1. Implementing High-Impact Nutrition
Interventions At Scale:
The ENA Framework
2014
Understanding the ENA Framework
Pre-session CORE Group. May 5th, 2014
Agnes Guyon, MD, MPH

2.  Based on proven impact:
 Women’s nutrition
 Infant & young child feeding
 Micronutrients
 Action-oriented, with clear
guidance
Who should take what action
Growing consensus that nutrition
interventions need to be…

3. The High-Impact Nutrition
Interventions
Evidence-Based Direct Interventions to Prevent and Treat
Undernutrition
Promoting good nutritional practices:
1. breastfeeding
2. complementary feeding for infants after the age of six
months
3. improved hygiene practices, including handwashing
Increasing intake of vitamins and minerals: Provision of
micronutrients for young children and their mothers:
4. periodic vitamin A supplements
5. therapeutic zinc supplements for diarrhea management
6. multiple micronutrient powders
7. deworming drugs for children (to reduce losses of
nutrients)
8. iron-folic acid supplements for pregnant women to
prevent and treat anemia
9. iodized oil capsules where iodized salt is unavailable
Provision of micronutrients through food fortification for
all:
10. salt iodization
11. iron fortification of staple foods
Therapeutic feeding for malnourished children with special
foods ($6.2 billion):
12. prevention or treatment for moderate undernutrition
13. treatment of severe undernutrition (‚severe acute

4. Two References (2013)

5. Control of Iodine
Deficiency Disorders
Control of Vitamin A
Deficiency
Optimal Breastfeeding
(BF)
Nutritional Care
of the Sick &
Malnourished Child
Complementary
Feeding with BFWomen’s Nutrition
Control of Anemia
Essential Nutrition Actions (ENA) Framework
First Developed in 1997

6. ENA Uses the Life Cycle Approach

7. Focuses on the
1000 Day Window of
Opportunity
Before
conception

8. Promotion: Support Women’s Nutrition
In Adolescence, Before Pregnancies, and Between Pregnancies
Promote & Support improved diet
 Diversified diet and appropriate amount for
adolescent needs
 Increase mineral intake
Provide Micronutrients
 Iron-folic acid supplementation and treatment of
anemia
 Deworming
With
 Delay first pregnancy
 Keep girls in school
WHO 2013

9. Promotion: Support Women’s Nutrition (1)
During Pregnancy & Lactation
Promote & Support Improved Diet
 Diversified diet
 Increased food and MN intakes
 1 extra meal/day when pregnant (550 Kcal/day)
 2 extra meals/day when lactating (650 Kcal/day)
 Consumption of iodized salt
 Sleep under insecticide-treated nets
With
 Spacing of Pregnancy
 Cessation of smoking, alcohol or other substances
Women’s nutrition in the context of HIV and emergencies
WHO ENA, 2013

10. Promotion: Support Women’s Nutrition (2)
During Pregnancy and Lactation
* Countries with anemia < 20%
** Countries with night blinder>5%
*** Countries with low calcium
intake
**** Countries with < 20% iodized
salt
Provide Micronutrients
 Daily iron-folic acid(30-60/0.4mg)
or
 Weekly 2-3 intermittent iron-folic acid (120/2.8mg) for non-anemic*
 Daily (10 000IU) or Weekly (25 000IU) vitamin A**
 Daily (1.5 gr) Calcium***
 Daily or annual iodine****
With
 Intermittent Preventive Treatment (ITP) of malaria
 Deworming during pregnancy (twice)
 Treatment of anemia
 Timely cord clamping

11. Protection-Promotion-Support
Breastfeeding < 6 months
Protect Breastfeeding
 Legislation & enforcement of breastmilk substitutes code
Promote & Support key practices
 Immediate initiation of breastfeeding
 Exclusive breastfeeding for 6 months
 Correct positioning & attachment
 Breastfeed day and night at least 10 times
 Empty one breast before switching to the other (Fore-milk vs hind milk)
 Infant feeding in the context of HIV and emergencies
Other practices (control & prevention of anemia)
 Timely cord clamping
WHO ENA 2013

12. Protection-Promotion-Support (1)
Complementary Feeding with Breastfeeding 6-24 Months
Promote & support Improved Diet
 Introduce appropriate CF at 6 months
 Continue breastfeeding until 24 months & more
 Frequency:
 Amount adapted to age
 6-8 months: 200 kcal/day
 9-11 months: 300 kcal/day;
 12-23 months: 550 kcal/day
 Diversity (fruits, vegetables, animal source, MNP, fortified CF, iodized salt)
 Density: from mashed to family food
 Utilization (handwashing, clean water, food & utensils)
 Active feeding
Protect CF
Codex Alimentarius & Marketing of complementary food
WHO ENA 2013
 6-8 months: 2-3 meals/day
 9-23 months: 3-4 meals/day, 1-2 snacks/day

