NUTRITION

Module competence
Acquire knowledge on nutrition, apply relevant skills and attitudes to promote health, prevent
and manage illnesses

Objectives
1. Demonstrate the understanding of importance of nutrition in disease prevention and
maintenance of good health
2. Recognize and manage nutritional disorders

Module content
Definitions
Nutrition: is the sum total of the processes involved in the taking in and the utilization of food
substances by which growth, repair and maintenance of the body are accomplished.
It involves ingestion, digestion, absorption and assimilation.
Nutrient- are compounds in foods that are needed by human body for energy to work, for
growth of body tissue, for repair and maintenance of body tissues and also to support body’s
immune function all that works towards a healthy living. Basically, nutrients are substances
required by the body to perform its basic functions
Food: any nourishing substance that is eaten, drunk, or otherwise taken into the body to sustain
life, provide energy, promote growth,
Balanced diet: a diet that provides the correct amount of nutrients for the needs of an individual
Malnutrition: incorrect or unbalanced intake of nutrients, may be insufficient or excess
Macronutrients: an essential nutrient required in relatively large amounts, such as
carbohydrates, fats, proteins, or water;
Micronutrients: A substance, such as a vitamin or mineral, that is essential in minute/small
amounts for the proper growth and metabolism of a living organism.
Community Nutrition: Refers to the social, economic, cultural and psychological implications
of food and eating.
Human nutrition: is the study of food in relation to health of individual and groups of people
particularly the infants, adolescents, pregnant and lactating mothers (vulnerable groups) and
functioning of the body organs and provide the energy the body requires.
Food bio availability – reduced or increases effects due to interaction eg when spinach is mixed
with meat in anaemic patient works excellent, spinach produces oxalic acids which binds to iron
thus increase iron absorption but when taken with tea it works bad coz tea binds with iron
preventing oxalic acid binding to iron absorption to the body hence iron deficit
Junk foods- less important foods
Faddism – false information in a community done as a fashion
Pulses – green legumes – miji, French bean
Nutritional status is a condition in the body resulting from intakes absorption and use of food.
Malnutrition is a term encompassing under nutrition (wasting, stunting, underweight and
deficiencies of essential vitamins and minerals) and over nutrition (obesity)
Acute malnutrition (wasting) is the result of recent rapid weight loss or failure to gain weight
and is associated with an increased risk of mortality. can be moderate or severe
Chronic malnutrition (stunting)is the result of inadequate nutrition over a much longer period
of time and is associated with an increased risk of disease/eventual death
Underweight is the outcome of wasting or stunting or a combination of both and is associated
with poor growth and development

IMPORTANCE OF GOOD NUTRITION

Its especially important for:
 Physical and mental dev. Of children and adolescents.
 Healthy pregnancies and deliveries.
 Resistance to infections
 For energy for working well
 To prevent deficiencies i.e. Kwashiorkor.

FOOD CLASSIFICATION
Food is classified according to the nutrients it contains and functions it performs. There are two
types of nutrients according to the body requirements; -
 Macronutrients –those that the body requires in large quantities measured in grammes.
 Micronutrients – those that the body requires in small quantities and a re measured in
milli- or micro grammes.

Food is classified into 3 major groups according to nutritional functions.

 Energy producing
 Body building
 Protective foods.

Nutrients
Macronutrients micronutrients
Proteins fats carbohydrate water vitamin, minerals
PROTEINS
They are the chief substances of the cells of the body. They are made up of simpler substances
known as amino acids. These amino acids are made of carbon, hydrogen, oxygen and nitrogen.
They are categorized as essential and non essential.
 Essential- those not synthesized by the body and must be included in the diet.

They include-histidine, methionine, tryphtophan, isoleucine, leucine,lysine, threonine, valine and

phenilanine
  Non essential- those that can be synthesized by the body and need not to be in the diet.

They include alanine, arginine, aspartic acid, asparagine, cysteine, cystine, glutamic acid,
glutamine, glycine, hydroxyproline, proline, serine, and tyrosine
The nutritional value of protein depends on the amino acids of which it is composed of. Some
foods are referred to as complete proteins because they contain all the essential amino acids in
the proportions required to maintain health. They are derived almost entirely from animal
sources e.g. meat, fish, milk, eggs, soya beans, and milk products excluding butter. They are also
known as high quality proteins since they are easily digested.
Sources of proteins
1. Animal products
2. Plant products e.g. legumes cereals
3. Other sources like oil seeds

Functions of proteins
Amino acids are used for;-
1. Growth and repair of body cells ad tissues
2. Synthesis of enzymes, plasma proteins, immunoglobulin and some hormones.
3. Provision of energy. When consumed in exces or there is deficiency of carbohydrates in
the diet and fat stores are depleted. 1 gram of protein produces 4.1 calories.

When proteins are consumed in excess of the body requirements the nitrogenous part is detached
(deaminated) and excreted by the kidney as urea and the remainder is converted to fat for
storage,
Protein deficiency
Protein energy malnutrition (PEM) is one of the most common health problems in the developing
countries. It is in two forms
 Marasmus- due to starvation leading to auto digestion of body tissues. Kwashiorkor-
unbalanced diet

Essential features of
Marasmus – marked wasting of muscles, severe growth retardation and texture modification of
hair.
Kwashiorkor- oedema of the face, lower limbs and sometimes generalized growth retardation
less than in Marasmus, mental changes, hair usually sparse straight silky and depigmented and
skin may be depigmented.
Body requirements
These depend on the sex, physical factors, physiological factors, age among others. Generally
1 gm per kg body weight per day. An extra amount is to be provided for heavy workers
and in convalescents or those with ailments involving either loss or destruction of body tissues
e.g. blood loss, surgery e.t.c.
CARBOHYDRATES
They are the main sources of energy and are composed of carbon, hydrogen and oxygen. 1 gram
of carbohydrates yields 4.1 calories. Carbohydrates are classified according to the complexity of
the chemical substances from which they are formed.
Monosaccharides – are the simplest forms and include glucose, fructose and galactose. They are
broken down into CO2 + H2O + energy after being converted into glucose.
Disaccharides – These consist of 2 monosaccharide molecules chemically combined. When the
molecules are split into monosaccharides energy is released for metabolic work. They include
 Sucrose- glucose + fructose + water
 Maltose- glucose + glucose + water
 Lactose- galactose + glucose + water

Polysaccharides- these are complex molecules made up of a large number of monosaccharide

molecules in chemical combination e.g. starches, glycogen, cellulose e.t.c The polysaccharides
are broken down during digestion to give monosaccharides. Not all polysaccharides can be
digested by human .g cellulose, this is because the enzymes required to digest them are not
produced by the body. Thus pass the alimentary canal untouched as roughage.
Sources
1. Starch- cereals e.g. wheat rice, millet, maize.
2. Sugars-
a. monosaccharides are found in fruits, honey, milk
b. Disaccharides like sucrose- sugar, lactose-milk, maltose-starch.
3. Cellulose- fibrinous substance found in vegetables, fruits and cereals.
Functions
1. Provision of rapidly available energy and heat. Glucose is the main fuel molecule for
energy production which is necessary for cellular activities.
2. It is essential for combustion of fats as fat is broken down using energy from catabolism
of carbohydrates.
3. Protein sparing- with adequate supply protein is not used for energy
4. Provision of energy for storage, when eaten in excess. In form of
a. Glycogen –as a short term energy store in the liver and muscles
b. Fat and deposited in the fat depots under the skin and other areas.

Daily requirements
The optimum quantity is 50-70% of the total energy requirements.
Deficiency /excess
-Since it is necessary to prevent problems of muscle and fat breakdown, it is deficiency will
result in the same wasting in Marasmus with production of ketone bodies in the blood resulting
in ketosis.
-Some diseases are thought to be predisposed by reduced intake of dietary intake of roughage/
fibre which results in constipation e.g. colonic cancer, appendicitis, gallstones e.t.c.
FATS
These are lipids that are solid at room temperature. Lipids are compounds that are insoluble in
water but soluble in organic solvents like ethanol or alcohol. They are made up of carbon,
hydrogen and oxygen. The hydrogen and oxygen proportions are not the same as those of water
and thus differ with carbohydrates.
They are classified as saturated and non saturated fats.
 Saturated –these are animal fats and contain saturated fatty acids and glycerol. They are
found in milk products, meat and eggs. All animal protein sources contain saturated fats.
Cholesterol is a saturated fat of clinical importance and is produced in the body but can
be found in meat and egg yolk.
 Unsaturated- this is vegetable fat containing unsaturated fatty acids and glycerol and is
found in margarine and vegetable oil. There are three main poly unsaturated fats which
are essential in that they cannot be synthesized by the body. Thus must be contained in
 the diet since they are necessary in the synthesis of plasma membrane lipids,
prostaglandins, leukotrines e.t.c. They are
o Linoleic acid
o Linolenic acids
o Arachidonic acids

Functions
1. Provision of most concentrated sources of chemical energy and heat.
2. Support of certain body organs e.g. kidneys, eyes
3. Transport and storage of fat soluble vitamins e.g. A, D, E, K.
4. Constituent of nerve sheaths and of sebum, the secretion of sebaceous glands in the skin.
5. Formulation of cholesterol and steroid hormones.
6. Insulation e.g. as a subcutaneous layer it reduces heat loss through the skin
7. Storage of energy in the adipose tissue
8. Satiety value- gastric emptying time is prolonged in chime containing fat thus prolonging
the return of hunger

Sources
-animal sources for non essential fatty acids and marine fish oils like cod-liver oil for essential
fats
-Vegetable sources – all vegetable oils have essential fat acids except coconut oil.
Fat malnutrition
-deficiency results in a condition known as phrynoderma which is a form of keratosis of
unknown aetiology but thought to be related to fat soluble vitamin deficiency
-Excess results in obesity and high levels of cholesterol in the body predisposing one to diseases
like atherosclerosis, coronary occlusion in coronary heart disease and cerebral vascular accident.

Daily requirement
It is suggested to be 10-20 grammes of fat per day depending upon the level of calories
consumed i.e. 20% of the total energy requirements

WATER
It is the most important nutrient because the functions of the cells occur in a fluid environment.
Water makes up about 60-70% of the body weight, approximately 65 in men, 55 % in women
and more in infants. Lean people’s body contains more water than that of the obese. Infants are
the most vulnerable to water deprivation or loss but everyone needs water for survival. Huge
amounts of water are lost everyday in form of urine, sweat and faeces. This usually balanced in a
normal individual by intake in food and fluids to satisfy thirst. Dehydration with serious
consequences may occur if intake does not balance loss. There also can be a positive balance in
some clinical conditions bringing about serious consequences.
Functions
1. Provision of a moist internal environment required by all living cell in the body
2. Participation in all the chemical reactions that occur in the body.
3. Moistening of food as saliva.
4. Regulation of body temperature as sweat
5. Major constituent of blood and tissue fluid thus is involved in transport of various
substances in the body.
6. Dilution of waste products and poisonous substances in the body
7. Providing medium for secretion of waste products e.g. urine sweat.

