BASIC NUTRITION

SEPTEMBER 2018 CLASS

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

• Demonstrate the understanding of importance of nutrition in

disease prevention and maintenance of good health
• 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
Definitions….ct
• 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.
Definitions….CT

• Food bio availability – reduced or increases effects due to interaction

e.g. 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.
Definitions….
• 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; -
1. Macronutrients –those that the body requires in large quantities
measured in grams.
2. Micronutrients – those that the body requires in small quantities
and are measured in milli- or micro grams.
FOOD CLASSIFICATION
• Food is classified into 3 major groups according to nutritional
functions.
• Energy producing
• Body building
• Protective foods.
Nutrients
Macronutrients
Proteins, fats, carbohydrate and water

micronutrients
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
 PROTEINS…..CT
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

• Animal products
• Plant products e.g. legumes cereals
• Other sources like oil seeds
Functions of proteins
Amino acids are used for;-
• Growth and repair of body cells and tissues
• Synthesis of enzymes, plasma proteins, immunoglobulin and some
hormones.
• Provision of energy. When consumed in excess 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 etc.
 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.
• Monosaccharaides – are the simplest forms and include glucose,
fructose and galactose. They are broken down into CO2 + H2O +
energy after being converted into glucose.
CARBOHYDRATES…..ct
Disaccharides – These consist of 2 monosaccharide molecules
chemically combined. When the molecules are split into
monosaccharaides 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
Starch- cereals e.g. wheat rice, millet, maize.
Sugars-
monosaccharaides are found in fruits, honey, milk
Disaccharides like sucrose- sugar, lactose-milk, maltose-starch.
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
• Glycogen –as a short term energy store in the liver and muscles
• 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 etc.
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.
 Fats…..ct
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
• Linoleic acid
• Linolenic acids
• 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 grams 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 every day 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 their 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. 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
VITAMIN C…..

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 otherwise 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
• 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
• It’s important for the nervous system function and muscles because of
the dependency of these tissues on glucose for fuel
• 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

N/B 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
Folates……
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
• DNA synthesis – without it mitosis and cell division is impaired
• Maturation of RBCs
• Metabolism of amino acids ( synthesis of purine and pyrimidines)
Deficiency results in megaloblastic or macrocytic anaemia
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
5. Dementia
6. Dermatitis
7. 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 etc..
Vitamin B6
It occurs in the 3 forms
1. Pyridoxine
2. Pyridoxal
3. Pyridoxamine
Functions
• Important in protein metabolism especially synthesis of nonessential
amino acids and molecules like haem and nucleic acids.
• Conversion of tryptophan to niacin
• Proper functioning of the central nervous system
Vitamin B6

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 etc.
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
• It is essential for DNA synthesis that is synthesis of purine
• Formation and maintenance of myelin-fatty substance protecting the
nerves
• 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
1. Generation of the light sensitive pigment rhodopsin in the retina of the
eye
2. Growth and differentiation especially fast-growing cells of the
epithelium
3. Promotion of immunity and defense against infection
4. 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
synthesize 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 mal absorption 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
1. It is an essential structural component (bone) in the body.
2. It is important in coagulation of blood
3. Muscle contraction
4. Requirements are higher in children and pregnant women although
can be adequate in a well balanced diet.
CALCIUM …..
Sources- cheese, liver and kidney
Deficiency- if there is adequate calcium in the body there is no
deficiency
Functions
1. Hardening of bone and teeth
2. Essential parts of nucleic acids (RNA, DNA)
3. Essential parts of energy storage molecules in cell ( ATP- adenosine
triphosphate)
SODIUM

Found in all foods and table salt. Intake usually exceeds requirement
thus excreted in urine. It is the most common occurring extracellular
sodium (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
1. Formation of hemoglobin
2. Oxidation of carbohydrates
3. Synthesis of hormones and neurotransmitters.
4. 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
VARIATIONS…..
• 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.
VARIATIONS…..
• 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
1. Normal meal: this entails the normal diet
2. 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
Food signal system
Principle for health food choices and cooking methods. od pyramid …..
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
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

1. Assess the needs of the target group

2. Formulate the objectives to be achieved
3. Means of achieving the objectives.
4. How to acquire the food and what food to be acquired
5. How to prepare, cook, serve, and eat.
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 e.g.. 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.
Principles…..

