Basic Nutrition Concepts & Nutrition Indicators: Training Manual For Project Management Unit Members

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Basic nutrition concepts & nutrition indicators: Training manual for project
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THE REPUBLIC OF UGANDA
Basic Nutrition Concepts

&Nutrition Indicators
Training manual
For Project Management Unit Members
December 2018
By: Beatrice Ekesa, Deborah Nabuuma,

Samalie Namukose and George Upenytho.
This manual was prepared by Bioversity International on behalf of the
government of Uganda and IFAD
Basic Nutrition Concepts

& Nutrition Indicators
Training manual
For Project Management Unit Members
December 2018
By: Beatrice Ekesa, Deborah Nabuuma,

Samalie Namukose and George Upenytho.
Table of Contents
Nutrition situation in Uganda 5
1.0 Basic Concepts in Nutrition 8
Nutrients, functions and sources 9
2.0 Recommended feeding practices 14
The Food Pyramid 15
3.0 Malnutrition 17
3.1 Causes of malnutrition 17
3.2 Forms of malnutrition 18
3.3 Cycle of malnutrition 21
3.4 Prevention of undernutrition 21
4.0 Food safety and hygiene 23
5.0 Food and nutrition assessment 26
Dietary diversity indicators 27
Nutrition status assessment 31
6.0 Action plans for PMU members 42
4 | Training manual for Project Management Unit Members

Nutrition situation
in Uganda
A
ccording to the Uganda Demographic and Health Survey (UDHS 2016), 33% of the Ugandan
population was malnourished in 2016, 29% percent of children under 5 were stunted, 11% were
underweight, 3.6% were wasted, 11.8% had low birth weight. Prevalence of anemia among
women of child bearing age was at 31.8%. The current levels of malnutrition in Uganda are unacceptable.
In Acholi region, 31% of children below 5 years of age are stunted, 4% are wasted and 15% are under
weight. In Central region, 19% of children under 5 years are stunted, 4% are wasted and 7% are
underweight. Therefore, nutrition warrants greater investment and commitment for Uganda to realize its
full development potential.
Among the main contributors of malnutrition is the low awareness of the available options and in some
instances - the poverty levels within certain regions that limits households from accessing enough food
or providing the appropriate health care.
It is upon this background that the Government of Uganda with the support from the International
Fund for Agricultural Development funded two projects in Kalangala region and northern Uganda. The
objectives of the projects were to improve households’ income by increasing productivity of farmers
through adoption of commercial farming.
The VODPII project in Kalangala was to achieve its objective through promoting commercial production
of oil palm thus increasing household incomes. In northern Uganda, PRELNOR aimed at increasing
production of food crops especially maize, beans, cassava and rice so that farmers have excess surplus
to sell.
VODPII
In 2003 the Government of Uganda, International Fund for Agricultural Development (IFAD), BIDCO
and individual farmers in Kalangala under Kalangala Oil Palm Growers Trust (KOPGT) teamed up to
establish an oil palm project with expertise from Malaysia, the pilot was rolled out on Bugala Island with
plans to expand the project to other neighbouring islands in the district.
The project was designed to improve the livelihood of the people of Uganda and Kalangala in particular,
more so on the nutrition status of the poor and reduction on the national cost burden of importation of
vegetable oils.
PRELNOR
Although only 20% of the Uganda population lives in Northern Uganda, it accounts for 38% of the
poor in Uganda with 26% of all the chronically poor living in the area. IFAD included Northern Uganda,
particularly the Acholi region, as a high priority in the IFAD project pipeline.
Most farmers returning from the IDP camps rely on the natural fertility of the soils, with minimal or
no inputs leading to low yields and productivity. The sub-region has excellent potential for agricultural
development, which is needed for lifting the rural poor out of poverty.
The PRELNOR project aims to achieve increased incomes through; adoption of improved farming
practices, improving market processes and structures and providing climate specific information to
Training manual for Project Management Unit Members | 5