MICRONUTRIENTS
VITAMINS
These are chemical compounds required in small quantities and are essential for normal
metabolism. Many are not produced in the body thus have to be supplemented in the diet. They
are contained in many foods but are affected by processing, storage and preparation of food.
Thus vitamin content is highest in fresh foods that are used quickly with minimal exposure to
heat, air and water.

Classification
They are grouped into water soluble and fat soluble vitamins depending on there solubility.
 Water soluble- vitamin B group and C
 Fat soluble are vitamin A, D, E, K

Requirement
Each vitamin has a specific function in the body. The minimum intake of many has been
determined but optimum remains speculative.
WATER SOLUBLE
They cannot be stored in the body and must be provided in the daily intake. When there is
enough of the specific vitamin to meet the catalytic demand, the rest of the vitamin supply acts as
a free chemical and may be toxic to the body thus the body excretes it.
Vitamin C
It is very soluble and easily destroyed by heat, aging, chopping, salting and drying.
Functions
1. Utilization of iron- it acts as an antioxidant thus important in the reduction of iron for its
utilization
2. Forms cement that holds cells together known as collagen and thus strengthens blood vessels
and promote wound healing
3. It is important in the maturation of RBCs
4. It helps in arresting bleeding and is important in providing the first line of body defense
5. It is catalyst I the metabolism of amino acids.

Sources – citrus fruits, green vegetables liver and glandular tissues in animals.
Daily requirements-approximately 40mg daily that is
 Adults-50mg
 Pregnancy-50mg
 Lactation – 50 + 30mg
 Infants 30-50mg

Deficiency
It becomes apparent within 2-3 months with
 Scurvy (severe deficiency)
 Poor wound healing
 Easy bruising and minor hemorrhages
 Lose teeth
 Anemia

Excess results in –
  kidney stones due to crystal formation
 Urinary tract infection
 Scurvy on withdrawal

Vitamin B1-thiamine
It is a relatively stable to heat in the dry form but other wise rapidly destroyed. The daily
requirement is 0.8- 1 mg and the body stores about 30mg thus the intake should be 5mg for a
1000 calories
Functions
1. Coenzyme in carbohydrate metabolism that is in the oxidation and citric acid cycle thus
deficiency results in accumulation of lactic and pyruvic acids which may cause oedema
2. Its important for the nervous system function and muscles because of the dependency of
these tissues on glucose for fuel
3. Important in maintaining appetite and normal digestion

Sources- whole grains, unmilled cereal, milk, nuts, meat, lentils, green leafy vegetables.
Malnutrition
Deficiency results in
 beriberi where there is
1. Severe muscle wasting
2. Delayed growth in children
3. Polyneuritis – degeneration of nerves
4. Susceptibility to infections
 Wernicke encephalopathy and Korsacoff syndromes in alcoholics whereby there is
irreversible memory loss, ataxia, visual disturbances (double vision) and cardiac
enlargement arrhythmias, calf tenderness and mental confusion. Rx is thiamine.

Excess results in rapid pulse headaches weakness insomnia and irritability

Vitamin B2
It is also known as riboflavin. The daily requirement is 1.1-1.3 mg. Only small amounts are kept
in the body and it’s destroyed by light and alkalis.
Functions
1. Coenzyme in protein metabolism
 2. Promotes healthy skin and eyes
3. Oxidation and reduction of fats

Sources- yeast, green, vegetables, milk, liver, fish, eggs, whole grain
Deficiency
 Cracking of the skin especially around the mouth – angular stomatitis
 Inflammation of the tongue – glossitis
 Photophobia
 Scrotal dermatitis
 Greasy skin around the angle of the nose

Excess- elevated blood glucose and uric acid In blood

Folates
Occurs in 2 forms in food
1. Free folates
2. Bound folates e.g. folacin folic acid

It is synthesized by the bacteria in the large intestines. It is destroyed by heat and moisture. Daily
requirements are
 Healthy adults-100 micro grams
 Pregnancy- 300
 Lactation-150
 Children-100

Only small amounts are stored in the body and deficiency is noted in a short time.
Sources – liver, kidney, fresh leafy green vegetables yeast and poultry functions
1. DNA synthesis – without it mitosis and cell division is impaired
2. Maturation of RBCs
3. Metabolism of amino acids ( synthesis of purine and pyrimidines)

Deficiency results in megaloblastic or macrocytic anima

Excess-masking of vitamin B12 deficiency, insomnia and diarrhea
Niacin- nicotinic acid
Required for utilization of carbohydrate. Amino acid tryptophan is converted to niacin in the
body.
Sources-meat, whole grain cereals, eggs and dairy products
Requirements -6.6mg/1000 calories/day

Functions
1. Coenzyme in energy production reactions
2. In fat metabolism it enables it inhibits production of cholesterol
3. Promotes healthy skin, gastrointestinal and nervous system functions
4. It helps in protein utilization

Deficiency-pellagra within 6-8 weeks of severe deficiency characterized by 3 Ds

1. Dementia
2. Dermatitis
3. Diarrhea- other gastrointestinal disturbances e.g. anorexia, nausea, dysphagia,
inflammation of the oral mucosa.

NB isoniazid used in Rx of TB leads to deficiency of niacin

Excess- ulcer, liver dysfunction, increased blood glucose e.t.c.
Vitamin B6
It occurs in the 3 forms
 Pyridoxine
 Pyridoxal
 Pyridoxamine

Functions
1. Important in protein metabolism especially synthesis of nonessential amino acids and
molecules like haem and nucleic acids.
2. Conversion of tryptophan to niacin
3. Proper functioning of the central nervous system

Daily requirements -1.2-1.4 mg and the dietary deficiency is rare but affected by like alcohol and
anti Tbs
Sources; meat, eggs yolk, peas, beans, yeast, liver e.t.c
Deficiency; chilosis, anaemia, skin lesions, CNS disturbances

Vitamin B12 (cobalamin)

It contains cobalt. It is found in food of vegetable origin. It is synthesized in the human
colon but in bound form.
Daily requirement
 Adult -2 micrograms
 Pregnancy- 2 micrograms
 Lactation-2.5 micrograms

Functions
1. It is essential for DNA synthesis that is synthesis of purine
2. Formation and maintenance of myelin-fatty substance protecting the nerves
3. Red blood cell maturation

Sources – milk, cheese, foods of animal origin

Deficiency- usually due to absence or insufficiency of intrinsic factor in stomach to assist in its
absorption
 Megaloblastic anaemia
 Infertility
 Peripheral neuropathy.

Pathothenic acid
It is destroyed by heat and freezing
Function-
 it is associated with amino acid metabolism
 Cholesterol synthesis
 Steroid hormones synthesis (activity of the adrenal cortex)

Sources- widely distributed in animal proteins

Daily requirements 3-7mg
Deficiency- no symptoms have been identified
Excess- increased need of thiamine, occasionally diarrhea and water retention
Biotin
Function – synthesis of fatty acid
-Utilization of glucose and vitamins B12, folate
Deficiency- not identified
Sources – synthesized in the gut microbes, liver, kidney, egg yolk green vegetables
Daily requirement – 10-20 micrograms and is relatively stable compound
FAT SOLUBLE VITAMINS
These vitamins can only be absorbed if fat absorption is normal.
Vitamin A
Sources-can be formed in the body from certain chemicals known as carotenes whose sources are
fruits, carrots and green vegetables but also found in milk egg yolk liver
Daily requirements 600-700 micrograms
Functions
 Generation of the light sensitive pigment rhodopsin in the retina of the eye
 Growth and differentiation especially fast-growing cells of the epithelium
 Promotion of immunity and defense against infection
 Promotion of growth through increas3 in the length of bones.

Deficiency
1. Xerophthalmia-drying and thickening of the conjunctiva leading to ulceration
2. Night blindness
3. Atrophy and keratinisation of other epithelial tissues leading to increase of infections like
the ear and respiratory tract infections
4. Immunity and bone development is compromised.

Vitamin D
Found mainly in animal fats e.g. butter, egg, cheese. Humans can synthesise it by action of ultra
violet rays of the sun on a form of cholesterol found in the skin (7-hydrocholesterol)
Functions
Regulates calcium and phosphate metabolism by absorption in the gut and stimulating their
retention by the kidney. Thus calcification of bones and teeth.
Deficiency – rickets in children and osteomalacia in adults
Daily requirements- 10 micro grams although it is also stored in the muscles and fats thus
deficiency may not be apparent for several years.
Vitamin E
Also referred to as tocopherol, recently been shown to protect against coronary heart disease.
Found in nuts, egg yolk, wheat germ,, whole cereal and milk
Function- antioxidant – protects the body constituent’s e.g. membrane lipids from being
destroyed in oxidative reactions.
Deficiency is rare because of wide spread occurrence in foods but only seen in preterm babies
and conditions of impaired fat absorption e.g. cystic fibrosis.
-Hemolytic anemia i.e. cell membrane rupture
-Neurological abnormalities such as ataxia, visual disturbances
Dairy intake -10mg –men, 8mg for women
Vitamin K

Synthesized in the large intestine by microbes and significant amounts are absorbed. Absorption
depends on the bile salts in small intestine.
Found in the liver, vegetable oils and leafy green vegetables.

Daily requirements 1 microgram / kg body weight

Functions- in the liver for production of prothrombin and factors VII, IX and X, all essential for
blood clotting.
Deficiency occurs in adults with malabsorption problems e.g. celiac disease and liver problems
in the form of coagulopathies.
Newborn infants may be given vitamin K because their intestines are sterile and require several
weeks to become colonized by the vitamin K producing bacteria.
MINERAL SALTS
Necessary within the body for all body processes, usually in small amounts.
Calcium
Found in milk, eggs, fish, and green vegetables.
Functions
 It is an essential structural component (bone) in the body.
 It is important in coagulation of blood
 Muscle contraction

Requirements are higher in children and pregnant women although can be adequate in a well
balanced diet.
Phosphate
Sources- cheese, liver and kidney
Deficiency- if there is adequate calcium in the body there is no deficiency
Functions
 Hardening of bone and teeth
 Essential parts of nucleic acids (RNA, DNA)
 Essential parts of energy storage molecules in cell ( ATP- adenosine triphosphate)

Potassium
Found in all foods and table salt. Intake usually exceeds requirement thus excreted in urine. It is
the most common occurring extracellular cation (Na+) and associated with;
 Muscle contraction
 Transmission of nerve impulses along axons
 Maintenance of electrolyte balance in the body.

Potassium
Found in all foods especially fruits and vegetables and intake usually exceeds requirements. It is
the most commonly occurring intracellular cation and involved in many chemical activities in the
cells including
 Muscle contraction
 Maintenance of electrolyte balance
 Transmission of nerve impulses

Iron
It is a soluble compound found in the liver, the kidney, whole grain cereals and green vegetables.
In adults about 1 mg of iron is used by the body daily. The normal daily diet contains 9-15mg but
only 5-15% of the intake is absorbed.
Functions
 Formation of hemoglobin
 Oxidation of carbohydrates
 Synthesis of hormones and neurotransmitters.

