COMMUNITY NUTRITION

Course outline

1. Purpose:

To impact learners knowledge &skills on nutrition to enable them appreciate its importance to
community health.

2. Course content

1. Principles of nutrition

 Definitions
 Food classification
 Nutritional composition
 Energy values
 Digestion
 Absorption
 Metabolism

2. Nutritional requirements in different physiology states

 Pregnancy
 Lactation
 Infancy
 Childhood
 Adolescents
 Adulthood
 Old age

3. Community nutrition assessment

 Anthropometric assessment
 Dietary assessment
 Biochemical assessment
 Clinical assessment

4. Community nutritional problems

 Types of malnutrition
 Factors affecting nutritional status
 Causes of malnutrion
5. Food security

 Define terms
 Assessment of food availability in the community
 Actions to improve food security in the community

6. Nutrition surveillance

 Definitions
 Types of surveillance system &their purpose
 Collecting community based data
 Nutrition situations analysis

7. Intervention strategies

 Define terms
 Needs assessment
 Planning an intervention strategy(organization,
resourcemobilization training)
 Implementation,monitoring&evaluation
 Types of intervention programmes
 Supplementation
 Food fortification
 Social-economic status improvement
 Nutrition education promotion
 School feeding programme
 Supplementary feeding
 Food ratios
 Food for work
 Therapeutic feeding
 Kitchen garden
 1. PRINCIPLES OF NUTRITION
Community Nutrition:
It is a displine striving to improve the health, nutrition and well being of individuals and groups
within communities. It encompasses a broad set of activities designed to provide access to safe,
adequate, healthful diet to a population living in a particular geographic area.
These activities includes nutrition education, nutrition or health promotion, food programs,
preventive programs, local policy analysis and development and the organizational infrastructure
that supports it.
It involves four interrelated steps to deliver services:-
 Identify the problem
 Planning to meet the community nutrition problems
 Implementation to develop systems to reduce the problem
 Evaluation to see if problem has been ameliorated or solved

Nutrition: is the study of the influence of food intake on health and wellbeing maintenance and
reproduction.

Nutrition status: is a measurement of how well the nutrients in your diet are meeting the
physiologic needs of the body. This is done by reviewing and assessing many different
parametric to assess a person’s nutritional status by use of medical tests and other tools that
provides dietary information.

Deficiency diseases: are diseases in humans that are directly or indirectly caused by a lack of
essential nutrients in the diet

Balanced diet: refers to a serving of food that consists of adequate amounts of all the necessary
nutrients required for healthy growth and activity.

Nutritional composition: is defined as what a food is made up of and its impact on the body.
Nutrients: are substances in foods that are required by the body for growth, metabolism and for
other body functions. They are classified into two:-
 Macronutrients
 Micronutrients
Macronutrients are needed by the body in large amounts (carbohydrates, proteins and fats)
Micronutrients are nutrients that our bodies need in smaller amounts

Food Classification:
It is the grouping of different types of foods that humans consume based on nutritional properties
and their location in hierarchy of nutrition. Foods are grouped because they provide similar
amounts of the key nutrients of that food group.
For Example:
Milk, yoghurt, cheese – good sources of calcium and proteins
Fruit group is a good source of vitamins especially vitamin C
It is important to enjoy a variety of foods from each food group because different foods vary in
the amount of the key nutrients that they provide.
The basic food groups include:
1) Grains – there are two types of grains. Whole grain and refined grains. Whole grains
include whole wheat bread, whole grain cereals, oatmeal, and brown rice etc. Refined
grains include white bread, white rice and white pasta etc.
2) Dairy and Dairy products – dairy products are the best sources of calcium. They also
supply protein, riboflavin, vitamins A and D. They include milk, cheese, yoghurt and soy
beverages.
3) Meat and legumes – they include meat, poultry, seafood, beans and peas, eggs.
4) Vegetables – this includes dark green, red and orange vegetables. Examples include
broccoli, carrots, kale, spinach, tomatoes, can be consumed fresh, frozen, canned or dried.
5) Fruits – they include apples, apricots, bananas, dates, grapes, oranges, graoefruits
N//B: The amount of food you need to eat from each food group depends on your age, sex and
level of physical activity.
Energy Values: our bodies need energy to grow and repair them, keep warm and do physical
activity. Energy comes from food and drink in particular carbohydrates, proteins, fat and alcohol.
This energy is measured in calories (Kcal). While each of these macronutrients provides the
amount of calories that each one provides varies.
Energy values of different nutrients
Nutrient Amount of Energy
Carbohydrates 4 Kcalories per gram
Proteins 4 Kcalories per gram
Fat 9 Kcalories per gram
Alcohol 7 Kcalories per gram

