Community Nutrition.pdf community health nursing 2

Community Nutrition
Gladys Seroney Mooka
Department of Community Health
School of Nursing
Maseno University

• Nutrition;
– Process by which food consumed by an organism
is utilized through digestion, absorption,
transport, storage, metabolism and elimination
G. MOOKA, 2021- MASENO UNIVERSITY 2

Nutrition cont….
Purpose:
– Maintain life
– Growth
– Normal functions of organs
– Production of energy

Importance of good nutrition
• Physical and mental development of children
and adolescents
• Healthy pregnancy and delivery
• Resistance to infectious diseases
• Ability of adults to work well
• Prevention of deficiencies

Malnutrition
• Means “bad” nutrition
– Under nutrition – inadequate food
– Over nutrition – excess of fats, sugars and refined
foods

Basic Nutrition
• Classification of foods based on nutritional
function:
– Energy foods
– Body building foods
– Protective foods
• Balanced diet; diet that has all nutrients required
by the body in the right amounts
• Balanced diversified diet; food taken on daily
basis for too long may deny the body nutrients
available in a different variety of food in the same
food group

Constituents of a diet
Group Function
Carbohydrates Energy
Fats Energy and essential fatty acids
Proteins Growth and repair
Minerals Developing tissues and metabolic
processes
Vitamins Metabolic processes
Water Provide body fluid / regulate temp
Spices and flavorings Enhance taste
Roughage Transport other nutrients, add bulk
to diet, provide habitat for normal
flora and assist in elimination

Quantity proportions of food groups

Energy requirements
• Energy is required for normal body functions
• Amount of energy required varies from one individual to
another and from day to day
• Energy is derived from food through a process called
metabolism
• Amount of energy obtained from metabolism of food is
measured in calories
• Energy needed for essential body functions is known as Basal
Metabolic Rate (BMR)
• There is a relationship between amount of food eaten, energy
spent and body weight: Food eaten – energy spent = body
weight

Nutrients
Carbohydrates
– Main source of energy in African diets
– Contains carbon, hydrogen and oxygen
– One gram of carbohydrate gives 4 Cals of energy
– Classified into monosaccharide, disaccharides and
polysaccharides
– Inadequate intake caused marasmus in children

Nutrients cont….
Fats
– Rich source of energy in the diet
– Made up of carbon, hydrogen and oxygen
– One gram yields 9 Cals of energy – energy dense food
– Digestion results in glycerol and fatty acids
– Fatty acids classified into saturated and unsaturated
– Animal fat contains more saturated fatty acids which
cause degenerative diseases of the heart and blood
vessels

Nutrients cont…
Proteins
– Needed for growth and repair of tissues
– Made up of 26 different amino acids
– Made up of carbon, hydrogen, oxygen (nitrogen, sulphur)
– Essential amino acids cannot be manufactured by the body
hence derived from the diet.
– Main source of protein depends on staple food of the
particular cultural group
– Protein is not stored in the body
– Protein deficiency is often or nearly always associated with
energy- deficient diets
– Deficiency results in Kwashiokor in children

Vitamins
Vitamin A
– Fat soluble vitamin
– Retinol; animal origin only
– Carotene; plant origin, is an inactive form. This is
poorly absorbed in the intestines and has to be
converted to the active form
– Deficiency results in nyctalopia (night blindness),
exophthalmia/ kerotomalacia (dryness of the eye),
follicular keratosis (dryness of the skin and hair)

Vitamin A cont…
• Vitamin A is stored in the liver
• Supplementation is incorporated in child
immunization; 100,000 IU at six months, then 200,
000 IU every six months up to 5 years

Minerals
Iron
– Necessary for formation of haemoglobin and myoglobin
– Iron-deficiency anemia is the most common nutritional
deficiency world wide
Potassium
– Necessary in muscle building, organ/tissue repair,
carbohydrate metabolism and protein synthesis
– Deficiency causes fatigue, muscle cramps, and irregular
heart functions

Minerals cont…
Calcium
– Necessary for formation of bones and teeth, and metabolic
processes
– Pregnant women and growing children need extra calcium
– Deficiency results in tetany, osteoporosis, osteomalacia
and rickets
Phosphorous
– Component of bones, teeth and enzymes in the body
– Important in metabolism of food and formation of cell
membrane and enzymes
– Deficiency results in weak, fragile bones, fatigue, loss of
appetite, less energy and susceptibility to infections

Community Nutrition
• Refers to an approach that provides long term solutions,
promotes stability and supplies communities with
sustainable methods to reduce malnutrition
• Often referred to as food security
• Fight against global and local hunger must involve
community centered approach