Deficiency results in anaemia. Menstruating women, young people experiencing growth spurts
and pregnant mothers have increased iron requirements.
Iodine
Found in salt water fish and vegetables containing iodine. In areas of the world where iodine is
deficient in the soil, small quantities are added to table salt. Daily requirements depend upon the
metabolic rate.
Functions- It is essential I the formation of thyroxine and tri-idothyronine which are secreted by
the thyroid gland.
Deficiency results in goiter.
VARIATIONS IN ENERGY AND NUTRIENT NEEDS
Energy and nutrient needs are given for various groups of people. The needs of the various
groups that is age, sex etc vary.
Children need more energy, protein and other nutrients per kilo body weight than adults. This is
because they are growing very fast and require playing. For example the approximate calories
needed for each kilo body weight a day is-
0-1 year 110kCal
4-5 years 95kCal
9-10years 65kCal
14-16years 45kCal
20-30 years 40kCal
>60 years 35 kCal
Women who menstruate need more iron than men. Pregnant women need extra energy and
protein and other nutrients especially iron. Breast feeding mothers need extra energy and
proteins.
Men need more energy than women even if they are of the same age and do the same activities.
This is because men’s bodies contain more muscle and less fat than women’s bodies. Muscle
uses more energy than fat.
Old people need less energy (if less active) than younger adults but similar amounts of nutrients.
Women need less iron when they stop menstruating.
Big people need more energy, protein and some other nutrients than small ones. People who are
very active need more energy compared to those that are in active.

Nutrient needs and disease

Energy and nutrient needs increase during some infections e.g. energy, iron and folate needs
increase during malaria. They also increase during recovery from disease because of catch up
growth.
Nutrient needs and the type of diet
Protein and iron needs vary with the type of diet. Protein needs are lower if the diet contains
plenty of complete proteins and not too muscle fibre. Iron needs are lower if the diet contains
plenty of haem iron and other foods e.g. vitamin C rich foods, which increase the absorption of
non haem iron.
Individual variation
The energy and nutrient needs of an individual within the same age group vary. For example, the
average individual daily need for a group of men is 57g but the need of each man in the group
may vary between 53g-59g
NB; values in the attached table are for groups. Because of individual variation they can’t tell
you exactly how many calories or how much of a nutrient a particular individual child or an adult
needs.

MEAL PLANNING
A MEAL: is an occasion when food is eaten and can also refer to the food eaten in that occasion
e.g. lunch, breakfast, supper etc.
MEAL PLANNING: is organizing for an anticipated occasion of eating and the food that will be
eaten. Meal planning is important to ensure individuals/ families eat food that will provide them
with all the nutrients that will ensure maintenance of good health.

FACTORS THAT WILL INFLUENCE MEAL PLANNING

Aims/objective/goals of the meals are:-
Provision of energy.
Protection against disease
Proper growth and repair of tissues
Adequate hydration for normal body functioning
Resources available
Time available to prepare the meal and the time the meal will be taken
Amount of food available or money to purchase it.

Availability of the materials/resources in the preparation of the meal

Knowledge ability and skills.
Target
The number of people to be taking part in the meal.
The age groups- to determine their nutritional needs
The likes and dislikes.
In planning one has to consider WHAT, WHEN, HOW, WHERE and WHOM

TYPES OF MEALS
There are two main types according to the nutrients required
Normal meal: this entails the normal diet
Special meals: these entails one that contain a diet that is to be taken by person with specific
need or condition e.g. the therapeutic diet.
The type of meal may also be viewed from another angle as in:-
A light meal
Heavy meal
Snack

According to the occasion it may also be viewed as:-

Lunch, breakfast, super
Wedding meal
Christmas party
Birth day party

METHODS OF MEAL PLANNING

1. Food pyramid
2. Signal system
3. Hand jive
4. Plate model
5. Food exchange system
6. Glycemic index

Food group pyramid

Water should be
Adults: - 35-40mls/kg/24 hours
0 – 6 months - 150mls/kg/24 hrs
7-12 months - 120mls/kg/24 hrs
Starches – tubers – arrowroots, yams, cassava
Cereals – bread, rice, ugali
Consume at least 4 foods – each group daily
Food signal system
Principle for health food choices and cooking methods. This system is based on traffic light
concept of red for “stop” which also denotes danger, yellow for go slow or cautious and green
for “go” or safer road. It uses universally understood symbols which makes it simple and highly
useful way for a person to make an informed choice.
It focuses attention on processing and cooking, lays stress on GI (Glycemic Index), fiber content
of food, the amount and type of fat used and the mode of cooking.
It removes negative feeling about being on a diet and avoiding certain foods.
It empowers the person to make behavior change towards healthy eating .
Hand jive
Illustrates how to measure the amount of food “imaginatively” in a reasonably accurate manner
without scales
Carbohydrates – choose an amount equivalent to size of your 2 fists.
Protein – choose an amount equivalent to your palm and thickness of your little finger
Fat – amount equivalent to tip of your thumb
Vegetables – choose as much as you can hold in both hands

Model plate
Plate is divided with portions.
Sample basic meal planning guide
Fruit and milk served outside the plate

Food exchange
The word exchange refers to the food items on each list which may be substituted with any other
food item on the same list.One exchange is approximately equal to another in carbohydrate,
calories, protein and fat within each food list.
Glycemic Index
The Glycemic Index (GI) is a relative ranking of carbohydrate in foods according to how they
affect blood glucose levels. Carbohydrates with a low GI value (55 or less) are more slowly
digested, absorbed and metabolized and cause a lower and slower rise in blood glucose and,
therefore usually, insulin levels.
STEPS IN PLANNING
• Assess the needs of the target group
• Formulate the objectives to be achieved
• Means of achieving the objectives.
How to acquire the food and what food to be acquired
How to prepare, cook, serve, and eat.

Six principles to be considered when planning a meal

1. Adequacy in all nutrients-
2. Balance of foods and nutrients in the diet (proportionality between and among food
groups)
 3. Nutrient density- food that provided large amount of nutrient for a relatively small
amounts.
4. Energy density - Amount of energy is real in a food compared with its weight eg. Nuts,
cookies, fried foods.

5. Low energy density foods include fruits, vegetables and any other food that incorporates
a lot of water during cooking. modified by adding on peanuts, ground nuts, oil etc.
Increased Kcal in small amount.
6. Moderation in diet – portion size. This requires planning the entire days diet so as not to
under/over consume any one food. In planning the diets, the goal should be to moderate
rather than eliminate intake of some foods.
7. Variety of food choice
8. Eat different variety of foods as per food groups.

IMPORTANCE OF MEAL PLANNING

 It enables one to achieve the overall goal of adequate nutrition for health
 Saves time
 Enables one to spend within their pockets
 Ensures use of variety of foods to avoid monotony and thus increase appetite of the at
risk groups e.g. children.
 Ensures efficiency in preparation, cooking and serving of the food.
 Ensures regularity in the frequency of the meal times

8 Key messages for critical nutritional practices

1. Have periodic nutritional assessment done especially weight (with problem monthly,
without problem 3 monthly)
2. Increase energy intake by eating a variety of foods especially energy dense foods.
3. Drink plenty of clean and safe water (at least 8 glasses) 35 – 40ml/kg/24 hours
4. Live positively and practice healthy life style by avoiding risk behaviors' e.g. smoking,
alcohol,
5. Maintain high levels of hygiene and sanitation (hand washing, avoid ready to use foods,
wash fruits with soap under running Water).
6. Exercise physical activity – build muscles, improve appetite, manage stress, improve
overall health, relieve stress
7. Seen easy for infectious and use dietary practices to manage symptoms when possible.
8. Manage food and drug interactions.

BUDGETING FOR FOOD.

It is planning for time and money.
In this case is planning for the amount of money available to buy food in a particular period of
time.It also involves ensuring adequate amount of money is set aside specifically for food from
available income.
CHW have a duty to educate clients/ community that food is a priority and spending enough on it
ensure a well nourished and thus health family thus is free of disease
Factors influencing budgeting.

1. Size of the family.

2. Nutrition needs which then determines the amount of food one requires. These vary with the
age groups and the kind of work one does E.g
adults and adolescents 3.5-4.5kg cereal,1.0-1.5 kg legumes,1kg of dark leaves a week
Young children not breast feeding 1.25-2 kg of cereal, 0.5-1.0kg of legumes,0.8kg green leaves
etc.
3. Available amount of money to purchase the items.
4. The period of time one expects to use this food.
To ensure one gets foods that have a good value for their money one will Window shop for the
lowest prices. It is cheaper to buy food in large amount as long as they are not perishable.
Check for the cheapest brands but also consider the quality.
STEPS IN FOOD BUDGETING.
1. Establish the amount of money available.
2. Establish the period of time that money will be required to feed the family.
3. List food items that are available and those you may be able to buy in the 3 categories of
foods.
4. Indicate the prices of each of the food items bought that will be required for that period of
time.
5. Select the ones that will be friendly to your budget and will also be rich in nutrients.
6. Calculate the total cost of the items.
7. Add miscellaneous items e.g. tea leaves, salt, sugar; spices etc. then cost them per week
and have the total.
8. Calculate 5% of the total cost of the items and add it to the total to cater for any
emergency e.g. change of price.
9. It may be necessary to modify the current pattern of spending e.g. Keep track of all food
expenses for 2 weeks . Determine whether you are spending more money than you should
e.g. buy expensive food stuff.
10. Decide what to spend on food from your income.
11. The figure will form your budget.

FOOD HABITS AND PATTERNS.

Food habit: is a characteristic, attitude or tendency or practice towards food.
Food pattern: is a system of feeding in an individual family.
Factors that influence food habits and patterns
They are grouped into two:-
1. Those that influence the consumer demand by making food acceptable:
 Concern about food makes one to eat the right foods.
 Status of health e.g. those who are ill/sick.
 Exposure to the kind of food may be through media.
 Food preference and the appeal due to previous exposure.
 Lifestyle changes e.g. nomads
 Level of education, thus economic status and nutritional know how.
 Culture and religion.
2.Those that influence food availability thus food selection:
 Climate,
 Seasonal availability
 Storage
 Transportation
 Production
Food habits may be positive or negative towards health and nutrition.
To ascertain the food habits of a certain community a health worker may have to collect
information through observation, interviewing individuals and asking key informants as well as
discussing in focused group discussion .
One may then group these habits into good, neutral and negative or bad habits.
The role of a nurse thus may be to reinforce the good habits and eradicate the bad ones by giving
health education.
Importance of good habits
Good habits will ensure good health due to provision of good nourishment / proper nutrition.
To influence change a good health worker may need to involve the community through
community participation and through a multi sectorial approach.

