SOME THINGS THAT YOU SHOULD KNOW ABOUT NUTRITION MONTH 2005 AND THE NUTRITION of PRESCHOOL CHILDREN,

Aged 3-5 Years Old

1. What is nutrition month? Nutrition Month is the time of the year when the public's attention is focused on nutrition along a chosen theme. It is mandated by section 7 of Presidential Decree No. 491 (Nutrition Act of the Philippines, 25 June 1974), which states, ". . . The month of July shall be designated as the Nutrition Month for the purpose of creating awareness among our people on the importance of nutrition. Activities shall be coordinated by the National Nutrition Council (NNC) and the local governments". 2. What is the National Nutrition Council? The NNC is the policy-making and coordinating body on nutrition in the country. It has a Governing Board composed of 10 government organizations (GOs) and 3 representatives from the private sector. Chaired by the Department of Agriculture (DA), the NNC member agencies are the following: Department of Budget and Management (DBM) Department of Education (DepEd) Department of the Interior and Local Government (DILG) Department of Health (DOH) Department of Labor and Employment (DOLE) Department of Science and Technology (DOST) Department of Social Welfare and Development (DSWD) Department of Trade and Industry (DTI) National Economic and Development Authority (NEDA) The President of the Republic appoints three members from the private sector for a two-year term. At present, the private sector members are the ABS-CBN Foundation, Inc., GMA Kapuso Foundation, Inc. and a retired nutritionist, Ms. Elisa C.Valdecantos. The NNC Secretariat acts as the implementing arm of the NNC Governing Board. Thus, among others, it coordinates and leads in efforts to make the celebration more meaningful. While the Secretariat has a limited human resource base of only over 100, the NNC network, composed of interagency nutrition committees chaired by local chief executives, extends down to the barangay level. 3. What is the focus of 2005 Nutrition Month? The theme for the 31st Nutrition Month Celebration is "Batang may kinabukasan, sa wastong nutrisyon simulan". The theme reemphasizes the importance of ensuring good nutrition of every individual early in life for optimum health and psychosocial development. This year's celebration builds and follows through the gains of the immediate past 2 years' celebrations that focused on the nutritional importance of breastfeeding and complementary feeding, respectively. Thus, NM 2005 takes to center stage nutrition of preschool children, less than 6 years old.

Good nutrition during preschool age is crucial to every child's future. This is the time when the child needs adequate food to grow and build his or her body, to give him or her plenty of energy to play and to help him fight common infections. It is also important to note that brain growth is 75% complete by the end of the 2nd year. Given the right kinds and amounts of foods at the right time, young children are assured of their fundamental right to adequate food and nutrition to help them become healthy, happy and physically fit as well as mentally alert. Among others, these are the qualities we want every Filipino child to have, to become a "bright child". During preschool years, the foundation of becoming a bright child continues to be built. Along this line, adequate nutrition of the child presents a very significant building block, to help the child achieve his/her physical and mental potentials as a human being and therefore, enjoy a brighter and better future. 4. Why do we want a "bright child"? We want every Filipino child to be a "bright child" because it is the outcome of fulfilling the child's basic right to adequate nutrition and care. A bright child is a well-nourished child. He/she is healthy, strong, and alert, has good disposition and grows at a normal rate. His/her appetite, digestion and elimination are regular. Otherwise, the child is short, then, sluggish, lethargic, and frequently ill because of low resistance to infections. Prolonged inadequate food intake in the early years of life coupled with frequent bouts of infection can lead to malnutrition. While many undernourished preschool children survive, their academic performance tends to be lower than children who were well-malnourished in the first years of life. Under nourished children are also less productive as adults. In contrast, overnutrition may lead to obesity that may cause physical and emotional problems in childhood and later in life. 5. How can one ensure good nutrition of a preschool child? A key to ensure that a child achieves optimum nutritional wellbeing is eating a variety of foods in the right amount every day. No single food can provide all the nutrients needed for an active child to achieve good health and normal growth. Some foods have more of certain nutrients than others. By eating a variety of foods, a growing child has better chances of getting all the nutrients he/she needs. 6. What are the important foods in the diet of a growing child? For a young child to have nutritious or well-balanced diet every day, parents should choose and prepare foods from the different food groups: energy-giving, body-building, and bodyregulating foods or what we know as GO, GROW and GLOW foods. Go or energy-giving foods: The main nutrients in this food group are carbohydrates and fats. Carbohydrates and fats are chief sources of energy. Preschoolers are very active. Give them energy foods to keep them on the go, all the time. Examples of foods in this food group are: rice, corn, root crops, bread and bakery products, noodles, cooking oil, butter, margarine and other fats, and sugars.

