NUTRITION IN COMMUNITY HEALTH

INTRODUCTION

Terminology

Community is a group of people living in the same place and sharing the same culture and
beliefs.

Community nutrition is the process of helping individuals and groups to develop healthy eating
habits in order to promote wellness and prevent disease

Health refers to a state of complete physical, mental and social well-being and not merely
absence of disease.

Hunger is usually understood as an uncomfortable or painful sensation caused by insufficient

food energy consumption. Scientifically, hunger is referred to as food deprivation.

Malnutrition results from deficiencies, excesses or imbalances in the consumption of macro-

and/or micronutrients. Malnutrition may be an outcome of food insecurity, or it may relate to
non-food factors, such as:
- inadequate care practices for children,
- insufficient health services; and
- an unhealthy environment.

Nutrients
These are substances obtained from food and are used in the body to provide energy and
structural materials and to regulate growth, maintenance and repair of body tissue. They include
carbohydrates, protein, vitamins, minerals, fats and water.
Nutrition is the science of food, the nutrients and other substances therein, their action,
interaction, and their balance in relation to health and disease or

the process by which the organism ingests, digests, absorbs, transports, utilizes and excretes
food substances.

Micronutrients
These are nutrients needed in small amounts for a variety of body functions and processes. They
include the vitamins and minerals. Vitamins include Vitamin A, C,D, E, K and B complexes e.g.
B1, B2, B3, B5,B6, B9, B12, folate

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Nutritional status
Refers to the condition of health of an individual as influenced by the intake and utilization of
nutrients.

Macro-nutrients
These are nutrients needed by the body in large amounts and they include carbohydrates,
proteins and fats. They form the bulk of the diet and supply all the energy needed by the body.

Carbohydrates
Carbohydrates are organic compounds that consist of carbon, hydrogen and oxygen. In their simplest
form the general formula is (CH2O) n. The ratio of hydrogen to carbon is always 2:1 as can be seen in the
formula of glucose (C6H12O6) and sucrose (C12H22O11). Carbohydrates are classified on the basis of their
size and degree of complexity into simple carbohydrates, which include monosacharides and
disaccharides, and complex carbohydrates also known as polysaccharides.

Monosaccharides
These are the simplest sugar known. They have the same numbers and kinds of atoms, but in
different arrangements. These chemical differences account for the differing sweetness of the
monosaccharides. Monosaccharides include galactose, glucose and fructose.

Disaccharides
Disaccharides are pairs of monosaccharides linked together. Glucose occurs in all the three
disaccharides; the second member of the pair is fructose, galactose or another glucose. The three
disaccharides are: maltose, sucrose and lactose. To make a disaccharide, a chemical reaction known as
condensation links two monosaccharides together. A hydroxyl (OH) group from one monosaccharide
and a hydrogen (H) atom from the other combine to create a molecule of water (H 2O). The two
originally separated monosaccharides link together with a single oxygen (O) to form the disaccharide

Complex Carbohydrates
While simple carbohydrates contains glucose, fructose and galactose in singles and pairs, in contract
complex carbohydrates contain mostly glucose units strung together as polysaccharides i.e. many
monosaccharides linked together.

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  Functions of carbohydrates in the body
 Major source of energy for the body.
 Have a protein sparing action.
 Important for normal fat metabolism
 The disaccharide lactose is important in calcium absorption
 Cellulose and other closely related insoluble compounds such as dietary fibre aid normal fecal
elimination since it absorbs water to give bulk to intestinal contents.
 Provides the carbon skeleton for the syntheses of non-essential amino acids by the body
 Impart flavor and sweetness to food

Proteins
Proteins are chemical compounds that contain the same atoms as carbohydrates and lipids including

carbon, hydrogen and oxygen but with an importance difference, proteins also contain nitrogen atoms.

These atoms bond with each other to form amino acids. Proteins also contain sulphur and phosphorus.

Amino acids are the basic building blocks of all proteins. All amino acids have the same basic structure -

a carbon atom core with four bonding sites: one site holds a hydrogen atom (H), one an amino group

(NH2) and one an acid group (COOH). Attached to the fourth bonding site is a side group (R group), which

contains the atoms that give each amino acid its own distinctive identity, Figure 4.1.

NH2 (amino group)

(Hydrogen H – C – COOH (acid group)

atom) I

R
Side group (varies)

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Classification of amino acids

There are 20 common amino acids, 9 of which are essential and the remaining 11 are classified as
nonessential.

Essential amino acids

These are amino acids that the body cannot synthesize in amounts sufficient to meet physiological
needs. They thus must be supplied by the diet because deprived of essential amino acids; the body will
break down its own proteins to obtain them so as to make the proteins it needs to do its most
indispensable work. They are also referred to as indispensable amino acids. They are nine essential
amino acids and these include methionine, phenylalanine, histidine, leucine, valine, isoleucine, lysine,
threonine, and tryptophan.

Non-essential amino acids

These amino acids can be synthesized by the body from an available source of nitrogen and carbon
skeleton through a process called transamination. There are eleven non-essential amino acids. These
include glycine, alanine, arginine, asparagine, aspartic acid, cysteine, glutamic acid, glutamine, serine,
proline and tyrosine. They are also referred to as dispensable amino acids.

 Functions of protein in the body

 Help in Growth and Maintenance

 Used in Formation of essential body components e.g. enzymes, hormones, antibodies et.c.

 Help in maintenance Acid-base balance

 Help in Maintenance of Fluid balance

 Transport of nutrients eg. haemoglobin

 Help in blood clotting e.g. fibrin.

 Visual pigments e.g opsin

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  Used for Energy production

Lipids

Lipids are a group of substances made up of carbon, hydrogen and oxygen but in different ratio
than those of carbohydrates. Lipids have more carbon and hydrogen in proportion to their
oxygen. The lower amount of oxygen in relation to carbon and hydrogen results in fats being a
more concentrated source of energy than carbohydrates. One gram of fat supplies 9 kilocalories
of energy.

Classification

Depending on their degree of saturation/unsaturation in the carbon chain, they can be divided
into three classes:

 Saturated fatty acids (SFAs), if no double bond is present;

 Monounsaturated fatty acids (MUFAs), if only one double bond is present;
 Polyunsaturated fatty acids (PUFAs), if two or more double bonds are present.

Moreover on the basis of the absence/presence of double/triple bonds they can be grouped into
two broad classes:

 saturated FAs, if there are no double bonds in the carbon chain;

 unsaturated FAs, if there are one or more double bonds in the carbon chain.

 Functions of fats in the body

 Provide Satiety value

 Source of energy to the body
 Act as Carriers of fat soluble vitamins
 Give Palatability to foods
 Act as Energy Reserve in the body
 Provide Insulation to the body
 Protection of vital body organs e.g heart
 Act as Precursors of Prostaglandins

Community nutrition combines the study of diet with the effort to promote healthy eating and
to give the community resources to learn about nutrients and access healthy meals.

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This area of nutrition study is sometimes called public health nutrition. The primary goal of
community nutrition efforts is to reduce the instances of nutrition-related illnesses in the target
population. The target group could be a neighborhood, city, state, or an entire country. The
principles of community nutrition may also apply to single entities such as a nursing home or
school.

The goal of community nutrition is to educate individuals and groups so that they adopt healthy
eating habits. Health providers work with many other health care professionals in promoting
improved community nutrition. Their efforts emphasize a preventive approach in educating
individuals in how a change in dietary habits will reduce the risk of illness. Community nutrition
focuses on all age groups. The groups targeted range from babies to pregnant women to older
adults. For example, a young pregnant woman may not realize how poor eating habits affect her
developing fetus or she may be unaware of the importance of breastfeeding. Older adults may
lose interest in eating due to loneliness, inability to prepare meals, or a physical condition such as
difficulty chewing. Individuals with diabetes may not understand the need to control their blood
glucose levels through diet as well as medication.

Obesity is an issue for many age groups. Causes include lack of physical education programs in
schools and an overly busy lifestyle for adults. The availability of fast food and “supersized”
items are regarded positively because of their cost and convenience. Their accessibility and
convenience often prompts people to make unhealthy food choices. In a school cafeteria, for
example, a child may bypass a salad in favor of fries and a soda. A moviegoer may choose to
buy a tub of buttered popcorn because the purchase price includes a free refill.

Community nutrition programs attempt to change attitudes so that a diet rich in fruit, vegetables,
and whole grains is more appealing than diet high in fats and sugars. While sweet, high fat foods
may be an occasional treat, community nutrition emphasizes a lifetime of routine healthy eating.

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TOP 2: ASSESSING NUTRITION AND FOOD SECURITY

What is Food Security?

 Food security is a state that “exists when all people, at all times, have physical, social
and economic access to sufficient, safe and nutritious food that meets their dietary needs
and food preferences for an active and healthy life.” – FAO, 1996
 The core concept of food security carries the access to healthy food and optimal nutrition
for all.
 Household food security is the application of this concept to the family level, with
individuals within households as the focus of concern.

Food insecurity refers to a lack of access to enough good, healthy and culturally appropriate
food.

Importance of food security

Growth in the agriculture sector has been found, on average, to be at least twice as effective in
reducing poverty as growth in other sectors. Food insecurity – often rooted in poverty –
decreases the ability of countries to develop their agricultural markets and economies.

Access to quality, nutritious food is fundamental to human existence. Secure access to food can
produce wide ranging positive impacts, including:

 Economic growth and job creation

 Poverty reduction
 Trade opportunities
 Increase national security and stability
 Improved health and healthcare

Indicator of food security:

i) Indicators of availability

These include household food availability and national food availability indicators

Household food availability indicator includes:

 Crop production for household and

 Food crop diversity which means consuming variety of food ranging from plant
source foods to animal source foods.