ROLES OF A COMMUNITY HEALTH NURSE IN INFLUENCING CHANGE

The CHN will work with other members of the health team E.g.
Nutritionist: to prescribe and assessing
P.H.O: to give health education and treatment.
Doctors: to make diagnosis after assessing, prescription and give treatment.
Records officer: to identify the magnitude of the problem and the previous experience.
Dentist: Identifying nutritional problems.
The CHN will also collaborate with the intersectorial members to bring about change e.g.
Social workers: to advise the community on culture change.
Agriculture sector: to advice on good crops to grow and method to use to ensure maximum
yields.
Educational Sector: eradicates illiteracy and lays a foundation for a better future.
Administration: help in coordination of the community activities by mobilizing the community
members. Ensuring good infrastructure e.g. roads for the transportation of food substances and
the good necessary in food production.
For the CHN to play her part well he/she must know factors that:-
 Encourage good nutrition e.g. knowledge
 Food production e.g. climate, security
 Food habits and patterns e.g. culture
 Food availability: economy
 Food adequacy: family planning.
The nurse will collect data using various methods, to be able to identify the habits and classify
them
Plan the action which she will take to encourage positive and discourage the negative habits.
These actions may include:-
i. Encouraging breast feeding for at least 2 years.
 ii. Emphasize on the nutritional value of the locally available foods and advice on the mixed
foods.
iii. Advise on proper storage and preparation of food
iv. Advise on the 3 classes of nutritional needs in terms of nutrients giving examples of the
locally available food items.
v. Start demonstration Shambas at the health facilities to help educate on the importance,
use, and maintenance of the kitchen garden.
vi. Educate on environmental health to prevent diseases.
vii. Encourage them to take children for immunization.
viii. Encourage them to attend clinics where they can get health education as well as
management for various ailments.
ix. Encourage food programs to be run in the area by organization like the NGOs.

Feeding Methods
1. Tube Feeding:
This is done by passing a tube into the stomach or duodenum through nose which is nasogastric
feeding.
2. Parenteral Feeding:
There are numerous occasions when it is desirable for a hospitalized patient to be given nutrients
parenterally. This gives special attention to the provision of energy nutrients by peripheral or
central vein.
3. Total Parenteral Nutrition [TPN]:
The most sophisticated method of nutritional support is the total parenteral nutrition [TPN]. It
involves feeding the patients with sterile solution or glucose, amino acids, and micro-nutrients
usually via an indwelling catheter inserted into the large central vein (i.e. superior vena cava).
TPN entails either continuous infusion of nutrient solution round the clock or in a cyclic pattern
of infusion in which there is set period of time.
4. Enteral Nutrition Delivery System:
The enteral nutrition is utilized when the patient cannot or will not take in adequate oral
nutrients. Enteral route is preferred to parenteral nutrition as the later involves invasive
procedures which are more expensive, painful and may cause local or systemic infections and
sepsis.

THERAPEUTIC DIET
A therapeutic diet is a meal plan that controls the intake of certain foods or nutrients. It is part of
the treatment of a medical condition and are normally prescribed by a physician and planned by a
dietician.
A therapeutic diet is usually a modification of a regular diet. It is modified or tailored to fit the
nutrition needs of a particular person. Therapeutic diets are modified for
(1) nutrients
(2) texture
(3) food allergies or food intolerances.
Common reasons therapeutic diets may be ordered/importance of therapeutic diet
1. To maintain nutritional status
2. To restore nutritional status
3. To correct nutritional status
 4. To decrease calories for weight control
5. To provide extra calories for weight gain
6. To balance amounts of carbohydrates, fat and protein for control of diabetes
7. To provide a greater amount of a nutrient such as protein
8. To decrease the amount of a nutrient such as sodium
9. To exclude foods due to allergies or food intolerance
10. To provide texture modifications due to problems with chewing and/or swallowing
FACTORS TO BE CONSIDERED IN PLANNING THERAPEUTIC DIETS
 The underlying disease conditions which require a change in the diet.
 The possible duration of the disease.
 The factors in the diet which must be altered to overcome these conditions.
 The patient’s tolerance for food by mouth
The normal diet my be modified to
 Provide change in consistency as in fluid and soft diets.
 Increase or decrease the energy value.
 Include greater or lesser amounts of one or more nutrients, for example, high protein, low
sodium, etc.
 Provide foods bland in flavour.
COMMON THERAPEUTIC DIETS
1. Clear liquid diet – Includes minimum residue fluids that can be seen through. Examples are
juices without pulp, broth, and Jell-O.
Is often used as the first step to restarting oral feeding after surgery or an abdominal procedure.
Can also be used for fluid and electrolyte replacement in people with severe diarrhea.
 Should not be used for an extended period as it does not provide enough calories and
nutrients.

2. Full liquid diet – Includes fluids that are creamy. Some examples of food allowed are ice
cream, pudding, thinned hot cereal, custard, strained cream soups, and juices with pulp.
Used as the second step to restarting oral feeding once clear liquids are tolerated. Used for
people who cannot tolerate a mechanical soft diet. Should not be used for extended periods.

3. No Concentrated Sweets (NCS) diet

Is considered a liberalized diet for diabetics when their weight and blood sugar levels are under
control. It includes regular foods without the addition of sugar.
Calories are not counted as in ADA calorie controlled diets.
4. No Added Salt (NAS) diet – Is a regular diet with no salt packet on the tray. Food is seasoned
as regular food.
5. Low Sodium (LS) diet – May also be called a 2 gram Sodium Diet. Limits salt and salty
foods such as bacon, sausage, cured meats, salty seasonings, pickled foods, salted crackers, etc.
•Is used for people who may be “holding water” (edema) or who have high blood pressure, heart,
liver , or first stages of kidney disease
6. Low fat/low cholesterol diet – Is used to reduce fat levels and/or treat medical conditions that
interfere with how the body uses fat such as diseases of the liver, gallbladder, or pancreas.
Limits fat to 50 grams or no more than 30% calories derived from fat.
Is low in total fat and saturated fats and contains approximately 250-300 mg cholesterol.
7. Renal diet – Is for renal/kidney people. The diet plan is individualized depending on if the
person is on dialysis. The diet restricts sodium, potassium, fluid, and protein specified levels.
8. Mechanically altered or soft diet – Is used when there are problems with chewing and
swallowing.
9. Pureed diet – Changes the regular diet by pureeing it to a smooth liquid consistency.
•Indicated for those with wired jaws extremely poor dentition in which chewing is inadequate.
10. Food allergy modification – Food allergies are due to an abnormal immune response to an
otherwise harmless food. The most common food allergens are milk, egg, soy, wheat, peanuts,
tree nuts, fish, and shellfish. A gluten free diet would include the elimination of wheat, rye, and
barley. Replaced with potato, corn, and rice products.
11. Food intolerance modification – The most common food intolerance is intolerance to
lactose (milk sugar) because of a decreased amount of an enzyme in the body. • Other common
types of food intolerance include adverse reactions to certain products added to food to enhance
taste, color, or protect against bacterial growth. Common symptoms involving food intolerances
are vomiting, diarrhea, abdominal pain, and headaches.

WEANING
Is the process of gradually introducing an infant human or mammal to what will be its adult diet
while withdrawing the supply of its mother's milk.
Factors to be considered before introducing weaning food includes:
 Allow the infant to become familiar with the food before trying to give another.
 Introduce small amounts of any new food at the beginning.
Weaning food can be gradually transitioned from liquids to mashed solids to unmashed
solids.
Variety in choice of foods is important.
 If baby has an acute dislike for a particular food after few trials, omit that item for a week
or two and then try again.
 Freshly prepared foods should be given.
 Food should be given between breast feeds.
 Foods should be only slightly seasoned when necessary.
 Do taste the food before feeding it to baby.

The Three Stages of Weaning

Weaning at 6 months
Weaning at 6-9 months
Weaning at 9-12 months
Assignment read more on the three stages, advantages and disadvantages of weaning

FOOD SECURITY
Food security is a measure of the availability of food and individuals' accessibility to it, where
accessibility includes affordability.
Household food security: exists when all members, at all times, have access to enough food for
an active, healthy life.
Measurement of food security
1. Household Food Insecurity Access Scale (HFIAS) – continuous measure of the degree of
food insecurity (access) in the household in the previous month
2. Household Dietary Diversity Scale (HDDS) – measures the number of different food groups
consumed over a specific reference period (24hrs/48hrs/7days).
3. Household Hunger Scale (HHS)- measures the experience of household food deprivation
based on a set of predictable reactions, captured through a survey and summarized in a scale.
4. Coping Strategies Index (CSI) – assesses household behaviours and rates them based on a set
of varied established behaviours on how households cope with food shortages. The methodology
for this research is based on collecting data on a single question: "What do you do when you do
not have enough food, and do not have enough money to buy food?"

Pillars of food security

In 2009, the World Summit on Food Security stated that the "four pillars of food security are
availability, access, utilization, and stability".
1.Availability:- Food availability relates to the supply of food through production, distribution,
and exchange.
2. Access: - Food access refers to the affordability and allocation of food, as well as the
preferences of individuals and households

3. Utilization: -food utilization, which refers to the metabolism of food by individuals. In order
to achieve food security, the food ingested must be safe and must be enough to meet the
physiological requirements of each individual
4. Stability: -refers to the ability to obtain food over time
Challenges to achieving food security
 Global water crisis
 Land degradation
 Climate change
 Agricultural diseases
 Food versus fuel:-Farmland and other agricultural resources have long been used to produce
non-food crops including industrial materials such as cotton, flax, and rubber.
 Politics
 Food waste
Assignment: read and make note on Risks to food security
COMMUNITY NUTRITION ASSESSMENT METHODS
Purpose of Nutritional assessments:
◦ Identify nutritional problems
◦ Assess prevalence
◦ Identify causative factors (immediate, underlying and basic)
◦ Identify most appropriate intervention
◦ Assess food security situation
◦ Identify most affected group/at risk
◦ Evaluate an existing nutritional program
Definition of terms.
Nutritional status; A state of balance between nutrient intake and nutrient expenditure.
The measure of the degree to which an individual’s physiological needs for nutrients are met
Nutritional Screening-A onetime rapid assessment used to identify individuals likely to be at
risk or to be responsive to an intended intervention.
Nutrition surveillance - Continuous collection and analysis of nutritional status in order to give
warning of impending crisis or to make policy and programmatic decisions that will lead to
improvement in the nutrition situation of the population.
Growth monitoring-The practice of following a child’s physical development, by regular
measurement of certain indicators (usually weight and sometimes length) in order to maintain
good health by detecting growth faltering and intervening in a timely manner.
Methods of nutritional status assessment
1. Anthropometry
2. Biochemical Tests
3. Clinical Examination
4. Dietary intake
ABCD
1. DIETARY INTAKE
Quantitative
I. 24-hour recall
II. Weighed food records
III. Estimate food records
IV. Weighed food records

Qualitative
I. Dietary histories
II. Food frequency questionnaires
Dietary intake: quantitative
24-hour recall: these measures what an individual consumed on one or more specific
days.

Features of a 24-hour recall

1. Takes note of food preparation methods, recipe ingredients, brand names of commercial
products, use of dietary supplements

2. Interviewer needs to be trained and skilled

3. Uses open-ended questions, avoiding asking questions in a manner that might influence the
subject’s responses
2. Food record method
Measures actual food eaten by the responded in the specified time interval usually 3 or 7days
period.
Estimated in terms of household measures (Cup, spoon) or weighed with a weighing scale before
consumption
Food records: features
 Food intake is recorded by the subject or (observer) at the time the foods are eaten.