Digestion: the process of breaking down food by mechanical and enzymatic action in the
alimentary canal into substance that can be used by the body.
Absorption: it is the passage of the end products of digestion from the digestive tract into the
blood vessels and the cells of tissues.
Metabolism: is a term used to describe all chemical reactions involved in maintaining the living
state of the cells and the organism. It is also referred to all the physical and chemical processes in
the body that convert or use energy, such as breathing, blood circulation, controlling body
temperature, excretion, food digestion and functioning of the brain and nerves.
Metabolism can be conveniently divided into two categories:
 Catabolism- the breakdown of molecule to obtain energy
 Anabolism – synthesis of all compounds needed by the cells
 2. COMMUNITY NUTRITION PROBLEMS
Malnutrition: state of the body not having enough nutrients or has excess of the required
nutrients.
Components of nutrition
1. Macronutrients; proteins, fats&carbohydrates are macronutrients that make up the bulk or a
diet &supply the bodies energy.
In resource poor population carbohydrates are often a large part of the diet and the main source
of energy. Fats also an essential component in the diet its resource population makes up about
10% of the diet.
Fats also supply energy and are important in cell formations. Proteins are required to build new
tissues and derived from animal origin such as meat, milk and eggs. Theseanimals by product
contain essential amino acids that cannot be produced by the body but must be eaten.
Proteins from cereals and pulse alone do not provide the sufficient balanced amino acids and
therefore to obtain the correct balance without requiring from an animal sources cereals and
pulses must be combined when planning a meal
Macronutrients are required in large amounts in the body
2. Micronutrients; There are around 40 different micronutrients that are essential for good
health. They are divided into two classess; type one includes iodine, ion, vit A and C
Deficiencies in type 1 micronutrient and thus deficiency in type 1 micronutrient is not
determined by anthropometric measurements
Deficiency in type 1 causes major illnesses like anaemia, scuvy and impaired immunity
Type 2 includes magnesium,sulphur,phosphorous,zinc,potassium,chloride and sodium
They are essential for growth and tissue repair. Type 2 micronutrients are required in small
quantities the correct balance is essential for good health.
A deficiency in any of these micronutrients leads to growth failure measured by wasting and
stunting.
CATEGORIES/TYPES OF MALNUTRITION
There are two major categories
1. Acute malnutrition
2. Chronic malnutrition
1. Acute malnutrition is brought about by the shortage of food for short periods of time which
results into wasting. It’s categorized into
 Moderate acute malnutrition
 Severe acute malnutrition
There two determined by the patient degree of wasting SAM is further classified into two:
 Marasmus
 Kwashiorkor
Patients may present with a combination of the two, which is referred to as marasmic
kwashiorkor.
CHARACTERISTICS OF MARASMUS &KWASHIORKOR
MARASMUS
1. Sever weight loss and wasting
2. Ribs are prominent
3. Limbs are emaciated
4. Muscle wasting
5. Good appetite
6. With correct treatment there is good progression.
KWASHIORKOR
1. Bi-lateral oedema and fluid accumulation
2. Loss of appetite
3. Brittle trinning hair
4. Hair colour change
5. Apathy and irritable
6. Face may seem swollen
7. High risk of death
CHRONIC MALNUTRITION
It’s determined by a patient degree of stunting (when a child has not reached his or her expected
height for a given age)
To treat a patient with chronic malnutrition requires a long-term focus that considers household
food security in the long term,homecare practices i.e. feeding and hygiene and issues related to
public health.
Chronic malnutrition is as a result of long deprivation of food for a long period of time.
CAUSES OF MALNUTRITION
This conceptual framework on the causes of malnutrition was developed in 1990 as part of the
UNICEF nutrition strategy. The framework shows that causes of malnutrition are multisectoral,
embracing food, health and caring practices. They are also classified as immediate, underlying,
and basic, whereby factors at one level influence other levels. The framework is used at national,
district and local levels, to help plan effective actions to improve nutrition. It serves as a guide in
assessing and analysing the causes of the nutrition problem and helps in identifying the most
appropriate mixture of actions.

Immediate causes
Inadequate dietary intake: due to insufficient and poor variety of food, too few meals or foods
being too bulky
Diseases: such as diarrhoea, acute respiratory infections, measles, malaria, worms and AIDS.
Diseases cause malnutrition by:
 Reducing appetite and absorption the gut so the body gets fewer nutrients
 Increasing the rate at which the body uses nutrients.
Health workers can help prevent the immediate causes of malnutrition by:
 Promoting exclusive breastfeeding for four to six months, then encouraging mothers to
introduce nutritious complementary foods while continuing to breastfeed
  Discussing with families how to improve child feeding practices
 Distributing micronutrients such as vitamin A and iron if needed
 Reducing disease by promoting immunisation, deworming, good hygiene practices and
use of safe water. Early treatment and care of sick children during illness and the
recovery period is also important.
Underlying causes:
Not enough food (Household Food Insecurity), and sometimes water, in the home. There are
many reasons why families are unable to produce or buy enough food to meet their nutritional
needs. For example: poverty, landlessness, illness, drought, flood and armed conflict.
Many of the activities needed to increase the amount of food available in homes are outside the
role of health workers. However health workers can play a part by encouraging home gardens
and small-scale income generating activities. They can also strengthen links with other sectors,
for example by working with agricultural extension workers.
Inadequate care for children and women:A child's growth and development depends on good
care. But to give good care, a carer (usually the mother) needs to know which behaviours help a
child's growth and development. Care behaviours that support nutrition include:
 Good hygiene practices
 Safe food preparation and food storage
 Giving appropriate food at the right age
 Psychosocial care such as attention, affection and encouragement.
To give good care mothers themselves must be healthy and ha e the time, confidence and right
environment within which to carry out these behaviors. This means they need access to health
services, a reasonable workload and emotional support from family members and community
networks. They also need control of, or access to the resources needed to practice the behaviors,
for example, enough money to buy food and adequate maternity leave to be able to breastfeed
exclusively.
Health workers can encourage good care for both women and children by:
 Encouraging support groups such as breastfeeding groups
 Promoting services, such as antenatal care and immunization, in the local community
 Supporting families to improve the care of sick children at home.
Poor health services and unhealthy environments:Improving health services, sanitation, water
supplies and the home environment help to prevent malnutrition through control of disease.
Basic causes:
They are political, economic and cultural situations, which affect the underlying causes.
Political causes include instability, poor system of government, and centralization of authority.
Civil wars can cause malnutrition because often people are displaced and unable to grow or buy
food.
Economic causes are linked to poverty. Poor people are normally the most malnourished. A
minimum income is necessary to get the food, goods and services needed for good nutrition.
Alleviation of poverty is essential to the elimination of malnutrition.
Culture determines eating, sanitation and health-seeking behaviors, which can have good,
neutral or negative impacts on nutrition.
Environmental causes: natural disasters such as drought, famine, earthquake can cause
malnutrition because of the effects these have effect on growing of crops or harvest.
Health workers can help to remove basic causes of malnutrition. For example, they can identify
beliefs and habits about feeding children and promote those which improve nutrition.
 3. COMMUNITY NUTRITION ASSESSMENT
It’s a continuous method of obtaining varying &interpreting data needed to identify nutritional
related problem their causes and significance in the community.

Nutrition assessment can be defined as the interpretation of information obtained from dietary,
biochemical, clinical and anthropometric studies. The information is used to determine the health
status of individuals of population groups as influenced by their intake and utilization of
nutrients.

