Topic : The Essential Nutrition Actions (ENA)

Academic 2025
Semester II
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The Essential Nutrition Actions (ENA)
The essential nutrition actions should be affordable and effective interventions to
improve the nutritional status of women and children and a framework for
program actions to deliver nutrition services and messages on:
 Exclusive breastfeeding for 6 months

 Adequate complementary feeding starting at 6 months with continued breastfeeding for 2

years
 Appropriate nutrition care of sick and malnourished children
 Adequate intake of vitamin A for women and children
 Adequate intake of iron for women and children
 Adequate intake of iodine by all household members

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The Critical Nutrition Actions (CNA)

 Along the lines of the ENA, nutritionists developed a set of Critical Nutrition Actions
 Originally for people living with HIV but later applied to adults with any infectious or chronic
disease.
 The CNA messages can be used in nutrition education and individual counselling.

The Critical Nutrition Actions

 Get weighed regularly and have weight recorded.
 Eat a variety of foods and increase your intake of nutritious foods
 Drink plenty of boiled or treated water
 Avoid habits that can lead to poor nutrition and poor health
 Maintain good hygiene and sanitation
 Get exercise whenever physically possible
 Prevent and seek early treatment of infections and manage symptoms through diet

 Take medicines as prescribed and manage side effects and medicine-food interactions through
Below are general tips for dietary counselling
 Make specific recommendations. For example, when encouraging a caregiver to
enrich a child‘s porridge, explain exactly how often and how much to feed.
 Try to include portion sizes for specific nutrient-rich foods. Use examples or pictures
of local measuring utensils to counsel on portion sizes.
 Use pictures of food groups, with healthy foods divided into sections to show
recommended daily consumption, to counsel on dietary diversity. Food groups are
not the same in all countries, but in general, they include carbohydrates, protein, and
micronutrients.
 Demonstrate how to prepare or use foods whenever possible.

 Severely malnourished people need treatment with ready-to-use therapeutic food

(RUTF), but moderately malnourished people can improve their nutritional status by
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eating adequate amounts of a variety of locally available foods.
Counselling on how to increase energy intake
 Eat mashed bananas, baked bananas, sweet potatoes, nuts, or porridge enriched with oil
and sugar. Add honey to staple foods.
 Add milk, cheese, or oil to foods.

 Fortify milk by adding 4 spoons (15 ml) of milk powder to 500 ml of milk. Stir well and
keep in a cool place. Use full-fat milk powder if available instead of skim milk powder.
Use this fortified milk in tea, on cereals, and in cooking.
 Add yogurt to soups, puddings, cereals, and drinks.

 Stir a beaten egg into porridge or mashed potatoes and cook for a few minutes more to
cook the egg. Do not eat raw eggs.
 Put nut paste, jam, butter/margarine, or tinned fish on bread.
 Eat nuts as a snack and put chopped nuts on food or add nut paste to food.
 Eat foods rich in fat, such as avocado, fatty fish, coconut, oil, and fried foods, if tolerated.
 Eat fermented and germinated (sprouted) foods. 5
Counselling on how to address moderate malnutrition
Eat regular meals, even if you have been prescribed fortified blended food, which is
meant to supplement the home diet.
 Eat not only cheap staple foods to provide energy and protein, but also foods from all
food groups.
 Eat foods with essential fatty acids (fish and shellfish, oil, pumpkin seeds, sunflower
seeds, and leafy vegetables).
Counselling on infant and young child feeding (IYCF)
 Inadequate feeding, care, and hygiene practices cause malnutrition in children.

 Breastfeeding is the most effective preventive public health intervention for child
survival and has the potential to prevent 13 percent of all deaths in children under 5 in the
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developing world.
The benefits of breastfeeding are listed below.
 Breast milk provides all the food and water an infant needs for the first 6 months of life.

 Breast milk is completely hygienic and contains antibodies that protect infants from
disease.
 Its composition adjusts to serve the special needs of pre-term infants, newborns, and
older infants.
 Breast milk includes fatty acids absent in formula or animal milks that are important
in brain development.
 Breastfeeding promotes mother-child bonding and psychosocial development.

 A breastfed infant has lower risks of illness and death from diarrheal disease and
pneumonia, reduced incidence of allergies and otitis media (ear infections), and in
later life, reduced incidence of overweight, obesity, and some chronic diseases.
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 There is evidence that exclusive breastfeeding improves children‘s performance on
intelligence tests.
 For mothers, early initiation of breastfeeding helps contract the uterus and expel the
placenta and reduces postpartum bleeding.
 Exclusive breastfeeding delays the return of menstruation, helping mothers recover
iron stores and acting as a natural form of birth spacing.
 Women who breastfeed have lower rates of premenopausal breast and ovarian cancers.
Complementary feeding
 Complementary feeding should begin when infants reach the age of 6 months.

