Speaker: Ms Zamazulu Mtshali – Deputy Manager for the Integrated Nutrition Programme (INP), KwaZulu-Natal Department of Health Ms Mtshali's presentation will highlight studies that show the presence of nutritional transition in KwaZulu-Natal, where both under and over-nutrition are prevalent. Within the context of the HIV and AIDS pandemic and food insecurity, the high prevalence of under-nutrition, micronutrient deficiencies and emergent over-nutrition presents a complex series of challenges. Over the years, significant gains have been made with regards to scaling up nutrition, with the development of policies and guidelines for the implementation of nutrition strategies. There is now a renewed focus on specific priority groups for nutrition interventions to have a bigger impact.

1. KZN DOH APPROACH TO
NUTRITION
(Integrated Nutrition Programme
INP)
25 March 2014
Info 4 Africa Forum
Presenter: Ms Zamazulu Mtshali

2. The Integrated Nutrition Programme
Vision
Optimum Nutrition for all South Africans
Mission
Improvement of the nutritional status of all South
Africans through the implementation of integrated nutrition
strategies

3. Principles
 Good nutrition for all South Africans should be promoted as a basic
human right and as an integral component and outcome measure of the
country’s social and economic development
 Nutrition programmes should be integrated, sustainable, environmentally
sound, people and community driven
 There should be a clear strategy for promotion of nutritional well being
and the nutritional status of the population must be monitored
 Nutrition policies, strategies and programmes are dependent on the
development of human and institutional capacities and the provision or
adequate financial resources
 Existing structures and programmes should be used to address nutrition
concerns
 An integrated primary health care approach, which includes monitoring to
generate useful information for better targeting of services, will be
adopted in this programme

4. Nutrition
• Nutritional status influenced by three broad factors: food,
health and care
• Optimal nutritional status: when people have access to
affordable, diverse, nutrient-rich food; appropriate maternal
and child-care practices; adequate health services; and a
healthy environment including safe water, sanitation and good
hygiene practices.
• These factors directly influence nutrient intake and the
presence of disease
• Food, health and care are affected by social, economic and
political factors

7. Millennium Development Goals

8. KZN Scenario
1 in 20 children die before their 5th birthday
Of these…
 38% die outside the health service
 55% die in association with HIV
 33% have underlying severe malnutrition
(Save Children, 2011)

9. KZN SCENARIO
 KZN bears a disproportionately high burden of poverty with 63% to
82% of households living on less than R800 per month (District
Health Barometer)
 Malnutrition remains one of the leading comorbidities for children
under the age of 5 years. Between 2010/11 and 2011/12, the
severe malnutrition under-5 year incidence decreased from 7/1000
to 6.7/1000 (DHIS).
 HIV incidence 37,4% (Antenatal Seroprevalence Survey, 2011)
 > 50% child deaths were related to HIV
 Diarrhea & Pneumonia: 2 leading causes of death in children
<5yrs
 SANHANES-1 2012 found more stunting (H/A<-2SD) in KZN
 Increase in overweight and obesity (W/H > +2SD) in Children 2-5
years Nationally and KZN

10. Nutrition Scenario
• Concern: Malnutrition; HIV, AIDS & TB
• PLWHA, poor nutrition worsens the effects of HIV by further weakening the
immune system.
• HIV interferes with the ability to access, handle, prepare, eat and utilize
food, thus increasing the risk of malnutrition
• Food and nutritional intake can affect adherence to antiretroviral drugs
(ARVs) as well as their effectiveness.
• Food insecurity and inadequate knowledge of good nutrition
• Nutrition in transition situation where both under and over nutrition
(underweight, stunting, wasting, overweight & obesity) exist in same
community
• Consequences: Non communicable diseases: diabetes, hypertension,
cardiovascular illnesses

11. KZN Situational Analysis
Year Stunting Underweight Wasting Overweight
1994 (SAVACG) 16% 4% 1% 7%
1999 (NFCS) 19% 6% 9% 4%
2005 (NFCS) 15% 5% 1% 6%
2012
(SANHANES)
Boys
Girls
13.5%
14.4%
3.4%
1.5%
2.4% 6.3%
Table indicating the anthropometric status of children aged 1-9 years in KwaZulu Natal
Source: Health Review 2008, Health Systems Trust, SANHANES 2013

12. INDICATOR PROVINCIAL STATUS NATIONAL STATUS
Infant mortality rate (IMR)18 42/1 000 45/1000
Child mortality rate (U5MR)18 61/1 00018 59.4/1000
Maternal Mortality Rate18 165.5 /100 00018 150/100 000
Low birth weight19 12.5% 8%
Exclusive Breastfeeding20
0 – 3 months (14weeks)
0 – 5 months
34.3% 10%
7%
Stunting9
Boys
Girls
13.5%
14.4%
16.7%
13.7
Wasting9
Boys
Girls
2.4%
-
3.8%
1.7%
Severe Malnutrition 0.5%18 2.8%
Underweight9
Boys
Girls
3.4%
1.5%
1.4%
3.6%