7. Moderation in diet – portion size. This requires planning the entire

day’s 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.
8. Variety of food choice
9. 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
3. adults and adolescents 3.5-4.5kg cereal,1.0-1.5 kg legumes,1kg of dark
leaves a week
4. Young children not breast feeding 1.25-2 kg of cereal, 0.5-1.0kg of
legumes,0.8kg green leaves etc.
5. Available amount of money to purchase the items.
6. The period of time one expects to use this food.
7. 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.
8. Check for the cheapest brands but also consider the quality.
STEPS IN FOOD BUDGETING.
Establish the amount of money available.
Establish the period of time that money will be required to feed the
family.
List food items that are available and those you may be able to buy in
the 3 categories of foods.
Indicate the prices of each of the food items bought that will be
required for that period of time.
Select the ones that will be friendly to your budget and will also be
rich in nutrients.
Calculate the total cost of the items.
STEPS………
Add miscellaneous items e.g. tea leaves, salt, sugar; spices etc. then
cost them per week and have the total.
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.
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.
Decide what to spend on food from your income.
The figure will form your budget.
water
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 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.
FOOD HABITS AND PATTERNS….

 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 .
Importance of good habitS
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.
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
• 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:-

• Encouraging breast feeding for at least 2 years.

• Emphasize on the nutritional value of the locally available foods and advice on
the mixed foods.
• Advise on proper storage and preparation of food
• Advise on the 3 classes of nutritional needs in terms of nutrients giving
examples of the locally available food items.
• Start demonstration Shambas at the health facilities to help educate on the
importance, use, and maintenance of the kitchen garden.
• Educate on environmental health to prevent diseases.
• Encourage them to take children for immunization.
• Encourage them to attend clinics where they can get health education as well as
management for various ailments.
• 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.
Methods….

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.
Methods..

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.
Methods…
5. 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
1. The underlying disease conditions which require a change in the
diet.
2. The possible duration of the disease.
3. The factors in the diet which must be altered to overcome these
conditions.
4. The patient’s tolerance for food by mouth
5. The normal diet my be modified to
6. Provide change in consistency as in fluid and soft diets.
7. Increase or decrease the energy value.
8. Include greater or lesser amounts of one or more nutrients, for
example, high protein, low sodium, etc.
9. 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.
COMMON THERAPEUTIC 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.
COMMON THERAPEUTIC DIETS
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.
COMMON THERAPEUTIC DIETS

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.
NUTRITION ASSESSMENT
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
1. Procedures are simple, safe, noninvasive and are applicable to large sample
sizes
2. Inexpensive, portable and durable equipment
3. Relatively unskilled personnel can perform the procedures

4. Information is generated on past long-term nutritional history which

cannot be obtained with equal confidence using other techniques

Disadvantages of Anthropometry
1. Cannot distinguish between specific nutrient deficiencies
2. Non nutritional factors can reduce specificity and sensitivity of
anthropometry
Uses of anthropometry
I. Identifying socio and economic inequalities
II. Identifying individuals at risk of malnutrition
III. Evaluating the effects of changing nutritional, health, or
socioeconomic influences and interventions
IV. Excluding individuals from certain programs/treatment
V. 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
N/B. 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
Mid Upper Arm Circumference……
• 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 Circumference Colour of Cord Nutritional status
(cm)

<12.5 Red Acute Malnutrition

12.5-13.5 Yellow Mild Malnutrition

>13.5 Green Normal

Classifications

UNDERWT :<18.5
NORMAL WT :18.5 TO 24.9
OVERWT :25-29.9
• Obese : ≥30.00
Obese class I : 30.00 - 34.99
Obese class II : 35.00 - 39.99
Obese class III : ≥40.00
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