 Intensive training for the subjects or the observer is required

 The field worker or subject weighs the raw ingredients, as well as the individual portions of
the cooked dishes to determine individual food intakes
Strengths and limitations of the 24-hour dietary recall and food record methods
Strength
1. Both methods are based on actual intake to estimate absolute amount rather than relative
amount of nutrients.
2. Both methods are open ended and with a high level of specificity about the information given
Limitation: both methods have day to day variation in food intake.
Recall and record compared

Strength (recall vs. food record)

 Recall does not need literacy
 Recall is less likely to alter eating behavior because it’s a surprise and the respondent is
not for-warned.
 Relatively minimal respondent burden
Recall and record compared
Limitation (recall vs. food record)
- Reliance on memory
- The need for a highly trained interviewer
Limitation (food record)
-High level of subject motivation

Qualitative

1. Dietary histories
The dietary history asks questions on typical or usual food intake for a long time period (more
than 1 year).

2. Food frequency questionnaires

A food frequency questionnaire comprises a list of foods and beverages on which respondents
report their usual frequency of consumption over a given period. (can be 6 months or 1 year)
2. BIOCHEMICAL ASSESSMENT
Used to detect sub clinical deficiency or confirm a clinical diagnosis
Biochemical assessment is done to determine the levels of specific nutrients in biological
materials or tissues.
Expensive and not used for surveillance and screening. - research purposes

3. CLINICAL ASSESSMENT
Whole body clinical exam for physical signs of malnutrition
Done by trained nutritionist/clinicians
CHECK FOR OEDEMA

• Using you thumb, gently apply pressure to both feet for 3 seconds.
• If you can still see the print of your thumb on both feet, then the child has oedema
 • Oedema is a sign of the child being severely malnourished. The child needs to be taken to
the closest health facility immediately to receive specialized treatment including
therapeutic food and medical treatment

4. ANTHROPOMETRY
Nutritional Anthropometry - measurement of the variations of the physical dimensions and
the gross composition of the human body at different age levels and degree of nutrition.
Advantages of Anthropometry
I. Procedures are simple, safe, noninvasive and are applicable to large sample sizes

II. Inexpensive, portable and durable equipment

III. Relatively unskilled personnel can perform the procedures

IV. Information is generated on past long-term nutritional history which cannot be obtained with
equal confidence using other techniques

Disadvantages of Anthropometry
I. Cannot distinguish between specific nutrient deficiencies
II. Non nutritional factors can reduce specificity and sensitivity of anthropometry

Uses of anthropometry
 Identifying socio and economic inequalities
 Identifying individuals at risk of malnutrition
 Evaluating the effects of changing nutritional, health, or socioeconomic influences and
interventions
 Excluding individuals from certain programs/treatment
 Research purposes
Two groups of anthropometry
Growth -Measurements
I. Height (stature)
II. Weight
III. Age

Body composition
- Body mass (fat free mass and body fat)
– skinfolds and circumferences

Building blocks of anthropometry

Four building blocks
Age determination
Examine documented evidence priority
Reported by the mother
Local events calendar
RECORD THE AGE IN TERMS OF DATE OF BIRTH
Equipment
Weight measurements
Equipment – spring scale (Salter), Electronic weight scales, pediatric scale
Height (Length) Measurement
Equipment – height board, length board, microtoise or measuring tape with head board.
Mid Upper Arm Circumference –measuring Tape, Colored strip
Skinfolds – Skinfold calipers
ANTHROPOMETRY DATA COLLECTION
A. WEIGHT
Weight
B. HEIGHT /LENGTH
Height/length
 Length is measured for children less than 24 months of age and is referred to as the
recumbent length.
 Height is measured for children older than 24 months of age
 Mid Upper Arm Circumference
 Appropriate in Children 6 to 59 months of age
 Measurement taken on the left upper arm with a flexible non stretch tape made of
fibreglass or steel.
 Measurements taken with a sleeveless shirt at the midpoint between the shoulder and the
tip of the elbow.
 To locate the midpoint of the upper arm – should be bent at the elbow
 Identify the acromion and the olecranon processes
 Measure the arm length and put a mark on the midpoint

 Extend the left arm of the subject so that it is hanging loosely by the side, with the palm
facing inwards

 Wrap the tape gently but firmly around the arm at the midpoint, care being taken to ensure
that the arm is not being squeezed.

 Take and record the measurement to the nearest centimeter

 Coloured Strip – Rapid surveys
 Mid Upper Arm Circumference
MUAC cut off
Arm Colour of Nutritional status
Circumferenc Cord
e (cm)
<12.5 Red Acute Malnutrition
12.5-13.5 Yellow Mild Malnutrition
>13.5 Green Normal

ANTHROPOMETRY FOR ADULTS

  Nutritional status of adults can be determined with Body Mass Index (BMI) which is the
Weight (kg) divided by the square of height in meters:
BMI = WEIGHT (KG
HEIGHT (M)2
Type of malnutrition BMI cut off
Obese 30.0+
Overweight 25.0 - 29.9
Normal 18.5 - 24.9
Mild under-nutrition 17.0 - 18.4
Moderate 16.0 - 16.9
Severe <16.0

Classification of malnutrition in adults based on the BMI

BMI is used to measure over nutrition and chronic energy malnutrition (CEM) in adults

The cut-off point defining malnutrition is the same for all adults, regardless of their age,
height, or sex:

Weight management

Energy
Adjust level of energy intake to meet individual weight reduction requirements. A decrease
of 1000kcal daily is required to lose about 1kg a week and a reduction of 500 kcal daily
brings about a weight loss of nearly ½ kg.

 Anthropometry data
 Analysis and interpretation
Anthropometry data analysis and interpretation
This section will cover the following aspects:
 Anthropometric indices/indicators of nutritional status
 The concept of a reference population
 Calculation and expression of the nutritional status indices with EPI info computer based
software
 Malnutrition Cutoff points
Anthropometric indices/indicators of nutritional status
 Each of the 4 building blocks of anthropometry provide specific information about an
individual.
 When two of these variables/building blocks are used together they are called an index. (If
many Indices)
 Three indices are commonly used in assessing the nutritional status of children:
3 indices of assessing nutritional status
1. Weight-for-length or Weight-for-height.
2. Length-for-age or Height-for-age;
3. Weight-for-age;
The three indices are used to identify three nutritional conditions namely wasting, stunting and
underweight.
1. Weight for height
 Is calculated from the weight and height measurement of the child. A low weight-for-
height helps to identify children suffering from current or acute under-nutrition or wasting
 It is very useful when exact ages of children are difficult to determine.
 Weight for height
 Weight for height is appropriate for examining short-term effects such as seasonal changes
in food supply or short-term nutritional stress brought about by starvation or severe
disease/illness.
A low weight for height is referred to as wasting
Wasting is the result of a weight falling significantly below the weight expected of a child of the
same length or height.
Wasting indicates current or acute
malnutrition resulting from failure to gain
weight or actual weight loss.
 Causes of wasting include: inadequate food intake, incorrect feeding practices, disease, and
infection or, a combination of these factors
2. Height –for-age
Height for age is derived from the measured height of a child and the age
Height for age reflects cumulative linear growth. A low height for age indicates past or chronic
inadequacies in nutrition and/or chronic or frequent illness,
Height for age cannot measure short-term changes in malnutrition
 A low height for age is referred to as stunting and reflects a reduced growth rate in human
development.
 Stunting is an indicator of past growth failure.
 Stunting is caused by long-term factors including chronic insufficient protein and energy
intake, frequent infection, sustained inappropriate feeding practices and poverty.
3. Weight-for-age
 Weight-for-age is derived from the measurement of weight and the age of the child.
 A Low weight-for-age index identifies the condition of being underweight, for a specific
age.
 W/A is commonly used for monitoring growth and to assess changes in the magnitude of
malnutrition over time.
 A low weight – for –age is referred to as underweight.
 The advantage of this index is that it reflects both past (chronic) and/or present (acute)
under-nutrition.
 Underweight is recommended as the indicator to assess changes in the magnitude of
malnutrition over time. Underweight
Indices summarized
Nutritional index Nutrition problem measured
Weight-for-height Acute Malnutrition (Wasting)
 Height-for-age Chronic malnutrition (stunting)
Weight-for-age Any protein-energy malnutrition
(underweight)

Sources of error -anthropometric measurements

COMMON SOLUTION
ERRORS
All measurements
Restless child Postpone measurement. Involve parent in procedure
Inaccurate reading Training and retraining stressing accuracy
Recording Record results immediately after taking measurements and confirm
record
Length or height
Incorrect method for Use length only when child is <2 years or <85cm
age
Foot wear / headgear Remove – in privacy if necessary

COMMON ERRORS SOLUTION

Length or height contd…….

Child not straight along Correct technique with practice and regular retraining. Provide
board, knees bent, feet adequate assistance – 3 people needed. One for head, one for
pointing down when lying arms and middle and on for knees, feet and measurement taking.
down Get parent in middle to hold arms and talk to child to calm them.
Sliding board not firmly Settle child. Ensure adequate pressure applied. Move head board
against heels/head to compress hair and ensure head touches board.
Child not straight along Don’t take measurements while child is struggling. Ensure
height board – feet apart or assistants and parent all help position child. One for legs and
knees bent feet, one for head and measurement taking. Parent can talk to
child.

Weight

Scale not calibrated Recalibrate after every measurement

Child wearing heavy clothing Remove in private or make allowances for clothing and
 or amulets amulets by subtracting their weight equivalent from child
weight e.g. 100g of clothes for underwear
Child moving or anxious in Wait until child is calm. The more s/he moves and tries to
hanging pants garb measurers the more likely the measurement is to be up
to 1kg out. One assistant to talk to child and other to position
head in front of scales at the right angle to read measurement
as soon as the scale stabilises.
MUAC

Child won’t let go of mother Get mother to hold child on her hip with child’s left arm
facing measurer.
Mid upper arm point incorrect Find tip of shoulder and elbow slowly. Practice finding half
way between the two.
MUAC tape too loose or too tight giving Practice, supervise and retrain. Get measurer to practice on
an incorrect reading calm, older children and adults. Demonstrate.

