Nutrition Assessment, Counselling and Support (NACS) Reference Manual

1. Introduction

The Nutrition Assessment, Counselling and Support (NACS) Reference Manual provides a practical framework for healthcare workers in hospitals, health centres, and clinics to identify, treat and prevent malnutrition among patients. It aligns with national nutrition policies and the WHO guidelines on Integrated Management of Acute Malnutrition (IMAM). The manual is designed for both novice and experienced providers, offering stepbystep instructions, illustrative tools, and evidencebased counselling messages.

Purpose

• Standardise nutrition screening and assessment across health facilities.
• Equip providers with communication skills for effective nutrition counselling.
• Facilitate monitoring and followup of patients at risk of or living with malnutrition.

2. Core Components of NACS

2.1 Nutrition Screening

Screening is the first contact point. All patients, regardless of diagnosis, should be screened at admission, during outpatient visits, and at discharge. The manual recommends the Mini Nutritional Assessment (MNA) shortform for adults and the MidUpper Arm Circumference (MUAC) measurement for children under five.

1. Ask the three screening questions:
   • Unintentional weight loss in the last 3 months?
   • Reduced appetite or food intake?
   • Physical weakness or fatigue?
2. Measure weight and height (or length for infants) to calculate BMI.
3. Record MUAC for children 659 months.

2.2 Detailed Nutrition Assessment

If screening indicates risk, a comprehensive assessment follows. This includes:

• Anthropometric measurements (weight, height, MUAC, head circumference for infants).
• Clinical signs (edema, hair loss, skin changes).
• Dietary intake assessment (24hour recall, food frequency).
• Biochemical tests when available (haemoglobin, serum albumin).
• Socioeconomic and household food security interview.

The manual provides illustrated charts for interpreting zscores and percentiles.

2.3 Nutrition Counselling

Counselling is patientcentred and should be delivered in a language the patient understands. Key points include:

• Assess knowledge, attitudes and practices related to nutrition.
• Use the ASKTELLASK communication model.
• Provide specific, actionable messages (e.g., Add one extra boiled egg to your child's meal each day).
• Tailor advice to the patient's cultural food preferences and economic situation.
• Document the counselling session and set realistic goals.

2.4 Nutrition Support

Based on the assessment, support may involve:

• Therapeutic feeding (e.g., ReadytoUse Therapeutic Food for severe acute malnutrition).
• Supplementary feeding programmes for moderate malnutrition.
• Micronutrient supplementation (iron, folic acid, vitamin A).
• Fortified blended foods for pregnant and lactating women.
• Referral to specialised nutrition services when indicated.

All interventions must be monitored weekly for progress and adverse effects.

3. Training Approach for Service Providers

The manual outlines a blended learning strategy consisting of:

1. Theoretical Sessions 2day classroom teaching covering basic nutrition concepts, classifications of malnutrition, and the NACS algorithm.
2. Practical Workshops Handson practice of measurements, use of growth charts, and roleplay for counselling.
3. Onsite Mentoring Onemonth supervised implementation with weekly feedback.
4. Refresher Courses Quarterly short courses to reinforce skills and introduce updates.

Learning Outcomes

• Accurately screen and assess nutritional status of patients of all ages.
• Develop individualized nutrition care plans.
• Deliver culturally appropriate nutrition counselling.
• Document and report nutrition indicators in the health information system.

4. Monitoring, Evaluation and Reporting

Effective NACS implementation requires routine data collection and analysis. The manual recommends the following indicators:

Data should be entered into the District Health Information System (DHIS2) and reviewed in monthly nutrition coordination meetings.

5. Resources and Tools

• Screening Checklist Onepage form for rapid assessment.
• Anthropometry Kit Weight scale, length board, MUAC tape.
• Counselling FlipChart Visual aids depicting portion sizes, food groups, and feeding frequency.
• Recipe Booklet Locally appropriate, nutrientdense recipes for families.
• Referral Form Standardised form for higherlevel nutrition services.

All tools are printable in colour and available for download from the Ministry of Health website.

6. Challenges and Solutions

Challenge: Limited staff time for thorough assessment.

Solution: Integrate NACS steps into routine vital sign collection; use taskshifting to allow community health workers to perform screening.

Challenge: Inadequate supply of therapeutic foods.

Solution: Establish buffer stocks at district warehouses and develop a rapid resupply request form.

Challenge: Low patient adherence to counselling messages.

Solution: Involve caregivers in counselling, provide practical cooking demonstrations, and use peersupport groups.

7. Conclusion

The NACS Reference Manual equips healthfacility based providers with the knowledge and tools needed to combat malnutrition at the point of care. By standardising screening, assessment, counselling and support, health systems can improve early detection, increase recovery rates, and ultimately reduce morbidity and mortality associated with undernutrition. Consistent training, supportive supervision, and robust monitoring are essential for sustained impact.

For the full manual, training schedules, and downloadable tools, please visit the official Ministry of Health NACS portal.