Impediments to Adequate Nutrition
Global nutrition monitoring framework: Some community dietitians conduct home visits for patients who are too physically ill to attend consultations in health facilities in order to provide care and instruction on grocery shopping and food preparation. Accessed 12 July Daily iron and folic acid supplementation is currently recommended by WHO as part of antenatal care to reduce the risk of low birth weight, maternal anaemia and iron deficiency. If you're interested in the Level 1 Certification, we strongly recommend you join the presale list below. The infant is however, allowed to receive ORS and drops and syrups containing vitamins, minerals and medicine. A general framework was presented earlier see Figure , representing a holistic model of causes of malnutrition and mortality, which was endorsed by most international organizations and nutrition planners.
However, under new rules which commenced 1 July ,  health care providers must either have statutory registration or be members of their national professional association to obtain a provider number.
In Canada , 'Dietitian' is a protected professional title. Additionally, 'Registered Dietitian' and 'Professional Dietitian' are protected in some provinces. Each province has an independent professional college for example, The College of Dietitians of Ontario.
The colleges are entirely funded from licensing fees collected from dietitians. To practice as a registered dietitian within a province, a dietitian must register with the college and obtain a license. The activities of the college are governed by legislation passed by the provincial government. It is the presence of this regulatory body which distinguishes registered dietitians from nutritionists in Canada, the regulations for which vary by province Exceptions: Alberta where "Registered Nutritionist" is a protected title that can only be used by dietitians.
Similarly in Nova Scotia and Québec "Nutritionist" is protected and can only be used by dietitians . The colleges also set the minimum entry requirements for admission into practice as a registered dietitian. The national professional association in Canada is Dietitians of Canada. Requirements for eligibility for registration include a recognised bachelor's degree in dietetics or nutrition from an accredited educational institution.
The undergraduate training should include the three practice areas of therapeutic nutrition, community nutrition, and food service management. Academic programs, professional associations, and credentialing requirements do not exist for dietitians in most other African countries, where the number of professionals in dietetics is very low.
In the United States, nutrition professionals include the dietitian or registered dietitian RD , as well as "dietetic technician" or "dietetic technician, registered" DTR see below.
These terms are legally protected, regulated by the Academy of Nutrition and Dietetics which registers and confers professional credentials. The Academy also recognizes and certifies certain specialty areas, such as in Gerontological Nutrition.
Dietitians are registered with the Commission on Dietetic Registration the certifying agency of the Academy and are only able to use the label "Registered Dietitian" when they have met specific educational and professional prerequisites and passed a national registration examination. Besides academic education, dietitians must complete at least hours of practical, supervised experience through an accredited program before they can sit for the registration examination.
In a coordinated program, students acquire internship hours concurrently with their coursework. In a didactic program, these hours are obtained through a dietetic internship that is completed after obtaining a degree. Once the degree is earned, the internship completed, and registration examination passed, the individual can use the nationally recognized legal title, "Registered Dietitian", and is able to work in a variety of professional settings.
To maintain the RD credential, professionals must participate in and earn continuing education units often 75 hours every 5 years. In addition, many states require specific licensure to work in most settings. Any person representing himself or herself as a registered dietitian shall meet one of the following qualifications:.
It is a misdemeanor for any person not meeting the criteria This group is made up of approximately 72, members nationwide who support each other and develop their Professional Portfolio together.
Dietetics associations are professional societies whose members have education qualifications in food, nutrition and dietetics recognized by a national authority. The ICDA supports national dietetics associations and their members, beyond national and regional boundaries, by providing:.
These titles are general designations of nutrition personnel. Specific titles may vary across countries, jurisdictions and employment settings. In particular the title nutritionist is, in some countries, unregulated so anyone may claim to be a nutritionist. Dietetic technicians are involved in planning, implementing and monitoring nutritional programs and services in facilities such as hospitals , nursing homes and schools. They assist in education and assessment of clients' dietary needs, and may specialize in nutritional care or foodservice management.
Dietetic technicians usually work with, and under the supervision of, a registered dietitian. The training requirements and professional regulation of dietetic technicians vary across countries, but usually include some formal postsecondary training in dietetics and nutrition care. In Canada, there are national standards for academic training and qualifications for dietetic technicians, according to CSNM the Canadian Society for Nutrition Management.