Anthropometry data analysis and interpretation

 The concept of a reference population

The reference standards most commonly used to standardize anthropometric measurements

were developed by the US National Center for Health Statistics (NCHS) (1977) and the
WHO 2000 which contains data for normal children from around the world(Brazil, United
States, Norway, Ghana, Oman, and India).
 The reference population chosen by NCHS was a statistically valid random population of
healthy infants and children.
 The NCHS/WHO reference standards are available for children up to 18 years old

Calculation and expression of the indices

 Anthropometric indices are constructed by comparing observed measurements with those of
comparable individuals (in terms of age and sex)
 Each child is usually compared to a comparable group in the reference population.
 For example to assess weight for height of an individual child, that child’s weight is
compared to all children in the reference population who are of the same sex and same
height.
Ways of expressing anthropometry into indices
 Z scores (standard deviation)
 Percent of Median
 Percentiles
1. Z score (standard deviation)
A z-score, or standard deviation, is a measure of the dispersion of data.
Definition of a Z score; The deviation of an individual's value from the median value of a
reference population divided by the standard deviation of the reference population
Z-score formula
Z-score (or SD-score) =

(observed value) - (median reference value)

standard deviation of reference population
Nutritional status Z-score values
Normal > -1
Mild <-1 to -2.0 Z score
Moderate malnutrition <-2.0 to -3.0 Z score
Severe malnutrition < -3 Z score

Percent of median
Observed Value * 100
Median Value of reference population (from tables)
Classification of malnutrition based on percent of median (Road to Health system)
Percent of median Nutritional status
> 80% normal
60% - < 80% mild-to-moderate
< 60% severe

Gomez classification
Percent of median Classification of malnutrition
> 90% normal
75% - < 90% mild
- < 75% moderate
< 60% severe

 Percentile
A percentile (or centile) is the value of a variable below which a certain percent of
observations fall.
For example:
The 20th percentile is the value (or score) below which 20 percent of the observations may be
found.
It’s the rank position of an individual on a given reference distribution, stated in terms of what
percentage of the group the individual equals or exceeds.
Anthropometry data Presentation- reporting
  Descriptive – Present the descriptive statistics of the measured raw data – mean
(SD)height, weight, MUAC, Age

 Nutritional status indices are used for presenting the prevalence of child malnutrition in
terms of Weight-fore-age (underweight), Weight-for-height (wasting) and Height-for-age
(stunting).
 Make an interpretation of the findings discussing the forms of malnutrition that is most
prevalent and give reasons for the trends.
MALNUTRITION
Malnutrition
Def1-is deviation from good nourishment either under or over nutrition or is a body state of
having deficiencies, excesses or imbalance of particular nutrients.
Def 2-Malnutrition is defined as “a state in which the physical function of an individual is
impaired to the point where he/she can no longer maintain adequate bodily performance
processes such as growth, pregnancy, lactation, physical work, and resisting and
recovering from disease

FACTORS INFLUENCING NUTRITION

.1. Biological factors: –
 Age – different age groups require different RDA e.g infant, adolescent, elderly
 Sex – males require higher RDA than females
 Growth – the size of a person determines the quantity of food to be taken, children with
poor developed milestone require high nutritive diet (energy and nutrient dense diet)
 Diseases state/condition – worms, malaria cause blood loss thus increases in nutrient needs,
Pregnant/lactating mothers require increased RDA, DM/HTN require restricted diet, PLHIV
require special diet rich in vitamins etc
 Genetic makeup – people have different growth hormone and different digestive juice
production thus nutrition process are different to specific people
2. Social economic – poverty – no variation in nutrient intake, household food insecurity, those
of low class may fail to afford balanced diet unlike the high class
3. Climatic condition – some season may have plenty of foods while others may have no food
produce
4. culture- beliefs and superstitions may prevent someone from eating the right diet
5. Family size – large family size there is competition for food
6. Knowledge – concept of preparing quality food
7. Locality – homestead might be located near locally available nutritious foods e.g those near
the lakes get fish locally
CAUSES OF MALNUTRITION
1. Immediate Causes of Malnutrition: Lack of food intake and disease are immediate
cause of malnutrition and create a vicious cycle in which disease and malnutrition
exacerbate each other. It is known as the Malnutrition- Infection Complex.
Thus, lack of food intake and disease must both be addressed to support recovery from
malnutrition
 Altered digestion
Nausea/vomiting
Gastritis

Altered food Altered

intake metabolism
Nausea Increased energy
Altered food likes requirements
Lack

Malnutrition

2. underlying causes of malnutrition include:

•Food: Inadequate household food security (limited access or availability of food).
•Health: Limited access to adequate health services and/or inadequate environmental health
conditions.
• Care: Inadequate social and care environment in the household and local community, especially
with regard to women and children.
3. Basic Causes of Malnutrition
The basic causes of malnutrition in a community originate at the regional and national
level, where strategies and policies that affect the allocation of resources (human,
economic, political and cultural) influence what happens at community level. Geographical
isolation and lack of access to markets due to poor infrastructure can have a huge negative
impact on food security.
When conducting an assessment to determine the causes of malnutrition in a community, it
is important to research the actions at each level and how these actions, or inactions,
influence malnutrition rates.

Causes of malnutrition in kenya

1. Lifestyle – eg. Smoking, alcohol, sedentary, junks, faddism
2. Poverty – not able to afford balanced diet
3. Social economic Status – feel locally available foods are not the best
4. CultureLack of knowledge – not able to make a balanced diet despite every nutrient
being available
5. faddism

Nutrition vulnerable groups

Vulnerability is the degree to which a population or organization is unable to anticipate, cope
with, resist and recover from the impacts of disasters (WHO ,2002)
Certain vulnerable groups in the population have special nutritional needs.
1. Pregnant and lactating women
2. Infants and children
3. School age children
4. Refugees and displaced persons
5. The elderly
6. Immuno suppressed

Forms of malnutrition; two main forms

 Undernutrition- insufficient intake of food-energy and nutrients
 Overnutrition- excess intake of energy and nutrients
 Micronutrient deficiency- hidden hunger
Categories of malnutrition
1. Chronic malnutrition: Determined by a patient’s degree of stunting.
2. Acute malnutrition: Determined by the patient’s degree of wasting.
Acute malnutrition is categorised into:
 Moderate Acute Malnutrition (MAM) and
 Severe Acute Malnutrition (SAM).
Severe Acute Malnutrition (SAM) is further divided into:
1. Marasmus
2. Kwashiorkor
 3. Marasmic kwashiorkor ( combination of 1 & 2)
Triage of under nutrition
Categorized by BMI and Z- scores for children under five years
1. Mild or those at risk; -2 to < -1 Z score
2. Moderate Acute Malnutrition: Children under five years with weight for age < -2 Z
Score (use the child health card) or children 6 to 59 months with MUAC <12.5 cm
3. Severe Acute Malnutrition: Children under five with weight for age < -3 Z Score or
children 6 to 59 months with MUAC <11 cm and/or children 6 to 59 months with bi-
pedal pitting edema
Malnutrition related death: death in a child who is suffering from malnutrition as the primary
illness
Difference between the PEM condition
Acute malnutrition is distinguished by its clinical characteristics, namely;
1. Marasmus (severe weight loss leaving ‘skin and bones’)
2. Kwashiorkor ( bloated appearance due to water accumulation or oedema)
3. Marasmic-kwashiorkor – a combination of both

There are two basic objectives in the management of acute malnutrition:

1. To prevent malnutrition by early identification, public health interventions and nutrition
education
2. To treat acute malnutrition to reduce morbidity and mortality.
Signs and symptoms
MARASMUS
• Severe weight loss and wasting
• Ribs prominent
• Limbs emaciated
• Muscle wasting
• May have good appetite
• With correct treatment, good prognosis
KWASHIORKOR
1. Bi-lateral oedema and fluid accumulation
2. Loss of appetite
3. Brittle thinning hair
4. Hair colour change
5. A pathetic and irritable
6. Face may seem swollen
7. High risk of death
The malnutrition surveillance goal is:
Ministry of Health has decided to integrate malnutrition into the routine surveillance system.
Admission: Children with SAM, appetite and no medical complication. Treated with food
supplements such as RUTF and follow-up
Rationale: Children with uncomplicated SAM or those at risk of SAM can be identified and
treated at home before complications arise. This will reduce chances of complicating and
avoid congestion in hospitals

In patient management of children with SAM

Admission: Children with a WFL/H<-3 and or MUAC<115mm.Children with bilateral pitting
Oedema and clinical complications such infections, loss of appetite
Rationale: These children are at the highest risk of death and will most benefit from treatment

Triage of Acute Malnutrition

Community Health Workers (CHWs) can screen children in the community using MUAC
and the presence of oedema. They refer those who are malnourished to a health facility.
However, the diagnosis of malnutrition for children under five years old is the responsibility
of health staff at a health clinic, health dispensary, or an out-patient department (OPD) and
hospital casualty department.

When severe acute malnutrition is identified, the anthropometric admission criteria are the same
whether the child can access an in-patient facility or an out-patient therapeutic care (OTP). If
there is no out-patient community therapeutic care available, all patients who have a criteria in
the red column (severe malnutrition) o- with or without complications - are admitted to the
health centre’s in-patient section where they are to stay for each phase of recovery of severe
acute malnutrition. Also, patients with medical complications and/or ++, +++ oedema and lack
of appetite require in-patient treatment of acute severe malnutrition.
When out-patient therapeutic care service is available, the health staffs determine the patients
who are eligible for it. Patients without complications and with good appetite may go directly for
outpatient treatment. It is important to conduct an Appetite Test to confirm if the child
has a good appetite.
Based on the information gathered above, health workers should classify if the patient is severe
acute malnourished (SAM), moderate acute malnourished (MAM) or healthy, and follow guide
below

Steps on Admission
Step 1: Check for general signs of malnutrition
Health facility staff must check the patient for general signs of malnutrition.
Step 2: Gather patient information
• Carry-out the patient’s anthropometric measurements.
• Measure weight and height (if the patient’s height is less than 85cms, or if the patient
is younger than two years old, measure length instead), and calculate weight-for-height
percentage median or z-score.
• Take a MUAC measurement.
• Check for bi-lateral oedema.
• Record all measurements on patient card and register.

Step 3: Identify cause of malnutrition

• Is there an illness that leads to the child’s weight loss?
• Are there economic issues in the family that reduces food availability and/or access?
• Is there dynamics within the household contributing to the situation? (e.g. the mother
sick)
Step 4: Conduct Appetite Test
If outpatient therapeutic care is available, conduct the Appetite Test. The Appetite Test is
one of the main criteria to determine if a severe acute malnourished patient requires inpatient
or out-patient treatment.
Step 5: Determine appropriate treatment
A triage process must be established so that the acutely ill are examined and admitted
quickly to the in-patient facility to start treatment immediately. In other words, a “fast
track system” must be in place.
Establish the following parameters:
• Any child older than six months and a MUAC <11cm must be admitted to the nutrition
programme for treatment of severe acute malnutrition as low MUAC has a high
mortality risk
• A child diagnosed with severe acute malnutrition: if out-patient treatment of
malnutrition is not available; the patient must be admitted to an in-patient facility for
nutrition management. If out-patient management of malnutrition is available, determine
if the patient can be managed in the community or requires admission to an in-patient
facility
• A child identified as malnourished by the MUAC community screening process but
whose anthropometric measurements taken at the health facility are not considered
severely malnourished is referred for Supplementary Feeding if it is available
SAM patients who are waiting for admission in the health facility waiting area
should receive 50ml glucose 10% to prevent hypoglycaemia (1 rounded 5ml
teaspoon of sugar in 50ml water) by a member of the health staff.

MANAGEMENT OF SAM
Overview
Severe acute malnutrition (SAM) is identified by severe thinness or wasting. Sometimes
patients also present with bi-lateral oedema, called nutritional oedema. Severe acute
malnutrition is often a life-threatening condition. These patients are very fragile, often with
a serious electrolyte imbalance. They do not always present with the typical symptoms
of an illness (e.g. fever, rapid pulse or rapid respirations). Also, it can be very difficult to
diagnose dehydration or anaemia however it is extremely important to do so accurately. A
misdiagnosis can lead to a high risk of mortality.
Traditionally the treatment of severe acute malnutrition has been in-patient, health facility
based. However, recent research in emergency settings has revealed that severe
uncomplicated acute malnutrition can be treated at home with weekly visits to a health
facility for monitoring and re-placement of specialized food. There must also be a
community component to managing severe acute malnutrition at home. Relevant people
in the community must be aware of the risks of acute malnutrition for children, and how
to identify children with acute malnutrition. There must be Community Health Workers
(CHWs) who are trained on screening procedures for acute malnutrition in the community.
They are responsible for monitoring and supporting children at home who are receiving
nutrition support from Out-patient Therapeutic Care (OTC). Specialized food products
designed to support nutrition rehabilitation, referred to as ready-to use therapeutic food
(RUTF), must also be available.