Community nutrition cont…
• Individual causes of malnutrition within the community must
be identified and dealt with;
– Chronic and seasonal food shortages
– Diet diversity
– Inadequate feeding practices
• In community centered approach, the community answers
these questions with help of trained individuals and develop
long term solutions to nutritional problems

Community nutrition cont..
• Characteristics of sustainable nutritional programmes
– Low cost
– Protect community resources
– Function with minimal external input
• This approach provides better ability to adjust to
unexpected changes , because they are rooted in the
knowledge of the community

Causes of Malnutrition
Direct causes
• Also known as immediate causes of malnutrition
• Result from deficient intake of a particular nutrient
• Activity: Identify disorders caused by deficiency in
particular nutrients

Indirect causes of malnutrition
1. Infection and disease
• Undernourished children are prone to infections,
recover from illness more slowly and frequently die
from infections
• Infections interfere with intake and absorption of
food, resulting in malnutrition
• Infections also increase nutrient demands, hence a
child with poor reserves is easily tipped into a state
of malnutrition

Indirect causes of malnutrition
2. Ignorance about nutrition
• Knowledge of quality and quantity of food
• Lack of knowledge on frequency of meals in the course of
the day
3. Seasonal changes and lack of food production
• Food shortages occur in particular seasons
• Worst seasonal food shortages usually occur a few weeks
before next crop is ready for harvest: referred to as the
“hungry period”

Indirect causes of malnutrition cont…
4. Unequal distribution of food
• Maybe within the family, region or the whole country
• In the country- low production of food in some areas, poor
infrastructure, lack of storage and preservation facilities
and poverty increase incidence of malnutrition in some
parts of the country
5. Customs and beliefs affecting nutrition

Factors promoting good nutrition
1. Good agriculture
2. Good economy
3. Healthy environment
4. Good education
5. Healthy social / family life
6. Prevention and control of diseases

Nutritional Assessment
• Refers to assessing nutritional status of an individual.
Purpose :
• Identify individuals or population groups at risk of becoming
malnourished
• Identify individuals or population groups who are malnourished
• To develop health care programs that meet the community needs
which are defined by the assessment
• To measure the effectiveness of the nutritional programs &
intervention once initiated

Methods of Nutritional Assessment
• Nutrition is assessed by two types of methods; direct and
indirect.
– Direct methods deal with the individual and measure
objective criteria
– Indirect methods use community health indices that
reflects nutritional influences.

Direct Methods of Nutritional Assessment
These are summarized as ABCD
• Anthropometric methods
• Biochemical, laboratory methods
• Clinical methods
• Dietary evaluation methods

Anthropometric Methods
• Anthropometry is the measurement of body height, weight &
proportions.
• It is an essential component of clinical examination of infants,
children & pregnant women.
• The building blocks or measures used to undertake
anthropometric assessments are
– Age
– Sex
– Height or Length
– Weight.
• Each of these variables provides one piece of information
about a person.
• When they are used together they can provide important
information about a person’s nutritional status.

Anthropometric measurements cont…
• When two of these variables are used together they
are called Index (Indices).
• Anthropometric indices
– Weight for age
– Weight for height/length
– Height/length for age
– Mid Upper Arm Circumference

Anthropometry cont….
Weight
• Most important measurement
• Useful when age of child is known
• Weight is recorded on road to health chart
• 80 % – 100% of standard are normal
• 60% - 79% of standard are underweight (Mild PEM): Child
at high risk of malnutrition
• Below 60% of the standard; clinical malnutrition, needs
hospital admission
• Best information is obtained from series of weights that
will show whether child is gaining, not gaining or losing
weight over a period of time

Height
• Height remains stationary when a child becomes
malnourished
• Height for age may be used to detect chronic malnutrition
(stunting) in children
• Weight for height is useful when age is not known, helpful in
detecting acute malnutrition(wasting / thinning)
• Useful in nutrition surveys to detect deficiencies, using the
appropriate charts

Mid Upper Arm circumference (MUAC)
Used when;
• A child is over 6 months and under five years
• Used when weighing scales / graphs are not available
• As a screening method in out patient work
• In community nutrition surveys
Method:
• Circumference of upper arm is measured half way between the
shoulder and elbow.
• With the left arm bent, find the midpoint of the arm between
the shoulder and the tip of the elbow.
• A flexible measuring tape is wrapped around the mid-upper arm
(between the shoulder and elbow).