Some of the food products in this group, e.g. bread and bakery products, noodles, cooking oil, and margarine have been fortified with vitamin A. or Iron or Iodine or a combination of vitamin A with Iron or Iodine. When buying these products, look for the Sangkap Pinoy Seal (Figure 1) or the Diamond Seal (Figure 2), a sign that the product has been fortified at levels approved by the Department of Health. In particular, the Diamond Seal was awarded to manufacturers of fortified cooking oil, flour, salt, sugar and rice, among others.

Grow or body-building foods: These foods are high in protein and minerals needed for growth and repair of body tissues. Protein also gives energy, but it is more important to children as a body-building nutrient. The foods in this group are: meat, fish, poultry, eggs, organ meats, milk and milk products, and dried beans like monggo and nuts. These foods are also high in vitamin A and iron that can be used readily by the body. Glow or regulating foods: These are the green, leafy and yellow vegetables like malunggay, kamote tops and squash, other vegetables, vitamin C-rich fruits like guava, mango and orange, and other fruits. Foods in this group are rich in vitamins, minerals, and fiber. Vitamins and minerals are essential for growth, for healthy eyes, for strong bones and teeth and high resistance to infection. Fiber is important for regular bowel movement. 7. How much food should a child eat? Here is a table to guide us on the daily recommended kind and amount of food for preschool children. Recommended Amounts 1-3 years 2-3 1/2 cups, cooked 4-6 years 3-4 1/2 cups, cooked

Food Groups Energy-giving Foods Rice and alternatives Rice and others 1 serving of rice or alternatives = 1 cup rice, cooked, or 4 pcs pandesal (about 17 g each), or 1 cup macaroni or spaghetti, cooked or 1 packed instant noodles, or 1 small size rootcrop, 180 g Fats and Oils Sugar

6 teaspoons 4 teaspoons

6 teaspoons 5 teaspoons

Body-building Foods Meat and alternatives Fish/Meat/Poultry/Dried Beans/Nuts 1 serving

1 1/3 servings

1 serving of fish = 2 pcs (55-60 g each), about 16 cm long fish; 1 serving of meat/poultry = 30 g lean meat, cooked, or 11/2 cups cooked dried beans, preferably taken at least 3 times a week Egg Whole milk 1 glass = 240 ml (1 glass whole milk is equivalent to 4 tbsp powdered whole milk or 1/2 cup evaporated milk diluted in 1 glass water) 1/2 piece 1 glass 1/2 piece 1 glass

Regulating Foods Vegetables Fruits Green, leafy and yellow Others Vitamin C-rich 1/4 cup, cooked 2 tbsp, cooked 1/3 cup, cooked 1/4 cup, cooked

1/2 medium size 1/2 - 1 medium or 1 slice of a big size or 1 slice of fruit a big fruit 1/2 medium size 1/2 - 1 medium or 1 slice of a big size or 1 slice of fruit a big fruit 4-6 glasses (240 ml) 5-7 glasses

Others

Water and Beverages

The FNRI has converted the above food guide into Food Pyramid for Children (Figure 3) which is available at their website. Figure 3

printed by Nestle Phils. for the Food and Nutrition Research Institute

8. How do we know if the child is eating "correctly"? Monitoring growth of the child over time through the growth chart is a useful and important way to know if the child is growing as expected and is healthy and fit. A growth chart is a chart on which weight and height measurements of a child can be plotted. Ideally, height and weight measurements of children between the ages of 1 month and 3 years should be taken every month, the first 3 years being a period of rapid growth. Thereafter, these should be done at least once every 3 months. It is important to observe the direction of the curve of plotted measurements, i.e. is it going up? going down? flat? A going up curve is desirable because it is a sign that the child is growing adequately. On the other hand, a going down or flat curve is undesirable because both curves signal poor growth of the child needing special attention for correct intervention. For example, being underweight may be associated with nutrient deficiencies indicating that something must be done to improve, among others, the quantity and quality of food given to the child. It is important to remember that when results of growth monitoring are used to adjust the nutritional care given to the child, growth monitoring can help prevent the onset of malnutrition.

