Practical Skill Development (PSD)

on

Project Design on Nutrition in Saptari, Nepal

(PSD was carried out in partial fulfillment of the requirements for
Epidemiology of Diseases and Health Problems: PSD 521)

Submitted to:

Department of Public Health

Master of Public Health Program

Nobel College, Sinamangal, Kathmandu

Pokhara University

Submitted by:

Second Semester, 2023

Nobel College

S.N. Name Roll No.

1 Mr. Krishna Kumar Yadav 23690001
2 Ms. Pratiksha Bhattarai 23690002
3 Ms. Surakshya Devkota 23690003
4 Ms. Sangita Raj Ghatani 23700001
DECLARATION
We students of second semester 2023 batch, hereby declare that the PSD work entitled
“Project Design on Nutrition in Saptari, Nepal” submitted towards partial fulfillment of the
requirements for Epidemiology of Diseases and Health Problems, EPI521 is our original
work.

Group Members:

Krishna Kumar Yadav ………………………….

Pratiksha Bhattarai …………………………

Surakshhya Devkota …………………………

Sangita Raj Ghatani …………………………

Faculties:

Dr. Baburam Marasini

…………………………

(Subject faculty) Signature

_____________________

…………………………

(External faculty) Signature

i
ACKNOWLEDGEMENT
This report on the topic “Project design on nutrition in Saptari, Nepal” has been undertaken
as per the requirement of practical skilled development (PSD) of Master’s in Public Health
Program.

Without the guidance and support of respectable professors and faculties, we would not have
been able to complete this work in an insightful manner. We are truly grateful to them for
their assistance.

We would like to express our special thanks to Dr. Baburam Marasini for his valuable
guidance since orientation until completion of this PSD work. Our deepest gratitude goes to
our Coordinator Mr. Bal Krishna Bhatta sir for his valuable comments and time, we like to
give heartily thanks to MPH Program and all the faculty members of Nobel College for their
support.

We are also thankful to all the seniors and staffs of Nobel College who had helped us to
complete this task directly and indirectly.

At last, but not the least, special thanks and warm gratitude to our dear friends for their
continuous support.

Second Semester, 2023 Batch

ii
LIST OF ACRONYMS
PEM Protein Energy Malnutrition

SUN Scaling-Up-Nutrition

MSNP Multi-sector Nutrition Plan

CHD Child Health Division

WHO World Health Organization

SAM Severe Acute Malnutrition

MAM Moderate Acute Malnutrition

FCHV Female Community Health Volunteer

NAGA Nepal Nutrition Assessment and Gap Analysis

RUFT Ready to use Therapeutic Food

RUST Ready to use Supplementary Food

WHA World Health Assembly

SDG Sustainable Development Goal

IDA Iron Deficiency Anemia

VAD Vitamin A Deficiency

IDD Iodine Deficiency Disorders

IYCF Infant and young child feeding

MIYCN Maternal, Infant, and Young Children Nutrition

IMAM Integrated Management of Acute Malnutrition

MNP Micronutrient Powder

RDA Recommended Daily Allowance

UNICEF United Nation Children’s Fund

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TABLE OF CONTENTS

DECLARATION..............................................................................................................................
ACKNOWLEDGEMENT...............................................................................................................
LIST OF ACRONYMS..................................................................................................................
TABLE OF CONTENTS...............................................................................................................
LIST OF TABLES...........................................................................................................................
LIST OF FIGURES........................................................................................................................
CHAPTER I INTRODUCTION......................................................................................................
1.1 Background............................................................................................................................
1.2 Global context:.......................................................................................................................
1.3 National context:....................................................................................................................
1.5 Problem statement:.................................................................................................................
1.6 Rationale of the study............................................................................................................
1.7 OBJECTIVE..........................................................................................................................
CHAPTER II...................................................................................................................................
2.1 Project Name..........................................................................................................................
2.3 Project Timeline.....................................................................................................................
2.4 Project Location.....................................................................................................................
2.5 Target beneficiaries................................................................................................................
CHAPTER III..................................................................................................................................
CHAPTER IV................................................................................................................................