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National food availability indicators include:

 Import capacity of the country where the country is able to import food from foreign
country in case it not able to produce adequate amount.
 Food stocks in national stores will show if the country has enough food to feed her
people.
ii) Food accessibility indicators

Household indicators –

 Household income which can be inform of monthly salary, daily wages and /or own crop
income.
 Purchasing power – this is the ability of the household to buy common commodities for
household uses.

National indictors –

 Transport and market infrastructure which include tarmac roads which the remote area
be accessible and development of modern market places.
 Food aid – this is aid given in form of food to households which are food insecure or
most likely to be food insecure.

iii) Food utilization indicators

These includes:

 Food safety and quality

 Clean water
 Health and sanitation
 Care, feeding and health seeking practices

iv) Food Stability indicators

These include:

 Weather variability or seasonality - During draught or dry seasons, there will be unstable
supply of food products leading to food insecurity unlike during rainy seasons.
 Price fluctuations – fluctuation in prices of common commodities in the market places
show unstable supply these food products.
 Political factors e.g. political instability in the country leads affect food production thus
leads to food instability.

Determinant of food security

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Concept of food security also includes the presence of following characteristics:

 Enough food production: If there is adequate food as per one’s need and requirements.
 Good food: It should be with desirable taste, texture and other attributes.
 Healthy food: It should be nutritious and sustaining with proper vitamins, minerals,
fibre, energy, and all the other things that our bodies need.
 Culturally appropriate food: Having access to culturally appropriate food means that
people have food that they are familiar and comfortable with including availability of
familiar foods & varieties.
 Good health and nutritional status: a population which is food secured will manifest
good nutrition and health status with low prevalence of diseases.
 Political stability; Country with a political stability is most likely to be food secure than
the one with political instability. The incidence of political violence in a society, such as
assassinations, demonstrations, ethnic violence and so forth will affect the country food
security.
 Conducive Climatic condition; harsh climatic condition leading to famine results to
household food insecurity while a favorable climatic conditions result in high yields of
crops grown within the area.

Food security Interventions

These are actions/activities carry out to curb or prevent food insecurity at an individual,
household or national level. They include:

 Localization of food nutrients

This is the process of adapting food nutrients to specific local markets. Localization of food
nutrients to remote area where these food nutrients are lacking or present in small quantities
will help to prevent/reduce malnutrition.

 Food fortification

This is the addition of some micronutrients not present (or present in small amounts) prior to
processing. This help to prevent micronutrient deficiencies in the area where these foods are
commonly consumed. Example is fortification of cooking oil with vitamin A.

 Food supplementation

This is the food enrichment is the practice of adding micronutrients back to a food product that
were lost during processing. This also helps to prevent micronutrient deficiencies.

 Food aid

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 This is the provision of food to those who are food insecure. It can be given as general
feeding to those who are most likely to be malnourish or given as supplementary feeding.

Roles of stakeholders in food security

A stakeholder can be defined generally as any individual, end-user or organisation who has an
interest in a particular issue.

1. The Kenya Food Security Steering Group (KFSSG) is a sub-committee of the Kenya
Food Security Meeting (KFSM) and is made up of representatives from NGOs, UN
agencies, donors and Kenya Government (GoK). KFSSG acts as a technical think-tank
and advisory body to all stakeholders on issues of drought management and food
security. It plays a central role in both guiding the KFSM and informing on decisions
taken, organizes multi-sectoral rapid assessments during emergencies.
2. National Cereals and Produce Board. The Board procures, stores and maintains a
Strategic Grain Reserve (SGR) stock of up to four million bags on behalf of the
Government to be used for food security. National Drought Management Authority
Reviews all coordination structures on a periodic basis and makes appropriate
adjustments to them in line with a) the national mandate of the Authority; b) the
provisions in the Constitution; and c) an evaluation of their performance, including
feedback from stakeholders
3. Ministry of Agriculture- The mandate of the Ministry of Agriculture is to promote and
facilitate production of food and agricultural raw materials for food security and
incomes; advance agro-based industries and agricultural exports; and enhance
sustainable use of land resources as a basis for agricultural enterprises.
4. World Food Programme- WFP's unique network of food security analysts works
closely with national governments, UN partners and NGOs. Their work informs the
policies and programmes that WFP and its partners adopt in order to fight hunger in
different circumstances. NGOs and the Civil Society- NGOs now attempt to intervene to
protect small farmers from eviction, indigenous people from losing traditional lands and
fishing grounds, and segments of the population from discriminatory food supply
schemes.
5. House Holds- Households have the role of contributing to food security through their
own initiatives and efforts of poverty alleviation and economic growth. FAO- It is
mandated to achieving food security for all - to make sure people have regular access to
enough high-quality food to lead active, healthy lives.
6. Kenya Food Security Meeting (KFSM): Established and housed in the Office of the
President, responsible for food security monitoring and for advising on emergency
response. Inter-ministerial Coordinating Committee on Food and Nutrition (ICCFN):
Housed in the Ministry of Planning and National Development responsible mainly for
nutrition issues in development planning. The Agricultural Sector Coordinating Unit
(ASCU): Responsible for coordination of reforms among agricultural sector ministries as
provided for by SRA. National Food Safety Coordinating Committee (NFSCC):

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 Responsible for increasing awareness and advising on food safety and quality related
issues

Food security policies

 National schools meals and nutrition strategies(2017-2022)

 National food and nutrition security policy

 Kenya Food composition tables (KFCT) policy brief (2018)

 Kenya Health Policy 2012 - 2030

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Topic 2: Applying Nutrition in Human Development
Terminologies

Life expectancy refers to the length of life projected for a population of a given age.

Determination of nutrition in Human development

Factors affecting human nutritional needs

In order to estimate nutritional requirements of individuals or groups, we need to consider the

following factors:

 Physical activity — people who are engaged in heavy physical activity tend to require
more food nutrients than those who are physically inactive.
 The age and sex – children and adolescence tend to need more nutritional needs than
older people because of the rapid growth that they experience during these stages of life.
On sex, male people require more nutrients than female because male have more muscle
than females.
 Body size and composition — people of the same age and sex may have different
nutritional needs depending on their level of body muscles and fats.
 Climate — whether a person or group is living in hot or cold climate. People who live in
cold regions experience high metabolic rate (BMR) which make their nutritional needs to
be high compare to those who are in hot regions.
 Physiological states/condition, such as pregnancy. Good maternal nutrition during
pregnancy promotes healthy weight of the newborn and in turn leads to good weight gain
of the mother during pregnancy and prevent congentital disorders such as preterm,
stillbirth e.t.c.
 Trauma - a person who has a trauma such as emotional stress, body physical injuries,
infections cause increased needs for more nutrients by the body to support healing than
the one who doesn’t have trauma

Vulnerable groups

i) Pregnant mother

Pregnancy is the period from the time of conception in the fallopian tube to the time of delivery.
For human, it takes around 36-38 weeks and it is divided into three trimesters.

Malnutrition prior and around pregnancy makes the placenta fail to develop fully
therefore it cannot optimally nourish the foetus. A well-nourished woman before conception
begins her pregnancy with a reserve for several nutrients so that the needs of the foetus can be

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met without jeopardizing her health. Underweight and overweight women experience more
complications during pregnancy than women of normal.

Nutrition prior to pregnancy influences the birth weight of the baby. Underweight women risk
bearing preterm and low birth weight infants. Obese women have an increased risk of
complication associated with hypertension, gestational diabetes and risks of caesarian sections
since they have high birth weight. Low birth weight is a key factor in infant mortality and other
developmental and learning disorders in children. Full term infants weighing less than 2500
grams are referred to as small for gestational age (SGA) and this is due to intrauterine growth
retardation. Deficiencies of some nutrients (such as calcium, iron, vitamin D and folate) as well
as use of certain drugs and alcohol have detrimental effects on the growing embryo even before a
woman realizes she is pregnant. The time to focus on good nutritional and other health habits is
therefore before a woman becomes pregnant.

Physiological changes during pregnancy

During pregnancy many physiological changes occur in the body of a pregnant woman. These
changes include:

a) Weight gain
Weight gain is an obvious change during pregnancy. Women may lose weight especially in the
first trimester due to vomiting and nausea. However the overall pattern is weight gain. The
amount of weight gained and composition are major determinants of the extra energy and
nutrient needs. The weight gained is also a determinant of birth weight. Weight should be
monitored throughout pregnancy and therefore, the baseline measurement should be taken.
Adequate weight gain is essential for foetal growth and desired weight gain is based upon
pre-pregnancy weight using BMI criteria and pre-conceptual nutritional status of the
woman. Underweight women are advised to gain more weight during pregnancy to avoid giving
birth to pre-term and low birth weight babies while overweight women are advised to limit
weight gain during pregnancy. However, pregnancy should not be used as a time for weight loss.

Desired weight gain during pregnancy

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BMI Index Appropriate weight to gain
Underweight( BMI<18.5) 12.5-18 kg
Normal weight ( BMI 19-25) 12-15 kg
Overweight ( BMI 26-29) 7-11.5 kg
Obese (BMI >30) 6 kg

b) Blood volume and composition

Increases in total blood plasma volume are approximately 33% above normal levels and may
increase to 50% by the end of pregnancy especially in primiparas or in multiparas. This increases
move blood to circulate through the placenta to carry nutrients to the foetus and carry metabolic
wastes. Red cell mass increases only by 15-20% causing haemodilution and therefore the
haemoglobin and hematocrit concentration decrease especially during the second and third
trimester when the largest rise in plasma blood volume occurs. Albumin and water soluble
vitamins increase but per volume value drops. The level of most globulins, lipids and free fatty
acids increase in concentration.

c) Placenta
The placenta is an organ of exchange for nutrients and metabolic products between the
developing embryo/foetus and the mother. It is comprised of maternal and foetal component and
accounts for 0.68 kg of pregnancy weight. Its development begins during the third week of
embryonic development with metabolic exchanges between the mother and foetus beginning at
four weeks. The placenta allows nutritional, respiratory and excretory interchange of materials
by diffusion between the embryonic and maternal circulatory systems. The functions of the
placenta are:
 Conduct exchange of nutrients, oxygen and waste materials between the embryo and
mother through simple diffusion, osmosis, hydrostatic pressure and active transport.
 Produces fetal placental transfer enzymes and production of glycogen, cholesterol, fatty
acids for use by the developing foetus and for production of hormones.