There are different methods of community nutrition assessment includes;

1. Anthropometrical assessment
2. Biochemical assessment
3. Clinical assessment
4. Dietary assessment
5. Social-economic status
6. Physical activity

ANTHROPOMETRIC MEASUREMENTS

The anthropometric measurements of certain parameters of the human body are frequently used
to:

 Assess nutritional status in young children and adults

 Used to study growth and development of school aged children and adolescents
 Assess acute under-nutrition in adolescent

Anthropometric measures require two essential items:

 Anthropometric indicator
 Cut off points

NUTRITION INDICES

Anthropometric indices are also referred to as an anthropometric indicator. It is a measurement

or a combination of measurements made in field such as weight and height or the combination of
measurements with the additional data such as age and sex.

Indexes are important in making conclusions about the specific measurement. Nutrition indices
are developed through comparing the measurements to standard or references measurement.
Indices for interpreting anthropometric data that are commonly used are;

1. Weight for height - used to detect wasting

 2. Height for age –used to detect stunting level
3. Weight for age-used to show/detect underweight
4. Body mass index-is a way of comparing an individual weight with that of a reference
points used mainly in adults

BODY MASS INDEX

Body Mass Index (BMI) is a number calculated from a person's weight and height. BMI provides
a reliable indicator of body fatness for most people and is used to screen for weight categories
that may lead to health problems.

BMI=BODY WEIGHT IN(KGS)/HEIGHT(M2)

If a person weighs 75kgs and the height is 169cm. determine his/her BMI

=75/1.692

=26.3

Cut off points of adults by use of BMI are less than >18.5

BMI NUTRITION IMPLICATION

< 18.5 Underweight
18.5 – 24.5 Normal/Desired Weight
25 – 29.9 Overweight/Pre-Obese
> 30 Obese

MID-UPPER ARM CIRCUMFERENCE (MUAC)

MUAC is the measure of thinnest or [Link]’s mainly used in children and pregnant
[Link] is never used in the case of oedema.

Interpretation of Mid-Upper Arm Circumference MUAC indicators

 MUAC less than 110mm (11.0cm), RED COLOUR, indicates Severe Acute Malnutrition
(SAM).The child should be immediately referred for treatment.

 MUAC of between 110mm (11.0cm) and 125mm (12.5cm), RED COLOUR (3-colour Tape)
or ORANGE COLOUR (4-colour Tape), indicates Moderate Acute Malnutrition (MAM).
The child should be immediately referred for supplementation.

 MUAC of between 125mm (12.5cm) and 135mm (13.5cm), YELLOW COLOUR, indicates
that the child is at risk for acute malnutrition and should be counselled and followed-up for
 Growth Promotion and Monitoring (GPM).

 MUAC over 135mm (13.5cm), GREEN COLOUR, indicates that the child is well nourished.

Advantages of Mid-Upper Arm Circumference (MUAC) screening

 It is simple and cheap. It can be used by service providers at different contact points
without greatly increasing their workload and it can be effectively used by community-
based people for active case finding.

 It is more sensitive. MUAC is a better indicator of mortality risk associated with

malnutrition than Weight-for-Height. It is therefore a better measure to identify children
most in need of treatment.

 It is less prone to mistakes. Comparative studies have shown that MUAC is subject to
fewer errors than Weight-for-Height (Myatt et al, 2006).

 It increases the link with the beneficiary community. MUAC screening allows service
providers from peripheral health units and from the community to refer children with
acute malnutrition to therapeutic or supplementary feeding programs. The MUAC colour
coding is easy to understand for the child's care-taker.

BIOCHEMICAL ASSESSMENT

They are laboratory tests that are used to detect a developing deficiency imbalance or toxicity
state by taking a sample of body tissue or fluids and analyzing them in a laboratory and
comparing the results with the normal values of a similar population. The goal of nutrition
assessment is to discover early signs of malnutrition before the symptoms appear.

Lab tests also confirm results from other assessment methods to check for haemogloblin levels a
HB test is done.12 means it’s normal. If they get 11 is normal for post [Link] who have a
less than 10 it means that they have a mild deficiency. If it’s less than 7 one has severe condition.

Blood samples – plasma required for examination of albumin, vitamin A, Ascorbic acid, Iron,
Haemoglobin levels, alkaline phosphates. Urine samples – thiamine, urea, riboflavin,
nicotinamide.

CLINICAL ASSESSMENT

This technique is a physical examination that works for clues for poor nutritional status. Every
part of the body can be examined to offer clues e.g. the hair,the eyes,the skin,tongue etc. The
examination requires skills because many physical signs can reflect more than one nutrient
deficiency or toxicity even non nutritional condition.
Like other assessment tests a physical examination does not by itself provide conclusions but
instead may reveal possible nutrients imbalances for other assessment techniques to confirm data
collected from other assessment measures.

BODY PARTS CLINICAL ASSESSMENT NUTRITIONAL

IMPLICATION
HAIR Change in colour,texture,hair thatAcute malnutrition
can easily be pulled out wide gap
between the hairs
EYES Bitotspots(dry grayish of white Vit A deficiency
spots on the white part of the
eye)If the cornea becomes dull
milky and opaque.
Sunken eyes
Dehydration
TEETH White or brownish patches Excess fluorine
Spongy or a swollen gum VitCdeficiency
THYROID GLANDS If they are enlarged Iodine deficiency
BONES Knocked knees,bow legged Vit D&calcium deficiency

DIETARY ASSESSMENT

It involves asking the individual the foods and drinks they are consumed over a period of time. It
comprises of dietary practices e.g. number of meals consumed per day. Type and amount of
nutrients and the kilo calories consumed,frequency of consumption of particular food and
whether food was adequate or not.

Dietary assessment can also be used to assess if client s have a physiological problem and mal-
absorption e.g. clients appetite can be assessed whether they have nausea, [Link]
inhibiting food intake are;thrush,mouth ulcers and sores. In assessing nutritional status, it gives
insight of dietary intake both quality and quantity.

Dietary Assessment methods involves the assessment of food consumption, patterns and these
methods identify the dietary diversity adequately,availably and accessibility and affordability.