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LIST OF TABLES

Table 1 The nutritional value of Moringa and Soyabean................................................................

Table 2 Lesson plan.......................................................................................................................

v
LIST OF FIGURES
Figure 1 Nutritional Value of SoyBean...........................................................................................
Figure 2 Nutritional Value of Moringa............................................................................................

vi
CHAPTER I INTRODUCTION
1.1 Background

Malnutrition in children and women is a major public health problem in most of the developing
countries and Protein Energy Malnutrition (PEM) is more common among under five year
children. Nutrition is a globally recognized development agenda. Since the year 2000, several
global movements have advocated nutrition for development. The Scaling-Up-Nutrition (SUN)
initiative calls for multi-sectoral action for improved nutrition during the first 1,000 days of life.
The Government of Nepal as an early member of SUN adopted the Multi-sector Nutrition Plan
(MSNP) in 2012 to reduce chronic nutrition. Recently, the UN General Assembly declared the
2016–2025 period as the Decade of Action on Nutrition. The National Health Policy, 2071
highlights improved nutrition via the use and promotion of quality and nutritious foods generated
locally to fight malnutrition. The Nutrition Technical Committee was established in CHD in
2011 to support multi-sectoral coordination for developing nutrition program.

Carbohydrates, fats and proteins (“macronutrients”) provide us with energy in the form of
calories. Of these three, the majority of our energy should come from carbohydrates — not
proteins. Carbohydrates should make up 45-65% of our total daily calories; protein should make
up 10-35%; and fat, 20-35%.

“Micronutrients,” also referred to as vitamins and minerals, are no less important than
macronutrients. They’re just needed in smaller amounts. They include vitamins, such as C, D and
K, and minerals such as iron, magnesium and calcium. While micronutrients don’t give us
energy, they’re critical for the many chemical reactions that occur in our bodies, including
extracting energy from food and creating new cells.

The consequences of malnutrition are serious and life-long, falling hardest on the very poor and
on women and children. Overall, in developing countries nearly one-third of children are
underweight or stunted (low height for age). Undernutrition interacts with repeated bouts of
infectious disease; causing an estimated 3.5 million preventable maternal and child deaths
annually and its economic costs in terms of lost national productivity and economic growth are
huge. In all its forms malnutrition accounts for more than 50 per cent of child mortality in Nepal
(WHO estimates). Malnourished children who do survive are more frequently ill and suffer the

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life-long consequences of impaired physical and cognitive development. These consequences
translate to poor human resource capital and poor economic development.

A nutritional deficiency occurs when the body does not absorb or get from food the necessary
amount of a nutrient. Deficiencies can lead to a variety of health problems. These can include
digestion problems, skin disorders, stunted or defective bone growth, and even dementia.
Nutrition section under Child Health Division is responsible for national nutrition program for
improving the nutritional status of children, pregnant women and adolescents. The national
nutrition program is priority program of the government. There is high level commitment to
improving the nutritional status especially of women and of young children.

The term malnutrition can include

i. Wasting and nutritional oedema (Acute Malnutrition)

ii. Stunting (Chronic Malnutrition)

iii. Underweight

iv. Micronutrient deficiencies and

v. Overweight/obesity (Overnutrition).

1.2 Global context:

• In 2022, 2.5 billion adults were overweight, including 890 million who were living with
obesity, while 390 million were underweight.

• Globally in 2022, 149 million children under 5 were estimated to be stunted (too short for
age), 45 million were estimated to be wasted (too thin for height), and 37 million were
overweight or living with obesity.

• Nearly half of deaths among children under 5 years of age are linked to undernutrition.
These mostly occur in low- and middle-income countries.

• The developmental, economic, social and medical impacts of the global burden of
malnutrition are serious and lasting, for individuals and their families, for communities
and for countries.

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South Asia context:

• According to the WHO global estimates (2021), around 149.2 million children under 5
years of age suffered from stunting, 45.4 million were affected by wasting, 20.5 million
were underweight and 38.9 million were too heavy for their height.

• Around 89% of those stunted, 93% of wasted and 77% of overweight children are more
likely to live in low and middle- income countries.