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  The placenta also synthesizes several hormones responsible for regulating foetal growth
and development of maternal support tissues such as estrogen and progesterone.

d) Nutritional needs of pregnant women

Energy needs

Energy needs during the first trimester of pregnancy are essentially the same as during the non-
pregnant state. During the second and third trimesters, the average pregnant woman requires an
extra energy intake of approximately 300 kcal/ day to support the growth of the foetus, placenta
and maternal tissues and for the slow steady rise in basal metabolic rate (BMR) of the pregnant
woman. If a woman is active during pregnancy the energy she expends is added to any extra
energy needed for pregnancy to balance her total energy use. Much of the increase in energy
requirement in the second trimester is due to maternal development resulting from pregnancy. In
the last trimester, the foetus is the primary factor influencing the increased need for energy. This
calls for consumption of sufficient amounts of carbohydrates to spare the proteins for body
building. To avoid possible damage to the foetal activity, a pregnant woman should not fast for
more than 6-8 hours because there is a more rapid fall in circulating glucose, insulin and
gluconeogenesis of amino acids than in non-pregnant women.

Proteins

There is an increased need for proteins in pregnancy in view of the amount of new tissues that
must be formed. The protein requirements are based on the assumption that energy available
from the diet will be adequate, otherwise proteins will be used to provide energy and therefore
will not be available for its body building functions. During pregnancy the recommended dietary
allowance (RDA) for proteins is increased by 10 grams/ day for women over age 24 and by
about 15 gram/ day for those under age 24. Problems of premature births, low birth weight,
infant mortality and mental retardation can result from gross inadequate intakes of proteins and
calories.

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Carbohydrates
Carbohydrate needs are about 100g/day. This amount prevents ketosis ( see section on functions
of carbohydrates) which may interrupt fetal development and brain maturation.

Vitamin needs
Vitamin needs are generally increased during pregnancy, especially the need for vitamin D and
folate.

 Folate
Synthesis of DNA requires folate therefore this nutrient is especially crucial during embryonic
development. Both fetal and maternal growth in pregnancy depends on an ample supply of
folate. Red blood cell formation also requires folate. As a result of its role in DNA synthesis,
folate breakdown also increases in pregnancy. Serious megaloblastic anaemia can result if
folate intake is inadequate during pregnancy.

Mineral Needs
Mineral needs generally increases during pregnancy. An adequate intake of iron, calcium, zinc
and iodine are particularly important for maternal and fetal health.

 Iron
Extra iron is needed for haemoglobin synthesis during pregnancy. The RDA doubles to
30mg/day, especially in the 2nd and 3rd trimesters. Pregnant women are encouraged to consume
iron fortified foods. Eating foods rich in Vitamin C along with non-heme iron containing foods
helps to increase iron absorption. Iron supplementation is routine during pregnancy in Kenya.
Severe iron-deficiency anaemia in pregnancy may lead to preterm delivery, maternal
complications or death during delivery and increased risk for infant mortality. Iron supplements
cause nausea, constipation and depressed appetite in some people, women are advised to take
these supplements between meals with liquids other than milk. Milk should not be consumed
with a supplement as Calcium interferes with iron absorption. Pregnant women should also wait

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until the second trimmester to start iron supplementation since pregnancy related nausea
generally lessens by this time.

2) Lactation Mothers

Lactation is the process of breastfeeding the baby with the breast-milk. During lactation period,
the mother nutritional needs increase due to secretion of the breast-milk. The baby is exclusively
breastfed for the first six months of life without giving the infant other feeds including water and
cow milk. Complementary feeding is initiated when the infant attain the age of six months with
continuation of breastfeeding until the baby reach 2 years of age. During lactation period, the
mother/care-giver is advised to ensure that her baby receive all immunizations during her post-
natal clinic attendance. Intake of certain medications that pass into breast milk and adversely
affect the breastfeeding infant may be advised to avoid breastfeeding. In addition, women who
have serious chronic diseases such as tuberculosis, hepatitis and HIV/ AIDS or who are being
treated with chemotherapy medications should not breastfeed.

3) Children

This is a period when rapid physical and social growth and development takes place. These
changes affect feeding and nutrient intake. The baby’s birth weight is determined by the length
of the gestation period, the mother’s pre-pregnancy weight and weight gain during pregnancy.
After birth the genetic influences begin looking for their predetermined growth channel. Infants
lose weight during the first few days of life but the birth weight is usually regained by the 7 th-
10th day of life. Growth after the tenth day proceeds at a very rapid but decelerating rate. Infants
usually double their birth weight by 4- 6 months of age and triple it by one year. By the end of
the first year the growth rate slows considerably. Infants increase their length by 50% during the
1st year of life and double it by four years of age. Total body fat increases rapidly for the first 9
months after which the rate gain tapers off for the rest of childhood. The new born has a
functional but physiologically immature kidney that increases in size in the early weeks of life.
Its ability to form acid, urine and concentrate solutes is limited. The stomach capacity increases
from 10-20 ml at birth to 200ml by one year.

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Good nutrition from birth to three years is the most important foundation for baby to grow
healthy and bright. After the age of two or three years, the effects of chronic malnutrition in your
baby will be irreversible.

Nutrient needs during infancy and early childhood

Nutrient needs of infancy reflect the rate of growth, energy expended in activity and basal
metabolic needs and the interaction of nutrients consumed. New borns receive needed nutrients
through breastfeeding or formula feeding. Solid foods are usually not needed until after 6
months. Even when solids are added to the diet, breast milk or formula form the basis of an
infant’s diet until about 1 year of age. The nutrient needs of the infants differ from those of
adults in both amount and relative proportion.

Energy
Infants require 85-95 kcal/ kg body daily to supply them with adequate energy compared with
adults 40 kcal/kg body weight. At 6 months of age an infant weighing about 7 kg needs about
700 kcal of energy per day. Infants need an ease way to consume this amount of energy. The
basal and total energy requirements are higher than those of adults per unit body weight. The
composition of either breast milk or formula is ideal for meeting infant’s energy needs during the
first six months. Both are high in fat and supply about 650 kcal/ litre. After this initial period, the
use of solid food along with breast milk or formula can provide the additional energy as the
infant gets older. The energy needs of infants are driven by their rapid growth and high
metabolic rate. The high metabolic rate is caused in part by their high ratio of body surface area
to weight. More body surface allows more heat loss from the skin; therefore the body must use
extra energy to replace that heat.

Proteins
The RDA for protein in infancy ranges from 1.6 to 2.2 g/kg of body weight. This is required for
tissue growth and replacement. Over 40% of total protein intake should come from essential
amino acids. The recommendations are based on the composition of breast milk whereby it is
assumed that the mother’s milk is 100% utilized. Breast milk is adequate during the first 6
months and provides about 2.2 g of protein per kg body weight. During the next 6 months an
infant requires 1.6 g of protein kg body weight and between 1-3 years about 1.2 gm /kg body

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weights. In the second 6 months of life the diet of infants should be supplemented with high
quality proteins.

Lipids

The RDA for fats is 3.8g/ 100 kcal (minimum) and a maximum of 6g/ 100kcal. This is
adequately presented in breast milk. Skimmed milk has a significantly low fat content. Essential
fatty acids such as linoleic acid should make up at least 3% of total energy intake. Fat is an
important part of the infant’s diet because it is energy dense and vital to the development of the
nervous system. Deficiency could lead to skin lesions, diarrhea and growth retardation.

Carbohydrates
Carbohydrates should supply 30 to 60% of the total energy intake during infancy. Lactose in
breast milk provides 37% of the kilocalories in breast milk.

Water
The water requirements are determined by the amount lost from the skin, lungs, faeces and urine
and the small amount needed for growth. Human milk supplies water in amounts adequate under
ordinary conditions. Additional water may be required if the weather is hot and humid and due to
losses such as during diarrhea and vomiting.

Calcium
An RDA of 400-800 mg/ day is recommended. Large percentage of calcium from breast milk is
retained by the infant. Rapid rate of calcification of bones is needed to support the weight of the
body by the time the baby walks. Inadequate intake of calcium leads to delayed motor
development.

Iron

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Iron in breast milk is highly bioavailable. Iron stores of infants get depleted from 4-6 months.
There is need to introduce other iron rich foods after 6 months. Milk other than breast milk is a
poor source of iron and also has factors that inhibit absorption. The RDA for infants is set at 6
mg/ day.

Zinc
Zinc is necessary for growth and normal brain development. Breast milk provides adequate
amounts of zinc for the first year of life. The zinc content of breast milk is however dependent on
the mothers stores. Zinc is found in high amounts in the colostrums at 4 mg/ litre but reduces to
0.5 mg/litre at one year. The RDA is 5mg/ day for the first year and 10 mg/ day between 1-3
years.