 They should be offered semi-solid foods and gradually introduced to the regular family diet by
the age of about 1 year, with continued breastfeeding until they are around 2 years or older.

Below are counselling messages on complementary feeding.

 Feed foods from all food groups in each meal, not only starchy foods.
 Try different combinations, tastes, and textures if children refuse foods.
 Young children have small stomachs so they should eat small, frequent meals.

 When children are 9 to 24 months of age, feed three or four main meals (one meal = 1 cup) and two
nutritious snacks between meals, in addition to milk. As children get older, increase the quantity of
foods.
 Feed finely flaked fish, eggs, beans, ground-up nuts, finely sliced meat, or other soft and easily
digestible foods from the family pot.
 Feed mashed fruits and vegetables such as ripe banana, pawpaw, avocado, and pumpkin as often as
Counseling on IYCF for children who are ill
 Sick children may not seem to have an appetite, but they need to eat to get enough
nutrients to make up for losses from diarrhea, vomiting, and reduction in intake and to
strengthen their immune systems.
 Below are nutrition counselling messages for caregivers of sick children.

 If the child is breastfed, continue to breastfeed when the child is sick or breastfeed more
often.
 Be extra patient in encouraging the child to eat and making the child comfortable.

 Feed a variety of foods that are rich in nutrients, such as fruits, and rich in energy, such as
enriched porridge.
 Feed foods that the child likes.
 Feed small meals often.
 Pay attention to the child and make feeding time happy.
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 After illness, appetite usually increases. Feed extra food to help the child regain lost
weight and possibly speed up catch-up growth. Either breastfeed the child more often
or, if the child is older than 6 months, give food more often than usual and include an
extra meal.

 Feed fruits and foods with extra energy and/or nutrients such as enriched porridge.

 Give the child extra fluids (if the child is not breastfeeding exclusively) and make
sure drinking water is boiled and treated.

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Counselling HIV-positive mothers on IYCF
Global guidance includes the following messages:
 Mothers of HIV-positive infants should breastfeed exclusively for 6 months, then begin
complementary feeding and continue breastfeeding along with complementary foods up
to 24 months of age and beyond.
 Mothers of infants who are HIV negative or of unknown HIV status should breastfeed
exclusively for the first 6 months, then introduce complementary foods and continue to
breastfeed for the first 12 months.
 They should stop breastfeeding gradually, over 1 month, only when they can provide their
infants with a nutritionally adequate and safe diet without breast milk.
 National prevention of mother-to-child transmission (PMTCT) guidelines should be
followed when counselling HIV-positive mothers on infant feeding. 12
Nutrition counselling for people who are ill

 Infections and diseases can reduce appetite, decrease nutrient absorption, and make the
body use nutrients faster than usual, for example, to repair the immune system.
 Nutritional status and the immune system are linked in a reinforcing cycle, as shown in
the figure below.
Nutrition counseling for people with infectious diseases
 With chronic infectious diseases. Nutrition therapy is part of treatment guidelines for
people with HIV and tuberculosis (TB).
 People with chronic infectious diseases can be counselled to manage symptoms of
illness through diet.
.
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 Counselling for optimal nutritional status is a critical component of care for people
living with HIV, who often lose weight progressively and have poor nutritional status.
 Their reduced appetite cannot accommodate their increased energy needs caused by HIV
and opportunistic infections.
 They also have impaired gastrointestinal function and increased metabolic rate.

 Poor nutritional status can have a negative effect on treatment outcomes and further
depress immunity.
 Dietary counselling, along with treatment of malnutrition, may prevent wasting and
alleviate some symptoms of the disease.
 Food-insecure people living with HIV may have difficulty adhering to treatment and
require economic strengthening or food security support
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Nutrition counseling for people with infectious diseases
 Below are general nutrition counselling messages for people living with HIV.
 Eat a variety of foods from all food groups every day.

 Increase energy intake to meet the extra energy needs caused by HIV and
opportunistic infections.
 Take antiretroviral drugs (ARVs) as prescribed to stimulate appetite and help
recover body mass and improve immune function.
 Skipping doses increases the viral load and lowers resistance to opportunistic
infections.
• Some ARVs should be taken with food, some without food, and some either
with or without food to maximize their effectiveness and minimize negative
side effects

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Nutrition counseling for people with infectious diseases
 Tuberculosis makes malnutrition worse, and malnutrition weakens immunity, increasing the
likelihood that latent TB will develop into active disease.
 Like other infectious diseases, TB is likely to increase energy requirements, and most people
with active TB lose weight.
 Co-morbidities of TB, such as HIV, diabetes, smoking, and alcohol or substance abuse, have
their own nutritional implications.
 Below are messages for counselling people with TB on micronutrient supplements.

