhya Pradesh, Orissa, Maharashtra, Tamil Nadu and West Bengal
Until 2006, the World Health Organization (WHO) recommended the US
National Center for Health Statistics (NCHS) standard, and this was used
inter alia in the first and second rounds of the National
Family Health Survey. In April 2006, the WHO released new standards
“based on children around the world (Brazil, Ghana, India, Norway, Oman,
and the United States) who are raised in healthy environments, whose
mothers do not smoke, and who are fed with recommended feeding
practices” (International Institute for Population Sciences, 2007, p. 268).
These new standards were used in the third National Family Health Survey.

Growth monitoring, health check up to monitor early signs of vitamin

and mineral deficiencies.

• It is difficult to assess whether a child is undernourished from just one

measurement. The direction of growth is much more important.

• It is also important to encourage mothers to come for regular weighing at

the Anganwadi centre and that the weights are accurately plotted on
growth card every month. Mother should be provided health and nutrition
counseling based on the progress of child health.

• So, in Panchayat where 60% of children are undernourished, it is

important to identify and spot cases of growth failure early. This process
will help to prevent malnutrition.
It is also important to check the vitamins and mineral deficiencies in a
regular interval.

Recognizing Micro nutrient deficiencies

Iron- Anemia
Vitamin A- Bitot’s Spots
(Community Survey Bitot’s>0.5%, Night blindness>1%)
Iodine- Goitre
(6-12 years Survey Mild >=5% Moderate >=20 % Severe >=30%)
Vitamin B (Thiamine)- Angular Stomatitis

Milestones in development of young children:

It is important to note that in the weight for age chart introduced by ICDS
the height of the child is not taken in to consideration. This is because weight
is the most sensitive measure of growth and any deviation from normal can
be detected easily by comparison with reference curve. In short we can say
that growth chart offer a simple and inexpensive way of monitoring weight
gain and trend of child health in a period of time.

Along with growth chart it is also important to monitor the physical and
cognitive development of the child and following table indicators some
indicator of mile stones development. ( Text book of preventive and social medicines
by Park and Park)
Milestones given here are approximation to assess any individual child.
Age Motor Language Adoptive Socio –
developme developme developme personal
nt nt nt developmen
t
6-8 weeks Look at
mother and
smiles
3 months Hold head
erect
4-5 months Listening Begin to reach Recognizes
out for objects mother
6-8 months Sits without Experimenting Transfer Enjoy hide and
support with noises objects hand sick
to hand
9-10 months Crawling Increasing Releases Suspicious of
range of sound objects strangers
10-11 Stands with First word
months support
12-14 Walks side builds
months base
18- 21 Walks narrow Joining words Beginning to
months base together explore
beginning to
run
24 months Runs Short
sentences

Role of Civil Society Organizations

• It is important to ensure that regular growth monitoring is done and

plotting is done in a correct manner.
• Periodic meeting on the “at risk” or MAM or SAM children, mother
and adolescent girls. This meeting should be organized involving local
women leaders, Samiti members and health staff or medical Officer.
• Community, NGO, PRI members should follow the strategy to assess
the situation and analyse it and act accordingly.

ASSESS the
ACT or DO
situation

ANALYSE
the context

Nutrition is one of a range of inter-related indicators that are useful for early
warning of both food and humanitarian crises. Joint ownership and
participation by a number of agencies (both government and non-
government) should be promoted in developing and sustaining nutrition
information systems. Investment in capacity building in its widest sense is
essential to sustain a nutrition information system. Nutrition datasets should
be made universally available in order to encourage open debate and
transparent interpretation (A Review of Save the Children UK’s
Nutritional Surveillance Programme in Ethiopia- Nutrition Works IPRNG-
http://www.alnap.org/pool/files/erd-3584-full.pdf)

Even in a non-crisis year, in many locations:

• There is a large seasonal variation in nutritional status.