Treatment Process
Severe acute malnutrition requires specialized treatment to ensure rapid recovery and reduce the
risk of mortality. The management of severe acute malnutrition in the in-patient setting is
divided into three phases:
1) Phase 1,
2) Transition Phase
3) Phase 2.

Phase 1: Nutrition and Medical Stabilization

 Covers nutrition and medical stabilization, treatment of medical complications, and
commences nutritional rehabilitation. When a malnourished patient is admitted to the in-
patient facility, particularly during the initial stabilization phase, check for severe
infections as well as hypoglycaemia, hypothermia, and dehydration. These usually occur
soon after admission and need to be addressed urgently to prevent death. Infections and
electrolyte imbalance may manifest at any time during treatment.

 Patients without an adequate appetite and/or a major medical complication are initially
admitted to an in-patient facility for Phase 1 treatment. Also, when there is limited or no
community capacity to handle out-patient treatment of severe acute malnutrition, and
only in-patient care is available, patients with severe acute malnutrition are admitted to
inpatient for Phase 1 nutrition.
 The formula used during this phase (F75) promotes recovery of normal metabolic
function and nutrition-electrolytic balance.
 In Phase 1 the patient receives F75 formula at 100kcal/kg/day. Rapid weight gain at this
stage is dangerous, that is why the quantities and formula are formulated so that patients
do not gain weight during this stage. A routine, systematic medical treatment is
commenced in Phase 1, and medical complications are treated. It is important in Phase 1
that oedema, if present, reduces. When oedema is reduced from +++ to ++, only then can
these patients graduate from Phase 1 to Transition Phase. Patients who initially require
intravenous (IV) therapy or nasogastric (NG) feeding must have completed these
therapies and the tube/cannula removed before transfer to Transition Phase.
 In many of settings in Kenya, HIV testing or Diagnostic Counselling and Testing (DTC)
is considered on admission to care for severe malnutrition in order to identify the need for
chemo-prophylaxis and early assessment for the staging of HIV/AIDS disease
progression and readiness for paediatric ART care.
 The patient remains in Phase 1 until the medical complications stabilize and until the
appetite improves and the patient completes the designated quantity of F75 or equivalent
diet at each mealtime.

Transition Phase: Increase Diet and Prevent Complications

 The transition phase covers a gradual increase in diet leading to some weight gain while
preventing complications of over-feeding.
 Patients normally remain in Transition Phase for two to three days. This phase is
designed to slowly increase the diet and prevent complications of over-feeding for the
stabilized, acutely malnourished patient.
 F75 is replaced with F100 or a locally made-up milk of the equivalent nutritional value.
 The patient’s diet is increased from 100kcal/kg/day to 130kcal/kg/day for children.
  The quantity of milk remains the same, but the calorie content changes by changing
products from 75kcal to 100kcal per 100ml of milk.
 The patient in Transition Phase receives around 30% more calories than when in Phase 1.
 Daily weight gain can be expected at about 6gm/kg/day. For example, a child who
weighs 4kg should gain about 24g a day.
 For patients qualified and willing to be discharged from Transition Phase to Outpatient
 Therapeutic Care for the remainder of nutrition treatment, the equivalent calories are
given to the patient in the form of Ready-to-Use-Therapeutic Food (RUTF).

Phase 2: Catch-up Growth and Discharge

 This is a rapid weight-gain phase (catch-up growth), and covers preparation for
discharge.
 In the in-patient setting for the treatment of severe acute malnutrition, patients move from
Transition Phase into Phase 2 when:
o They have a good appetite;
o They are tolerating the diet given;
o Have no major medical complications;
o Oedema is resolved.
 This is usually after about two to three days in Transition Phase.
 In Phase 2, the patient receives F100 at 200kcal/kg/day or the equivalent in the form of
RUTF. Those formulas are designed for patients to rapidly gain weight (more than 8g/kg/
day). Recovered patients are discharged for supplementary feeding if available at the
nearest health facility.

Requirements for the In-patient Setting

Treatment Area
 Patients are admitted into the paediatric ward if available or another in-patient ward in the
hospital.
 Staff: Should be fully trained in management of acute malnutrition and must be available.
All staff must be have received appropriate training.
Individual Roles and Responsibilities
 The parent, caregiver, or guardian is the main caretaker of the malnourished patient.
He/she may be the mother, the father, a sibling, a relative or a family friend.
 Nutritionists, nurses and nurse assistants are responsible for most of the medical and
nursing care. Their responsibilities include:
 Conduct regular weight and height measurements of malnourished children;
 Prepare diet, calculate the amounts of feeds, and distribute and record the amount of
 food taken by the malnourished child;
 Administer oral medication, assess and record clinical signs, and record all information
 in the Multi-chart. (See Appendix 2.1 for Multi-chart)
 Support mothers to feed the child
 The nurse in charge is the manager who teaches and supervises the medical and nursing
 assistants. The nurses are responsible for all technical procedures, such as giving
 intravenous medication and other invasive procedures.
 The doctor supports the nurses and nutritionist. They work closely together as a team.
  The doctor is specifically responsible for the care of the very sick severely malnourished
 children, those who are failing to respond to routine management, or are having
diagnostic difficulty.
Materials and Equipment
 Medicines and medical equipment including antibiotics, anthelminitics, minerals and
vitamins, NG tubes.
 Therapeutic milks (F75, F100) or the ingredients required to produce locally-made milks
including combined mineral vitamin mix (CMV).
 Anthropometric equipment: height board, Salter scales, infant scales, MUAC tapes, baby
scales.
 Laboratory and diagnostic services is important but not essential.
Documentation
 For severely malnourished patients admitted to the in-patient facility, health staff should
use the Multi-chart to record all medical information, food quantities and type of diet. All
daily activities such as daily weights, measurement of vital signs are also recorded in the
Multi-chart. Fluid intake and output is also recorded in the Multi-chart.
51
Section Two
For severely malnourished patients with severe oedema (+++), reduce the quantity of F75 by up
to 20% until the oedema begins to subside. Breastfed children are always offered breast milk
before the diet, and always on demand.
Preparation of F75
If F75 is available, add one packet (410g) of F75 to two (2) litres of water. (Water must be boiled
and cooled prior to mixing.) If five or less children are being treated for severe acute
malnutrition, less quantities of F75 milk are necessary. Smaller volumes can be mixed using the
red scoop (4.1g) included with the F75 package (20 ml water per red scoop/4.1g of F75). Prepare
enough milk for the next three hours, not longer, to assure that it will not spoil. If there is access
to a refrigerator, milk can be stored for a maximum of 12 hours.
Feeding Technique for Severely
Malnourished Children
Due to muscle weakness and slow swallowing, the risk of aspiration pneumonia is high for
malnourished children. Therefore, great care must be taken while feeding. The following
information lessens the risk of aspiration pneumonia.
Sitting Position
The child sits straight up (vertical) on the mother’s lap,leaning against her chest with one arm
behind her back.
The mother’s arm encircles the child. She holds a saucer under the child’s chin.
Appropriate Feeding
• The milk feed is given by cup. Any dribbles that fall into the saucer are returned to the cup.
• The child is never force fed, never has his/her nose pinched, and never lies back and has the
milk poured into the mouth.
• Meal times are best to be social. The mothers can sit together in a semi-circle around
an assistant who encourages the mothers, talks to them, corrects any faulty feeding
technique, and observes how the children are taking the milk.
• Caretakers do not take their meals beside the patient. The child is likely to demand
some of the mother’s meal and this sharing is not recommended as the child’s appetite
will reduce and then the milk will be refused.
Naso-gastric Feeding
Naso-Gastric (NG) tube feeding is required only when a patient is not taking a sufficient
diet orally, which is less than 75% of the prescribed diet per day.
NG tube feeding is required when one or more of the following is true:
• The patient takes less than 75% of the prescribed diet per 24 hours in Phase 1
• The patient presents with pneumonia with a rapid respiration rate
• The patient has painful lesions of the mouth
• The patient has a cleft palate or other physical deformity
• The patient is experiencing disturbances of consciousness
Each day, try patiently to give the patient F75 by mouth before using the NG tube. NG
tube feeding should not exceed three days, and is only used in Phase 1.
Routine Medication
Vitamin A
F75, F100, RUTF and locally-developed milk provide the adequate amount of
Vitamin A to manage mild Vitamin A deficiency and to replace low liver stores of Vitamin
A during treatment. However, many malnourished patients have a serious Vitamin A
deficiency, therefore:
• Administer a dose of Vitamin A to all new admissions except:
Patients who have received Vitamin A within the last month, or
 Patients with oedema. For children admitted with oedema, administer a single
dose of Vitamin A at discharge from in-patient facility after completion of Phase 2,
or when patient is transferred to OTP administer Vitamin A on week four of OTP
management
• If patient has signs of severe vitamin A deficiency (clinical signs such as night
blindness, conjunctival xerosis with Bibot’s spots, corneal xerosis or ulseration or
keratomalacia), give a dose of vitamin A according to Table 2.4, for two consecutive
days, followed by an additional dose two weeks later.
• Administer a dose of Vitamin A to all in-patients on the day of discharge4 (i.e.
completion of Phase 2). For patients managed at OTP, including those initially admitted
as in-patients and transferred to the OTP, administer a dose of vitamin A at week four
after admission.
Table 2.4 Vitamin A systematic treatment
Age Vitamin A/IU orally on Day 1
6 to 12 months 1 blue capsule 100,000IU = 30,000ug
12 months and older 2 blue capsules 200,000IU = 60,000ug
3. A 10kg child taking maintenance amounts of F75 (1000kcal) will receive 7300 IU (2.2mg) of
Vitamin A per
day. The Recommended Daily Allowance (RDA) USA for such a child is 1700 IU (0.5mg) per
day.
4. “In-patients” refer to patients admitted to in-patient facility for their entire treatment. It does
not refer to
patients transferred to OTP
5. A 10kg child taking maintenance amounts of RUTF will receive 400 micrograms of folic acid
per day. The
RDA (USA) for such a child is 80 micrograms per day.
54
Integrated Management of Acute Malnutrition
Section Two
Folic Acid
There is sufficient folic acid in F75, F100 and RUTF to treat mild folate deficiency.5 If
a patient shows clinical signs of anaemia give 5mgs of folic acid. Moderate Anaemia is
identified by palmer paler (very pale palms of the hands), and/or check conjunctiva colour.
A very pale conjunctiva is a sign of moderate or severe anaemia.
Iron Supplementation
High-dose iron tablets are contraindicated as they can increase the risk of severe infection
in severe acute malnourished patients due to the presence of free iron in the blood.
If moderate anaemia is identified:
• For in-patients receiving entire treatment of acute malnutrition in the in-patient health
facility: Add iron to the F100 in Phase 2.
Other Nutrients
F75, F100, RUTF and locally-developed milks with CMV contain the micro-nutrients
required to treat the malnourished child. Additional potassium, magnesium or zinc is not
administered. A “double dose” ---one coming from the diet and the other prescribed---is
potentially toxic. Additional potassium should never be given with these diets. Even for the
severe acute malnourished patient with diarrhoea, it is not advisable to give additional zinc.
Systematic Antibiotics
All severe acute malnourished children receive antibiotic treatment upon admission,
regardless if they have clinical signs and symptoms of systemic infection or not.