They must complete a dietetic internship with a minimum of supervised practice hours in the areas of Food Service Theory and Management, Community Dietetics, and Clinical Dietetics. They must also successfully pass a national registration examination administered by the Commission on Dietetic Registration CDR of the Academy. The DTR is an Academy-credentialed nutrition practitioner who works independently in many nutrition settings; however, when performing clinical dietetics, they must work under the supervision of a Registered Dietitian.
Some states have legislation specifying the scope of practice for the DTR in medical nutrition therapy settings. Effective June 1, , a new pathway to becoming a Registered Dietetic Technician has been made available by the Commission on Dietetic Registration. As for Registered Dietitians, in many cases the title "Dietetic Technician" is regulated by individual states.
Dietary assistants , also known as "nutrition assistants" or "dietary aides", assist dietitians and other nutrition professionals to maintain nutritional care for patients and groups with special dietary needs. They assist in preparing food in hospitals, childcare centres, and aged care facilities.
Dietary aides in some countries might also carry out a simple initial health screening for newly admitted patients in medical facilities, and inform the dietitian if any screened patients requires a dietitian's expertise for further assessments or interventions.
Dietary clerks , also sometimes known as "medical diet clerks" or "dietary workers", prepare dietary information for use by kitchen personnel in preparation of foods for hospital patients following standards established by a dietitian. They examine diet orders, prepare meal trays, maintain the storage area for food supplies, and ensure practice of sanitary procedures.
They may operate computers to enter and retrieve data on patients' caloric requirements and intake, or to track financial information. Dietary workers are typically trained on the job. Dietary managers supervise the production and distribution of meals, as well as the budgeting and purchasing of food and the hiring, training and scheduling of support staff in various types of workplaces offering larger scale foodservices , such as hospitals, nursing homes, school and college cafeterias, restaurants, correction facilities and catering services.
Training requirements vary across jurisdictions and employment settings. The Government of India's National Nutrition Policy, apart from setting nutrition goals to control and prevent malnutrition in the country, recommended that a National Nutrition Surveillance System should be developed. For the purpose of formulation of policies and strategies to control and prevent malnutrition, it is essential to assess continuously the nutritional problems in the country.
Monitoring of the nutritional status of population, therefore, becomes an important aspect of any nutrition intervention programme to assess the impact of these massive inputs and to determine the direction in which the community's nutrition is progressing, so as to initiate appropriate corrective actions.
All the members of the team are given intensive training in the methods of data collection, analysis and interpretation. Each state has also been provided with a vehicle for field survey. Household demographic and socioeconomic status, Dietary intake of individuals and households Nutritional anthropometry on all the available members of the households, Village level information on population, agricultural production, nutrition and other developmental programmes.
Measurement of diet related chronic diseases such as obesity and hypertension. Moreover, respondents to a questionnaire or subjects under observation can modify their responses or behaviour in a normative way. People who are overweight, for example, often minimise their actual food intake when interviewed for a food consumption survey.
Reproducibility guarantees that an indicator can be measured at repeated intervals in a comparable manner - a quality which is crucial when using the indicator to assess and monitor the situation.
A complementary characteristic is specificity, which refers to the ability to identify those not affected by the risk or characteristic.
Sensitivity is measured in practice by the ratio of the number of individuals identified by the indicator as being at risk or as having the characteristic to the number of individuals who are actually at risk or have the characteristic. Specificity is the ratio of the number of individuals not identified by the indicator to the number of individuals who are actually not at risk or do not possess the characteristic.
Sensitivity thus gives an idea of the degree of correct or misclassification linked to the use of an indicator. Not all indicators lend themselves to an assessment of sensitivity. Sensitivity applies essentially to indicators with cut-off values. Moreover, sensitivity is measured with respect to a given goal; sensitivity of an indicator such as weight-for-height at a given cut-off value will not be the same, depending on whether the goal is to identify children who are wasted or those who are at risk of dying in coming months.
Data for quick computation of these parameters sensitivity, specificity are not always available, so in practice, reference is made to existing data from the literature to find those closest to the chosen cut-off values and expected prevalences.