9. Do preschool children need nutritional supplements? Strictly speaking, nutritional supplementation is only necessary when deficiencies in vitamin A, iron and iodine are prevalent. Specifically, high-dose vitamin A supplementation is given to children twice a year for protection against vitamin A deficiency disorders. Furthermore, children with food allergies or intolerances or those following very strict diets may also need supplements. Remember though that supplements can be toxic to children if taken in excess and should be stored and used with caution. Eating a variety of foods from each of the three food groups is the best way for preschoolers to get the nutrients they need. Using fortified foods with the Sangkap Pinoy and Diamond Seals would also be helpful. 10. What factors influence food intake of preschool chuildren? A study done by Bayaga (2004) on the nutritional needs of preschool children revealed that a child's food choices are largely determined by the family environment and other community or external factors. Family environment With or without conscious effort, the family guides and shapes the food preferences and establishes the food pattern and eating habits of preschool children.

Family as significant model for proper food intake. Many mothers believe that their children eat what they see them eating at meals and snacks. If they drink milk or eat vegetables, children do the same. Thus, it is important to set a good example of eating the right food. Nutrition knowledge of parents. The more literate the parents are, the better the nutritional status of the members of the family. Ordinal position of the preschooler in the family. Birth order affects the child's food intake specifically when the family prioritizes older siblings than the younger ones. Parent-child interaction. Positive relationship between parent and child is important for the child to achieve optimum nutrition. Parents must understand that by two years of age, the child can hold a cup and use a spoon well and by 6 years, children have refined skills and begin to use knife for cutting and spreading (Bongga, 2005). Accidental spillage of food and mess on the dining table should not be reason for scolding the child. Parents should support the child's efforts of self-feeding. Successful eating helps children feel good about themselves. Atmosphere around food at mealtimes. Making mealtimes pleasant and enjoyable and encouraging a happy talk could promote a good appetite among children. Keep mealtime fun, laugh together and share funny stories. When a child learns to enjoy eating, he/she has more chances to form good eating habits and attitudes. Parents should also encourage their children the practice of good dental hygiene. The composition of the diet and the child's eating habits are factors in the development of dental caries.

Influence of television The amount of time children spend watching television could have negative effects.

Television affects food requests of children. Children tend to request foods which are commonly advertised on television which are low in fiber and high in sugar, fat or sodium. Extensive television viewing encourages sedentary lifestyle. This results to obesity and passive use of leisure time. Television viewing is correlated with between-meal snacking that lessens the child's appetite for the next meal. Preschoolers are unable to distinguish commercial messages from regular programs. They are attracted more to commercials, thus, they are easily influenced by the messages conveyed particularly those related to food.

Peer influence

As preschoolers grow, their world expands and their social contacts become more important. Peers affect their food habits and choices. Children usually eat well when in a group. Willingness to try new foods may be influenced by peers. Group settings are also ideal for imparting nutrition information during mealtimes.

11. What can we do to help children use television and media in positive ways and to avoid the negative influences? Parents being role models can create opportunities that promote learning and healthy living. Set boundaries for television and media use, allowing them to be educational and positive family experiences. Here are various ways to do this:

To the extent possible, limit television viewing to less than two hours per day. Encourage children to take breaks and move around every half hour when watching television. Identify television programs that the entire family can watch together. If the child watches television alone, be aware of the content of the program and the commercials. Talk about it and ask questions. Follow up the television program or commercials by discussing what happened. How did the child feel about the characters and the story? Why? Can the child distinguish between "fact" and "fiction"? Discuss your values. Talk about how your family is different from or similar to the family shown on television. Explain body size and body image so children recognize that the people on television are not necessarily the realistic and healthy sizes. Use commercials as avenues for critical thinking. Encourage children to analyze and understand why and how they are trying to market specific food products. Encourage children to watch television programs that teach values in life and about food and consumerism, among others.