• According to the global nutrition report, Pakistan and India was reported the home of
almost half of all stunted children around the globe carrying 10.7 million and 46.6 million
stunted children respectively.

• India is home to the world’s most wasted children (25.5 million).

• Bangladesh is ‘on course’ to prevent childhood wasting but still, 9.8% children are
affected by wasting which is higher than the average for the Asia region (8.9%).

1.3 National context:

• Malnutrition is a leading cause of child mortality, contributing to around half of all child
deaths.

• The burden of PEM in terms of DALY was higher in under-five children (912 per
100,000 populations)

• In 2019, a UNICEF report had estimated that 850,000 children under five were
underweight and over 300,000 were wasted.

• According to an analysis from Family Health Survey and National Health and
Demographic Survey 1996-2022, child stunting has reduced to 24.8 per cent in 2022
compared to 56.6 per cent in 1996. However, progress has not been uniform when the
economic status of citizens is considered.

1.5 Problem statement:

In Nepal, the nutritional status of mothers and children under five is extremely poor. According
to Nepal Demographic and Health Survey 2022, (25%) of the children are stunted and (8%) are

3
wasted. Today malnutrition, especially undernutrition, has been the major health issue of
children. Similarly, poverty and inequality are major challenges especially in marginalized
communities such as Dalit, Muslim and Aadiwashi Janajati as they cannot afford nutritious food
in a sustainable way.

Around 18 percent of under-five children in Saptari district of Madhesh Province have been
found suffering from wasting, the most immediate, visible, and life-threatening form of
malnutrition. The national average of wasting is (8%) percent but around 18 percent of children
from Saptari district are found to be affected by wasting, which is alarming
(https://kathmandupost.com/health/2022/09/11/severe-wasting-in-two-eastern-districts-hints-at-
a-hidden-health)

1.6 Rationale of the study

Currently, the Government of Nepal depends on Ready to Use Therapeutic Food (RUTF) and Ready to
use Supplementary Food (RUSF) which are not the sustainable solutions to the management of
malnutrition. The SDGs are an agenda for the world, and for Nepal, to leave no one behind and transform
the way the world ends hunger, ensures food security, and tackles malnutrition in all its forms, through an
integrated approach. Hence this project intends to address the aforementioned challenges and scaling up
this project will provide local and sustainable solution for the people of Saptari district. Overall, this
project aims to assist and address the problem of malnutrition in Saptari District.

1.7 OBJECTIVE

General Objective:

To develop knowledge and skills of mothers having children below 5 years and FCHVs to
prepare super cereals utilizing local resources.

Specific Objectives:

 To increase the level of awareness regarding malnutrition and its consequences among
mothers of children below 5 years of age and FCHVs.
 To develop skill of mothers and FCHVs on preparing super cereals.

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1.8 Project Introduction

We understand that effective screening of Severe Acute Malnutrition (SAM) cases and their
management/treatment are central to the success of any community-based nutritional program.
Therefore, in our project, we aim to assist, stimulate and train mothers having children below 5
years of age and FCHVs to develop knowledge regarding SAM and help them to prepare super
cereals by utilizing local foods that are abundantly available in their community. Our approach
and design of the project is integrated which involves assisting the FCHVs to screen and manage
the malnutrition cases as well as enhancing the skill and knowledge for the sustainable change.
Specific approach such as; to develop skills where the rural women are trained to prepare the
cereal, use moringa in varieties of way and use different forms of soyabean in rural household
with their local resources.

1.9 Project Vision

Malnutrition free Saptari

1.10 Project Mission

To support in the reduction of incidence and prevalence of Malnutrition in Saptari and to create a
further enabling environment to help control the factors associated with malnutrition.

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CHAPTER II
Project design on malnutrition in Saptari, Nepal

DESCRIPTION

2.1 Project Name

Project design on malnutrition among rural women group having 6-59 months children in
Saptari, Nepal

2.3 Project Timeline

1st January 2025 – 31st February 2025 will be the Project Timeline

2.4 Project Location

Saptari District, Nepal. Saptari is an outer Terai District and is a part of Madhesh Province with
an estimated population 6,39,284.