One particular aspect of sensitivity is the ability of an indicator to measure change, not in order to identify or target a particular category of individuals as previously but to detect the smallest possible change in the phenomenon described, in a significant way. While sensitivity, in general, is important when establishing a baseline, and for defining the target groups to which the activities will be directed, this ability for measuring change is crucial for assessing or monitoring trends, in particular to detect changes in the situation during implementation of the programme.
However, it is relatively inert when assessing small progressive changes in nutritional status over time, and the weight-for-height indicator will be preferred in this case, since it is more sensitive to change. Also, urinary iodine will respond to introduction of salt iodization in a region quicker than prevalence of goitre, which will decline only slowly.
In addition to these inherent characteristics of indicators, their operational value should be examined; it will be essential when the choice of indicators is made, especially in terms of speed and cost of collecting data for producing these indicators. It represents the practical possibility of making available the indicator in question.
It implies the feasibility of collecting the corresponding data by whatever means. There are indicators described as "ideal" which nobody is in practice able to collect.
As a result of major international conferences and of programmes that have followed them during the last two decades, many of the required indicators are already systematically and regularly collected within the framework of such programmes and are thus very easily available. It affects use of the indicator not only at the descriptive stage, but also when monitoring the situation.
An indication of the quality of the measurements, of sampling and of the confidence interval of the result is essential here to assess dependability. Occasionally, it has been observed that the number of malnourished children estimated by nutritional surveys carried out by various organizations on identical populations and during the same periods, differed substantially; using the results for targeting purposes or for monitoring the situation is ruled out in this case.
The reason was usually the lack of precision of the anthropometric measurements or of the definition of age, and occasionally a sampling problem. Data on food consumption obtained by weighing food are more precise than those obtained with the "recall" technique, although the former implies technical constraints and can therefore only apply to small samples, so that there is a broad confidence interval in the results.
Recall techniques, on the contrary, can easily be applied to a large sample, obviously with a smaller confidence interval.
The various available data must therefore be carefully examined before using them for monitoring purposes, and a choice will sometimes be made between data collected with a higher level of accuracy but lower power at the level of the target population, or the opposite.
On this depends, in part, the speed and frequency with which the indicator can be regularly measured. When the data necessary for the construction of the indicator need to be collected specifically for evaluation or monitoring, cost should be considered; it depends on the difficulty and sophistication of the measurements, the accessibility of the objects or people to be measured, the frequency of collection and the complexity of the analysis subsequently.
The cost of non-collection may be measured, in the case of a food subsidy programme, for example, by the difference between the cost of the programme if it is carried out without particular targeting, in the absence of any indicator allowing targeting, and the cost of the programme for the target population, plus the cost of targeting, if the programme is to be directed at a high risk group only.
Nevertheless, information on the cost of collecting an indicator for each situation is seldom available. It is difficult to measure, and estimates are generally based on the cost of different types of survey within the country, taking account of the fact that several indicators are collected at the same time. Indicators can be categorized schematically in the following way according to the level at which they are produced or made available:.
They include both indicators regarding the implementation of services as well as indicators regarding the situation or the impact of actions under way. It is generally easy to obtain them from the departments concerned, which usually have time series that are very useful in distinguishing medium- and long-term trends.
Even so, it is not always possible to cross-tabulate these indicators, since they do not necessarily come from the same databases and are accessible only in a relatively aggregated form. It is also difficult to verify the quality of the original data. Lastly, even if the data are collected on a frequent basis monthly reports, for example , recovery and analysis may take too long. Such data tend not to be immediately accessible except in summary form, although it is easy to organize new analyses with the departments in charge of them.
These data allow statistical cross-tabulation to be made between the many variables collected simultaneously on the sample. Although carried out at best at very long intervals, they can be updated with reasonable projections, especially if information on trends in the fields of interest, based on routinely collected data, are also available.
These data are often kept together in national statistical offices. They consist of a regular collection of information based on a small number of selected indicators.
The system varies by country, those that perform best are based on an explicit conceptual framework and are linked to a clear decision-making mechanism. They can represent a sound basis for central monitoring. A particular category is derived from surveys conducted by international bodies for various purposes: These cross-sectional surveys are conducted directly at household level on samples which are representative at national level but of variable size; they include a wide variety of indicators in number, goals and qualities and are now frequently repeated.