• The seasonal prevalence of malnutrition (including oedema) may be

high.
30 x 30 cluster sample nutrition surveys are popular today. These surveys
provide a reliable estimate of the level of malnutrition (usually restricted to
wasting in under fives) at one point in time
However single nutrition surveys can be interpreted only

• If comparable data is available from the same season in a previous

non-crisis year. This is rare.

• If the absolute values are extreme e.g. a malnutrition prevalence of

50%.
 and then only in terms of current nutritional status i.e. surveys cannot
be used to predict how nutrition will evolve.

HEA Nutrition survey

Unit of analysis Household Individual (child 6-59 months)
Prevalence relates to the entire
Data Breakdown by socioeconomic 6-59 months or breakdown by
categorisation category age groups (i.e. no breakdown
by wealth group)
Tells of the situation over previous
Time period
months Can make projections over Reflects the situation at one
covered by the
coming months Describes seasonal point in time (snapshot)
results
variation

• Anthropometric surveys describe an outcome (nutrition status), HEA describes

processes.
• HEA assessments take the household as the unit of analysis whereas nutritional
surveys use the individual (child 6 - 59 months). A cause-effect relationship
cannot be assumed without considering the intermediary level: the intra-
household food distribution and the child's food intake/utilisation. Without any
intra-household information, for instance, one cannot rule out the possibility that
food insecure households may preferentially feed the younger children during
difficult periods.
• HEA data is analysed by wealth group, whereas nutrition surveys relate to ALL
children within the population. Therefore the results are not directly comparable.

It is equally crucial to take into account the timeframe and the dates at which the
assessments were conducted. For example, if a household food deficit translates into
inadequate food for the child, the impact of this on the nutritional status might not be seen
straight away.
Key Learning:
- Able to identify Protein Calorie Malnutrition, Micro Nutrient deficiency,.
- How to conduct growth monitoring for Under 5 Years (tools are
weighing scales and growth card).
- Role of NGO and PRI in analyzing and managing SAM and MAM

Session Plan:

7 min: Concept of malnutrition, (maybe low birth weight, maternal nutrition)

10min: Interactive- Methods of Nutrition assessment, Existing Sources of

information on Nutrition, Protein Calorie Malnutrition (pictures Marasmus/
Wasting and Oedema)

7 min (Milestones of development and) Micronutrient deficiencies

(pictures)

15 min: Demonstration on how to plot the growth card,

Exercise: growth monitoring and identification of SAM and MAM children,

10 mins: Brain Storming on Analysis- pitfalls of single survey, Household

Economic Analysis and Nutrition Survey

20 min: Group work using role data from UN and Indian sources i)
international comparison (compare with zoning in HEA), ii) timeline, iii)
wealth quintiles. Learn how to give feedback and plan actions to be taken.

20 min Plenary and Conclusion (brief mention of calorific value of different

food types and 2100 calorie standard in emergencies)

Method:
Presentation, demonstration of growth monitoring, plotting of growth chart,
brainstorming, group work

Teaching materials:
Handouts- Assessment of Nutrition (Child)
Pictures of Oedema Marasmus Pallor Bitot’s spots (Print outs or Power Point
screen show)
Growth Chart and chart paper and pens.
Flip Chart with Stand
(Cards for Brain Storming)
Blue tack or Sticky Tape (with Scissors)
Handouts- Handout on Analysis

Reference Files:
• Weight for Height Boys And Girls (WHO)
• Adult BMI
• MPR Monthly Progress Report 2008-09
• India NFHS
• SPHERE Nutrition Guidance Note
• Food Needs for Children
• Nutrition- HW (IMNCI Module)
• Children Below 5 (IMNCI Chartbook)
• IMNCI Photos/ Nutrition Essentials

Reference Books
• Garibi, Khane ki Kami aur Kuposhan –Ek Swasthya Karyakarta Ya Gramin
samak Kya Kare by JSS Ganiyari (jss_ganiyari@rediffmail.com)