Summary of Management Severely malnutrition

1Treat/prevent h hypoglycaemia
2. Treat/prevent hypothermia
3. Treat/prevent dehydration
4. Correct electrolyte imbalance
5. Treat/prevent infection
6Correct micronutrient deficiencies
7. Start cautious feeding
8.Achieve catch-up growth
9.Provide sensory stimulation and emotional support
10. Prepare for follow-up after recovery

The malnutrition surveillance goal is:

 Early warning and problem identification
 Policy-making and planning
 Program management and evaluation
 Assess effectiveness of public health response that address the causes of malnutrition in
children

Effects of malnutrition
1. Impaired immune response
2. Impaired wound healing
 3. Reduced muscle strength
4. Inactivity especially in bound patient
5. reduced respiratory muscle strength
6. Water and electrolyte disturbances
7. Impaired thermoregulation
8. Vitamin and other deficiencies
9. Menstrual irregularities / amenorrhea
10. Impaired pyscho-social function
Interventions targeted at infants and young children (6–23 months) 20
• Continued breastfeeding
• Complementary feeding
• Use of multiple micronutrient powders for home fortification of foods consumed by
infants and young children 6–23 months 24
• Vitamin A supplementation for children under five years
• Vitamin A supplementation in children with measles
• Daily iron supplementation for children 6–23 months
• Zinc supplementation for diarrhoea management
• Reaching optimal iodine nutrition in young children
• Nutritional care and support of HIV-infected children 6 months to 14 years

MICRONUTRIENT DEFICIENCY
Vitamin A deficiency.
It is the most common in children especially those with marasmus, kwashiorkor, measles and
persistent diarrhoea. It occurs when one has used up the stores of vitamin A in the liver and is not
enough from food.
Causes of vitamin A deficiency
 Some diseases may increase the risk of VAD because they:-
 Reduce appetite so that a person eats less vitamin A
 Decreased absorption E.g. due to diarrhea, worms
 Increased vitamin A needs in disease conditions e.g. measles.
Signs of vitamin A deficiency.
It is not easy to see early sign. It is often not recognized until the deficiency is severe and results
in an eye disorder known as Xerophthalmia

Signs of Xerophthalmia occur in sequence and it forms the basis of the WHO classification of
the severity of the condition

WHO staging of Xerophthalmia

Class Lesions of xerophthalmia prognosis
 XN Night blindness Reversible and responds to
vitaminA therapy
X1A Conjunctival Xerosis(abnormal drying of “
mucus membrane)

X1B Bitot’s spot. Dryness and apparent roughness “

of the conjuctiva, often accampanied by foamy
or cheesy patches near the outer edge of the
iris.

X2 Corneal xerosis- characterized by dryness, “

dullness or clouding (milky appearance) of the
cornea. In this stage the disease progresses very
fast in matter of hours to the next stage.

X3A Corneal ulceration- the most severe stage Irreversible and leaves a
which may be followed by perforation of the sequelea
cornea resulting in the loss of eye contents and
permanent blindness

X3B Keratomalacia- softening of the cornea “

XS Corneal scars “
SF Xerophthalmia “

Treatment.
Xelophthalmia is a medical emergency
Children and adult males
Immediately after diagnosis
< 6 months -50,000 I.U
6-12 months 100,000 I.U
>1 year – 200,000 I.U
Following day – same age specific dose
Women of reproductive age.
Daily dose of 5000I.U or a weekly dose of 25000 I.U
Pregnant women
Diet rich in Vitamin and small doses of 40000I.U /25000 I.U weekly.
High risk groups
Infants with severe protein energy malnutrition, measles, diarrhoeal, respiratory disease, chicken
pox and serious infections the risk of vitamin A deficiency.

PREVENTION.
 i. Measles immunization
ii. High dose of vitamin A supplements
iii. Encouragement of breast feeding, which should be continued during illness including
diarrhoea
iv. Promotion of local production and consumption of green leafy vegetables and also animal
products
v. Environmental sanitation and personal hygiene measures especially those designed to
prevent diarrheal disease.
Prevention for high risk groups
Infants<6 months of age 50000 I.U
6-12 months 100,000 I.U
>one year 200,000 I.U
Supply
Soft gelatin capsules e.g 200000I.U of vitamin A +40 I.U of vitamin E
Sugar coated tablets with 10000 I.U of vitamin A for pregnant and fertile women.
2. VITAMIN C DEFICIENCY(SCURVY)

causes
Inadequate intake of food rich in ascorbic acid e.g. fresh fruits and green leafy vegetables.
Prevalence is higher among pregnant, lactating women and adolescents male. Vitamin C favors
absorption of iron.
Signs and symptoms
i. Bleeding and swollen gums especially between teeth
ii. Swollen and painful joints especially of the knees, hips and elbow
iii. Easy bruising
iv. Anemia
v. Gingivitis due to bleeding
vi. Sub periostal hemorrhages leading to pseudo paralysis.

Treatment
1g of ascorbic acid daily for 2-3 weeks
Prevention
At least 10mg of vitamin C daily in diet e.g. 15mls of fresh citrus juice, aquarter of an orange,
small fresh tomato, and 20g of green leafy vegetables, fresh milk from cows, goats and camels
contain good amount of vitamin C
Treatment
1g of ascorbic acid daily for 2-3 weeks.

3. VITAMIN B1 DEFICIENCY (BERIBERI)

Mostly common in area with polished rice, wheat and maize and occurs when energy
expenditure is high e.g. in pregnant, lactating women and young active men. It is also common in
alcoholism.
Signs and symptoms
Wet form
Heart enlargement and failure leading to acute swelling (edema)
Increasing in breathlessness and sudden death
Dry form
Weakness
Weight loss
Disturbance of sensation
Progressive ascending paralysis of the toes, fingers, and limbs.
If a person can’t be able to stand up from a squatting position without support it implies beriberi,
anemia, or PEM.
Infantile form
Occurs after an acute infection with loss of appetite, vomiting, restlessness, and palor. The infant
becomes breathless, cynotic with a weak rapid pulse. In severe cases aphonia occurs. In older
infants CNS signs of spasmodic contraction of facial muscles and convulsions as well as fever.
Treatment.
In severe heart failure, convulsion or coma in infantile beriberi 25-50 mg of thiamine should be
given by slow I.V infusion then I.M dose of 10 mg for about 6 weeks.
In less severe cases 10mg of thiamine per day P.O (I.M) during the first week followed by 3-5
mg per day orally for 6 weeks.
Critically ill adults 50-100mg of thiamine very slowly I.V followed by the same oral doses as the
infants.
Lactating mothers with latent or mild beriberi should receive 10mg of thiamine P.O per day for 1
week then 3-5 mg per day for at least 6 weeks to prevent acute beriberi in their infants.
Prevention.
1 mg of thiamine daily. Adequate amounts can be obtained from whole grain cereals, nuts, dry
yeast pulses ( beans) and red meats.

NIACIN DEFICIENCY (PELLAGRA)

Causes
Occurs when diet is chronically deficient in nicotinic acid (niacin) or contains excess isoleucine.
Occurs in population whose staples are maize and sorghum especially if stored for a long time.
Signs and symptoms
The 4 Ds
i. Dermatitis- characteristic symmetric rash where skin exposed to sunlight
ii. Diarrhoea- severe diarrhoea
iii. Dementia- mental deterioration
iv. Death- ultimately.
The mouth is sore and tongue brilliant red or beef red in color swollen and painfull. It is common
disease of the adults (20-50years) rarely after infants and young children.
Treatment
Oral dose 300mg daily for 3-4 weeks. The nicotinamide form I.e.100mg 8 hourly is preferred for
treatment since large dose of niacin cause flushing of skin, nausea and vomiting as well as
numbness of the tongue and lower jaw.

Prevention
Intake of 15-20 mg per day of niacin. Food sources are nuts, whole grains cereals, meat
(especially liver), fish, milk, and cheese.
VITAMIN D DEFICIENCY (RICKETS/OSTEOMALACIA)

It is characterized by deformity, soft bones since lack of vitamin D affects growth of bone and
cartilages. It’s generated in the skin by action of ultra-violent rays of the sun. With normal
regular exposure to sunlight rickets does not occur.
Signs and symptoms.
i. Early sign is the enlargement of bone/cartilage junctions at the end of long bones (wrist
and ankles) and in the ribs.
ii. The skull forms an irregular square form while the long bones are bowed and the pelvis
deformed
iii. Walking is delayed
iv. Young children are more prone to recurrent respiratory infections.
Treatment
v. Oral administration of 5000 I.U of vitamin D daily for 4-6 weeks then 1000 I.U daily for
6 months. These supplements are usually in capsules and are commonly derived from fish
liver oils
Prevention
Exposure of unclothed child to sunlight 10-15 minutes daily and or fortification of baby foods
with vitamin D
IRON DEFICIENCY ANEMIA
Causes
vi. Nutritional deficiencies
vii. Malaria
viii. Intestinal parastic infections
ix. Chronic infections e.g. HIV
x. Malabsorption.
xi. Not breastfeeding
xii. Diet rich in caffeine or cereals which inhibit iron absorption.

Assignment; read and make notes on signs and symptoms of anemia and the management

IODINE DEFICIENCY
Causes a variety of disorder including:-
i. Thyroid enlargement (goiter)
ii. Miscarriages and still births
iii. Neonatal and juvenile thyroid insufficiency
iv. Dwarfism
v. Mental defects
vi. Deaf mutism
vii. Spastic weakness and paralysis
Causes
Lack of iodine in the diet
Treatment
Iodized oil administered per oral 3, 6 or 12 monthly or I.M injection every 2 years.
Prevention
Intake of iodine in foods e.g iodized common salts
The adult requirement is 150 micrograms rising to 200 micrograms during pregnancy.
Micronutrient deficiency
Most micronutrients are classed as Type I;includes iodine, iron, Vitamins A and C.
Deficiencies in Type I micronutrients do not affect growth (i.e. the individual can have normal
growth with appropriate weight and still be deficient in micronutrients) and thus deficiency in
Type I micronutrients is not determined by anthropometric measurement.
Deficiencies in Type I micronutrients will cause major illness such as anaemia, scurvy and
impaired immunity.
Type II micronutrients
Type 2 micronutrients, includes magnesium, sulphur, nitrogen, essential amino-acids,
phosphorus, zinc, potassium, sodium and chloride, are essential for growth and tissue
repair.
Type 2 micronutrients are required only in small quantities, but the correct balance is essential
for good health.
A deficiency in any of the Type 2 micronutrients will lead to growth failure, measured by
stunting and wasting.
Assignment; read and make notes on mineral deficiencies