Date on food consumed assists in the identification if nutrients [Link] of dietary

involves the use of computer software and food composition tables’ nutrients intake assessment
through .dietary methods are used to complement anthropometry biochemical and clinical data.

Analysis of dietary intake involves

 Grouping of foods accordingly to predetermine systems to determine dietary diversity

 Determining the frequency of food consumption of food in each food groups
 Determining the amounts consumed
 METHODS OF DIETARY ASSESSMENT

i) 24 Hour Recall

A 24hr recall;the respondents are asked to remember the type and quantity of food consumed in
the previous [Link] value of these measurements are converted into grams or milliliters (for
drinks&beverage)

The amounts of various nutrients are calculated using the food composition tables and nutritional
computer packages designed these particular nutritional methods. One of the advantages of a
24hr recall is that the method is quick and cheap.

The main disadvantage is respondents may withhold or alter information about what they due to
embarrassment.

Time Type of Household

AmAmount Volum Volum Volume Volume Amount ingredients
dish measure e e that consumed taken
cooked served remained
Breakfast
Mid-morning
snack
Lunch
Afternoon
snack
Super
Evening snack

ii) FOOD RECORDS

It is used to record the food taken at the time of consumption. The respondent is asked to record
at the time of consumption all food and drinks [Link] respondent gives a detailed
description all foods and drinks taken as well as methods of food preparation and [Link]
amount of ingredients in the dish and the amount consumed are recorded.

The food proportion sizes can be estimated by the respondent using a variety of procedures at
differing levels of precision e.g. spoons,glass or cups

The number of days included in an estimated varies like 24hr recall,7day food frequency,14days
food frequency and 1month food recall.

Advantages

1. There is no recall biasness

2. It yields more accurate information because there is no recall bias.

Disadvantages/limitations

1. Its too demanding &tedious because of weighing

[Link] requires literacy on the respondent to be able to record the foods

3. There is likelihood to forget companion foods like sauces for chips

4. Recorders may be forced and forget to record all the foods.

iii) FOOD HISTORY

This involves obtaining information about food consumption for a pre determined period of time
e.g. one can predetermine consumption for the last 1 week, 1month prior to interview among
other. Information on cultural aspects of food consumption is factored in. It includes detailed
information of food frequency of consumption, usual food portion sizes taken in a common
household.

Advantages

[Link] for anthropological (study of culture)to assess what people take

2. Provide information on dietary changes overtime and reasons for change

Disadvantages

1. Time consuming

2. Requires a skilled interviewer

3. Recall biasness

[Link] concentrated on regular meal patterns and hence irregular meal may be
underestimated.

iii) FOOD FREQUENCY

This method is used in obtaining qualitative and descriptive information about food [Link] has
a set of food and a set of consumption by respondent. The person being interviewed expected to
indicate if he doesn’t consume the food at [Link] frequency certain foods are consumedis used
to determine diet [Link] method is also used to determine dietary habits.

Advantages

1. It’s a good indicator of food diversity

Disadvantages

1. It does not reflect on the amount of food taken one may forget to include some foods in
the list.

iv) FOOD DIVERSITY SCORE

A household dietary diversity is defined as the number of different food group consumed over a
period of [Link] number of different food groups consumed implies the diversity in both the
micro and macro nutrients.

Analysis of household diversity dietary score involves an interview in form of series of yes or no
between person collecting data and the respondent who is the person responsible for food
preparation.
4.0 THE NUTRIONAL REQUIREMENTS IN
DIFFERENT PHYSIOLOGICAL STATES
All people - pregnant and lactating women, infants, children, adolescents, and adults – need the
same nutrients, but the amounts they need vary depending on their stage of life.
Other factors that determine individual’s nutrient need:-
 Age – adolescent versus oldage
 Occupation – sedentary versus manual labourerer
 Gender – men versus women
 Physiological factor – pregnant versus sick people
 Climatical factors – Cold versus hot areas

NUTRITIONAL REQUIREMENTS IN PREGNANCY

Pregnancy is a time of increased nutrient need and not [Link] nutritional and health
status of each woman is different but there are general principles with regard to increased
nutritional [Link] is a correlation between maternal nutrient intake during pregnancy and
birth weight.
Increased energy need
Normally a pregnant woman requires 300callories during the 2 nd and 3rd trimester. Energy needed
the first trimester are essentially the same for a non-pregnant woman,while energy needed during
the 2nd and 3rd trimester represents only about 15% increase based on addition of 300calories.
Adequate energy intake is easy to achieve, and can be assessed appropriate weight gain
[Link] a woman is active during pregnancy, she needs to add to the extra energy she uses
to the energy allowances. Her greater body weight requires more energy and activities like
walking swimming and light aerobic are generally advised.
Increased protein and carbohydrates needs
The protein RDA for pregnancy is an additional 25 grams per day higher than for non-pregnant
women for the fetus, enlargement of the uterus, mammalian glands and the placenta, the increase
in blood volume, formation of the amniotic fluid, storage reserves for labour, delivery and
lactation.
Carbohydrates needs are at least 100g daily and these amounts per ketosis which can harm the
[Link] women alreadyconsume these amounts of [Link]- production of
ketones.
Increased vitamin needs
Vitamin needs increase by up to 80% for B-vitamins group except vitamin B6 which its needs by
45% and folate which increases by 50%. The extra amount of vitaminsB6 and other B –
vitamins(except folate)needed in the diet is easily met via food dozens. Folate are required in
pregnancies for both foetal and maternal growth and red blood cell formation therefore folate
requirements increases during pregnancy.
The RDA for folate increases during pregnancy to 600micogrammes (mg) per
[Link] at conception and therefore after has been associated with birth defects
specifically neurotube defects e.g. spinal – spina bifida in infants
Increased mineral needs
Calcium
The infant is born with approximately 28grams calcium which must come from the mothers’
reserves. If sufficient calcium is not consumed during pregnancy for a minority of women
pregnancy may represent a drained of a body store of calcium and subsequently increases
susceptibility to osteoporosis. However, in the majority cases if calcium needs are not meet by
an increased dietary intake of calcium it’s removed from maternal stores either in pregnancy or
lactation and the calcium and the bone density are restored by 12months postpartum.
Iodine
Iodine deficiency during pregnancy remains a major public health issue in many parts of the
world and this because of its irreversible condition that is known as cretinism(retarded growth
and mental retardation which is caused by severe lack of iodine during foetal development and
its characterized by both mental and physical retardation.
On the mothers side there is goiter. Pregnant women need extra iodine around 220 mgs per day
for prevention of [Link] use of iodized salt is usually enough to provide the required intake