enable improved farming.
This Guide is therefore designed for use by field level staff. The guide gives details that are aimed at
enabling the field service providers within PRELNOR and VODP II projects to gain an understanding major
concepts in nutrition, identifying nutrition needs for different categories of people, identifying different
forms of malnutrition, their causes, consequences, management and preventive strategies. Nutrition
indicators and their measurement and monitoring methods are also included. Finally, information on
food safety and hygiene is also given. The target trainees include: field level staff (Community based
facilitators, Household Mentors and Unit leaders) following the trainings, the field extension service
providers will have gained knowledge and skills that can be transferred to communities and household
members in projects’ target regions.
Outcome
This training guide is intended to build capacity of Project management Team to transfer knowledge
on basic concepts regarding appropriate dietary patterns and use of existing farming systems for better
household nutrition. In referring to this manual, the Project management team will be able to transfer the
information gained to community level field extension workers. The expected impact is that enhanced
knowledge of the links between agriculture, nutrition and health, formation and/or upgrading of existing
home gardens into comprehensive gardens as well as proper dietary and health practices will eventually
lead to enhanced nutrition and health status.
Outputs
Number of Project Management Unit members trained and able to train their field extension workers.
This will be measured on number of households reached with the intervention, Number of households
trained by extension field workers that can implement the recommended practices.
Users of the Guide

This guide it to be used in creating awareness of the field extension workers with regards to nutrition to
enable mainstreaming of nutrition into PRELNOR & VODP II projects. It will be used for training Project
management Team.
Overview of the Training Guide

The guide has 6 Main sections:
1. Basic Concepts in Nutrition
2. Recommended Feeding practices
3. Malnutrition, its forms and causes
4. Food and nutrition assessment
5. Food safety and hygiene
6. Nutrition assessment and related nutrition indicators
Each section includes a time allocation, a pre-test, an overview of the learning objectives, materials
needed, notes and facilitator fact sheets pertaining to the section. Also contained is an activity that
generates discussion and helps in recapping information while focusing on the key learning objectives.

Training Program
Time Topic/Activity Details of topic/Activity Facilitator

8:00 - 8 :15 am Introduction Name, program/project
(15 minutes) involved in, role, expectations
8:15 - 8:30 am Objective of the training Training objectives
8:30 - 9:00 am Pre-training evaluation Assessing the entry behaviour
of participants
9:00 - 9:15 am Overview of nutrition Over view of nutrition situation
in Uganda and in the project
area
9:16 - 9:45 am (30 Basic Concepts in Nutrition - Definition of food
minutes) - Definition of nutrition
- Difference between FS & NS
- Nutrients, Macro and micro
nutrients
- Food groups
9:46 - 10:45 am (1hr) Recommended feeding Basic food groups basing
practices on function in body (Energy,
building, protective)
- Standard food groups,
function, sources
15 minutes TEA BREAK
11:00 - 12:00 (1hr) Recommended feeding - Definition of a balanced diet
practices - Components of a balanced
diet
- Food pyramid
- Important nutrition points to
remember
12:00 - 1:00 pm (1hr) Malnutrition -Stunting, Underweight, wast-
ing, Thinness (low BMI)
Micronutrient deficiencies
Food safety and hygiene -Basic concepts in food safety
and hygiene
LUNCH BREAK
2.00 - 4.00 pm Food and nutrition assess- Food intake assessment
(2hrs) ment and related indicators House hold food security
indicators
Anthropometry. Clinical signs of
malnutrition.
Management, referral
15 minutes Tea Break
4:15 - 4:30 pm Re-cap Key messages from the
(15 minutes) sessions
4:30 - 4.50 pm Way forward How they will mainstream
(20 minutes) nutrition into the PRELNOR and
VODP II frame work
4:50 - 5:00pm Closure

1.0 Basic Concepts in Nutrition
Time: 60 minutes
Method: Question / answer
Materials needed: Flip chart, Flip chart board, Marker pens, Block notes
Activity: (using a flip chart, ask at least three participants their

understanding of the concepts below,
Learning Objectives
What is good nutrition?
What are some of the common nutrient groups?
At the beginning of the session
What are some local food sources of the common nutrient groups?
the facilitator is expected to
understand the entry level What is the function or use of these nutrient groups?
knowledge of participants
regarding the session content. (Facilitator asks at least three participants to describe their
understanding of nutrition)
At the end of this session
participants are expected to: After the participants provide the responses the facilitator
moves forward to provide the right definition and details as
Briefly describe what good provided in the session technical notes and ensuring there
nutrition is. is great participation and discussion during the process and
welcoming questions and making clarifications.
List at least six nutrients found in
foods and their function.
Session technical notes
List at least five local sources of Nutrition is all about the study of food and how our bodies use it
carbohydrates, proteins, vitamins as fuel for growth, reproduction and maintenance of health.
and minerals.
Nutrition comprises the process of providing the nutrients needed

for health, growth, development and survival.
Food is any substance (solid, semi-solid, or liquid) taken into the

body to provide one or more nutrients.
Good nutrition is important for:

Physical activity, movement, work, and warmth.
Physical growth and brain development essential for learning,
so good nutrition is especially important for children.
Body building, replacement and repair of cells and tissues.
Protection from illnesses, fighting infections and recovery
from illnesses.
For good health to be maintained, a daily diet of foods must
accomplish the above four functions.
The things in food that help us accomplish one or more of the
four functions are called nutrients.

Types of nutrients Nutrients, functions and sources
Facilitator asks the participants to mention the
types of nutrients they know of and examples of Time: 40 Minutes
food items available in their community that are
rich in each of the nutrients listed, let participants 1. Carbohydrates
mention as many types as they can. After the
Carbohydrates provide your body with the fuel it
participants provide the responses the facilitator
needs to keep running. Depending on how quickly
moves forward to provide the right information
they convert to sugar in the body, they can be simple
and details as provided in the session technical
or complex, carbohydrates are mainly in form of
notes and ensuring there is great participation and
starches, sugars or fiber.
discussion during the process and welcoming
questions and making clarifications. Starch and sugars provide energy needed to keep the
body breathing and alive, for movement and warmth,
and for growth and repair of tissues. Some starch and
sugar is changed to body fat as storage of energy.
The fiber in carbohydrates makes faeces soft and
1. Macro (big) nutrients bulky and absorbs harmful chemicals, and so helps to
These are nutrients needed in large amounts. They keep the gut healthy. It slows digestion and absorption
include: of nutrients in meals, and helps to prevent obesity.
Carbohydrates (starches, sugars and dietary fire).
Fats Sources of carbohydrates
Proteins Main sources of carbohydrates are:
Water.
Cereals Starchy roots and tubers
2. Micro (small) nutrients Maize/ maize flour Sweet potato

These are needed in small amounts. There are many Millet Yam / Taro
of these but the ones most likely to be lacking in the Sorghum Irish potato
diet are: Rice Fresh cassava, Cassava flour
Minerals – iron, iodine, zinc and calcium. Wheat flour Plantain, / banana
Vitamins – vitamin A, B-group vitamins, folate and
vitamin C. Figure 1. Examples of carbohydrates.
Whether or not a food is a good source of a nutrient

depends on:
The amount of nutrient in the food. Foods that
contain large amounts of micronutrients compared
to their energy content are called ‘nutrient-rich’
(or sometimes ‘nutrient-dense’) foods. They are
preferred because they help ensure that the diet
provides all nutrients needed. The Appendix lists
foods that supply useful amounts of different
nutrients.
The amount of the food that is eaten usually.
How readily available the nutrient in the food is for
absorption and use by the body.