Measuring MUAC
• MUAC should then be
measured on the left upper arm
while the arm is hanging down
the side of the body and
relaxed.
• Healthy children should have
MUAC of over 12.5 (green)
• Any child over 1 yr with MUAC
between 11.5 and 12.5 (Yellow)
is considered moderately
malnourished and at high risk

Other Anthropometric Measurements
• Skin fold thickness
• Head circumference
• Head/chest ratio
• Hip/waist ratio
• BMI

Advantages of Anthropometry
• Objective with high specificity & sensitivity
• Measures many variables of nutritional significance (Ht, Wt, MAC,
HC, skin fold thickness, waist & hip ratio & BMI).
• Readings are numerical & gradable on standard growth charts
• Readings are reproducible.
• Non-expensive & need minimal training

Limitations of Anthropometry
• Inter-observers errors in measurement
• Limited nutritional diagnosis
• Problems with reference standards, i.e. local versus
international standards.
• Arbitrary statistical cut-off levels for what considered as
abnormal values.

Laboratory tests
• Useful in hospital in-patients
• Expensive, need skilled personnel and are time consuming,
therefore not often done in surveys
• Includes:
– Hb estimations
– Blood counts
– Serum protein levels
– Urine creatinine estimations
– X- ray for rickets

Advantages of Biochemical Method
• It is useful in detecting early changes in body metabolism &
nutrition before the appearance of overt clinical signs.
• It is precise, accurate and reproducible.
• Useful to validate data obtained from dietary methods e.g.
comparing salt intake with 24-hour urinary excretion.

Limitations of Biochemical Method
• Time consuming
• Expensive
• They cannot be applied on large scale
• Needs trained personnel & facilities

Clinical Examination
• It is the simplest and most practical method of ascertaining
the nutritional status of a group of individuals
• It utilizes a number of physical signs, (specific & non specific),
that are known to be associated with malnutrition and
deficiency of vitamins & micronutrients.
• General clinical examination, with special attention to organs
like hair, angles of the mouth, gums, nails, skin, eyes, tongue,
muscles, bones, & thyroid gland.

Clinical examination
Clinical signs of malnutrition
• Edema of both feet
• Visible severe wasting
• Signs of dehydration
• Shock – cold feet and hands, delayed capillary refill
• Dry conjunctiva, bitot’s spot , corneal ulceration
• Mouth ulcers
• Skin changes; hypo/hyper pigmentation, desquamation,
ulceration, exudative lesions

Clinical Assessment
• Advantages
– Fast & Easy to perform
– Inexpensive
– Non-invasive
• Limitations
– Did not detect early cases

Dietary Assessment
• Nutritional intake of humans is assessed by five different
methods:
– 24 hours dietary recall
– Food frequency questionnaire
– Dietary history since early life
– Food dairy technique
– Observed food consumption

Dietary Assessment
24-hr recall
• By means of an interview, the respondent enumerates the
foods and beverages consumed in the last 24-hours.
• Usually quantities are also recorded.
• Gives a fair representation of the average consumption of a
population group.
Dietary records
• The respondent records the foods/ beverages consumed, at
the time of consumption.
• Estimation of quantities using household utensils
• Record of 3 days

Data on food intake cont….
Food frequency questionnaire
• Ask the subject on his/her usual frequency of consumption of
foods listed in a questionnaire for specific periods (past days,
weeks, and month’s year).
• May be combined with estimation of quantities or nutrient
intake.
• Nutrient intake estimated with food composition tables.
Diet history
• Normally combine the three methods (24-hr recall, to
determine the usual meal pattern, food frequency
questionnaire and 3 day dietary record).
• Diet history is comprehensive in its approach and helps in
increasing the validity of food consumption survey.

Data on food intake cont…
Food balance sheets (FBS): Population level
• The FBS are constructed by FAO using the information
provided by each Country.
• They show the average quantities of food commodities
available for human consumption at national level over a
given period of time.
• Main use: determine whether Countries are facing difficulties
in covering their national food and nutritional needs.

Data on food cont…
Household Budget Surveys
• Tool for estimation of food availability at the household level.
• HBS are normally multipurpose surveys.
• HBS collect data on food availability within a nationally
representative sample of households.
• HBS collect data considering household purchases together
with the contribution from own production.
• The HBS can provide a more detailed description of the
dietary choices of the population as well as of population sub-
groups.

Indirect Methods of Nutritional
Assessment
These include three categories:
• Ecological variables including crop production
• Economic factors e.g. per capita income, population density &
social habits
• Vital health statistics particularly infant & under 5 mortality &
fertility index

Community Nutrition Assessment
• Epidemiological survey on distribution and causes of
nutritional problems
Aim
• To determine extent of under – nutrition in the community
• Assess influence of socio- economic, agricultural and
climatic factors on the nutritional status of the community
• To gain sufficient information to plan a sound nutrition
program within the community

Community nutrition assessment
Direct methods
• The direct methods can be used for individuals and for groups
• The results are often age dependent and are compared with
standard reference values ( international / national) from the
group to which the individual belongs.