12. What are the common feeding problems in preschool children? A preschool child is sometimes a difficult child. His/her appetite is erratic and behavior sometimes capricious. The child's loss of interest in food can sometimes become the source of irritation between the mother and the child. In most instances, parents treat young children as little adults and imposing their own adult-style dietary restrictions on them. But, this will be counterproductive and feeding problems and interference with the child's physical and psychosocial development can result, thus, negatively affecting his or her nutritional status. Food Jags At preschool age, children accept only very few foods and reject all others. It is likely that the child's appetite is lost because of too much parental urging or the child has become tired of the same foods eaten everyday. There is no real problem if the accepted foods represent a nutritionally adequate diet and do not contain excess additives or salt. If not, parents are advised to do the following:

Offer a variety of foods but start the meals with the foods the child likes best. Serve small portion sizes with options for seconds. Praise the child for eating even a little. Present foods attractively; observe some sense of order, i.e. no mixed dishes. Remember that a child is very keen on the taste, flavor, texture, and temperature of food. Introduce one new food at a time.

Dawdling A child who dawdles is one who lingers or dilly-dallies with food during mealtime. Oftentimes, the child is given portions that are too large; or the child may not be feeling well or may be trying to get attention. If this happens, parents should avoid fussing over the child. Let the child enjoy eating. Gagging A child sometimes feels like vomiting especially when fed coarse foods. The situation can be remedied by feeding the child in a well-ventilated and clean place, eating with other children, encouraging self-feeding and using colorful and easy-to-handle utensils. Eating too much Overeating is often a habit learned by a child who is encouraged by his/her parents to overeat because of the mistaken notion that a fat child is a healthy child. This attitude has to be corrected because it may result to obesity leading to physical and emotional problems during childhood and even in adulthood. Thus, the child must be taught good eating habits and the practice of eating a variety of foods. Among others, the child should be restrained from eating too much energy-rich foods like cakes, pastries, candies, chocolates and ice cream, as well as fatty foods.

Aversion toward some foods Mothers frequently complain about their children's dislike for vegetables. In most instances, the unpalatable preparation of vegetables is to be blamed for the aversion. Vegetables must be prepared and served in such a way that they are attractive to children. For example, the mother may use colorful vegetables such as carrots, baguio beans and squash and cut them in different shapes. Leafy vegetables can be sliced finely so children can chew them easily. Breakfast skipping Children who skip breakfast usually make more errors when given tests and have slower memory recall. Brain functioning is sensitive to short-term variations in nutrient availability. Among the reasons cited are lack of time, not hungry in the morning, and dislike for breakfast food. Here are some ways to make breakfast successful:

Eat breakfast with your child. Some preparation the night before may contribute to a more relaxed morning routine. Offer 2 or 3 food choices, if possible. Give your child time to wake up and settle down. Rushing puts pressure on breakfast eating. Let the child help you prepare breakfast.

13. What about feeding between meals? Should children be given snacks? Yes, children should be given snacks. The habit of taking snacks should not be discouraged. Given the right kind of food at a reasonable time, snacks can contribute significantly in meeting the child's nutritional needs. Here are a few suggestions in preparing snacks for your child:

Consider snacks as part of the daily food intake, not something eaten in addition to regular meals. If the child eats many snacks a day, reduce the amount of food to be eaten at mealtimes. Milk, fresh fruits, fruit juices instead of soft drinks together with small sandwiches, cookies or native delicacies like kutsinta, maja, halaya and suman are appropriate choices for nutritious snacks. Do not offer snacks too close to mealtime so as not to reduce appetite. An allowance of 2 hours before mealtime will not spoil the child's appetite.