or
wt (lb) X 705
ht (inches) 2
FOOD

• The term 'food' brings to our mind countless images. We think of

items not only that we eat and drink but also how we eat them and
the places and people with whom we eat and drink. Food plays an
important role in our lives and is closely associated with our
existence. It is probably one of the most important needs of our lives.
The term ‘food’ refers to anything that we eat and which nourishes
the body. It includes solids, semi-solids and liquids.
 FUNCTIONS OF FOOD
There are basically three important functions of food:
Social Function
• Food and eating have significant social meaning. Sharing food with any other
person implies social acceptance. Food is also an integral part of festivity
every where in the world.
Psychological Function
• We all have emotional needs, such as need for security, love and affection.
Food is one way through which these needs are satisfied. Food is often
served as a reward
Physiological Function
• There are three physiological functions performed by food. These are energy
giving, body building, regulating body processes and providing protection
against diseases. Let us see them in detail.
IMPORTANCE OF FOOD

• Food provides energy

• Food helps in body building
• Food regulates body processes and provides protection against
diseases
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.
Factors….

• 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

1. Weaning at 6 months
2. Weaning at 6-9 months
3. 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
Safe preparation and storage of foods
a) washing caregivers’ and children’s hands before food
preparation and eating,
b) storing foods safely and serving foods immediately after
preparation,
c) Using clean utensils to prepare and serve food,
d) using clean cups and bowls when feeding children, and
e) Avoiding the use of feeding bottles, which are difficult to
keep clean.
Infant feeding
Objectives
By the end of this unit, the participants
should be able to:
• Be familiar with the National infant feeding guidelines
• Discuss the two feeding options recommended for infants
• Discuss maternal and infant conditions
Definition of key terms
Exclusive breastfeeding:is giving a baby only breast milk, and no other
liquids or solids, not even water. Drops or syrups consisting of vitamins,
mineral supplements or medicines are permitted.

Replacement feeding is the process of feeding a child who is not

breastfeeding with a diet that provides all the nutrients the child needs
until the age at which the baby can be fully fed with family foods

Cup-feeding: Feeding from an open cup without a lid, whatever is in

the cup.
Exclusive breastfeeding
Advantages of Exclusive Breastfeeding
• Breast milk is the perfect food for babies and protects them from
diseases
• Breastfeeding improves brain growth and development
• Breast milk gives babies all of the nutrition and hydration they need
• Breast milk is always available and does not need special preparation
Breast milk
• Perfect nutrients
• Easily digested; and efficiently used
• Protects against infection
Advantages of EBF…

• Helps bonding and development

• Helps delay a new pregnancy
• Protects mothers’ health
• Costs less than artificial feeding
How breastfeeding works
• When a baby suckles at the breast, sensory impulses go from the
nipple to the brain. In response, the pituitary gland at the base of the
brain secretes prolactin.
• Prolactin goes in the blood to the breast, and makes the milk-
secreting cells produce milk.
• Most of the prolactin is in the blood about 30 minutes after the feed
− so it makes the breast produce milk for the next feed. For this feed,
the baby takes the milk which is already in the breast.
• More prolactin is produced at night; so breastfeeding at night is
especially helpful for keeping up the milk supply.
• . Hormones related to prolactin suppress ovulation so breastfeeding
can help to delay a new pregnancy. Breastfeeding at night is
important for this
Good Positioning And Good Attachment
Good Positioning:
• Baby’s head and body in line
• Baby held close to mother’s body
• Baby’s whole body supported
Baby approaches breast, nose to nipple

Good Attachment
• More areola seen above baby’s top lip
• Baby’s mouth open wide
• Lower lip turned outwards
• Baby’s chin touches breast
Expressing and Heat-treating Breast Milk

• Expressing milk: Removing

milk from the breast, usually by hand. However there are pumps that
are used to express breast milk.