2.5 Target beneficiaries

� The rural women group having 6-59 months children.

� FCHVs of Saptari district.

2.6 Project Method

A base-line information of the incidence and prevalence of wasting will be taken from the
record section of district health office (DHO). Thereafter, the project will be implemented.

The Project Activities has been divided into two parts;

i) enhancement of knowledge and skills through education(orientation) and training

ii) demonstration on preparing super cereal.

Super Cereals comprises : two-part cereals consisting of carbohydrate + one-part pulses

consisting protein. The soybean will be used as a main source of protein. In addition to these
ingredients, sweet potato and Moringa powder will be added to enhance taste, vitamins and
minerals.

6
The main ingredient of this cereal is the soybean and Moringa.

Table 1 The nutritional value of Moringa and Soyabean

Food Carboydrate Protein Fat Dietary Water Vitamins Minerals

Item Fiber

Soyabean 9.37g 13.09 6.7 g 1.1 g 69.05 B1,2,3,5,6,9 Cu, Mn, Mg,
g g P,Fe, Zn, K, Ca
c

Moringa 66.7 g 33.3 g 33.3 g 33.3g A and C Ca and Fe

Figure 1 Nutritional Value of SoyBean

7
Figure 2 Nutritional Value of Moringa

8
CHAPTER III
Project Intervention on malnutrition in Saptari, Nepal

Our goal is to promote the utilization of the local nutritious foods and prevent malnutrition in
Saptari District. Similarly, demonstrations on preparation of super cereals will be done. The
basic education and awareness of health and nutrition will be provided to the participants through
mainly two activities:

Activities:

A) Enhancement of Knowledge and Skills Through Education and Training.

B) Demonstration on preparing Super cereals.
C) Follow-up visits to monitor preparing and feeding super cereals to children.

A) Enhancement of Knowledge and Skills Through Education and Training

STEPS
a) Pretesting of mothers of under 5 years children and FCHVs will be done.
b) Orientation on the prevalence and incidence of malnutrition (wasting) in Saptari district
to mothers of under 5 years children and FCHVs will be given.
c) Knowledge will be provided on wasting, its causes, consequences and how to overcome
the problem.
d) Importance of intake of nutritious diet.
e) Orientation on nutritional contents of Super cereals.
B) Demonstration on preparing Super cereals
STEPS
a) All the ingredients will be made ready before the demonstration.
b) 2 parts of carbohydrate + 1 part of soybean + moringa + sweet potato will be mixed in an
appropriate proportion to make super cereals.
c) All the participants will prepare super cereals.

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Table 2 Lesson plan

Group Discussion

Brain stroming/

10
 C) Follow-up visits to monitor preparing and feeding super cereals to children.

a) One week after the training has been conducted, follow-up visits will be done at
household level to monitor if the mothers are preparing super cereals and feeding their
child. Also, feedback on super cereals will be obtained from children and their
mothers.
b) FCHVs will be followed up to ensure if they are orienting mothers on super cereals
who were not able to attend the training

CHAPTER IV
Project Analysis on malnutrition in Saptari, Nepal
4.1 LOGICAL FRAMEWORK ANALYSIS

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Summary of Project Summary Indicators MOV Assumptions / Risk
Objectives /
Activities

Goal Decrease in the Morbidity rate from Growth monitoring Defective weighing
incidence and wasting in Saptari report of health post. machine
prevalence of decrease by 5%.
wasting.

Project Purpose Wasting decrease in 10% of wasting Case load of wasting Health Post staff
Saptari. decrease in health post provide the report.

Results / Outcome Awareness among About 80% of Pre-test and Post - All participants will
mothers and FCHVs mothers and FCHVs test be able to answer
on wasting. explain the risk the questions
factors and
consequences of
wasting.
Participants gain Will prepare super
knowledge About 80% of cereal at home.
regarding super participants have
cereals. knowledge on super
cereals.
Participants are able
to prepare super About 70%
cereals. participants prepared
super cereals.