Vitamins of special interest

Breast milk is an adequate source for all the vitamins with the exception of vitamin D. Vitamin D
is essential for the utilization of phosphorous and calcium and is obtained in great measures
through exposure to adequate sunlight. Deficiency of vitamin K may result in bleeding or
hemorrhaging disease of new borns. Breast milk contains 15 micrograms of vitamin K and it is
recommended that all formulas contain a minimum of 4 micrograms of vitamin K.

4) Adolescence
The average age is 10 to 17 years for females and 12 to 21 years for the males. It is marked by
the appearance of sexual maturity and terminates with the cessation of growth in stature.

Physiological development during late childhood and adolescence

Girls generally begin the period of rapid growth at 10 to 11 years of age and peak at 12 years.
Stature growth ceases at a median age of 17.3 years. Since peak weight occurs before peak
height, many girls and parents become concerned about what happens to the excess weight.
Weight loss during this period may affect ultimate adult height. Girls also experience a
disproportionate deposition of fat compared to muscle tissue due to the effects of estrogen. Girls
also experience less bone growth than boys do. The differences account for the difference in
calorie requirements. In contrast, boys usually begin the growth spurt at about 12 to 13 years of

20
age and peak at 14 years. Stature growth ceases at a median age of 12.2 years. Nutritional needs
increase later for boys than for girls. Boys also experience a greater increase in muscles mass,
lean body tissue and bones, accounting for their higher calorie requirements than girls.
Nutrient needs during adolescence
Generally nutrient needs are higher during adolescence than at any other time in the lifecycle
with the exception of pregnancy and lactation.

Energy
Males require higher amounts since they grow faster and develop more lean body tissues. The
peak energy value of 3000 kcal is at 15 to 18 years. Since girls start growing earlier than boys,
their energy needs peak sooner and decline more rapidly. The peak value is at 11 to 24 years and
they require about 2200 kcal per day.

Proteins
For boys the highest protein allowances begins at 15 years and persists to adulthood. They
require about 59 grams of proteins per day. For girls, protein allowance peaks at 11 to 14 years
and they need 46 grams of protein per day.

Carbohydrates and lipids

Carbohydrates should provide 55% to 60% of total calories per day. Lipids should provide 25%
to 30% of total calories per day.

Calcium
Calcium needs are based on needs for skeletal growth. During the growth spurt, 45% of the
skeletal mass is added, making the needs for calcium greater during this time than during
childhood or early adulthood. For both male and female adolescents, the RDA for calcium
increases to 1300 mg. Low calcium intake if impaired with physical inactivity may compromise

21
the attainment of peak bone mass which is considered to be the best protection against age
related bone loss and fractures.

Iron
Adolescents have increased needs for iron related to an expanding blood volume, the rise in
haemoglobin concentration, and the growth of muscles mass. In boys, iron requirements quickly
decrease after the growth spurt, allowing for recovery if a deficiency developed during the
growth spurt. Adolescent girls tend to develops iron deficiency slowly after puberty and this is
related to poor eating habits, chronic fad dieting, and menstrual losses. The requirements for iron
in girls almost double between the 9 to 13 years of age grouping and the 14 to 18 year age
grouping. The requirements for iron remain high until menopause. The RDA for girls is
15mg/day while for boys is 12 mg/day.

Zinc
Zinc requirements increases during adolescence because it is associated with muscles growth and
is necessary for sexual maturation. The recommended allowance for boys is 15 mg/day and girls
are 12 mg/day.

Vitamins

Vitamins needs for those vitamins that play a role in energy metabolism increases directly with
increased caloric intake. These are vitamins B1, B2 B3 and B6. The needs for vitamins B12 and
folate which are involved in tissue growth also increase during adolescence. Vitamin D is
required for skeletal growth and so its requirements increases during adolescence.

5) Elderly years

The elderly is a term used to refer to the age group of 65 years and above. There are many
factors that affect health and nutrition of elderly. These include:

22
  Decreased appetite which in turn reduce food intake

 Smell and taste: Sensitivity to smell, taste and smell often decreases with age.
 Thirst: Elderly people often partially lose their sense of thirst, and in turn don’t drink
enough fluids.
 Organs function: With age, the liver, pancreas, kidney etc. function less efficiently
 Hearing and vision both decline as we age. Approximately 4% of people under 45 years
of age and 29% of those 65 years or over have a handicapping loss of hearing.

INTERGRATED MANAGEMENT OF ACUTE MALNUTRITION IN CHILDREN

UNDER FIVE YEARS

Overview Malnutrition
Malnutrition refers to a deviation from normal nutrition due to inadequate or excess intake of
nutrient(s) in the body resulting to macronutrient (protein and energy) malnutrition and
micronutrient (vitamins and mineral) malnutrition. The deficiency or excess (imbalance) of
nutrients can cause measurable adverse effects on tissue/body form (body shape size and
composition), function and clinical outcome.

Under nutrition defines a state when the body does not have enough of the required nutrients.
There are two categories of under nutrition namely, acute (wasting) and chronic (stunting). These
forms are frequently accompanied by multiple or single micronutrients and /or mineral
deficiencies although these may occur in the absence of macronutrient depletion and give rise to
specific deficiency syndromes.This chapter focuses on wasting which is acute form of
malnutrition.

Chronic malnutrition measured by patient’s degree of stunting (height for age) occurs over
long period usually over the first two years of life and is irreversible after this period. Nutrition
intervention is therefore critical within the first two years of life to correct or prevent it.
Underweight is a reflection of either acute or chronic malnutrition or both. In both cases of
stunting and underweight, nutrition counseling is encouraged.

In adults, under nutrition normally occurs in form of wasting (weight loss) and is measured
using body mass index (BMI) or Mid Upper Arm Circumference (MUAC) in pregnant and
lactating women or patients to ill to stand (Bedridden).

Causes of malnutrition

23
The conceptual model identifies three levels of causality:

1. Immediate causes that act on the individual.

2. Underlying causes that act on households and communities.
3. Basic causes that act on entire societies but have a greater or lesser impact on specific
groups within society.

Figure 1: A simplified conceptual model for understanding the causes of malnutrition.1

Malnutrition, disability,
morbidity and death
Manifestations

Inadequate diet Disease Immediate

causes

Inadequate Inadequate Inadequate health

household food care services & unhealthy
Underlying
security household environment causes

Potential resources: financial,

human, physical, social and natural

Basic
causes
Social, economic, ideological and
political context

24
This section is intended mainly for practitioners and program managers.

It covers management of severe malnutrition, with an in-patient outline based on WHO standards
and updates from Professor Michael Golden, and an out-patient outline based mainly on the
Community-based Therapeutic Care (CTC) Field Manual by the CTC Research and
Development program (collaboration between Valid International and Concern Worldwide).

For management of moderate malnutrition, the outline is based on UNICEF standards in

emergency-settings and on the Community-based Therapeutic Care (CTC) Manual 163 pages
1.4mb

Diagnosis of Acute Malnutrition

 Anthropometric Measurement Techniques

 Interpretation of Anthropometric Indicators
 Decision-making at a glance

Management of Severe Acute Malnutrition in Children Under Five Years

 Introduction
 Admission
 In-patient Treatment
 Out-patient Treatment (Phase 2)
 Discharge and Follow-up
 Special Cases

Management of Moderate Acute Malnutrition in Children Under Five Years

 Introduction
 Admission
 Supplementary Feeding Programs
 Discharge and Follow-up

Management of Micronutrient Deficiencies

 Management of Iron Deficiency anaemia (IDA)

 Management of Vitamin A Deficiency (VAD)

Admission and discharge criteria for children who are 6–59 months of age with severe
acute malnutrition

WHO recommendations (1)

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Criteria for identifying children with severe acute malnutrition for treatment

1. In order to achieve early identification of children with severe acute malnutrition in the
community, trained community health workers and community members should measure the
mid-upper arm circumference of infants and children who are 6–59 months of age and examine
them for bilateral pitting oedema. Infants and children who are 6–59 months of age and have a
mid-upper arm circumference <115 mm, or who have any degree of bilateral oedema should be
immediately referred for full assessment at a treatment centre for the management of severe
acute malnutrition.

2. In primary health-care facilities and hospitals, health-care workers should assess the mid-
upper arm circumference or the weight-for-height/weight-for-length status of infants and
children who are 6–59 months of age and also examine them for bilateral oedema. Infants and
children who are 6–59 months of age and have a mid-upper arm circumference <115 mm or a
weight-for-height/length <–3 Z-scores of the WHO growth standards (2), or have bilateral
oedema, should be immediately admitted to a programme for the management of severe acute
malnutrition.

Criteria for inpatient or outpatient care**

3. Children who are identified as having severe acute malnutrition should first be assessed with a
full clinical examination to confirm whether they have medical complications and whether they
have an appetite. Children who have appetite (pass the appetite test) and are clinically well and
alert should be treated as outpatients. Children who have medical complications, severe oedema
(+++)***, or poor appetite (fail the appetite test****) or present with one or more IMCI danger
signs† should be treated as inpatients.

Criteria for transferring children from inpatient to outpatient care*

4. Children with severe acute malnutrition who are admitted to hospital can be transferred to
outpatient care when their medical complications, including oedema, are resolving and they have
good appetite, and are clinically well and alert. The decision to transfer children from inpatient to
outpatient care should be determined by their clinical condition and not on the basis of specific
anthropometric outcomes such as a specific mid-upper arm circumference or
weight-for-height/length.

Criteria for discharging children from treatment

5. a. Children with severe acute malnutrition should only be discharged from treatment when
their:

 weight-for-height/length is ≥–2 Z-scores and they have had no oedema for at least 2
weeks, or
 mid-upper-arm circumference is ≥125 mm and they have had no oedema for at least 2
weeks.