• Heat-treating: Heating the expressed milk to the boiling point to kill

the HIV before the milk is fed to the infant
Exclusive Replacement Feeding

• When replacement feeding is acceptable, feasible, affordable,

sustainable and safe, (AFASS) avoidance of all breastfeeding by HIV-
positive mothers can be taken up as an alternative; otherwise,
exclusive breastfeeding is recommended during the first months of
life.
 AFASS…
Acceptable:
The mother perceives no barrier to replacement feeding. Barriers may have cultural or
social reasons, or be due to fear of stigma or discrimination.
Feasible:
The mother (or family) has adequate time, knowledge, skills and other resources to prepare the
replacement food and feed the infant up to 12 times in 24 hours.
Affordable:
The mother and family, with community or health-system support if necessary, can pay for the
cost of purchasing/producing, preparing and using replacement feeding, including all ingredients,
fuel, clean water, soap and equipment, without compromising the health and nutrition of the
family.
Sustainable:
Availability of a continuous and uninterrupted supply, and dependable system of distribution for
all ingredients and products needed for safe replacement feeding, for as long as the infant needs
it, up to one year of age or longer.
Safe:
Replacement foods are correctly and hygienically prepared and stored and fed in
Breast conditions
Common breast conditions:
Flat and inverted nipples
Engorgement
Blocked duct and mastitis
Sore nipples and nipple fissure

Assignment; Read on each.

Benefits of breastfeeding

Breastfeeding has an extraordinary range of benefits.

• It has profound impact on a child’s survival, health, nutrition
and development. Breast milk provides all of the nutrients,
vitamins and minerals an infant needs for growth for the first
six months, and no other liquids or food are needed.
• breast milk carries antibodies from the mother that help
combat disease.
• The act of breastfeeding itself stimulates proper growth of
the mouth and jaw, and secretion of hormones for digestion
and satiety.
Benefits….
• Breastfeeding creates a special bond between mother and
baby.
• Breastfeeding also lowers the risk of chronic conditions later
in life, such as obesity, high cholesterol, high blood pressure,
diabetes, childhood asthma and childhood leukaemias.
• Studies have shown that breastfed infants do better on
intelligence and behaviour tests into adulthood than formula-
fed babies.
 Barriers to breastfeeding

1. Inaccurate information
2. Lack of support from male partners
3. Lack of access to skilled counselling
4. Face aggressive marketing of breastmilk substitutes
5. Return to work soon after giving birth.
6. These barriers make it exceedingly difficult for women to
breastfeed exclusively for six months (with no additional
liquids or food) and to continue breastfeeding for two years
or longer,
Nine Key action areas of global strategy and status
1. Appoint a national breastfeeding coordinator and establish a
breastfeeding committee
2. Ensure that every maternity practice the ten steps to successful
breastfeeding (Baby Friendly Hospital Initiative -BFHI)
3. Take action to give effect to international code of MBMS and
subsequent relevant WHA resolutions- Enactment of national
legislations (BMS) Act
4. Enact legislation protecting the breastfeeding rights of working
women

5. Develop, implement, monitor and evaluate a comprehensive

policy covering all aspects of MIYCN
Nine Key action areas of global strategy and status
6. Ensure H/C systems and other relevant sectors protect, promote and
support EBF and continued BF for up to 2yrs or beyond while
providing women with support they require to achieve this goal in
the family, community and workplace
7. Promote timely, adequate, appropriate and safe
complementary feeding with continued breast feeding up to 2 years
and beyond
8. Provide guidance on feeding of infants & young children in
exceptionally difficult circumstances
9. Consider what new legislations or other suitable measures that may
be required to give effect to the principles and aim of ICMBMS
TEN STEPS TO SUCCESSFUL BREAST FEEDING
1. Have a written breastfeeding policy that is routinely communicated
to all health care staff.
2. Train all health care staff in skills necessary to implement the policy.
3. Inform all pregnant women about the benefits and management of
breastfeeding.
4. Help mothers initiate breastfeeding within half an hour of birth.
5. Show mothers how to breastfeed and how to maintain lactation,
even if they should be separated from their infants
TEN STEPS…
6. Give new-born infants no food or drink other than breast milk,
unless medically indicated.
7. Practice rooming-in - allow mothers and infants to remain together
- 24 hours a day
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers)
to breastfeeding infants
10. Foster the establishment of breastfeeding support groups and
refer mothers to them on discharge from the hospital or clinic.
COMMON NUTRITIONAL DISORDERS

MALNUTRITION
Def.1-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
FACTORS INFLUENCING NUTRITION
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
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
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.
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.
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
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.
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. Culture Lack 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
Under nutrition- insufficient intake of food-energy and nutrients
Over nutrition- 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 categorized into:
Moderate Acute Malnutrition (MAM) and
Severe Acute Malnutrition (SAM).
PROTEIN ENERGY MALNUTRITION(PEM) /
PROTEIN CALORIE MALNUTRITION
PEM
is a condition that develops when the body does not get the proper
amount of protein, CHO, vitamins and other nutrients it needs to
maintain healthy tissues and organ function.
Kwashiorkor and marasmus
It occurs during periods of starvation and when dietary intake is
inadequate to meet increased requirements
Prevalence of malnutrition
Malnutrition remains of the worlds highest priority health issues not
only because its effects are so widespread and long lasting, but also
because it can be eradicated.