Iron
The extra iron(27mg per gram) is needed to synthesize the greater amounts of haemoglobin
needed during pregnancy and to provide ions stores. All women often need a supplement ion
source especially if they start pregnancy with low ion stores. Milk, coffee or tea should not be
consumed with iron consumption. Eating that rich in vitamin C helps increase iron absorption.
Zinc
The requirement for zinc is increased during pregnancy and the foods that are rich in zinc are
meat and fish,nuts and legumes are also good sources but zinc is less available in strict
vegetarians. In strict vegetarians zinc supplements may be recommended.

NUTRIENTS NEEDS IN LACTATION

Lactation should be considered the normal continuation of the reproductive cycle in all nations
higher rates of breastfeeding are associated with increased maternal education
Energy
Energy needs increase significantly during lactation to provide the amount of energy in the breast
milk which is approximately 630kcal in seven and fifty ml of breast milk as well as to allow for
the energy to produce the milk. Most authorities suggest that some of the requirements needs of
in lactation should come from mobilization of fat stores laid down during pregnancy.
Hence the recommended daily intakes are in the range 400+500Kcal with the additional required
energy coming from mobilization fat stores.

Requirements for many of nutrients are mostly similar requirements during pregnancy and there
is a sustained need for calcium and a lower requirement for folate because breast milk is
considered rich in Vitamin A. Vitamin A recommendations are higher during lactation. Vitamin
C should provide 95Mg and 19mg of zinc per day during the 1stmonths of lactation.
Vegetarians are advised to take vitamin B12 supplement to ensure normal milk levels for the
baby which is 1mm per [Link] the other hand levels of Vitamin D are in milk and infants are
given Vitamin D supplements beginning at two weeks after birth in high latitude counties
During lactation the lack of normal menstrual flow results in reduced ion needs. Breast milk is
low in ion so demands for these nutrients are lower during lactation composed to pregnancy.

NUTRITIONAL REQUIREMENTS DURING INFANCY

Energy
Infants needs about 98 to 110Kcal per kg of body weight daily depending on age. Based on body
weight this is 2-4 times more energy than adults need. Either human milk or infant formula is
ideal for the first few months both are high in fat and supply about 700kcal per litre and later
human milk or infant formula supplemented by solid foods can provide even more energy. The
infants high energy needs are primarily derived by its rapid growth and high metabolic rate.
Proteins
Daily protein needs vary from0.7-1g for each pound of body weight(1.6-2.2kg of body
weight)depending on age. About half of total protein intake should come from essential amino
acids. Excess nitrogen and minerals supplied by high protein diets of cows milk would exceed
the ability of an infancy feeding to excrete the metabolic waste products and therefore adding
stress to the infants kidneys function.
Fats
Infants and children up to 2years should consume about 40%of the energy from fats. Fats are an
important part of an infant’s diet because they are energy debts and also to the development of
the nervous system. As a source of energy fat helps to resolve the potential problem of the
infants high energy needs and small stomach capacity.
Vitamins
Breastfed infants of mothers with poor vitamin D statusrequire a vitamin D supplements. Those
whose mothers are total vegetarians should receive vitamin B12 supplements. Infants who take
goat meat need a dietary supplement of folate because this milk does not supply an efficient
amount of this [Link] fed infants receive the vitamins they need from the formulas.
Minerals
The iron stores with which infants are born with are generally depleted by the time birth weight
doubles in 4-6months. To maintain a desirable iron status formula fed infants should be given an
iron fortified formula from birth. The breastfed infants need solid foods to supply extra ion at
about 6months of age. Iron deficiency anaemia can lead to poor cognitive development in
infants. They need adequate amounts of zinc and iodine to support growth.
Human milk and infant formulas adequately supply these needs as long as they supply energy to
meet needs. Fluoride: it’s important in aiding tooth development
Water
An infant needs(over 6months)about 150ml per kg of body weight. Infants consume enough
human milk or formulae to supply this [Link] that leads to water loss e.g. fever,
diarrhea,vomiting and too much sun can lead to need for supplement of water. Infants are easily
dehydrated a condition that has a serious effect if not looked up. Special fluid replacement
formulas containing electrolytes such as sodium and potassium are available to treat dehydration.

NUTRITION REQUIREMENT IN CHILDHOOD

Energy
Children between 1-5years need special attention because they show a good deal of physical
activity and growth therefore they need extra protein, vitamin and minerals. The energy
requirements of a child aged 1year is about 100kcal daily and after age 1 the energy needs maybe
calculated by adding 100kcal for every year.
Proteins
The total protein increases slightly with age. The RDA for proteins is 1-3 years about 1.05kg of
body weight and 4-10 years is 0.95kg.
Vitamins and minerals
They increase with age. A balanced diet of nutrients foods can meet children’s needs for those
nutrients with the notable exception of iron. Iron deficiency anaemia is a major problem
[Link] the 2nd year of life toddlers progress from an infant diet rich in iron to adult
foods low in [Link] prevent iron deficiency, children’s foods must deliver approximately 10mg
of iron per day.
To achieve this goal snacks and meals should include ion rich foods and milk intake should be
reasonable so that it will not displace lean meat,fish,poultry,eggs, legumes and whole grains or
enriched products.