26
b. The anthropometric indicator that is used to confirm severe acute malnutrition should also be
used to assess whether a child has reached nutritional recovery, i.e. if mid-upper arm
circumference is used to identify that a child has severe acute malnutrition, then mid-upper arm
circumference should be used to assess and confirm nutritional recovery. Similarly, if weight-
for-height is used to identify that a child has severe acute malnutrition, then weight-for-height
should be used to assess and confirm nutritional recovery.

c. Children admitted with only bilateral pitting oedema should be discharged from treatment
based on whichever anthropometric indicator, mid-upper arm circumference or weight-for-height
is routinely used in programmes.

d. Percentage weight gain should not be used as a discharge criterion.

Follow-up of infants and children after discharge from treatment for severe acute
malnutrition

6. Children with severe acute malnutrition who are discharged from treatment programmes
should be periodically monitored to avoid a relapse.

Additionally (3-6):

 visible severe wasting is not included as a diagnostic criterion. However, all

malnourished children should be clinically examined when undressed, as part of routine
management;
 all anthropometric indicators are assumed to be derived from the WHO growth standards;
 children with severe acute malnutrition with medical complications or failed appetite
test1 should be admitted to hospital for inpatient care;
 admission may also be warranted if there are significant mitigating circumstances such as
disability or social issues, or there are difficulties with access to care;
 children with severe acute malnutrition and without these signs or mitigating
circumstances can be managed as outpatients by providing appropriate amounts of ready-
to-use therapeutic food.

Maternal infant young children nutrition

Maternal Nutrition
A pregnancy during adolescence often increases the risk for malnutrition, complications during
pregnancy and delivery, and poor birth outcomes, including death of the mother and child. The
nutritional requirements of pregnant adolescent girls are greater than the requirements of
pregnant adult women because an adolescent is usually still growing. Her daily intake must
satisfy both the requirements of the developing girl and those of the developing fetus. Adolescent
mothers are also more likely to have Low Birth Weight babies because of the competition for
nutrients between mother and fetus, as well as poorer placental function. This perpetuates the

27
intergenerational cycle of malnutrition. By addressing the special requirements of adolescents
before they become pregnant as well as during pregnancy there is a potential opportunity to
break the cycle.
Adequate nutrition for women in pregnancy prevents nutrition deficiencies that affect mental,
physical and physiological development of the child before birth. In addition to improving
pregnancy outcomes, promotion of adequate maternal nutrition before, during and after
pregnancy is vital for reducing maternal morbidity and mortality.

The following policy guidelines shall be used to support this;

i. Nutritional needs of pregnant/lactating women should be prioritized and met through access to
the minimum required healthy diet in terms of frequency, energy content and variety.
ii. Provide and promote intake of iron/folate through antenatal health services and support the
establishment of a monitoring and support system to address maternal anemia.
iii. Monitor maternal weight during pregnancy to support optimal maternal nutrition
iv. Provide special care to pregnant and lactating adolescents, women with low weights, HIV-
positive women to support optimal care.
v. Strengthen focus on family planning for all women during antenatal and postnatal care to
optimize MIYCN.
vi. Support and advocate for the implementation of 90 days of paid leave under the Maternity
Protection (Employment Act, Part 5, and Section 25) to support optimal infant feeding and care.
vii. Ensure that women receive support for knowing their HIV status through PMTCT services in
order to maximize interventions that reduce the risk of mother to child transmission. HIV
infected
mothers should be supported for the most appropriate infant feeding option and their own
health.
viii. All HIV positive pregnant women should be evaluated for HAART eligibility and if not
eligible, provided with ARV prophylaxis.
ix. All pregnant women should be educated on appropriate IYCF practices.
x. Lactating mothers with difficulties should be assisted to start, maintain, enhance or re-
establish breast feeding by means of re-lactation, when necessary.

Infant and Young Child Nutrition (0-5years)

Good nutrition is a key to child survival, growth, and development of children in Kenya.

In order to address the current child malnutrition situation, the following policy statements shall
guide infant feeding practices in the first 6months (exclusive breastfeeding), and complementary
feeding 6-24 months.

28
i).Infants and young children shall be appropriately fed during the first 5years of life, with
specific attention to the first 2 years of life, to prevent under-nutrition and over-nutrition,
including obesity

ii). Newborn babies should be initiated to breastfeeding within one hour from birth and no pre-
lacteal foods like water or glucose should be given by health workers or birth attendants.

iii).Mothers should be supported to initiate breastfeeding within one hour of birth.

Iv). Exclusive breastfeeding should be recommended for all infants during the first 6months of
their life unless otherwise medically indicated.

v). Continue to promote, support and protect breastfeeding from 6-24 months or beyond with
timely, appropriate and adequate complementary feeding.

vi).Where use of breast milk substitutes(BMS) is required, procurement, distribution, targeting

and use, should be in compliance with the Breast Milk Substitutes (Regulation and Control) Act,
2012 and that safety procedures are strictly adhered to.

GENARALLY, Poor nutrition in infancy and early childhood increases the risk of infant child
morbidity and mortality, diminished cognitive and physical development marked by poor
performance in school.

Malnutrition also impacts on productivity later in life.

Malnutrition in children can be attributed to a variety of factors including

i) poor infant and young child feeding practices,

ii) poor maternal nutrition,
iii) low access to adequate and diversified diets,
iv) childhood illnesses and
v) inadequate access to health and nutrition services.

According to Lancet Nutrition Series published in 2008, if the package of Essential Nutrition
Interventions is effectively accessed by mothers from the conception period and children up to
two years of age and implemented on a wider scale, in the short run, infant mortality would
reduce by 25%, maternal mortality by 20% and chronic malnutrition/stunting in children by
30%. Improving the nutritional status of women of reproductive age while delaying pregnancy
could reduce risk factors that affect the health and survival chances of both mother and child.
The main causes of malnutrition among Women of Reproductive Age include:

 sub-optimal feeding practices especially during pregnancy,

 heavy workload, and
 low micronutrient intake during pregnancy.

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Strategic objectives one in the National nutrition Action Plan (NNAP) 2012 to 2017 focuses on
activities that will ensure that women of reproductive age receive adequate micro and macro
nutrients, while strategic objective 2 focuses on activities that will contribute to the exploitation
of the critical ‘window of opportunity’ from pre-pregnancy until children are two years of age as
endorsed in the 2010 UN summit resolution on nutrition.

Priority Areas

 Promote healthy dietary practices among Women of Reproductive Age

 Promote adequate micronutrient intake
 Promote routine weight monitoring and appropriate counselling for pregnant women
 Promote appropriate management of malnutrition of pregnant and lactating women
 Ensure that all HIV positive mothers are counselled on good nutrition practices.
 Strengthen the capacity of health facilities to adequately offer maternal nutrition services.
 Promote exclusive breastfeeding for the first six months of baby’s life
 Promote optimal complementary feeding with continued breastfeeding for at least two
years
 Provide appropriate micronutrient supplements to children less than five years
 Strengthen growth monitoring and promotion for children less than five years of age
 Strengthen referral mechanism and linkage between the community and health facility.
 Develop a national monitoring plan for nutrition commodities
 Ensure food safety of nutrition commodities.

Expected outcome:

 Improved nutritional status of women of reproductive age

 Improvement in nutritional status of children under the age of five years

National Programmes Supporting Infant and Young Child Nutrition

i. Baby Friendly Hospital/Community Initiative
ii. Focused Antenatal Care
iii. Growth Monitoring and Promotion
iv. Integrated Management of Acute Malnutrition
v. Vitamin A Supplementation and Micronutrient Deficiency Control
vi. Integrated Management of Childhood Illnesses
vii. Prevention of Mother-to-Child Transmission of HIV
viii. Kenya Expanded Programme on Immunization.
ix. Community Health Strategy
x. Malezi Bora
xi. School Health and School Feeding Programme

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Topic 3: Applying Nutrition in Disease Management

Nutrition Assessment

Nutritional status Refers to the condition of health of an individual as influenced by the intake
and utilization of nutrients

Under nutrition refers to a deficiency of energy or nutrients.

Over nutrition refers to excess intake of energy or other nutrients.
Nutritional assessment is the interpretation of anthropometric, biochemical (laboratory),
clinical and dietary data to determine whether a person or groups of people are well nourished or
malnourished (over-nourished or under-nourished).

Nutritional assessment can be done using the ABCD methods. These refer to the following:

 A-Anthropometry
 B-Biochemical/biophysical methods
 C-Clinical methods
 D-Dietary methods.

Anthropometric measures

These are the scientific study of the measurements and proportions of the human body.

The anthropometric measurements are used to assess either growth or change in the body
composition of the people.

The measurements include:

Weight

Height/length

Head circumference

To assess growth in children you can use several different measurements including length,
height, weight and head circumference.

Length

31
A wooden measuring board (also called sliding board) is used for measuring the length of
children under two years old to the nearest millimeter. Measuring the child lying down always
gives readings greater than the child’s actual height by 1-2 cm.

Procedure

To measure the length of a child under two years, you need one assistant and a sliding board.

As you can see in Figure below, you need an assistant to help you measure a child using this
method.

1. Both assistant and measurer are on their knees

2. The assistant holds the child’s head with both hands and makes sure that the head touches
the base of the board
3. The assistant’s arms should be comfortably straight
4. The line of sight of the child should be perpendicular to the base of the board (looking
straight upwards)
5. The child should lie flat on the board
6. The measurer should place their hands on the child’s knees or shins
7. The child’s foot should be flat against the footpiece
8. Read the length from the tape attached to the board.
9. Record the measurement on the questionnaire

Measuring length of a child using a length board

Height

32
This is measured with the child or adult in a standing position (usually children who are two
years old or more). The head should be in the Frankfurt position (a position where the line
passing from the external ear hole to the lower eye lid is parallel to the floor) during
measurement, and the shoulders, buttocks and the heels should touch the vertical stand. Either a
stadiometer or a portable anthropometer can be used for measuring. Measurements are recorded
to the nearest millimetre.