More than 35% of all preschool age children in developing countries are
under weight.

The unicef report found that 146 million children under five years in the
developing world are suffering from insufficient food intake, repeated
infections diseases, muscle wasting and vitamin deficiencies.
Severe Acute Malnutrition (SAM)
(SAM) is further divided into:
1. Marasmus
2. Kwashiorkor
3. Marasmic kwashiorkor ( combination of 1 & 2)

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.
MARASMUS
Definition:
It is a clinical syndrome and a form of under nutrition
characterized by failure to gain weight due to inadequate caloric
intake.

Incidence:
commonly in infants between the age of 6months. - 2years.
• Also referred as wasting Often identified by person’s physical
appearance which become skeletally thin due to Loss of body fat and
muscle tissues leads to withered appearance
Etiology
1- Dietary errors
2 – Infection :Acute or chronic as T.B, otitis media pyelo nephritis
3- Gastroenteritis: (acute or chronic )
4- parasitic infection situations as: Ascaris, ankylostoma ,giardia
5-Congenital anomalies as: Cardiac (P.D.A ,V.S.D, TF) ,Renal (renal
agenesis, obstructive uropathy) ,G.I.T (pyloric stenosis , cleftlip or palate
6-Metabolic diseases.: Galactosemia, Fructose intolerance, Idiopathic
hypocalcaemia
7- Prematurity
8- Some cases of mental retardation
9- Low socio economic status
10-Endocrine causes ( DM.hyperthyroidism )
Assessment of Marasmic Child/Infant

• failure to thrive ,loss of weight (weight < 60% of expected)

• loss of subcutaneous fat : measured at many parts of the body
according to the degrees:-
1 st degree : s.c fat in the abd. wall
2 nd degree : s.c fat in the abd. wall and limbs
3 rd degree : s.c fat in the abd. wall and limbs and face
Pictures of marasmic child.
Signs and symptoms
Severe weight loss and wasting
o Ribs prominent
o Limbs emaciated
o Muscle wasting
o May have good appetite
o Hair loss
o Wrinkled skin
o Old persons face
With correct treatment, good prognosis
Complications of Marasmus

1. Intercurrent infection : Broncho pneumonia . is the cause of death

2. Gastro enteritis
3. Hemorrhagic tendency, purpura
4. Hypothermia
5. Hypoglycemia
6. Edema(marasmic kwashiorkor
Investigations for Marasmic Infant

1. Urine analysis: culture, sugar, ketones, ca, phosphate,

aminoacids
2. Stool analysis for parasites
3. X- ray for chest and heart
4. Tuberculin test for T.B
6. E.N.T examination for otitis media
7.Blood analysis : (W.B.C ,Electrolytes Sugars,
ketones,Plasma proteins , normal or lowered )
Prevention

• proper diet ( balanced nutritional diet )

• encourage breast feeding up to 6/12months to then
weaning
• proper weaning
• proper vaccination as measles , T.B. whooping cough
• Education regarding the cheap sources of balanced diet,
family planning.
• Proper follow up of the growth rate
• Early treatment of defects or associated diseases
Curative treatment
A- Proper dietary management:-
• Adequate balanced feeding. teaching about nutritional needs.
Preparation of diet, technique of administration of food
• If there is vomiting or anorexia, give IV fluids or naso gastric tube
feeding.
• Gradual increase the amount and concentration of formula (total
calories is120-200cal kg d)
B – Treatment of the cause
C- Emergency treatment for complications
D – Blood transfusion
E – Vitamins and minerals supplementation
 KWASHIORKOR
• It is a clinical syndrome and a form of malnutrition
characterized by slow rate of growth due to deficient of
protein intake despite adequate calorie intake.
• Also called edematous malnutrition because its associated
with edema(fluid retention)

