Evidence: Use of Height <145 cm to classify Pregnant Women (PW) at - PowerPoint PPT Presentation

Evidence: Use of Height <145 cm to classify Pregnant Women (PW) at nutritional risk Several studies have shown the risk of short stature (<145cm) among PW: Low birth weight (LBW) infants - 29% LBW infants of PW (<145 cm) and 1.32 times additional risk of LBW (Kamaladoss et al. 1992) - 75% LBW infants of PW (<145 cm) (Bisai 2010) Preterm birth and Small for Gestational Age (SGA) (Khanam et al. 2018) Stunting, growth retardation and slower postnatal growth velocity (Sinha et al. 2017)

Evidence: Use of BMI (<20 weeks) to classify Pregnant Women (PW) at nutritional risk WHO BMI category (kg/m 2 ) Weight category (Pre- Asian BMI category (kg/m 2 ) [Misra et al. 2009] pregnancy weight/weight [WHO, 2000] recorded <20 weeks) Severe thinness <16.0 <16.0 Thinness 16.0-18.49 16.0-18.49 Normal weight 18.5-24.9 18.5-22.9 Overweight 25-29.9 23-24.9 Obese ≥ 30 ≥ 25 • WHO BMI for age categories: mainly on Caucasian population • Asian cut-offs lower as compared to WHO: higher body fat, excess metabolic perturbations, and cardiovascular risk factors at lower value of BMI in Asians versus white populations

Evidence: Weight gain monitoring in pregnancy [1] (i) Gestational weight gain recommendation among Indian women

Evidence: Weight gain monitoring in pregnancy [2] (ii) IOM, 2009/ WHO 2016 weight gain recommendations

Evidence: Weight gain monitoring in pregnancy [3] (iii) Weight gain: Recommended weight gain 2kg/month in second and third trimester [SBA guidelines, GOI] (iv) Risk point : Weight gain <1kg/month in second and third trimester [Mother and Child Protection card/Kruger et al. 2005] (v) Risk point : Weight gain >3kg/month in second and third trimester [SBA guidelines, GOI]

Evidence: Use of MUAC for determining thinness/severe thinness in PW MUAC Classification <19cm Severe malnutrition ≥19 and <22.0 cm Moderate malnutrition ≥22 and <23.0 cm Mild malnutrition ≥23.0 Normal Source: Food and Nutrition Technical Assistance III Project (FANTA). 2016. Nutrition Assessment, Counseling, and Support (NACS): A User’s Guide— Module 2: Nutrition Assessment and Classification, Version 2. Washington, DC: FHI 360/FANTA; Guidance Document – Nutritional care and support for patients with Tuberculosis in India, MoHFW, GOI, 2017

Evidence: Use of MUAC for determining obesity in PW [1] PW (n=578) attending antenatal clinics, South Africa (Okereke et al. 2013; South African National Guidelines, 2014) MUAC did not vary across the three trimester groups High Correlation

Evidence: Use of MUAC for determining obesity in PW [2] MUAC: ≥33cm had a sensitivity of 76% and specificity of 91% for BMI ≥30 kg/m 2

Evidence: Mild/Moderate/Severe Anemia cut-offs Criteria Pregnant women Normal Hemoglobin (Hb) ≥11 g/dl Mild anemia 10 – 10.9 g/dl Moderate anemia 7 – 9.9 g/dl Severe anemia < 7 g/dl Source: Guidance Document – Nutritional care and support for patients with Tuberculosis in India, MoHFW, GOI, 2017; Anemia Mukt Bharat – Intensified National Iron Plus Initiative, Operational Guidelines for Programme Managers, Ministry of Health and Family Welfare, Government of India, 2018.

Micronutrient Supplementation and Deworming Supplement Parameter Category Frequency IFA tablet (100mg iron and Hb ≥ 11mg/dl No anemia One IFA tablet daily from second trimester onwards 500mcg folic acid) Hb:7-10.9 mg/dl Mild/moderate upto 6 months post-partum anemia Two IFA tablets daily from second trimester onwards upto 6 months post-partum Calcium tablets (500 mg 2 tablets daily from second trimester onwards upto elemental calcium and 250 6 months post-partum International Unit (I.U.) vitamin D 3 Albendazole (400 mg): 1 tablet after the first trimester, preferably in the Deworming second trimester Source: Anemia Mukt Bharat – Intensified National Iron Plus Initiative, Operational Guidelines for Programme Managers, Ministry of Health and Family Welfare, Government of India, 2018; National Guidelines for Calcium Supplementation During Pregnancy and Lactation. Maternal Health Division, Ministry of Health and Family Welfare, Government of India, 2014; National Guidelines for Deworming in Pregnancy, Maternal Health Division, Ministry of Health and Family Welfare, Government of India, 2014.