Activities / Impact Orientation to Mothers and FCHVs Pictures during Target participants
mothers and FCHVs will be oriented on orientation, will attentively
on wasting of under the risks and attend the session.
5 children in Saptari consequences of
District. wasting through
lecture.

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 Training on super Participants will
cereals. have knowledge on
super cereals. Training register Participants will be
Demonstration on present on time.
preparation of super Participants will
cereals. demonstrate to
prepare super Video of participant
cereals. demonstrating. Participant will be
able to demonstrate
Expenses on training correctly.

4.2 Project Outcome

⮚ To increase the level of awareness regarding malnutrition by 80%.

⮚ To encourage every household in Saptari district to prepare super cereals.

⮚ To mobilize FCHVs to reach the unreachable mothers.

⮚ To reduce the prevalence of wasting from 18% to 8%.

Indicators

❖ Input Indicators:

� Trainer or facilitator enroll for conducting educational program

� Program /event site

� Teaching/Learning materials

� Amount of budget allocated

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� Production of cereals

❖ Process:

� No. of IEC materials distributed

� No. of malnutrition awareness program/ campaign

� No. of counseling session provided

❖ Output Indicators:

� No. of beneficiaries’ participant

� No. of IEC materials distributed

� No. of awareness program focusing on malnutrition

❖ Supervision

▪ Weekly supervision

▪ Weekly report preparation (i.e. Total no. of resource allocate, achievement of

target)

▪ Assessment of the participants activity performance

❖ Monitoring will be done on the basis of:

▪ Weekly follow-up

▪ Data recording

▪ Input Vs Output Assessment

▪ Relevancy of the program

▪ Utilization of resources

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Learning reflections:

✔ To describe the epidemiological determinants of malnutrition of public health importance

in the country.

✔ Learned about the benefits and ways of using moringa and soyabean.

✔ Critical analysis of the current policy’s, strategies and programs related to malnutrition

✔ Preparation of the sample projects on an innovative preventive, protective and control

measures for malnutrition.

Proposed Project Budget

Item Unit cost Quantity Total

Training module 50 100 5000

handouts

Cereals ingredients 5000 5000

Snacks 100 50 5000

Trainer fees 2000 2 4000

Total 19,000

ANNEX – I
References:
• Annual Report, NDHS, 2022
• https://www.ifpri.org/project/nutrition-program-nepal
• https://www.unicef.org/nepal/nutrition
• https://www.sciencedirect.com/science/article/pii/S2213398424000678

15
 • https://kathmandupost.com/health/2022/09/11/severe-wasting-in-two-eastern-districts-hints-
at-a-hidden-health crisis#:~:text=Around%2018%20percent%20of%20under,life
%2Dthreatening%20form%20of%20malnutrition
• https://npc.gov.np/images/category/TOWARDS_ZERO_HUNGER1.pdf
• https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.herbazest.com%2Fherbs
%2Fsoy&psig=AOvVaw1LcgMMEwcBC5HMgNel3umv&ust=1714268382056000&source
=images&cd=vfe&opi=89978449&ved=0CBIQjRxqFwoTCNjo9M6h4YUDFQAAAAAdAA
AAABAE
• https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.herbazest.com%2Fherbs
%2Fmoringa&psig=AOvVaw1Lstzi61HvHjpkkbTjyBDL&ust=1714267974671000&source=
images&cd=vfe&opi=89978449&ved=0CBIQjRxqFwoTCMDz0Ymg4YUDFQAAAAAdAA
AAABAK
• https://health.osu.edu/wellness/exercise-and-nutrition/micronutrients-vs-macronutrients
• Saif, S., Anwar, S. Unraveling the South Asian enigma: concurrent manifestations of child
anthropometric failures and their determinants in selected South Asian countries. BMC
Nutr 9, 120 (2023). https://doi.org/10.1186/s40795-023-00771-4
• Pradhananga P, Shrestha A, Adhikari N, Shrestha N, Adhikari M, Ide N, et al. (2022) Double
burden of malnutrition in Nepal: A trend analysis of protein-energy malnutrition and High
Body Mass Index using the data from Global Burden of Disease 2010–2019. PLoS ONE
17(9): e0273485. https://doi.org/10.1371/journal.pone.0273485

ANNEX II
How to Consume Moringa?
All parts of the moringa tree have been traditionally consumed in both culinary and medicinal
forms, in order to reap their medicinal properties and nutritional value.
Natural Forms

● Raw. In their fresh form, moringa leaves are a popular snack that provide great
nutrition and medicinal benefits when added to salads, soups, and other culinary
preparations.