• N/b: In kwashiorkor the main deficient nutrient is protein,

while in marasmus the deficiency is calorie
 Etiology

1. Unbalanced diet (of protein, CHO.)

2. Improper weaning (during and post weaning period ) i.e change of
breast milk to porridge
3. faulty management of marasmic baby
4. Lack of nutritional knowledge
5. poverty due to lack of money to purchase a well balanced diet
6. precipitating factors such as(acute infection with measles, diarrhea
and malaria, parasitic infestations)-which tends to use up the scarce
protein stored in the body
picture
Symptoms of kwashiorkor
o Bi-lateral oedema and fluid accumulation
o Loss of appetite
o Brittle thinning hair
o Hair colour change - brownish
o A pathetic and irritable
o Face may seem swollen
o Anaemia
o Mental rtetardation.
o High risk of death
Assessment
cardinal manifestation):
• Growth retardation :
 Weight is diminished (60-80%) of expected
• Edema :
 It is due to hypo proteinemia. It is starts in the feet and lower parts of
the legs) then becomes generalized edema to the face, hands, anus, feet
and bulging abdomen
Diminished muscle fat ratio (muscles being broken down for energy)
Generalized (muscle wasting) with subcutaneous fat
- Fatty liver :(due to accumulation of fats in the liver because of impaired
synthesis of B lipoproteins) It is detected by liver biopsy
- Mental changes :
The infant is irritable, has apathy never smile, looks sad and his cry is weak
Cont…
Poor resistance and liability to infections
Ascites and edema -due to reduced plasma protein
Growth failure and muscle wasting-protein metabolism
Mental apathy and irritability-loss of potassioum
Moon face-fat deposition
Anemia-due to lack of certain micronutrients
Complication of kwashiorkor

1.Secondary infection ,fungal and bacterial infection

2.Hemorrhagic tendency, purpura
3.Gastroenteritis
4.Hypoglycemia
5.Hypothermia
6.Heart failure due to anemia and infection
investigations for kwashiorkor

1. Blood analysis: (Albumin< 2.5gmld), Glucose (hypoglycemia), k

( hypokalemia )
2. Low pancreatic and intestinal enzymes
3. Urine analysis, culture for infection
4. Stool analysis for parasites
5. Chest x-ray
6. Tuberculin test
Common Nursing Diagnoses of Marasmus and KWO
1. Altered nutrition :less than body requirements related to knowledge
deficit, infection, emotional problems, physical deficit
2. Body temperature alteration (hypothermia) related to low
subcutaneous fat and deficiency of food intake
3. Impaired skin integrity related to vitamins deficiency
4. Fluid volume deficit related to active fluid loss
5. High risk for infection related to low body resistance
Nursing care of Marasmus
Support the infant and parents
1. provide food rich in essential nutrients
2. Give small amounts of foods limited in proteins, carbohydrates and fats
3. Maintain body temperature
4. Provide periods of rest and appropriate activity and stimulation
5. Record intake and output
6. Weight daily
7. Change position frequently
8. Proper treatment is given for infection
9. Protection from infected persons and injuries
10. Refer family to social worker for financial support
11. Education for parents about proper nutrition
Marasmus vs. kwarshiokor
Differences between PEMs
Marasmus Kwashiokor

Edema is absent Edema is present

Severe muscle wasting Muscle wasting mild or absent

No hepatic enlargement Hepatic enlargement

Main deficient nutrient is calorie Main deficient nutrient is protein

Good appetite Poor appetite

Old persons face Moons face

Rickets (Osteomalacia
Definition: Its is a systemic metabolic disease due to inadequate
intake of vit.D (it promotes calcium reabsorption) resulting to
inadequate deposition of calcium in developing cartilage and
bone leading to. bone deformities, hypotonia.
It affects children and young adults
Not the same as osteoporosis
Vitamin D:- it is a group of steroid fat soluble compounds
• It helps in the reabsorption of ca in the small intestines
It has two types:-
• Biologically ,D2 and D3 which are present (in-active) forms
and latter transformed to (active form) in the liver as
(Calcitriol)
- D2 called (Calciferol.) and D3 called (Cholecalciferol
pictures
Causes of vitamin D. deficiency rickets