NUTRITIONAL REQUIREMENTS IN ADOLESCENTS

Energy
The energy of adolescentsis influenced by activity levels. Increased Basal metabolic rates and
increased requirements to support growth and development. The RDA of an active boy of
15years may be around 3500kcal or more a day just to maintain his weight. A sedentary girl may
need around 1700kcal a day and especially if the growth is nearing at a standstill and if she is
avoiding excessive weight daily.
Proteins
The RDA for protein intake for females and males aged 10-13years is 0.95kg per day and 0.85kg
per day for 14-18years [Link] protein intakes are consistently inadequate delays in sexual
malnutrition and reduced accumulation of lean body mass maybe seen.
Carbohydrates
They provide the body primarily source of dietary energy and carbohydrates rich foods as fruits,
vegetables, whole grains and legumes are also the main source of dietary fibre. Dietary
recommendation suggests that 50%or more of total daily calories delivered from sweetness.
Dietary fibre
It’s important for normal bowel functions and it may pay a role in prevention of chronic diseases
as certain cancers and diabetes. The recommended dietary fibre for adolescents should be 0.5kg
of body weight.
Fats
The human beings require and essential fatty acids for normal growth and development.
Recommendations are adolescents should consume 25-35% of total calories from fats. Children
and adolescents should consume as little fats and milk and trans-fat as possible while consuming
an adequate [Link] is also suggested that adolescents consume no more than 300mg of dietary
cholesterol/per day.
Calcium
Achieving an adequate intake of calcium in adolescents is crucial to physical growth and
[Link] is the main constituent of borne mass. Calcium intake is of great
importance in developing dense borne mass and reducing the life time risk of fractures and
osteoporosis.
NUTRITION IN OLD AGE
Energy
Its needs decline an estimated 5% per decade and one reason is because people usually reduce
their physical activity as they age although they need not to do [Link] reason is that basal
metabolic rate declines one to 2% per decade as lean body mass diminishes.
Protein
Energy needs decreases and therefore proteins must be obtained from low calories sources of
high quality protein an example of high protein calories is lean meat,poultry,fish,eggs,fat free
and low fat meals products and legumes.
Proteins Is especially important for the elderly to support a healthy immune system and to
prevent muscle wasting.
Carbohydrates and fibres
Carbohydrates are needed to protect protein from being used as an energy source. Source of
complier carbohydrates such as legumes,vegetables,whole grains and fruits are also rich in fibre
and essential vitamins and minerals. Eating high fibre foods and taking water can elevate
constipation which is common among older adults.
Fats
Fat intake needs to be moderate in the diet of the most elders’ age enough to enhance flavours
and provide variable nutrients but not so much as to raise the risks of cancer and other diseases.
Vitamins and minerals
Most people can achieve adequate vitamin and mineral intake simply by including food of all
food groups in their diet but older adults often omit fruits and vegetables. Lack of vitamin D is a
problem among older adults and many older adults drink little or no milk further compromising
the vitamin D status of many older people especially those in nursing homes and have limited
exposure to sunlight.
Calcium
It’s important especially for women after menopause to protect against osteoporosis. 1200 of
calcium daily is recommended.
Water
It’s an essential for the older person as it is for the young individuals. The kidney is able to
function more adequately with there being sufficient fluid to eliminate wastes and 6-8glasses a
day may be healthy.
Iron
Iron needs on men remain unchanged throughout adult while for women the iron needs decrease
substantially when blood loss through menstruation [Link] people who take iron
supplements eat red meat regularly and include vitamin C rich food in their daily diet are likely
to have elevated iron stores than a deficiency.
 5. FOOD SECURITY
This is when all people at all times have access to sufficient safe nutritious food to maintain a
healthy and active [Link]’s also including both physical and economical access to food that meets
people dietary needs as well as their foods preferences.
DIMENSIONS OF FOOD SECURITY
Physical availability of food
Food availability addresses supply side of food security and is determines by the level of food
production stock levels and net trade
Economic and physical access to food
An adequate supply of food at the national or international level does not in itself guarantee
household levels of food security. Concerns about insufficient food access have resumed in a
greater policy focus on incomes expenditure,marketers and prices in achieving food security
objectives
Food utilization
Utilization is commonly understood as the way the body makes the most of several of nutrients
in the [Link] energy and nutrient intake by individuals is the result of good care, feeding
practices, preparation,diversity of the diet and intra-house distribution of food combined with
good biological utilization of food combines this determination the nutrients status of
individuals.
Stability
Stability of other three dimensions over time even if your food intake is adequate today you are
still considered to be food insecure if you have inadequate access to food in a periodic basis,
risking a deterioration of your nutritional status. Adverse weather conditions,political instability
or economical factors may have an impact on your food security status.
For food security objectives to be realized all four dimensions must be fulfilled simultaneously
TYPES OF FOOD INSECURITY
[Link] food insecurity. It’s a long term occurrence or it’s usually persistent and it occurs
when people are unable to meet their minimum food request over a sustained period of time
[Link] food insecurity: This is usually shorter or temporarily. It occurs when there is a
sudden drought with availability to produce or access enough food to maintain a good nutritional
status.
3. Seasonal food insecurity; it falls between chronic and transitory food insecurity. It is similar
to chronic food insecurity as it is usually predictable and follows sequence of known events.
However, seasonal food insecurity is of limited duration and it can also be seen as recurrent
transitory food insecurity. It occurs when there is a cyclical of adequate available and access to
food. It’s associated with season fluctuations in climate work opportunities of diseases.