13. Household food insecurity 63-73% 75% of households
Food consumption 43.4% of children eat less than they
should. 43.2% experience hunger1
10% of children 6 to 15 years don’t eat
Breakfast. 50% of children 1 to 9 years consume less
than half of the RDA for key vitamins and minerals
Consumption of iodised salt 87.6%1 62.4% of households
RtHC coverage 62.2% 75%
Poverty 63% 57% of population live in poverty
Diarrhoea 17.8% 13.2%
HIV/ AIDS (ANC) 37.5% 24.8%
Measured Hypertension9 8.4% 10.2%
Cardio vascular unfitd
(18-40 years)Females
Males
35.2%
25.5%
-
-
Diabetes (Self-reported)
Females
Males
9.6%
4.6%
6%
4%
CHD (Self-reported)
Females
Males
5.6%
2.3%
2.9%
1.5%
Hypertension Self-reported)
Females
Males
24.9%
15.8%
20.6%
12.0%
VAD prevalence Too low observations to record
(SANHANES 2012)
43.6%
Iodine deficiency: 16.5% 21.4%
Iron deficiency
(16 – 35years)
Too low observations to record
(SANHANES 2012)
9.7%
HIV/ AIDS23 15.8% (1,622,870)

14. Opportunities to scale-up Nutrition Interventions
• Four priority areas of government for the health sector:
• Increasing life expectancy,
• Decreasing maternal and child mortality
• Combating HIV&AIDS, decreasing burden of disease from TB,
• Strengthening health system effectiveness
• Window of opportunity: the first 1000 days of life
• Renewed focus on Breastfeeding
• Focus on Non-Communicable Diseases (NCD)
• Re-engineering of the PHC ( 3 Streams)
– Ward-based health care teams
– District-based health care teams
– School health services
• Community health worker cadre
• Political will to address all forms of malnutrition

15. Provincial Strategic Direction
• Guided by the:
– Provincial Growth and Development Plan
– KZN Health Strategy
• Nutrition is included in the Annual Performance Plan
– Prevalence of underweight Children under 5 years
– Child under 5 severe acute malnutrition incidence
– Children not gaining weight rate under 5 years
– Vitamin A Coverage 12-59 months

16. Strategic Direction
 Enhancement of IYCF (MBFI, HBM Banks, Regulation 991)
 Complementary feeding
 Micronutrient Supplementation
 Communication Strategy: Social Media & Marketing
 Integrated Management of Acute Malnutrition
 Re-orientation of HCW (including CCGs, NAs, Family Health
Outreach Teams)
 Phila Mntwana Centres, Framework for Accelerating
Community-based MNCWH and Nutrition Interventions
 Focus on Non-Communicable Disease (NCD)

17. KZN Specific Nutrition Policies
 Infant and Young Child Feeding in the context of HIV Policy
(G68.2010)
 KZN Guidelines for the Preparation of Powdered Infant
Formula in the Public Sector (Cir G10.2010)
 Implementation Guidelines for Nutrition Interventions at
Health Facilities (Cir G73.2013)
 Vitamin A Supplementation Programme (Cir G96.2012)
 MNCWH & Nutrition Community Framework
 Kwazulu-Natal Provincial Guidelines on the Integrated
Management Of Acute Malnutrition -IMAM (Cir 2014)

18. KZN Specific Nutrition Policies
• Infant and Young Child Feeding in the context of HIV Policy
(G68.2010)
– 20th of April 2010: KZN-DOH Head of Department approved
implementation of IYCF policy revision for implementation with effect
from 1 January 2011
This included a decision to stop issuing of free infant formula to
mothers in the PMTCT programme
Phased out approach
– 2 Indicators added to DHIS in April 2011
• Early breastfeeding initiation (1 hour of birth)
• Exclusive breastfeeding at 14 weeks
• KZN Guidelines for the Preparation of Powdered Infant
Formula in the Public Sector (Cir G10.2010)

19. KZN Specific Nutrition Policies
• Implementation Guidelines for Nutrition
Interventions at Health Facilities (Cir
G73.2013)
– Comprehensive policy that provide guidance for
implementation of nutrition services at all levels of care
• Vitamin A Supplementation Programme
(Cir G96.2012)
– Update of the supplementation protocol
– Issuing of Vitamin A by CCGs to increase 12-59 months coverage
– Stopping Vitamin A to post-partum mothers