Requirements Fats provide most of the energy to fuel muscular
Requirements vary by age, gender, activity, health work.
status. It is recommended that a person should eat Fat pads internal organs and insulates our bodies
carbohydrate rich foods 3 or more times a day. against temperature extremes and damage.
Fats form the major material of cell membranes
Insufficient intake of carbohydrates results into failure (especially brain and nerve cells).
to meet body energy requirements hence the rate
of growth is reduced as well as body mass (weight) Fats are converted to many important hormones
leading to lack of sufficient energy for metabolism (including sex hormones).
and work. Fat is a good thing! It’s only when there is too much
of a good thing that it can become problematic.
Excessive consumption of carbohydrates beyond
what the body requires leads to being overweight Requirements
hence increases the risk of ailments like heart disease
Fat needs are expressed as ‘percent of total energy
and diabetes.
needs’. The percent of total energy that should come
from fat in a healthy balanced diet is:
2. Fats and oils
30-40 percent for children on complementary
The fats and oils in foods serve many important feeding and up to the age of two years;
functions such as;
15-30 percent for older children and most adults;
Nutrient: Fat supplies essential fatty acids, for active adults up to 35 percent is acceptable;
which are needed for normal growth of infants
and children and for production of hormone-like At least 20 percent up to 30 percent for women of
compounds that regulate a wide range of body reproductive age (15-45 years).
functions and keep you healthy. Consuming more fats beyond what the body needs
Transport: Fat carries fat-soluble vitamins (A, D, leads to overweight, and increases the risk of
E, and K) and assists in their absorption. diseases like heart diseases, high blood pressure
and diabetes.
Sensory: Fat contributes to the smell and taste
of food.
Texture: Fat helps make foods tender (especially 3. Proteins
meats and baked goods). Proteins are the building blocks for muscles, organs
Satiety: Fat gives food satiety, so you feel full and many of the substances that make up our
and satisfied longer after a meal. bodies. They provide essential amino acids that
the body uses to make muscle tissue. The body
Energy: Fat provides a concentrated source of needs proteins and calories every day. Proteins also
calories. This is good if you are travelling long facilitate the production of enzymes that govern the
distances, expending a lot of energy, and carrying body’s processes such as growth and digestion.
your own food.
When you don’t get enough of calories and protein
In the body, fat has the following roles: everyday, your body breaks up its own supplies to
Fats are the body’s main form of stored energy make up for the lack of energy. This robs your body of
(important in times of illness and diminished food the calories it needs to stay healthy leading to weight
intake). loss.

Sources of Proteins Figure 2. Example sources of animal protein.
Protein can be found in both animal and

plant foods.
1. Animal sources
• Meats, poultry, fish, eggs, cheese, milk
and yogurt.
• These foods are considered “complete”
or “high quality” proteins because they
contain all the “essential” amino acids.
“Essential” means that they must be
consumed in our diet; our bodies cannot
manufacture them.
• Edible insects: Grasshoppers, termites,
white ants, crickets, caterpillars
Figure 3. Example sources of plant protein.
2. Plant sources
• Soy products (tofu, tempeh, soy milk,

and other products made from soy),
beans, peas, seeds, and nuts.
• There are also small amounts of

protein in breads, cereals, and other
grains, as well as in vegetables.
• Plant sources of protein are considered

“incomplete” because they are missing
one or more essential amino acids.
• Soy protein is the one exception--it is

considered “complete.”

Requirements riboflavin, niacin, vitamin B6, folic acid, vitamin
Requirements vary by age, sex, gender and activity B12 pantothenic acid, and biotin; and vitamins C,
(see appendix 1) but the general requirement is D, E, and K.
approximately 0.75 g per kg of body weight per day. Minerals are needed for growth and maintenance
Not consuming enough protein leads to reduced of body structures. They also help to maintain
growth rate, loss of muscle and build-up of fluid in the digestive juices and the fluids found in and
body as the body breaks down the muscles to obtain around cells.
the protein and energy needed for daily functions. In
Minerals are not made by plants and animals.
children it also leads to retarded growth and protein-
Plants get minerals from water or soil, and
energy malnutrition.
animals get minerals by eating plants or plant-
eating animals.
It should also be noted that consumption of
Vitamins and Minerals are also known as
high amounts of animal protein sources that are
constructive and protective foods; they help
accompanied with a lot of fat like meats, milk and
to build the immune system thus reducing the
eggs leads to excess consumption of fat which has
occurrence of infections and if they occur the
negative effects.
severity is reduced.
Micronutrients that are in shortest supply and
4. Vitamins and Minerals
cause the most micro-nutrient malnutrition
Vitamins include both Fat-soluble (vitamins A, D, E, worldwide are: Iodine, zinc, vitamin A, iron and
and K) and water-soluble (B-group and C vitamins). folate. Lack of vitamin A leads to night blindness,
Vitamins help the body turn food into energy and lack of iron/folate leads to anaemia, lack of
tissues. iodine leads to goitre, lack of calcium leads to
weak bones and teeth and lack of zinc leads to
There are 13 vitamins in all: vitamin A; the
growth retardation and delayed sexual and bone
vitamin B complex, which includes thiamine,
maturation.
Sources Figure 4. Example sources of vitamins and minerals.
• Orange vegetables, such as orange

sweet potato and carrots, and orange
fruits, such as mango and pawpaw
and red palm oil are excellent sources
of vitamin A.
• Red meat, red offal and liver of all
types are a very rich source of iron
and vitamin A.
• Most citric fruits and fresh (not
overcooked) vegetables provide
vitamin C.
• Dark green vegetables supply folate
and some vitamin A.
• Many vegetables (e.g., tomatoes,
onions) provide additional important
micronutrients that may protect
against some chronic conditions such
as heart disease.