Procedure

As with measuring a child’s length, to measure a child’s height, you need to have another person
helping you. Figure below illustrates the procedures,

Both the assistant and measurer should be on their knees.

1. The right hand of the assistant should be on the shins of the child against the base of the
board
2. The left hand of the assistant should be on the knees of the child to keep them close to the
board
3. The heel, the calf, buttocks, shoulder and occipital prominence (prominent area on the
back of the head) should be flat against the board
4. The child should be looking straight ahead
5. The hands of the child should be by their side
6. The measurer’s left hand should be on the child’s chin
7. The child’s shoulders should be levelled.
8. The head piece should be placed firmly on the child’s head
9. The measurement should be recorded on the questionnaire

Weight

A weighing sling (spring balance), also called the ‘Salter Scale’ is used for measuring the
weight of children under two years old, to the nearest 0.1 kg. In adults and children over two
years a beam balance is used and the measurement is also to the nearest 0.1 kg. In both cases a
digital electronic scale can be used if you have one available. Do not forget to re-adjust the scale

33
to zero before each weighing. You also need to check whether your scale is measuring correctly
by weighing an object of known weight.

Procedures

In Figure below you can see the procedures for weighing a child under two years old using a
Salter Scale. The photo shows a small boy being weighted using the scale.

Weighing a child using a harness and spring balance. (Photo: UNICEF Ethiopia / Indrias
Getachew)

1. Adjust the pointer of the scale to zero level.

2. Take off the child’s heavy clothes and shoes.
3. Hold the child’s legs through the leg holes (arrow 1).
4. Hold the child’s feet (arrow 2).
5. Hang the child on the Salter Scale (arrow 3).
6. Read the scale at eye level to the nearest 0.1 kg (arrow 5).
7. Remove the child slowly and safely.

34
Improvised way of measuring weight of the child using salter scale. (Source: UNICEF Ethiopia /
Indrias Getachew)

Sometimes you will have to improvise. For example in the field set up, it is difficult to measure
very young children who cannot sit by themselves using the weighing pant attached to the scale.
In addition, some children panic during the measurement and urinate, making the pant dirty.
Therefore, mothers or caregivers may not be happy to let their children be measured in such a
manner. The weighing scale with the pant can be improvised by using a plastic washing-basin
which is attached to the Salter Scale and adjusting the reading to zero. You need to ensure the
basin is as close to the ground as possible in case the child falls out, and to make the child feel
secure during weighing. If the basin is dirty, then you need to clean it with a disinfectant. This is
a much more comfortable and reassuring weighing method for the child and you can use it for ill
children much more easily than the approaches described above.

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 Converting measurements to indices

An index is a combination of two measurements or one measurement plus the person’s age.
The following are a few indices that you may find useful in your work:

Weight-for-age is an index used in growth monitoring for assessing children who may be
underweight. You assess weight-for-age of all children under two years old when you carry out
your community-based nutrition (CBN) activities every month.

Height-for age is an index used for assessing stunting (chronic malnutrition in children).
Stunted children have poor physical and intellectual performance and lower work output leading
to lower productivity at individual level and poor socioeconomic development at the community
level. Stunting of children in a given population indicates the fact that the children have suffered
from chronic malnutrition so much so that it has affected their linear growth.

Stunting is defined as a low height for age of the child compared to the standard child of the
same age. Stunted children have decreased mental and physical productivity capacity.

Weight-for-height is an index used for assessing wasting (acute malnutrition).

Wasting is defined as a low weight for the height of the child compared to the standard child of
the same height. Wasted children are vulnerable to infection and stand a greater chance of dying.

Body mass index is the weight of a child or adult in kg divided by their height in metres squared:
Weight (kg)/(Height in metres)2

Body Mass Index (BMI) = Weight (Kg)/Height (M2)

Here is how to calculate each index for children in your community.

Birth weight is weight of the child at birth and is classified as follows:

more than 2500 grams = normal birth weight

1500–2499 grams = low birth weight
less than 1500 grams = very low birth weight

Determination of Therapeutic Nutrition Requirement

There are many factors that determine the requirement for therapeutic nutrition which includes:

 A child below six month which weak and cannot suck breast milk
 Under five children who have weight for height/length W/H <-3 z-core
 Under five children who have bilateral oedema
 Under 5 children (6-59 months) whose MUAC measurements are <11.5 cm
 Pregnant mothers whose MUAC measurements are <16 cm

36
  Any adolescence or adult person who is underweight and has a BMI <16 kg/M2

Supplements

Supplements are substances you might use to add nutrients to your diet or to lower your risk of
health problems, like osteoporosis or arthritis. Dietary supplements come in the form of pills,
capsules, powders, gel tabs, extracts, or liquids. They might contain vitamins, minerals, fiber,
amino acids, herbs or other plants, or enzymes. Sometimes, the ingredients in dietary
supplements are added to foods, including drinks. A doctor’s prescription is not needed to buy
dietary supplements.

Nutrition management of chronic diseases

They are also known as Non-communicable diseases (NCDs).

They are not passed from person to person. They are of long duration and generally slow
progression.

Non-communicable diseases (NCDs) are not a new problem, having long been of concern in
developed countries; they are, however, of increasing concern in developing countries because
of:

 Their transition from low-income to middle-income status,

 the influence of globalization on consumption patterns, and
 the aging of populations.

Identified as “one of the major challenges for sustainable development in the twenty-first
century, NCDs have received greater attention worldwide and within the United States in recent
years, as global efforts to tackle this growing health challenge have become more organized and
prominent.

Examples include:

 Alzheimer's Disease.
 Cancer.
 Epilepsy.
 Osteoarthritis.
 Osteoporosis.
 Cerebrovascular Disease (Stroke)
 Chronic Obstructive Pulmonary Disease (COPD)
 Coronary Artery Disease.
 Diabetes mellitus

37
Cancer

The most common type of cancers are:

 Skin cancer.
 Lung cancer.
 Prostate cancer.
 Breast cancer.
 Colorectal cancer.
 Kidney (renal) cancer.
 Bladder cancer.
 Non-Hodgkin's lymphoma.

Risk factors to certain cancers.

 Age
 Alcohol
 Cancer-Causing Substances
 Chronic Inflammation
 Diet
 Hormones imbalance
 Immunosuppression
 Infectious Agents
 Obesity
 Radiation
 Sunlight
 Tobacco smoking

Prevention

Most experts are convinced that many cancers can either be prevented or the risk of developing
cancers can be markedly reduced. Some of the cancer prevention methods are simple; others are
relatively extreme, depending on an individual's view.

Cancer prevention, by avoiding its potential causes, is the simplest method. First on most
clinicians and researchers list is to stop (or better, never start) smoking tobacco. Avoiding excess
sunlight (by decreasing exposure or applying sunscreen) and many of the chemicals and toxins
are excellent ways to avoid cancers. Avoiding contact with certain viruses and other pathogens
also are likely to prevent some cancers. People who have to work close to cancer-causing agents
(chemical workers, X-ray technicians, ionizing radiation researchers, asbestos workers) should
follow all safety precautions and minimize any exposure to such compounds. Although the FDA
and the CDC suggests that there is no scientific evidence that definitively says cell phones cause
cancer, other agencies call for more research or indicate the risk is very low. Individuals who are
concerned can limit exposure to cell phones by using an earpiece and simply make as few cell
phone calls as possible.

38
There are two vaccines currently approved by the U.S. Food and Drug Administration (FDA) to
prevent specific types of cancer. Vaccines against the hepatitis B virus, which is considered a
cause of some liver cancers, and vaccines against human papillomavirus (HPV) types 16 and 18
are available. According to the NCI, these viruses are responsible for about 70% of cervical
cancers. These virus also plays a role in cancers arising in the head and neck, as well as cancers
in the anal region, and probably in others. Today, vaccination against HPV is recommended in
teenagers and young adults of both sexes. The HPV virus is so common that by the age of 50,
half or more people have evidence of being exposed to it. Sipuleucel-T is a new vaccine
approved by the FDA to help treat advanced prostate cancer. Although vaccine does not cure
prostate cancer, it has been shown to help extend the lifespan of individuals with advanced
prostate cancer.

People with a genetic predisposition to develop certain cancers and others with a history of
cancers in their genetically linked relatives currently cannot change their genetic makeup.
However, some individuals who have a high possibility of developing genetically linked cancer
have taken actions to prevent cancer development. For example, some young women who have
had many family members develop breast cancer have elected to have their breast tissue removed
even if they have no symptoms or signs of cancer development to reduce or eliminate the
possibility they will develop breast cancer. Some doctors consider this as an extreme measure to
prevent cancer while others do not.

Screening tests and studies for cancer are meant to help detect a cancer at an early stage when the
cancer is more likely to be potentially cured with treatment. Such screening studies are breast
exams, testicular exams, colon-rectal exams (colonoscopy), mammography, certain blood tests,
prostate exams, urine tests and others. People who have any suspicion that they may have cancer
should discuss their concerns with their doctor as soon as possible. Screening recommendations
have been the subject of numerous conflicting reports in recent years. Screening may not be cost
effective for many groups of patients or lead to unnecessary further invasive tests, but individual
patients' unique circumstances should always be considered by doctors in making
recommendations about ordering or not ordering screening tests.