20. KZN Specific Nutrition Policies
• MNCWH & Nutrition Community Framework
– In August 2010, the Head of Department approved the framework for
accelerating community based maternal, neonatal, child and women’s health
and nutrition interventions.
– This framework focuses on the community based approach to care for women
and children at the household level, with the community care givers (CCGs),
being recognized as key role players.
• Kwazulu-Natal Provincial Guidelines on the Community-
Based Management Of Acute Malnutrition (Cir G
102.2012)
– Policy includes management of malnutrition at these levels of care:
• Inpatient Care
• Community Outreach
• Outpatient Care

21. Target Groups
Children 0 - 23 months.
Children 2 – 14 years
At risk pregnant women
At risk lactating women
HIV and AIDS and TB clients
Chronic diseases of lifestyle

22. PRIMARY PREVENTION INTERVENTIONS
 Provide nutrition education and other relevant information on:
 Protect, support and promote breastfeeding
 Encourage appropriate complementary feeding of young
children
 Nutrition during pregnancy and lactation
 Growth monitoring and promotion
 Food Based Dietary Guidelines
 Supplementation with High Dose Vitamin A Capsules

23. SECONDARY TREATMENT INTERVENTIONS
 IMAM (Integrated Management of Malnutrition)
 NACS (Nutrition Assessment Counselling & Support)
 Details on Entry and Exit Criteria for Therapeutic Feeds
and Multivitamin Intervention Supplementation

24. Nutrition Assessment Screening Counselling and Support
• Malnutrition in children as a proxy of family malnutrition
• Proper assessment and screening to ensure that all underweight
children are detected early and treated accordingly
• Provision of adequate anthropometric equipment (baby scales and
length measures) was procured for all PHC facilities.
• The National Road-to Health-Booklets (RtHBs) are essential tools in
ensuring that regular growth monitoring and promotion occurs at
all levels of care, especially PHC.

25. Therapeutic Supplementation Programme
• A programme currently exists to ensure that all patients presenting
with underweight and severe malnutrition receive therapeutic
feeds.
• Food supplements to underweight children
• Nutrition supplements for those with AIDS/TB related malnutrition
porridge and milk supplements for legible clients
• Legible pregnant and lactating women receive therapeutic
supplements
• Therapeutic supplements for the aged, chronically ill and children
>5yrs.

26. Nutrition Indicators
• Number of underweight Pregnant women receiving
therapeutic supplements.
• Number of underweight lactating women receiving
therapeutic supplements.
• Number of underweight HIV+ patients 15 years and older
receiving therapeutic supplements.
• Number of underweight TB patients 15 years and older
receiving therapeutic supplements.
• Malnourished children under 5 years of age receiving
therapeutic supplements.
• Child under 5 food supplementation coverage

27. Nutrition Advisor Programme
 In 2011 the structure was approved to have Nutrition Advisors at
PHC
 Part of Primary Health Care engineering strategy
 All fixed clinics are earmarked to have Nutrition Advisors
 Posts were filled from a pool of CCGs and Youth Ambassadors
 Currently, 396 Nutrition Advisors are working at PHC facilities
 Phase 2 newly trained Nutrition Advisors starting 1 April 2014
 Job Purpose: To promote nutrition services at the primary Health
Care level according to the needs of the community in order to
promote optimal nutritional status.

28. Nutrition Advisor Programme
 Providing support in the implementation of integrated Nutrition
Programme interventions such as Nutrition Supplementation Programme,
Growth Monitoring and Promotion, Vitamin A Supplementation Programme
Infant feeding, Young child feeding, Nutrition and Health Education
 Participate in (and conduct) community outreach programmes in the
districts by being involved with Family Health Outreach Teams; School
Health Teams; Operation Sukuma Sakhe.
 Conduct nutrition interventions in Phila Mntwana sites / centres such as
nutrition education, growth monitoring
 Provide nutrition interventions such as nutrition and health education,
screening and distribution of nutrition IEC material during community
events

29. MUAC
• The introduction of Mid-Upper Arm Circumference Tapes (MUAC)
• MUAC tapes aim to ensure early detection of underweight and
prevent severe malnutrition at community level.
• Reliable screening tool and a population based indicator to address
the Millennium Development and monitor progress:
– MDG Goal 1 – Reduction in Poverty
– MDG Goal 4 Reduction in Child mortality
• This tool can be utilized at all levels from Community Based Care
Workers up to Medical Professionals.
• Community Health Worker cadre is trained on how to use MUAC for
screening and refer to health facilities for intervention where
required
• Main tool used for screening at Phila Mntwana centres

31. Ngiyabonga