Indirect methods
• Health statistics
– Age dependent death rates (e.g. infant mortality rate)
– Data on morbidity and mortality in function of the causes
(e.g. % children died of malnutrition).
– Statistics on health care (% children who are vaccinated)
– Frequency data on the occurrence of infections in relation to
nutrition (diarrhea, Tuberculosis, measles)

Indirect methods cont…
• Socio- economic factors
– Socio-economical factors (education, housing, electricity,
clothing)
– Health aspects (availability of water, latrine, garbage
collection)
– Demographical data (family size, birth spread, growth of
the population)
– Political factors
– Cultural influences (religion, age, gender, illness and
taboos)
– Geographical and climate information (rainfall, drought,
temperature)

Indirect methods cont….
• Ecological variable (relation to food)
– Food availability (accessibility-transport, intra- familiar
distribution, financial, technical)
– Food preparation methods
– Food consumption (intake, adequacy, utilization)

Nutritional intervention
• What is observed, as malnutrition is not only the result of
insufficient or inappropriate food, but also a consequence of
other conditions
• Thus planning for an intervention is complex, because many
issues need to be addressed simultaneously
• Planning should be formative and involve the participation of
the community

Nutritional intervention
1. Problem assessment
• Prior to intervention, one needs to gain insight into the
causes of the problem.
• This will clarify which information need to be gathered.
• It will also allow for the selection of problems by setting
priorities and relevance

Nutritional intervention cont..
2. Identification and selection of intervention
• Identification of the most appropriate action to solve
problem
• Formulate and prioritize broad objectives of the intervention
• Identify what has been done in the past
• Discuss and select relevant intervention
• Identify the most relevant intervention

Nutritional Intervention cont…
3. Constructing a Logical framework
• Inputs, procedures, outputs and outcomes of the intervention
are identified.
• These help to formulate the objectives of intervention,
estimation of resources needed, time frame and monitoring
and evaluation systems.
• All these should contribute to the long-term objectives
(outcomes) of the project - improvement of nutritional status
of the target population.

Nutritional intervention cont…
• Inputs : elements that are going to be transformed into
outputs by the intervention.
• Processes: activities undertaken in order to transform inputs
into outputs.
• Outputs : results of activities carried out in the intervention.
They correspond to specific objectives of the intervention.

Nutritional intervention cont..
4. Monitoring & Evaluation
– Is an important management tool.
– Should begin prior to the program
– Should be done in the course of the program
– Should be done at the end of the program
– Ideally the design of the M & E system should be
in place prior to project execution

Approaches to Nutrition intervention
Supplementation
• Via capsules or liquid effectively prevents the deficiency in
individual especially during emergency or sever prevalence
rates.
• Are expensive in terms of the support
• In the case of supplementation the product may be well
accepted and easily promoted
• The difficulties lie in reliable logistics and service delivery.
• Sometime low compliance level with taking might occur
• May be combine with immunization programs.

Approaches cont…
Fortification
• Addition of nutrients/micronutrient to foods commonly
consumed.
• May be targeted or universal
• The most successful fortification method is of iodized salt.
Food-based approach.
• Promoting increased consumption of nutrient dense foods
(i.e. Vitamin A rich foods) and good nutritional practices (i.e.
promotion of optimal breast feeding)
Nutrition Education
• Nutrition education can be effective, but the program strategy
needs to be designed on the basis of audience research.
• Messages must overcome many attitudinal barriers

Approaches cont…
Food production
• For proper nutritional status is necessary to widen the food
basket by diversification.
• The role of the vast diversity of minor traditional plant foods
in meeting the nutritional needs can be addressed through
food production.
• Home, school and community food production programmes is
a long term, sustained measure to alleviate nutritional
problems.
Food to Food fortification
• Food to food fortification involves the mixing of staple foods
at household level to enrich the content

Public health measures
Immunization
• Is effective but must include strategies to promote
acceptability and coverage.
Parasite control
• Parasitic infection may exacerbate micronutrient deficiency
(malaria and iron).
• Control and prevention of malaria and hookworm infections
must be put in place.
Safe water and sanitation
• To make a real impact on reducing under-nutrition, it is
essential to reduce the huge burden of
• gastro intestinal infections

Nutritional Interventions by health
workers
• Brain storming

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