Requirements (Think of the use of water when building a house,
Vitamins and minerals are required in small quantities. without the water, the cement, sand and concrete will
not be useful.)
Requirements are based on age, sex and activity
level but consumption of a variety of fruits,
vegetables and whole grains. Sources
The best way to make sure we get enough of Water;

each micronutrient and enough fibre is to eat a Fruit Juices;
variety of vegetables and fruits and whole grains
every day. Soup;
Milk;
5. Water Porridge;
Water just may be the most important nutrient. In fact,
Non-caffeinated drinks (caffeinated and alcohol
the body is more than half water. You can live without
beverages contain diuretic substances that cause
food for several weeks, but you can go less than a
the body to lose water).
week without water.
The body needs water to function. It is necessary for
Requirements
Maintaining body temperature;
1.5 liters/day or 8 glasses a day
Transporting nutrients throughout the body; Not drinking enough water leads to constipation,
Keeping joints moist; dehydration, dry skin, and build-up of toxins in the
body.
Digesting food;
Ridding the body of waste products.

2.0 Recommended feeding practices
Time: 60 minutes
Materials needed: Flip chart board, Flip chart, Marker pens, Block notes
Activity: (using a flip chart, the facilitator asks at least three

participants their understanding of the concepts below,
Learning Objectives
1. What is a balanced diet/meal?
2. Do the different family members (age group and condition) have
At the beginning of the session the same food needs?
understand the entry level After the participants provide the responses the facilitator
knowledge and behavior of moves forward to provide the right definition and details as
participants regarding the session provided in the session technical notes and ensuring there
content. is great participation and discussion during the process and
welcoming questions and making clarifications.
participants are expected to:
Know how to plan for a balanced Balanced meal
meal
A balanced diet provides the correct amounts of food energy and
Understand the food pyramid nutrients needed during the day to cover the dietary requirements of
concept when planning and the person eating it. A balanced diet must be composed of a variety
serving meals of different foods from different food groups so that it contains all
the many macronutrients and micronutrients the person needs in
Briefly describe the main sufficient quantities.
differences between the food
needs for the different family A good meal should contain:
members A staple food. Look at the list of carbohydrate foods made
in the previous session and see if it contains the local staple
foods. Add them if necessary.
Other foods that may be made into a sauce, stew or relish.
These should include:
• Legumes and/or foods from animals
• At least one vegetable
• Some fat or oil (but not too much) to increase the energy
and improve taste and facilitate absorption of some
nutrients like fat-soluble vitamins. Most of the fat or oil
should be from foods containing unsaturated fatty acids
(See sources of fats listed in the previous session).
It is good to eat fruits with a meal (or as a snack) and to drink
plenty of water during the day. Avoid drinking tea or coffee until
1-2 hours after a meal (when food will have left the stomach)
as these reduce the absorption of iron from food.

Encourage families to use: groundnuts, soybeans, melon seeds, sesame
seeds, eggs, fried fish, bread, boiled/roasted
Several groups of foods at each meal.
maize cob, boiled or roasted cassava, plantain,
Different vegetables and fruits at different meals yam, sweet potato, bananas, avocado, tomatoes,
because different vegetables and fruits contain mangoes, oranges, pawpaw, passion fruits.
varying amounts of the different micro-nutrients.
Eating snacks like these is a good way of improving
The more colors consumed the better.
a diet which may lack food energy and nutrients.
Serve meat, poultry, and offal or fish daily if However, frequent eating (snacking) throughout the
possible because these foods are the best day increases the risk of tooth decay, particularly
sources of iron and zinc (which are often lacking where oral hygiene is poor. This is particularly true for
in diets, especially the diets of young children and artificially sweetened snacks that stick to the teeth. It is
women). better to eat the fruit than make juice as many people
discard the fiber in the fruits when making juice.
Snacks
The Food Pyramid
Snacks are foods eaten between meals.
Although your food intake varies from meal to meal
Below are examples of foods that make good
and from day to day, keeping a balanced view of your
snacks
diet is a good idea. The food pyramid (see figure 5) is
Fresh milk, soured milk, yoghurt, cheese, roasted meant to be a guideline not rigid set of rules.
Figure 5. The food pyramid.
Fats, Oils and Sweets +Calcium, Vitamin D