● Dried. Once dried, whole moringa leaves can be added to baked goods, smoothies,
and many other culinary and medicinal preparations.

● Powder. The dried leaves of moringa are ground into a fine powder that can be added
to smoothies, baked goods, and more. This is the most popular way of reaping
moringa health benefits and nutritional value.

16
 ● Tea. Dried or powdered, moringa leaves can be brewed into a warm infusion with
anti-inflammatory and analgesic properties. Moringa tea can soothe gastrointestinal
discomfort, lower blood pressure, and help reduce blood sugar levels.
Herbal Remedies & Supplements

● Essential oil. Obtained from cold pressed seeds, moringa essential oil – also known
as “ben oil” - is rich in unsaturated fatty acids as well as in vitamins A and C. In this
form, the emollient and anti-inflammatory properties of moringa nourish and
moisturize the skin, also helping heal superficial wounds, scratches, and bug bites.

● Liquid extract. Moringa extract offers high concentrations of antioxidant, anti-

inflammatory compounds that can help control blood sugar levels, hypertension, and
gastrointestinal problems, such as irritable bowel syndrome (IBS).

● Capsules. This one of the most popular ways of consuming moringa, due its
availability and practicality. Moringa capsules and tablets come in standardized doses
that allows for proper absorption of their antioxidant compounds.

17
 Figure 4 Nutritional value of soyabean
How to Consume Soyabean?

● Soya Chunks: is the highest source of protein.

● Sprouted: Soybean sprouts are arguably the most nutritious form of soy; they are rich
in protein, vitamins, and essential minerals. Soybean sprouts can be added to salads
and often used in Asian stir fry dishes.

● Cooked: Widely known as "edamame", unripe soybeans should be boiled or steamed

before consumption. In this form, soybeans are higher in healthy fatty acids and
protein, and lower in carbohydrate.

● Vegetable milk: This is a great way to get soy protein without the fiber. Soy milk can
be home made by cooking dried soybeans, blending them with water and straining the
mixture through a cheese cloth

● Tofu: Also known as soy curd, tofu is the result of curdling soy milk with a coagulant
agent called nigiri. Widely popular and considered as a soft cheese-like food, tofu is
usually packaged in water and should be refrigerated until used. Tofu is rich in plant-
based protein, calcium, and iron, being a great meat substitute for vegetarians.

● Kinema: Kinema is a fermented soya bean food of Nepal. It is a food of the Kirat
community mainly Limbu and Rai of eastern hilly regions of Nepal.

● Paste: Made of fermented soybeans, along with other grains, marine salt
and koji mushrooms, this thick paste is called miso, and it is used to flavor many
Asian dishes. Miso is a good source of protein and it has been considered as a healing
product for centuries.

● Sauce: A signature flavor in Asian cuisine, soy sauce is traditionally made by

fermenting soybeans, wheat grains and sea salt. It has been shown to have digestive,
antimicrobial, and antioxidant properties. However, due to its high sodium content,
soy sauce must be consumed in moderation.

● Powder: This formulation brings a high concentration of soy protein. It is usually

taken as a substitute of meat for people with dietary restrictions, and as a
complementary source of protein to prevent and treat osteoporosis.

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 ● Oil. Extracted from soybeans and popularly used for cooking, this oil is rich in
polyunsaturated fats, which can help reduce bad cholesterol levels, as well as the risk
of heart disease and stroke.
Herbal Remedies & Supplements

● Syrup. This estrogen enhancer can be made at home from soy sauce, and it can help
relieve premenstrual syndrome, as well as menopausal symptoms.

● Capsules. These capsules offer a high content of isoflavones. They are usually
directed to women with estrogen deficiencies, so they can take advantage of the
estrogenic properties of soy.

19