Although conducted peripherally, they are generally available and used centrally. These sources, which are in principle fairly reliable, benefit from an advanced level of analysis allowing causal inference to be derived of relationships among various household indicators, and with individual indicators, such as nutritional status.
They represent a precious source when establishing a baseline and when analysing causes prior to launching an intervention. These are constructed primarily on the basis of routinely collected data from local government offices, community-based authorities.
They are usually passed on as indicators or raw data to the central level, and then sent back to the decentralized levels, with varying degree of regularity, after analysis. They are often disaggregated by district or locality, but are not always representative, since they often refer only to users of the services under consideration. They are generally grouped together at the central administrations of regions or administrative centres.
The indicators relate primarily to activities that lend themselves to regular observation, either because they record activities indicators of operation or delivery of services or because they are necessary for decision-making crop forecasts, unemployment rates or for monitoring purposes market prices of staples, number of cases of diseases, etc.
They do not necessarily include indicators of the causes of the phenomena recorded and are not in principle qualitative indicators. Indicators collected at decentralized levels should meet both the needs of users on these levels and also those of users on the central level for the implementation and monitoring of programmes. If these regularly compiled indicators do not have any real use at the local level and are intended only for the national central level, there is a danger that their quality will drop over time, for lack of sufficient motivation of those responsible for collection and transmission - and gaps are therefore often found in available data sets.
Nevertheless, they are invaluable in giving a clear picture of the situation on the regional or district level, together with medium-term trends. Generally speaking, their limitation is the low level of integration of data from different sectors. A certain number of indicators, particularly those concerning the life of communities or households and not touching on the activities of the various government departments, are not routinely collected by such departments and are in any case not handed on to the regional or central offices.
They are sometimes collected at irregular intervals by local authorities, but most often by non-governmental organizations for specific purposes connected with their spheres of activity - health, hygiene, welfare, agricultural extension, etc. Analytical capabilities are often lacking at this level, and the available raw data may not have led to the production of useful indicators.
Action therefore should be taken to enhance analytical capacities or else sample surveys will have to be carried out periodically on these data in order to produce indicators. A sound knowledge of local records and their quality is needed to avoid wasting time.
New collection procedures often have to be introduced for use by local units, while being careful not to overload them or divert them from their own work.
Otherwise a specific collection has to be carried out by surveying village communities targeted for analysis or intervention. These surveys are vital for a knowledge of the situation and behaviours of individuals and households and an evaluation of their relationship with the policies introduced. In general, they offer an integrated view of the issues concerned. They may have the aim of supplying elements concerning the local situation and local analysis, in order to confirm the consensus of the population and of those in charge as to the situation and interventions to be carried out, and also to allow an evaluation of the impact of such interventions.
The participatory aspect should be emphasized rather than the precision or sophistication of data. An FAO work on participatory projects illustrates issues of evaluation, and especially the choice of indicators in the context of such projects FAO If data already collected are used or if a new survey is carried out for use on a higher level, the size and representativeness of the sample must be checked, and it must be ensured that the data can be linked to a more general set on the basis of common indicators collected under the same conditions method, period, etc.
Verification of the quality of the data is crucial. Before undertaking a specific data collection, a list of indicators and of corresponding raw data should be developed which can be used by services at all levels; it is not unusual to find that surveys could have been avoided by a better knowledge of the data available from different sources.
To track down these useful sources and judge the quality of the data available and their level of aggregation, a good understanding is needed of the goals and procedures of the underlying information system. The country had set up a monthly national information system on production estimates for 35 crops, covering information on crop intentions, areas actually planted, crop yields and quantities harvested in each state.
The information was obtained during monthly meetings of experts at various levels - local, regional and national. The information was then put together at the state level, and then at the national level, reviewed by a national committee of experts, and sent on to the central statistics office.
The different levels thus had some rich information at their disposal, coming from a range of local-level sources. Although it was certainly fairly reliable, being confirmed by a large number of stakeholders and experts, its precision could not be defined, in view of its diversity. The usefulness of such data varies depending on information needs and thus on the quality of the data required.