14. What are some nutritious snacks for children? Are these available in the market? The Nutrition Center of the Philippines (NCP) through its subsidiary, the Philippine NutriFoods Corporation, produces and markets high protein-high calorie food supplements and snack foods like Nutripak, Nutricrackers, Nutrinoodles, Nutriflakes and Gro cookies. Interested parties may get in touch with

Dr. Florentino S. Solon Executive Director, Nutrition Center of the Philippines Nichols Interchange, South Superhighway, Makati City Tel. Nos.: 818-7397; 816-4123

On the other hand, the Food and Nutrition Research Institute (FNRI) of the DOST has developed some high calorie-protein snack foods like squash chips, snack crunchies made from a mixture of rice flour, skim milk powder and beef blood powder and rice-mongo crunchies fortified with vitamin A, thiamin, riboflavin and niacin. To improve nutritional quality of baked products, FNRI has also experimented with a mongo flour supplemented pan de sal, a traditional bun of the Filipinos. The technologies are available for transfer and commercialization. Interested parties may get in touch with Dr. Mario V. Capanzana OIC-Director, Food and Nutrition Research Institute DOST Compound, A. de los Santos Avenue Western Bicutan, Taguig Telefax No. 837-2934 15. What other factors hamper feeding the preschooler appropriately? Dimaano (1996) cited that feeding the child is sometimes hampered by fallacies handed down through generations. Some mothers still believe that some foods should not be given to preschoolers for varied reasons. For example, mothers avoid giving eggs and fish because they fear these would cause bad teeth and the presence of worms. Some mothers also do not give leafy vegetables believing that these are hard to digest. Furthermore, they believe that eating squash can cause mental dullness. Sour fruits and fruit juices are also avoided as these can cause stomach ache; so too milk and sour fruits eaten together. This is one reason why many mothers often omit milk and fruits on the daily menu. The idea that fruits cause stomach upset seems to have stemmed from the belief that fruits cause the stomach to be sour or acidic. These then point to the need for nutrition education efforts to improve feeding practices for preschool children in the Philippines. It is important to refute or correct these fallacies on certain foods. For one, studies have shown that fish can only become a carrier of worms when not properly handled, cooked and eaten. On the other hand, sour foods like fruits cannot cause acidity. On the contrary, scientific evidence shows that sour fruits are alkaline or baseforming foods. 16. What foods should be given to a sick child? Parents should feed a sick child with a nutritious diet for fast recovery. However, small but frequent feedings will have to be done. Diarrhea

Encourage the consumption of plenty of fluids (e.g. fruit juices like buko, calamansi,etc.). If necessary, give homemade or commercial oral rehydration solution

(ORS). To make homemade ORS, dissolve 1teaspoon of sugar and 1/4 teaspoon of salt in 1 glass of water. Encourage the child to eat as much as he/she can, especially of foods with low fiber and fat content. Include foods rich in pectin such as bananas and apple. This hastens the development of formed stool.

Fever

Encourage feeding during illness. Increase feeding during the convalescence phase to increase resistance. Encourage the consumption of more frequent meals and larger amounts of nutrientdense foods over a sustained period of time after illness. Increase the child's fluid intake.

Food allergy

Determine and eliminate the offending food. Substitute the offending food with other nutritious foods. Try giving offending food in small doses then gradually increasing until the child gets used to it.

Constipation

Offer the child plenty of fluids, especially water, to facilitate bowel movement. Offer foods that are high in fiber such as fruits and leafy vegetables. Give milk and dairy products in amounts appropriate for the child's age.

17. So, how is the nutrition situation of Filipino preschool children?

Various forms of malnutrition continue to afflict Filipinos especially children and women. These are protein-energy malnutrition (PEM), vitamin A deficiency disorders (VADD), iron deficiency anemia (IDA), and iodine deficiency disorders (IDD). Side by side with these forms of undernutrition is overnutrition. PEM has three forms, namely: underweight, stunting, and wasting. Results of the latest national nutrition surveys conducted in 2003 by the Food and Nutrition Research Institute of the Department of Science and Technology (FNRI-DOST) showed that there has been a reduction in the prevalence of underweight, stunted and wasted preschool children compared to 1998 and 2001 levels. However, there was an increase in the prevalence of overweight preschoolers. In terms of number, 3.18 million children are underweight, 3.50 million are stunted, 640,000 are thin, and 160,000 are overweight. VADD is a condition arising from low intake of foods rich in vitamin A, poor absorption of vitamin A due to low intake of fats, which is needed for absorption of vitamin A, and presence of illnesses such as respiratory infections, diarrhea and measles. The 2003 national nutrition survey showed that the number of children with deficient to low vitamin A levels was higher than in the 1998 survey (40.1 percent vs. 38.0