Diabetes Mellitus
Blood sugar is central to diabetes, but dietary sugar does not cause diabetes. In diabetes, blood
glucose remains elevated even when the body’s cells need glucose. This happens either because
the pancreas fails to make or secrete insulin or when the pancreas makes insulin but the cells fail
to respond to its action. For example failure of formation and/or liberation or failure of action by
circulating insulin. When glucose is deprived of entry into the cells, it continues to circulate in
the blood, setting up the abnormal situation referred to as hyperglycemia or high concentration
of blood glucose (more than 140mg/100 mls). When blood glucose exceeds 160-180 mg/100mls,
the kidney can no longer filter it out, and glucose is excreted in the urine, a condition known as

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glucosuria. Glucose tolerance test is usually done to determine the presence of diabetes. There
are two types of diabetes and these are described below:

 Insulin Dependent Diabetes Dellitus (IDDM).

It is also known as type I or Juvenile onset type. It accounts for 10% of total diabetic cases.
Onset begins suddenly between early childhood and the middle years generally before 40 years
when the pancreas ceases to produce insulin. It is insulin dependent in treatment.

 Non- Insulin Dependent Diabetes Mellitus (NIDDM)

It is also referred to as type II or mature- onset diabetes mellitus. It accounts for 90% of total
diabetic cases. It occurs later in life probably over 55 years. Oral hypoglycemic drugs are used
for treatment plus diet. Type II diabetic patients have normal or above normal blood insulin, yet
the insulin fails to bind to cellular membranes to perform its function.

• Gestational Diabetes: Pregnant women who have never had diabetes before but who
have high blood sugar (glucose) levels during pregnancy are said to have gestational diabetes.
Gestational diabetes affects about 4% of all pregnant women worldwide. It may precede
development of type 2 (or rarely type 1)
Risk factors for diabetes mellitus
These include:
 Heredity,
 age,
 sex,
 obesity,
 dietary factors,
 physical inactivity and
 infections

Common symptoms of DM include:

• Increased thirst (polydipsia)

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• Increased urination (polyuria)
• Increased hunger (polyphagia)
• Weight loss in Type 1 diabetes
• Over-weight/Obesity in type 2 diabetes
• Sugar in the urine (glycosuria)
• Elevated blood sugar or glucose (hyperglycemia)
• Skin irritation or infection
• Weakness/general loss of strength

Management Plan
The aim of management in diabetes is to control blood sugar and prevent development of disease
complications.

Objectives
 Attain and maintain blood glucose levels as close to normal as possible
 Prevent hypo- and hyperglycaemia
 Attain optimum blood lipids and blood pressure control and so reduce the risk of
macro vascular disease
 To promote physical, social and psychological well being
 To prevent, delay or minimize the onset of chronic degenerative complications
e.g. hypertension and renal diseases
 To achieve and maintain optimal metabolic and physiologic outcomes
 To provide relief from symptoms
Components of management plan
 Medical therapy
 Medical nutrition therapy
 Exercise and physical activity
Medical Nutrition Therapy
Medical nutrition therapy is an integral component of diabetes management. It has both short and
long term benefits for diabetes outcomes. Dietary modification is one of the cornerstones of
diabetes management, and is based on the principle of healthy eating in the context of social,
cultural and psychological influences of food choices. Dietary modification and increasing levels

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of physical activity should be the first step in the management of diabetes mellitus that have to
be maintained. The nutrition care process should be followed when managing diabetic patients.

Diabetes nutrition therapy aims to enable people with diabetes to make appropriate changes to
their lifestyle in order to reduce the risks of both micro- and macro vascular complications and
control blood sugar. Nutritional therapy should be individualized to accommodate age,
nutritional needs, religion, culture, preferences and lifestyle.Nutrition therapy involves
modifying both diet and patterns of physical activity.Positive outcomes of the therapy include:

 Improved metabolic control

 Decreased risk of micro- and macro vascular complications
 Quality of life and life expectancy similar to that of the general population
Aims of the Nutrition Therapy
Diet therapy aims at tailoring the diet care plan in accordance with the prevailing clinical
situation. Diet therapy is not only concerned with the prevention and management of micro and
macro vascular complications but also chronic complications of diabetes.

The objectives of nutrition therapy are to:

 Attain and maintain blood glucose levels as close to normal as possible
 Prevent hypo- and hyperglycaemia
 Attain optimum blood lipids and blood pressure control and reduce the risk of
macro vascular disease
 Assess energy intake to achieve optimum body weight (this can mean taking
action to either increase or decrease body weight).
 Promote physical, social and psychological well being
 Prevent, delay or minimize the onset of chronic degenerative complications e.g.
hypertension and renal diseases
 Achieve and maintain optimal metabolic and physiologic outcomes
 Provide relief from symptoms
 Individualize meal plan according to a person’s lifestyle and based on usual
dietary intake

CARDIOVASCULAR DISEASES

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Cardiovascular disease is a class of diseases that affect the heart and blood vessels (arteries and
veins). In the majority of cases, this is due to the progressive effects of atherosclerosis in the
arteries.

Coronary heart disease (CHD) occurs when plaques containing lipoproteins, cholesterol, tissues
debris, and calcium form on the intima, or interior surface of blood vessels. The plaques roughen
the intima, and platelets are attracted to the roughened areas, forming clots. When the plaques
enlarge sufficiently to occlude the blood flow, tissues are deprived of oxygen and nutrients,
creating an area of infarct. CHD is manifested when a myocardial ischemia such as angina
pectoris.

Common examples of cardiovascular disease include coronary artery disease, stroke, and
peripheral vascular disease. Some of the risk factors include; diet, age, diabetes, obesity,
smoking and heredity among others.

General risk factors for cardiovascular diseases

Non modifiable factors are age, gender, genetic factors and race. A family history of high blood
pressure (HBP) and a “pre-hypertension”120-139/80-89mmHg may be a risk of HBP, diabetes
and kidney diseases.

High salt (sodium chloride) intake: when sodium is taken in excess more water is drawn into
the circulation, increasing the volume of blood to be pumped. In addition, excess salt makes the
arterial walls to be more rigid leading to arteriosclerosis. Much of the salt we eat is added to the
table during eating (20%), fifteen percent comes from salt naturally found in foods and 60%
comes from salt added to processed foods (hidden salt).

High blood cholesterol: There are two types of cholesterol that is dietary cholesterol contained
in food and blood or plasma cholesterol that is essential from body metabolism. Excess
cholesterol causes arteriosclerosis (narrowing and hardening of arteries due to deposits of
cholesterol) and increased risk of heart attack (myocardial infraction) and stroke (thrombosis).
The amount of cholesterol in the diet is not reflected by the amount in the blood; this is mostly
determined by the amount of saturated fatty acids in the diet. Animal based foods and products
(milk and its derivatives, eggs, fish, shellfish and all types of meat), variety of meats especially
offal (particularly liver and brain), shrimps and eggs have the highest cholesterol content. Plant
based foods do not contain cholesterol. However, there are minute amounts of cholesterol in
vegetable oils that are considered incidental.

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Too much fat, saturated fatty acid, Trans -unsaturated fatty acids: These increases harmful
cholesterol (LDL) levels in the blood and reduces the good cholesterol. The major dietary
sources of saturated fatty acids include animal based foods and products such as butter, cured
cheeses, margarine, bacon, sausages and pork, fresh eggs, cream, hydrogenated vegetable fats,
lard, palm oil and whole cow’s milk. Plant based foods are low in saturated fatty acids with some
exception such as coconut and palm oil.

High levels of low density lipoprotein (LDL) cholesterol: Cholesterol is transported around the
body attached to specific proteins called lipoproteins. There are two types of lipoproteins; low
density lipoproteins (LDL) and high density lipoproteins (HDL). LDL carry about three-quarters
of the cholesterol in the blood and high LDL level usually reflect high cholesterol level and
imply a high risk of heart disease. HDL, which carry much less fat signals a lower than average
risk of heart disease.

Smoking cigarettes: produces nicotine which stimulates the production of certain body
chemicals. These chemicals raise pulse rate, BP and the force of heart contraction. Smoking also
makes the heart need more oxygen at the same time reduce the amount of oxygen available. In
addition, it helps to increase the substance that clogs the arteries.

Alcohol: has got a higher caloric density than protein or carbohydrates and is a source of
additional empty calories.

Obesity: although obesity is a disease on its own right, it is also one of the key risk factors for
CVD.

Reduced physical activity: makes the energy from food not to be expended thus leading to
increased body fats.

Stress: While stress can affect all the body organs and functions of the body, its effect tends to
be concentrated on the heart and the cardiovascular system which is obliged to work hard.

Prevention and nutrition management of CVD

Reduced sodium intake can prevent CVD in persons at risk and can facilitate CVD control in
older age persons on medication. Sodium should be limited to 6g per day, an equivalent of
100mmols of sodium (2400mg) per day. To achieve this, choose food low in sodium and limit
the amount of salt added to food.

Consumption of diets that include a wide variety of fruits and vegetables: These are high in
nutrients and fibre and relatively low in calories and hence are nutrient dense. In addition,
consuming a variety of fruits and vegetables (especially those that are dark green, deep orange or
yellow) helps ensure adequate intake of micronutrients normally present in these foods.

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Micronutrients that play a role in controlling HBP include, potassium, magnesium, calcium and
vitamin especially vitamin C.

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Dietary patterns high in grain products especially whole grains: Grain products provide
complex carbohydrates, vitamins, minerals and fibre. Foods high in starches (polysaccharides
e.g. bread, pasta, cereals and potatoes) are recommended over sugars. Sugars supply only energy
without the other nutritive benefits. A high complex carbohydrate diet is rich in fiber, minerals,
vitamins, saponin (a phytochemical) and essential fatty acids. It is rich in antioxidants E,
ascorbic acids and carotenoid especially lutein and zeaxanthin, which are important in preventing
heart disease and delaying aging. A high carbohydrate diet especially complex carbohydrate is
also rich in folic acid that helps to control an abnormal homocysteine level, an emerging
cardiovascular disease risk.