• lack of exposure to sun rays

• Malabsorption of vit.D as in (obstructive jaundice )
• Dietary deficiency of vit. D and Ca
• Congenital rickets
• Taking of anti convulsive drugs (calcium channel blocker)
• poor utilization of vit.D by the tissues leads to rickets as in :-
• hyperparathyroidism
• hypophosphatemia
• recurrent attacks of diarrhea due to G.E
Clinical picture
During assessment of the child / infant with rickets, the chief complains are:

1. Delayed motor development specially walking

2. Delayed dentition
3. Deformities of the bones
4. presence of one of any complications
Physical examination
A-Early manifestations:

• Craniotabes. (softening/thinning of the skull) in infant 3-

8months.
• Rickety rosary beads (along costochondral junction)
• Enlargement of the lower radioulna epiphysis. (thickened
wrist) and ankles
• Sweating at forehead, irritability
B- Late manifestations:
1. Head
• Enlargement of the head like (box shape skull) due to
frontal and parietal bossing)-pronounced forehead
• Delayed closure of anterior fontanel
• Delayed dentition
Physical examination
2-Thorax
• Rickety rosary beads
• Harrison sulcus (transverse groove at the lower part of the
chest at the costal insertion of the diaphragm and ribs)
• Longitudinal sulcus (lateral groove)
• Pigeon chest (protrusion of the sternum and ribs)
B- Late manifestations:
3- Spine : kyphosis, scoliosis
4- Pelvis : contracted pelvis
5- Extremities : deformities , green stick fracture
6- Muscles : weakness of muscles , hypotonic laxity of ligaments
as (In abdomen)
COMPLICATIONS
1. Bone fractures, limbs deformities as the following:

2- Tetany due to hypocalcaemia

3- Anemia (due to chronic infections or deficiencies)
4- G.I.T disturbances as: G.E, constipation- due to malabsorption
5- Respiratory complications as pneumonia, broncho –
pneumonia-due to chest deformities
6- low resistance , liability to infection as urinary tract infections
Treatment

 Oral calcium with vit.D intake should be increased.

 After healing, give. vit.D (400-800) IU and repeat blood
analysis for calcium.
 Surgical correction of deformities
 Treatment of any complications
 Vit-D (1500-5000)IU/ d .for 2months
Common nursing diagnoses

• Body image disturbance related to bone deformities

• High risk for infection related to low of immunity.
• High risk for injury related to weakness of bones and deformities.
• Altered nutritional requirements related to deficiency of calcium
Vitamin A Deficiency and the Eye
(Xerophthalmia)
• Commonest single cause of childhood blindness, an estimated
350,000 new cases each year.
• About 60% to 80% of children who become blind from vitamin A
deficiency die within a few years because of increased susceptibility
to disease and sometimes lack of care.
• Vitamin A deficiency can occur for three major reasons:
• because of reduced intake of foods rich in vitamin A
• because the vitamins are not absorbed, usually because of
diarrhoea
• because of increased need for vitamin A, as occurs during
infections, particularly measles.
WHO Classification of Xerophthalmia
• Night blindness (XN):
• Vitamin A is needed to replace the rhodopsin (visual purple) of the retina
and this is necessary for night vision/ low-light visions.
• An adult or older child will describe the problem of night blindness but a
very small child will not be able to offer this information.
• Conjunctival xerosis (XIA):
• Vitamin A is required for the production of secretions on the surface of the
eye. This dry appearance together with xerosis of the corneal epithelium
gives the condition its name, xerophthalmia.
• There is damage to the cells that produce secretions which moisten the
surface of the eye.
 keratomalacia
• Untreated Xerophalmia leads to keratomalacia
• Corneal ulceration/keratomalacia (X3B):
• Consequence of severe vitamin A deficiency. Onset is often sudden,
and the cornea may melt/liquify very quickly, even over a few hours
(keratomalacia).
• Corneal scarring (XS):
• End stage of malnutrition causing eye damage
• Often has a marked effect on vision.
• The anterior part of the eye may bulge forward (anterior staphyloma)
or the opposite may occur and the eye shrinks (phthisis).
N/B Not every child who is vitamin A deficient and at risk of blindness
will have obvious eye signs.
• Evidence of xerophthalmia in one child will indicate that other
children in the same family/community are also deficient.
• A child may have just enough vitamin A but have very little reserve in
the liver.
 Treatment of Xerophthalmia
WHO treatment schedule for children >1 yr old.
• Immediately on diagnosis (Day 1) - 200,000 IU vitamin A orally†
• The following day (Day 2) - 200,000 IU vitamin A orally
• Four weeks later (Week 4) - 200,000 IU vitamin A orally