WHY THERE IS FOOD INSECURITY

1. Poverty; Poor people lack access to sufficient resources to buy quality food. Farmers may
have small farms may use and less effective family technique and be unable things like fertilizers
and labour saving equipments all these limit food production. They cannot grow enough foods
for themselves let alone generate income by selling excess to others
2. Health: Without sufficient calories the body slows down making it difficult to undertake the
work needed to produce food. Without good health the body is less able to make use of the food
that is available.
3. Water and the environment: food production requires massive amounts of water and
producing sufficient food is directly related to having sufficient water. Irrigation ensures
adequate and reliable supply of water which increases yields of most crops where water is scarce
and the environment fragile achieving food security may be a challenging issue
4. Gender equity:women play a vital role in providing food and nutrition in their families
through their role as food producer, processors and income earners. Women have lower social
and economical status and this limits their access to education training land ownership,decision
making and credit and consequently their ability to improve their access to the use of food.
Increasing women involvement in decision making and their access to land and credit will in
return improve food security.
5. Disaster and conflicts:drought,foods,pests,earthquakes,fires all these can quickly wipe out
large quantities of food either when it grows or when it’s stored. Manmadedisasters may also
destroy food e.g. wars, deforestation etc. Preventionof disaster and conflicts will lead to food
security
6. Population and urbanization: people growth increases the demand for [Link] cities
plus food production further and further away from consumers as much land is used for
construction of houses and therefore leaving little land for food production and all these leads to
food insecurity.
7. Trade:many poor countries can produce staple food more cheaply than the rich countries but
barriers to trade such as distance from marketers’ trade regulations and tariffs make it difficult
for them to compete with rich [Link] additiontrade imbalances prevent poor countries from
importing agricultural products that could enhance their food security.

FACTORS TO IMPROVE FOOD SECURITY SITUATIONS

1. Improving food productions
Increasing the amountoffood available to feed the growing population using high yielding
varieties of crops to produce quality of food
 By use of fertilizers and pesticides to improve produce
 Integrating traditional and international methods in food production
 By provision of low cost finance to help farmers invest in seeds ,fertilizers and irrigation
techniques
2. Economic growth and trade liberalization
Increasing food production which leads to greater availability of food in domestic and overseas
markets - opening up markets for better trade
3. Distribution
Developing policies and plans to favour distribution to poor populations,A plan should be as
follows;
 Include nutrition goals in development policies and programmes
 Improve household foods and nutritional security
 Protect consumers by proving quality and safe foods
 Prevent and manage infectious diseases
  Promote breastfeeding
 Care for the socially and economically and nutritionally deprives population
 Prevent and control specific micronutrient deficiencies
 Promote appropriate diets and healthy lifestyles
 Assess, analyze and monitor nutrition situations
4. Recognizing the role of women
Gender equality is a first step for the eradication of poverty and hunger. Women should be given
more roles in agricultural production and foodpreparation. They should have access to food land
credit education health and decision making.
5. Food Aids
The need for foods during emergencies is addressed by the distribution of basic of basic food
supplies and fuels actions need to be taken early before disasters strike; foods need to be
distributed appropriately as needed by various populations. Food aid is normally free and should
be distributed freely.

COMMUNITY FOOD ASSESSMENT (CFA)

CFA is a collaborative and participatory process that systematically examines a broad range of
community. Food issues and assesses so as to inform change agents to make the community
more food secure. The purpose of the CFA is to determine the location and incidence of food
deserts these are the areas with healthy and fresh food and inform the decision makers of those
areas that need intervention.
CFA have 3 basic extensions
1. Assetbuilding; it seeks to tap ways into building a community resource centre.
2. Engagement of community members;community members’ help to set priorities they conduct
research and they conduct researches and they develop recommendation.
[Link] are action oriented; this means having Specific action plan and organizing any efforts to
make the required changes in the community. Each CFA is unique and they vary as much as the
communities themselves do. Outcomes of the CFA’s may include;
 improved transportation
 creation of a food policy committee
 enhance connections between farmers
  assistance for farmers
 community nutrition education
 gardening education and expansion of gardening activities
N//B:A CFA is usually the first step increating a stronger more food secured community
6. NUTRITIONAL INTERVENTION
Is defined as purposefully planned actionsintended to positively change a nutritional related
behavior environmental condition or aspect of health status for an individual target group or the
community at large.

Nutritional interventionsconsists of two components

1. Planning

2. Implementing

Targeted interventions are needed to improve the lives of the poorest people who either
permanently or during crisis periods are unable to produce enough food or do not have the
resources to otherwise obtain the food that they and their households required for active and
healthy lives.

TYPES OF INTERVENTION PROGRAMMES

1. Supplementation programmes;supplementation programmes are intended to provide

nutrients that they otherwise not be consumed insufficient quantities .eg. Vitamins,
minerals,fibre etc. It is an important way of preventing and controlling specific micronutrient
deficienct

2. Food fortification programme

These are programmes that involve themselves in the process of adding micronutrients to food.
Its aim is to reduce the number of people with dietary deficiencies. The most common fortified
food are cereals based products milk and milk products and infants formulas.

3. Nutritional education and promotion programmes

These programmes are intended to improve nutritional status by helping communities to improve
their nutritional problems and ways of solving these problems using resources available to them.
The ultimate of nutrition education programme is to bring about appropriate and meaningful
changes in knowledge attitudes and dietary.

4. School feeding programmes

Have been as targeted social safety net that provide both educational and health benefits to the
most vulnerable conditionthereby increasing enrollment rates reducing absenteeism and
improving food security at the household level. School feeding programmes often starts through
finding by international organizations
 5. Food for work programmes

In food for work programmes food is given as full as part payment to unskilled or semiskilled
workers who are employed in public work schemes such as building roads or drainage canoes
etc. In general food for work programmes are self targeting in nature the target beneficiaries by
means of selecting food ratios with a market [Link] enough to induce only those unable to
find more remunerative employments to participate. The principle aim is to provide income in
the form of food.

Advantages

 It contributes to national development projects

 It is less corrupt than with programmes than with programmes that provide cash
 The local consumer prices of commodities are kept low even for the non participating
people.