Data concentrated at the central level are probably useful primarily for analysing trends. On the other hand, apart from the figures, more general information on production systems exists at local level, and this can be useful for identifying relevant indicators of causes, or for simplifying monitoring of the situation.
We have seen that there is a great number of indicators which differ widely in quality; the availability of corresponding data is variable, and any active collection will be subject to constraints. Therefore the choice of indicators must be restricted to the real needs of decision makers or programme planners. This implies that a method is needed for guiding the choice.
The main elements that will guide choice are: Any intervention is based on an analysis of the situation, an understanding of the factors that determine this situation, and the formulation of hypotheses regarding programmes able to improve the situation. A general framework was presented earlier see Figure , representing a holistic model of causes of malnutrition and mortality, which was endorsed by most international organizations and nutrition planners.
However, the convenient classification that it implies, for instance into levels of immediate, underlying or basic causes needs to be operationalized through further elaboration in context.
The benefit of constructing such a framework, over and above the complete review of the chain of events which determine the nutritional situation, is to allow the expression, in measurable terms, of general concepts which, because of their complexity, are not always well defined. For example, it is not enough to refer to "food security"; one should state which of the existing definitions is to be used, on which dimensions of food security the focus is placed and the corresponding indicators.
The use of conceptual frameworks when implementing programmes or planning food and nutrition is not new. Many examples have been developed, focusing on different aspects. The concept of food security is generally perceived as that of sufficient availability of food for all.
However, several dozen different definitions have been proposed over these last 15 years! This concept may, for example, comprise different aspects depending on the level being related to: In the first case, analysis will focus on agricultural production, and in the second the emphasis will be on improving the resources of those who lack access to a correct diet.
This preliminary brainstorming exercise will allow a better definition of the perceived chain of causes production shortfall, excessive market prices, defective marketing infrastructures, low minimum wage, low level of education, etc.
It will then be easier to consider potential indicators of the situation and its causes, or potential indicators of programme impact. Obviously it is not so much the final diagram which is of importance as the process through which it was developed. Insofar as the relations between all the links of the chain of events or flow data, depending on the type of representation have been discussed step by step and argued with supporting facts, the framework will be adapted to the local situation and will become operational.
Methodologies have been developed for making this process effective in the context of planning, for example with the method of "planning by objectives" see ZOPP , which comprises several phases: During this planning process, all programme activities, corresponding partners, necessary inputs and resulting outputs as well as indicators for both monitoring implementation and evaluating impact of the programme will be successively identified.
The method acts as a guide for team work, encouraging intersectoral analysis and offering a simplified picture of the situation, so that the results of discussions are clear to all in the team. Let us again take the example of a problem of food security.
It can be broken down into three determining sectors: A series of structural elements can be defined for each sector: These elements affect both production levels and operation of markets. A certain number of macro-economic or specific policies will affect one or all the elements in this block. Each block can be considered in a similar way, and this will provide the groundwork for a theoretical model of how the system works see C.
The final steps in order to operationalize the model are i that of defining indicators that will, in the specific context of the country, reflect the key elements of the system, and ii , once policies and programmes have been chosen, that of identifying which of these indicators are useful for monitoring trends and evaluating programme impact. This will be the basis for an information system reflecting the overall framework of the programme and how it should work.
Another method has been proposed by researchers from the Institute of Tropical Medicine in Antwerp based on their field experience in collaboration with different partners Lefèvre et al.
Basically, it stresses the participatory aspect, with the aim of obtaining a true consensus on the local situation, the rationality of interventions in view of the situation, and the choice of indicators. It includes first a phase in which a causal framework is developed with the aim of providing an understanding of the mechanisms leading to undernutrition in the context under consideration.
The framework is constructed in the form of a schematic, hierarchized diagram of causal hypotheses formulated after discussions among all stakeholders. The way it is built tends to favour a clear, "vertical" visualization of series of causal relationships, eliminating the lateral links or loops that are often the source of confusion in other representations.
In a second phase, a framework is developed linking the human or material resources available at the onset inputs , the procedures envisaged activities , the corresponding results of implementation outputs , and the anticipated intermediate outcomes or final impact of each activity or of the programme.