Counseling Material [1] Group counseling (while waiting for test results and doctor’s visit) Individual need based counseling (before leaving the facility)

Counseling Material [2] Recipe book for underweight Recipe book for obese

Counseling Material [3]

Refer/Treat for underlying conditions as per GOI guidelines Severe Genito-urinary Anemia Malaria infection Hb: <7 g/dl Fever with Burning or itching chills ≥3 days sensation during urination Night blindness/ Bitot’s Tuberculosis spot Cough for >2 Vitamin A weeks/blood in Underlying deficiency sputum conditions GDM Goitre 2 hour blood Visible neck sugar (OGTT): swelling ≥140mg/dl Hypertension Fluorosis SBP : ≥140 mmHg Dental/Skeletal or DBP: ≥90 mmHg

Management of severe thinness through diet (National Guidelines of various countries) Several intervention studies on increasing energy requirements [ Range: 700-1200 kcal ] for PW with severe thinness have shown positive effects: - Fewer babies dying during labour - Fewer SGA and LBW babies - Incr. in BW among undernourished women - Incr. head circumference Study details Sample Intervention Malawi National Pregnant women: Acute undernutrition- Treatment up to BMI 17 : 2 pots of RUTF guidelines, 2006 MUAC < 19 cm (260g, 2700 kcal ) per day or 6 sachets of RUTF (92g, 3000 kcal ) per day Pakistan National Pregnant women: MUAC <21.0 cm RUTF (2-3 sachets/day) if sufficient supplies guidelines, 2009 (undernutrition) are available. Total calorie intake 2500 Kcal Uganda National Pregnant women: MUAC <22.0 cm and Supplementary ration should provide from guidelines, 2010 presence of bilateral oedema 1000 – 1200 Kcal per person per day and 35 – (undernutrition) 45g of protein

Management of severe thinness through GoI schemes Many states are providing additional calories and protein in the form of One full meal/THR/milk and eggs to pregnant women THR/OFM: Across Indian States Ingredients Nutrient composition under ICDS Telangana (OFM) Rice (150g), Dal (30g), Oil (16g), Milk (30 days) Energy: 1192 kcal 200 ml [additional], Egg (1/day), 50g Protein: 37.0 g [additional], Vegetables: 50g Calcium: 579 mg Karnataka (OFM) Additional chikki (jaggery + peanuts) Odisha (Ready to Eat wheat Chhatua : Wheat, Bengal gram (whole/roasted), Chhatua - Energy: 754 kcal , based Chhatua – THR) Groundnut and sugar Protein: 24.9g 2 boiled eggs/week (additional) Recommendation: 200g of Chhatua to be consumed, 2-3 times a day

Management of severe thinness through diet Normal RDA (sedentary women) - Energy: 1900 kcal, Protein: 55 g (ICMR, 2010) Pregnancy - Energy: 1900 + 350 = 2250 kcal, Protein: 55 + 23 = 78 g Evidence: Increased requirements for PW with severe thinness Trimester (IOM Normal Pregnant women Underweight Pregnant recommendations) (kcal/d) over and above the women (kcal/day) over and RDA above the RDA First No additional calories + 150 kcal Second + 340 + 590 kcal (340 + 250 kcal) Third + 452 + 752 kcal (452 + 300 kcal)

Hospital management of severe thinness: F-100 F-100 (350ml) – twice a day to be provided along with normal diet Source: Guidelines on Nutritional care and support for patients with Tuberculosis in India, GOI (2017) recommendations

Management of severe thinness [after review of evidence] Options to meet additional requirements a. If in facility, F-100 (350 ml), twice a day b. If in OPD, consider high risk pregnancy link for: 1) ICDS double THR (1200 kcal and 38-40 g protein) 2) Food basket through PDS 3) Egg/Milk through NRLM