Disadvantages

 Employment is temporary and insecure

 Its not sufficient to reduce permanently the food insecurity
 Outcome of the project may be poor owing to lack of technical support tools cash and
proper supervision
 It may result in population movement as people relocate in search of work and thus
placing pressure on social infrastructure

6. Kitchen gardening programme

This programme is aimed to improve income and food security of farmers and in house holds

7. General feeding programme

It’s a programme that can provide food ratios to households highly affected by food insecurity.
General food returns are usually provided as dry rations for people to cook in their homes. The
local communities’ food habits tastes and preferences must be taken into considerations when
distributing general food ratios

8. supplementary feeding programmes

The goal of supplementary feeding programmes is to rehabilitate individuals affected by

moderate acute malnutrition or and at the risk of becoming malnourished by providing a
supplementary food retain when is highly [Link] are two ways of distributing food
commodities
a)Theonsite feeding /wet ratio

b)Take home/dry ratio

The differences of on site feeding and take home feeding

Take home Onsite

It’s a regular bi-weekly distribution of food in dry Daily distribution of cooked foods or meals at a
form that is prepaired at home health facility or a feeding [Link] only
considered for extreme situations
Usually 2-3 meals are provided each day

9. Therapeuticprogrammes
This programmedeals with the management of sever acute malnourished patients.
[Link] SURVEILLANCE
Meaning keeping watch over nutrition in order to make decisions that will lead to the
improvement of nutrition in populations. It is the monitoring of changes in the nutrition status of
a population over a period of time. Three distinct objectives have been defined for surveillance
systems, primarily in relation to problems of malnutrition in developing countries: to aid long-
term planning in health and development; to provide input for programme management and
evaluation; and to give timely warning of the need for intervention to prevent critical
deteriorations in food consumption.
The need for nutritional surveillance especially in developing countries stems from the
recognition that the major cause of malnutrition is poverty and poverty contributes to
malnutrition in the following ways
i. Inadequate food availability
ii. Inappropriate distribution of food in the households
iii. Inappropriate living conditions
iv. Inadequate access for health services
Purpose of Nutritional Surveillance
i. It helps to identify the root causes of poor health and nutrition
ii. Assists in planning for basic needs e.g. education ,housing and nutrition
iii. It plays an important role in setting health strategies
iv. Nutritional surveillance provides nutritional and related data which is relevant for
developing health systems and for introducing nutrition and health concerns into other
sectors
v. For monitoring progress towards health objectives and for evaluation of outcome in
various intervention programmes nutrition indicates provide the necessary health i.e.
information infant mortality rates prevalence of low birth cots life expectancy prevalence
of malnutrition
vi. Necessary for the timely warning and intervention programmes in some situations major
episodes of malnutrition brought about by short term events impose on conditions of
severe poverty such as drought crop damage, pests price changes for agricultural produce
 increase in food prices conflicts and wars. The information helps in making decisions that
will help to make policies and programmes and initiation of new measures that will help
to improve nutrition.
vii. Nutrition surveillance assists in both of plans and policy directives. In Kenya nutrition
data is collected as part of the integrated rural surveys. Country can develop a
development plan. Development plan includes the nutrition problems in relation to
economic facts due to this the government set up the food and nutrition planning unit in
the ministry of planning and national development. The unit coordinates activities in
different sectors review programmes and policies as regarding the nutritional impact and
tries to address the nutrition problems in the country.

1. Nutrition Surveillance For Long Term Planning

By providing information on nutrition conditions and associated factors in different people
groups and how such conditions are changing with time. Therefore nutrition surveillance can
facilitate decision making in relation to
i. Current and physical policies
ii. Direct targeting for health related and food and nutrition programmes
iii. General development programmes
Nutritional surveillance information can be utilized to promote actions that will alleviate/prevent
malnutrition in the population or individual, family, community and regional levels.
Anthropometric data plays a very important role in the process.
2. Timely Warning
Timely systems are intended to prevent acute food shortages after resulting from drought and
floods. Timely is used to imply that a decision to intervene with a predetermined response e.g.
release and distribution of medication, food (stocks). Timely warning is dependent on the
collection and rapid analysis of a selected few predictive indicators.
3. Programme Management
Effective programme management calls for monitoring in order to ensure that services are being
delivered to the planned target group and are having the desired outcome. Anthropometry may
be useful in identifying the target group if the program is nutrition related, the component has a
role in checking the progress.
Finally anthropometry may be relevant in assessing the overall program performance and impact.
For management purposes the question normally asked “is enough of the right food getting to the
right people at the right time?”
Measurements used in nutritional surveillance:-
i. Health status indicators with respect to nutritional status of the children and morbidity
and mortality data
ii. Data from most suitable sources that is available which includes surveys and
administration data.
Nutrition Surveillance is relevant to the Ministry of health, Agriculture, Social services and
number of NGO’s.
Nutrition Planning and Evaluation
Nutrition planning involves the following
i. Identification of health and nutrition needs of a community
ii. Prioritization of the needs ranking of the needs within the community (food security)
iii. Setting objectives and outcomes
iv. Working out the resources for the selected program or problem
v. Be able to develop a systematic plan for implementation and evaluation of the
programme
In planning the 1st most important issue:
i. Who are planning for -: national, personal, village level
ii. Is it a long term plan, short term or emergency

Steps in developing a project plan

i. Statement of the problem(s) to be solved. Statement should be concise, should
include specific information that led you to identify the priority problem
ii. To identify the target group(s) in a population
iii. Ascertainment and consideration of alternative interventions and this will be
considered.
 Cost benefit
 Is the intervention able to address the problem
 Their inputs, outputs and outcomes
Evaluation
This is the most neglected component of the planning process. Evaluation is a tool by which we
measure whether and to what extent we have achieved our objectives. Evaluation should tell us
under which circumstances we’ve not achieved or met the objectives as well what has been the
success.
Evaluation is essential for the following reasons/purposes:-
i) It’s the only way to recognize success or failure of a programme or project
ii) Evaluation is crucial to our learning process. It enables one to improve on similar
efforts in future or to think about alternatives in the programmes
iii) Information from evaluation can be timely when the planners are examining the cost
effectiveness of alternative approaches to achieve the same goal.
Evaluation Frameworks
An evaluation framework consists of the following:
i) What kind of evaluation will be undertaken
ii) When each evaluation will be conducted
iii) What kind of information will be collected and how it will be used
iv) What will be the specific sources of information – women or children
v) How will the required data collected analyzed
Types of Evaluation
i) Process Evaluation: is done as the intervention programme progresses and it’s done
to improve the ongoing programme
ii) Impact Evaluation: is done at the end of the programme to determine the
effectiveness of the [Link] checks whether:
 the programme address the needs
 the accuracy of activities being implemented
 the programme needs modification
 the social processes are being put into consideration
 the evidence to support what’s going on/ happening