 Consume recommended micronutrients through food or fortified foods or, if that is not
possible, take micronutrient supplements to meet the recommended dietary allowance.
 If you have been prescribed specialized food products to treat malnutrition, do not take
multiple micronutrient supplements, which already contain the micronutrients you need.
 If you are pregnant and have active TB, take the same antenatal micronutrient supplements—
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Nutrition counseling for people with non-communicable diseases

 Diseases (NCDs), including cardiovascular disease, stroke, hypertension, cancer, and

metabolic diseases such as diabetes and obesity.
 It is projected that by 2030, NCDs will account for 46 percent of all deaths in sub- Saharan
Africa.
 Nutrition therapy is part of treatment guidelines for cardiovascular disease, diabetes,
hypertension, kidney disease, and chronic obstructive pulmonary disease (COPD).
 Nutrition counselling for people with NCDs should focus on the following
recommendations:
 Eat less sugar and avoid sugary drinks.
 Avoid processed foods.
 Eat plenty of fruits and vegetables to get needed vitamins and minerals.
 Get regular exercise.
 Eat more fiber from fruits, vegetables, whole grains, pulses, and nuts. 17
Counseling on water, sanitation, and hygiene (WASH)

 Poor water, sanitation, and hygiene conditions are associated with disease and disability all over the
world.
 Diarrheal diseases are the most common illnesses resulting from contaminated drinking water and food.
 Diarrhoea is most often caused by gastrointestinal infections that kill around 2.2 million people each
year, mainly children in developing countries.
 Poor WASH practices may be responsible for up to one-half of underweight in women and children.
 Children, pregnant women, the elderly, and people with compromised immune systems are especially
vulnerable to food- and water-borne bacteria, viruses, and parasites.
 It is thought that poor handwashing, poor food hygiene and sanitation, and lack of clean drinking water
contribute to child stunting by inducing a gut disorder called environmental enteric dysfunction.
 Constant exposure to fecal matter ingested by mouth results in flattening of the villi (finger-like
projections that protrude from the lining of the intestine).
 This limits the body's ability to absorb nutrients and increases exposure to microbes that lead to 18
Counseling on water, sanitation, and hygiene (WASH)

 Unsafe food creates a vicious cycle of disease and undernutrition.

 People with diarrhea eat less and are less able to absorb nutrients from food.
Malnourished people are more susceptible to diarrhea if they are exposed to fecal
material from the environment.
 Purchased food may be contaminated by preparation or handling in unhygienic
environments, and food that is prepared in the home may become contaminated if it is
prepared with unsafe water or not cooked or reheated adequately.
• Anemia is the most common nutritional deficiency in the world, caused by
iron deficiency and infections related to WASH (malaria, hookworm, and
schistosomiasis).

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Counseling on water, sanitation, and hygiene (WASH)

 Improving hygiene, sanitation, and water supply; controlling schistosomiasis and

malaria; and deworming every 6 months with an appropriate broad-spectrum
antihelminthic can help prevent anemia.
 No water or food is 100 percent safe at all times for all people, but following a few
simple practices can reduce the risk of water- and food-borne illness.
 A significant proportion of diarrheal diseases could be prevented by treating and
storing drinking water correctly, washing hands with soap and flowing water,
appropriate food hygiene, and using improved latrines.

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Counseling on handwashing
1. Wash hands under flowing water with soap or ash.
2. Wash hands at five critical times:
 Before preparing food
 Before feeding another person (including breastfeeding) or eating
 After using a toilet or latrine
 After cleaning a baby‘s bottom
 After cleaning up blood, vomit, urine, or feces

3. Air-dry hands (shake off the water) instead of drying them on a cloth or
clothing that may be contaminated with germs.
.

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Counseling on safe water treatment and storage
Simple, low-cost household water treatment can improve water quality and
reduce diarrheal disease.
 Water can be treated in the home by chlorinating, filtering, boiling, or using
solar ultraviolet water disinfection (SODIS).
 Some countries distribute basic care packages that include a water container,
hypochlorite solution, a treated bednet for malaria prevention, and a bar of
soap.
 This package could also include information on how and when to wash
hands, how to build a water-saving handwashing device called a ―tippy
tap,‖ how to build a latrine, and how to manage feces safely. 22
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