percent). This prevalence rate is higher than the cut-off point of 15 percent set by the World Health Organization (WHO), indicating that VADD still remains as a public health problem in the country. IDA is a condition where there is not enough hemoglobin in the red blood cells because of lack of iron. This happens when intake of iron-rich foods is low over a period of time, or when absorption of iron is low, or when intestinal parasites are present. The prevalence of anemia among 6 months to less than one year old children has continued to increase, and is alarmingly high at 66%. On the other hand, among 1-5 year old children, the prevalence is 29.1%. Prevalence among infants is indicative of a severe problem based on the WHO-FAO cut-off point of 40%. Overnutrition is also increasingly affecting Filipinos especially children, and including adults. While our genes have not changed, the environment has. Overnutrition results from increased intake of foods of higher energy density and reduced physical activity. The 2003 FNRI survey showed an increase in the prevalence of overweight children as compared with 1998 data. Among the 0-5 years old, 1.4% (equivalent to 160,000) are overweight. Thus, vigilance should be exercised in preventing an increase in overnutrition since the condition increases the risk to diet-related diseases such as diabetes, hypertension, cardiovascular diseases, and cancers in the later years of life. Malnutrition is not caused by one single factor but by many factors that are interrelated and intertwined. The immediate factors are food intake, health conditions, and care of children. But these are also related to macro and micro factors that affect food availability and accessibility at the national, community, household and individual levels.

18. What is teh government doing to address the situation and achieve a country of "bright" children?

The government addresses malnutrition through the Philippine Plan of Action for Nutrition or PPAN. The PPAN is the country's guide for action for nutrition improvement to help national government agencies, local government units, nongovernmental organizations, academic institutions, business corporations, international organizations and the citizenry align their actions accordingly. The PPAN is integral to the Medium-Term Philippine Development Plan or MTPDP, specifically in Chapter III on Social Justice and Basic Needs. PPAN 2005-2010 considers a number of contextual factors. These include opportunities such as the Millennium Development Goals; PGMA's 10-point agenda with its battle cry "BEATING THE ODDS" and specific focus on bringing about social justice and delivery of quality social services including nutrition and the target of making food plentiful;and ongoing programs that provide services to specific nutritionally at-risk population groups and depressed areas. The PPAN's ultimate goal is the improved quality of life for Filipinos through better nutrition, improved health and productivity. Specifically, it aims to: a) reduce the prevalence of protein-energy malnutrition (PEM) and micronutrient deficiencies; and low birth weight; and b) prevent the increase in the prevalence of overweight children and adults. Among the priorities of the government is the achievement of the UN Millennium Development Goals. The 8 MDGs are milestones in reducing extreme poverty and the

worst forms of human deprivation by the year 2015. Eradicating extreme poverty and hunger is one of the 8 MDGs. One measure that hunger had been reduced is the goal of reducing by half the proportion of underfive children who are underweight from the 1990 level. This means that we need to double or even triple our efforts in order to achieve the MDG by 2015. But government can not do it alone. Implementation of the PPAN shall be guided by the following principles: 1) focused targeting, 2) lifecycle approach, 3) partnership with non-traditional partners, and the 4) implementation of nutrition interventions to address the immediate causes of malnutrition, complemented by policies, programs and projects that should address the core issues of poverty and other socio-economic related issues. To achieve the nutritional goals, various programs that will contribute to improving food and nutrient intakes, and reduction and prevention of the incidence and duration of infections will be implemented. These include a) Home, School and Community Food Production; b) Food Assistance; c) Food Fortification; d) Micronutrient Supplementation; e) Livelihood Assistance; f) Nutrition Information, Communication and Education; and, g) Nutrition in Essential Maternal and Child Health Services. This particular mix of interventions is primarily meant to directly impact on the nutritional status of preschool children and at the same time address the root and underlying causes of malnutrition. Supporting the implementation of the proposed program strategies are facilitating activities such as a) Human Resource Development or HRD; b) Nutrition Advocacy; c) Research and Development; d) Resource generation and mobilization; e) Policy and Standards Formulation; and e) Strategic Planning, Networking and Coordination. These activities facilitate the delivery and management of nutrition interventions.