Diet high in fiber (Fibre)

Fiber is found exclusively in plant based foods. Animal foods such as milk, eggs, fish, meat and
their derivatives contain no fiber. Insoluble fibres are found in higher concentration in vegetables
such as carrots, green leafy vegetables, wheat and cereals. The insoluble fiber is found primarily
in grain bran. Other sources of insoluble fiber include brown rice, rice bran, wheat bran, corn
bran, whole grain bread and cereals, cabbage family, cauliflower, green beans, green peas,
legumes, mature vegetables, root vegetables, tomatoes, nuts, fruits such as pears, peaches, plums,
seeds, strawberries, apples and bananas. High concentration of soluble fiber occurs in fruits, oats,
barley and legumes such as peas, beans and lentils. High carbohydrates based on whole plant
foods prevent obesity.

Consumption of diet that lower LDL (harmful) cholesterol: polyunsaturated fatty acids which
include fish and fish oils, soybeans, wheat germ, canola oil, sunflower oil, corn oil, cotton seed
oil, walnut, some vegetables for example spinach, lettuce and broccoli, monounsaturated fatty
acids such as avocado, cashews, canola oil, peanuts and poultry. The polyunsaturated and
monounsaturated fatty acids lower BP, the level of triglycerides and LDL cholesterol and
consequently lead to increase in HDL cholesterol that carries cholesterol in the blood back to the
liver for recycling or disposal.

Fish and fish oils help prevent the development of atherosclerosis and heart disease. It is believed
that fish oil exert their protective effect by lowering BP levels, blood triglycerides and LDL. Fish
oils are also believed to reduce platelets and suppress the growth of smooth muscle cells in the
arterial walls.

Soy protein is well known to produce less hypercholesterolemia and less atherosclerosis than
animal proteins.

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Micronutrients and cardiovascular
Magnesium: High consumption of magnesium reduces the production of prostacyclin which is
vasodilating and increases the release of thromboxane which is vasoconstricting (Prostacyclins
and thromboxanes are hormone like the one compounds referred to as eicosanoids that regulate
BP, clotting and other body functions). Magnesium also stabilizes calcium channels. Low blood
magnesium lowers potassium level and leads to hypokalemia.

The food sources of magnesium ranked by milligram of magnesium per standard amount include
bran, pumpkin and squash seeds kernel roasted, sesame, nuts, wheat germ, whole wheat flour,
soybeans, molasses, spinach, white bean, green leafy vegetables, potatoes and oranges.

Potassium: Potassium causes increased excretion of sodium by the kidney. It may also result in
a decrease in BP via its response in neither circulating nor epinephrine (a hormone produced by
the adrenal gland and is a vasoconstrictor). In addition, it modifies the excitability of vascular
tissue and relaxes arteriolar muscle. Potassium also reduces secretion of rennin which operates to
conserve sodium and blood fluids.

Dietary sources of potassium include foods such as blackstrap molasses, soybeans, wheat germ,
pumpkins, bananas, almond, avocado, spinach, potatoes, sweat potatoes, carrot juice, tomatoes,
whole grain bread, melon, cucumber, prune juice, beans, oranges, mangoes. Others from animal
sources include salmon, cod, beef steak, cheese, cow’s milk and fresh eggs.

Vitamin C: Vitamin C is an electronic donor and this property accounts for its known functions.
It acts as a potent water soluble antioxidant in humans thus preventing oxidative damage to
tissues and the genesis of atherosclerosis. Vitamin C is found majorly in plant sources such as
sweet red pepper, guava, black currant, broccoli, orange, lemon, cassava, peas, tangerine,
tomatoes, potatoes and water melon. It may also be found in small amounts in animal sources
such as beef, liver, oyster, trout and chicken. Human beings can neither synthesize this vitamin
nor store it in significant amounts; therefore it must be taken in daily.

Calcium: It increases sodium excretion. It also alters the vascular smooth muscle reactivity.
Milk and dairy products are well known as the best sources of calcium. However, there are a
variety of plant based foods providing as much or more calcium as milk: sesame, blackstrap
molasses, almonds, beans, corn, cabbage, broccoli and oranges are also good sources of calcium.

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Physical activity: Physical activity has measurable biological effects affecting cholesterol
levels, insulin sensitivity and vascular reactivity. Moreover these effects are dose dependant such
that the more the exercise, the greater the health benefits. The WHO (2002) describes the
opportunities for people to be physically active in terms of 4 domains: at work; for transport; in
domestic duties and leisure time.

Engaging in moderate level of physical activities such as intermittent walking for 30 to 45

minutes is recommended for prevention of CVD. Moderate exercise such as walking may both
lower LDL and raise HDL levels if the activity is constantly pursued for a long time. Moderate
means 30 minutes brisk walking (3-4 miles) per hour, walking upstairs, dancing, bicycling and
any exercise that will expend 200 calories per day.

It is important to balance time of stress with moments of relaxation. Do something that takes the
mind off problems such as gardening, walking, playing as sport, meditating or listening to
soothing music.

Prevent and control obesity: Limitation of dietary fats and alcohol (7kcal/g) is effective means
to reduce both energy density and total energy. The diet should be within ≤30% of total
kilocalories as fat to predict a weight loss of ½ kg per week (minus 500 to 1000kcal/day).

MYOCARDIAL INFARCTION
This is sudden tissue death caused by blockages of vessels that feed the heart muscle, also called
heart attack/cardiac arrest. Risk factors include hypertension and arteriosclerosis. Other
contributors include abnormal blood clotting, spasms of the coronary artery, rheumatic heart
disease, infections of the membranes covering the heart and electrical disturbances that alter the
hearty rate.
Implications
 Strained cardiac function
Aims of nutritional management
 To reduce the work load of the heart
 To relieve pain and stabilize the heart rhythm
 To treat infections and the underlying causes
 To regulate electrolyte balance
Nutritional Management
 When the patient is in shock, withhold food intake-nil per oral until shock resolves
 When shock resolves provide between 1000-1200 kcal that progresses from low
sodium soft foods of moderate temperature in frequent and small feeding.

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  After recovery adjust the diet to meet the individual needs and to deal with the
underlying conditions such as hyper lipidemia, hypertension, and obesity
 Avoid caffeine as it stimulates metabolic rate and increase the workload of the heart
A healthy heart requires minimal consumption of saturated fats and cholesterol, reduced use of
salt and sugar, avoiding use of tobacco and too much coffee and regular exercise.

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CONGESTIVE HEART FAILURE
This is a syndrome in which the heart can no longer adequately pump blood through the
circulatory system. Risk factors include; uncontrolled atherosclerosis and hypertension.
Implications
 Pulmonary oedema
 Reduced blood flow to all organs
 Fluid retention hence stagnation of fluids in all organs
 Enlarged heart and rapid heart beat
 Malnutrition due to high energy needs
Aim of Management
 To reduce the workload of the heart
 To provide adequate nutrients
 To reduce weight for the overweight
Nutritional Management
 Restrict sodium, caffeine and fat intake
 Encourage gradual weight loss where necessary
 Use of liquid formula of high nutrient density as oral supplement or enteral or tube
feeding to prevent or reverse malnutrition is recommended. In some cases total
parenteral nutrition may be required
 Selection of enteral or parenteral formulas should be done carefully to ensure that
energy ,fluid, sodium intake will not overload the body
 Adjust dietary fiber to avoid constipation but avoid amounts and types that produce
gas and abdominal distention
 For overweight patient counsel on weight reduction
 Restrict cholesterol intake to 300 mg /day
 Reduce intake of saturated fats
 Encourage intake of unsaturated fats (oils)
 Increase intake of dietary fiber to control glucose/fat absorption
 Reduce alcohol intake and encourage the patient to avoid smoking to prevent
development of atherosclerosis

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HYPERTENSION
Hypertension is a cardiovascular disorder characterised by persistently elevated diastolic blood
pressure (BP) of above 95mmHg. Uncontrolled hypertension can affect various body organs and
can lead to impaired vision, kidney failure, stroke, paralysis, heart attack and brain damage. Risk
factors include; diet, race, stress, age, diabetes, obesity, smoking, atherosclerosis and heredity
among others.
Implications
 Strained cardiac and vascular function
 Cellular electrolyte imbalance
 Aneurysms (balloon out and busting of the arteries)
 Arterial lining injuries which accelerates the plaque formation
Aims of nutritional management
 To control blood pressure within the normal ranges
 To achieve a gradual weight loss in overweight and obese individuals and maintain
their weight slightly below the normal
 To reduce sodium intake based on severity
 To maintain adequate nutrition
 Regulate fat intake
Nutritional management
 Provide low calorie diet if the patient is overweight until ideal body weight is
achieved
 Regulate fat intake. Encourage intake of unsaturated fats (oils). The poly unsaturated
and monounsaturated fatty acids lower BP, the level of triglycerides and LDL
cholesterol and consequently lead to increase in HDL cholesterol that carries
cholesterol in the blood back to the liver for recycling or disposal. Fats should be 20%
of total kilo calorie
 Restrict alcohol intake
 Restrict sodium intake. To achieve this, encourage choice of food low in sodium and
limit the amount of salt added to food, restrict processed foods and use of sodium
containing spices
 Avoid stimulants e.g. caffeine and spirits
 Avoid cigarette smoking, which may lead to atherosclerosis
 In some cases it may be necessary to restrict fluid intake

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 Encourage physical activity for those leading a sedentary lifestyle. Physical activity
has measurable biological effects affecting cholesterol levels, insulin sensitivity and
vascular reactivity. These effects are dose dependant such that the more the exercise,
the greater the health benefits

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