• † If there is vomiting, an IM-injection of 100,000 IU of water soluble

vitamin A (not an oil-based preparation) may be used instead of the
first oral dose.
• If a child is under one year old or, at any age, weighs less than 8
kg: Use half the doses of the regimen given above.
• Immediately on diagnosis (Day 1) - 100,000 IU vitamin A orally
• The following day (Day 2) - 100,000 IU vitamin A orally
• Four weeks later (Week 4) - 100,000 IU vitamin A orally
 Treatment of Xerophthalmia-cont’d

• The third dose of vitamin A in both regimens may be given between

one and 4 weeks if follow-up is likely to be uncertain.
• A topical antibiotic eye ointment such as tetracycline 1% or
chloramphenicol 1%, 3 times daily, is recommended to reduce the
possibility of secondary bacterial infection.
• Carefully apply an eye pad to the eye, making sure the eyelids are
closed under the pad
Prevention of Xerophthalmia

• Education in nutrition
• Encourage breast feeding.
• Weaning foods should be rich in vitamin A.
• Adequate intake of vitamin A for the mother.
• Mass Treatment:
• Vitamin A capsules 200,000 IU may be given every 3 to 6 months to
children of one to 6 years of age who are at high risk .Half doses are
given to children between 6 and 12 months or if a child weighs less
than 8 kg.
• Each child with measles infection should have at least one dose of
vitamin A 200,000 IU orally even if his or her eyes appear healthy.
• Immunisation –measles vaccine.
Prevention of Xerophthalmia…..
• Immediately after her child is born a mother may be given 3 doses
of 200,000 IU vitamin A orally on Day 1, Day 2, and Day 8 after
delivery. This will help protect the breast-fed infant.
• Fortification of foods
• Widely used food such as maize flour, sugar, milk-can be fortified
• Health Education:
• Public knowledge of the eye condition.
• Women and schoolgirls (the mothers of the next generation)
especially need education.
Prevention for high risk groups

Vitamin A
• 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.
 Integrated Management of Acute Malnutrition
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
1.Treat/prevent hypoglycaemia
2. Treat/prevent hypothermia
3. Treat/prevent dehydration
4. Correct electrolyte imbalance
5. Treat/prevent infection
6. Correct 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
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
• Bleeding and swollen gums especially between teeth
• Swollen and painful joints especially of the knees, hips and elbow
• Easy bruising
• Anemia
• Gingivitis due to bleeding
• 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.
 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
Signs and symptoms…
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
Dermatitis- characteristic symmetric rash where skin exposed to
sunlight
Diarrhoea- severe diarrhoea
Dementia- mental deterioration
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.
IRON DEFICIENCY ANEMIA
1. Causes
2. Nutritional deficiencies
3. Malaria
4. Intestinal parastic infections
5. Chronic infections e.g. HIV
6. Malabsorption.
7. Not breastfeeding
8. 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:-
• Thyroid enlargement (goiter)
• Miscarriages and still births
• Neonatal and juvenile thyroid insufficiency
• Dwarfism
• Mental defects
• Deaf mutism
• 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.
Prevention
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
References
• Kenya National Clinical Nutrition and dietetics (2010)Reference
Manual . MOH,
• Sue R.D( 2002)Essentials of Nutrition and Diet therapy.california 8th
ed.
• www.andjrnl.org
• Wood c. (2008 )community health AMREF.
• Etc