13. Protection-Promotion-Support (2)
Control & Prevention of MN Deficiencies
WHO ENA 2013
Provide Vitamin A Supplementation
 Biannual vitamin A Capsules for children 6-59 months
 100 000IU for children 6-11 months
 200 000IU for children 12-23 months
Provide Iron-Folic Acid Supplementation
 Daily iron-folic acid (2mg/kg) for 3 months for children 6-23 months
 With treatment of malaria in endemic areas
Provide Micronutrient Powder (MNP)
 Daily for at least 2 months for children 6-23 months
Provide Iodized Oil*
 Annually (200 mg) for children 6-23 months
* Countries with <20% iodized salt
With
 Biannual deworming for children 12-59 months
 Malaria prevention & treatment

14. Nutritional Care
Sick Child & Management of Acute Malnutrition
Promote & Support of Improved Diet
 0 to 24 months:
increase breastfeeding frequency during and after illness
 6 to 24 months & older:
Increase feeding during illness and after illness
(e.g., feed 1 extra meal each day for two weeks after illness)
Provide Appropriate MN Treatment (following national protocols)
 Vitamin A
 Zinc for treatment of diarrhea with oral rehydration therapy
 Anemia
Management of moderate & severe acute malnutrition
Nutritional care of HIV-positive children (6 months-14 years)
WHO ENA 2013

15. Promotion-Support
Nutrition-Sensitive
WHO ENA 2013
Immunization
 EPI
 New vaccines (Rotavirus and Pneunococcus)
Prevention of Childhood Illnesses
 Essential Hygiene Actions (Handwashing,
sanitation)
 Household water treatment
 Reduction of indoor air pollution
 Context of HIV: Mother To Child Transmission
Family Planning

16. Global Interventions
Wheat and Maize Flour Fortification
WHO ENA 2013

17. How & Where to Implement?
Control of Iodine
Deficiency Disorders
Control of Vitamin A Deficiency
Optimal Breastfeeding (BF)
Nutritional Care
of the Sick &
Malnourished Child
Complementary
Feeding with BFWomen’s Nutrition
Control of Anemia

18. We Know That a Multisectoral Approach is
Critical
Source: Lancet 2013

19.  A framework to operationalize the
implementation of existing nutrition
programs that:
 pulls together existing vertical programs in a
sensible 'action-oriented' way
 greatly expands coverage to multi-contacts and
multi-platforms.
 Provides an excellent training
framework on which to train service
providers and community members:
 Simple
 Uses existing structures.
The ENA Framework

20. Within the health sector:
Use existing nutrition programs & increase their
performance
Child Health
Newborn health
Immunization
Treatment of
childhood illnesses
Management of acute
malnutrition
Reproductive Health
Lactation Amenorrhea
Method
With Family Planning
Safe Motherhood
Infectious Diseases
Control of
Malaria
Tuberculosis
HIV and AIDS
(PMTCT)

21. DELIVERY: safe delivery, FP, STI
prevention, Optimal delivery, VCT,
ARVs, Delay cord clamping, early
& exclusive breastfeeding, iron-
folic acid, diet
PREGNANCY: TT, antenatal visits,
FP, STI prevention, safe delivery,
VCT, Options, Safe Sex, danger
signs,
Diet, iron-folic acid, deworming,
anti-malarial, iodized salt,
calcium, vitamin A, preparation
of breastfeeding
POSTNATAL AND FAMILY
PLANNING: STI prevention,
child’s vaccination, VCT, Safe
sex, Support to
breastfeeding, diet, iron-
folic acid, FP
WELL CHILD AND GMP: check
and complete vaccination, VCT,
Safe Sex, Monitor growth, assess
and counsel on child feeding,
iodized salt
SICK CHILD: assess and treat per
IMCI/immunization/VCT, counsel on
infant feeding, assess and treat for
anemia, check and complete
vitamin A, deworming
IMMUNIZATION: vaccinations, FP,
and STI referral, VCT, Safe Sex,
Support to infant and young
child feeding, vitamin A,
deworming, assess and treat
infant’s anemia
Critical Contacts for Essential Nutrition
Actions

22. Outside the Health Sector
Use Existing Contacts to Extend Nutrition
Coverage
Agriculture
Food diversification
Food security
Household food
production
Micro-credit
Women’s farmers clubs
Pre-service Education
Doctors, nurses, and
midwives
Sanitation
Clean water
Public health
education
Mass Media
TV
Radio
Local broadcasting
Community Nutrition
Community Workers
Positive deviance
Schools
Children & Adolescent
Deworming
Iron supplementation

23. Maximizing contacts to
enhance food diversity
Critical Contacts Within the Agriculture
Sector

24. Ultimate Goal: Saturation
Within the Agriculture Sector Within the Health
Sector

25. The remaining
challenge:
‘just to do it’
Thank You