(use spairingly) Vitamin B - 12
Supplements
Milk, Youghut and Meat, Poultry, fish, Dry

cheese group (1 glass beans and nuts group
of milk / 1 medium (2 boiled eggs/cooked fish,
cup youghut) meat or chicken / 2 cupped
palms of cooked beans)
Vegetables group Fruits group

The servings for the (2 medium bananas /
day are equivalent 2 medium pieces of
to (Approximately 2 pawpaw, mango)
cupped palms cooked
leafy vegetables)
Cereals and grains (6 slices of bread / 2 cupped palms Cooked Ugali, Matoke, Boiled
banana / 3 cupped palms cooked Rice / 3 medium pieces of Cassava or Sweetpotatoes)
Water - (2 litres / 6-8 glasses of fluid per day) This includes the water, juices or soup taken
(Source: Modified from the Food Guide Pyramid; Centre for Nutrition Policy and Promotion CNPP, 2009)

It is healthy to eat more of the foods from the bottom no single food can supply all of the nutrients that your
levels of the pyramid and fewer of those from the top. body needs on a daily basis. This can help to expand
The top of the pyramid is for foods that should be your food choices. It is best to eat foods of all colours.
consumed in small quantities because large amounts The more colours and textures in your daily meals, the
are not good for the body. better range of nutrients you’ll get. You can choose to
vary different foods in a day or aim to vary different
The Food Pyramid as a guide helps to promote
foods across a whole week.
the 3 basic rules for a healthy diet:
• Variety Balance means that you must eat the right amounts
of foods from all levels of the Food Pyramid each day.
• Balance
This way you will get all the calories and nutrients you
• Moderation need for proper growth and development.
Variety means that you must include many different Moderation means that you are careful not to eat too
foods from each level of the Food Pyramid because much of any one type of food.
Important nutrition points to remember
Good nutrition during pregnancy and appropriate

health seeking behavior are very important for both
mother and child
Pregnant women should receive ante-natal care

from health facility. They should receive iron
supplementation because of increased iron needs
during pregnancy
A pregnant or breastfeeding woman needs to eat age even as you provide other foods
enough food to supply the extra energy, protein,
vitamins and minerals needed by the growing fetus If a child is sick, encourage them to eat and
or baby during breastfeeding. Her meals must be drink, even if they have little appetite. Increase
balanced. breastfeeding frequency, provide more fluids (water,
juice, soup)
Early initiation of breastfeeding (within the first 30
minutes of delivery) whether at hospital, at home, Ensure the diet includes foods rich in protein,
or at the midwife’s, and give colostrum to the baby. vitamin A and iron to ensure the child’s growth
Colostrum protects infant from disease by providing
the infant’s first vaccine Obtain vitamin A supplementation for children under
5 years from the health centre
Exclusive breastfeeding of all children below 6
months of age. Breast milk provides all the nutrients Deworm all children every 6 months starting at 2
needed to satisfy huger and promote growth years
No other foods or drinks should be given to children Ensure that children are fully immunized and keep
below 6 months of age. This reduces infections and the health card/book safely
diarrhoea
Use iodized salt in the home for the whole family.
Children at 6 months and above should be given a Iodine promotes physical development and
balanced diet in addition to the breast milk. These prevents miscarriages
foods should not be too thin as they will not provide
enough nutrients. Have a backyard garden with different green leafy
vegetables to provide the vegetables needed by the
Continue breast feeding up to at least 2 years of family throughout the year

3.0. Malnutrition
Time: 60 minutes
Materials needed: Photos of children with different clinical signs of malnutrition
Method: Presentations and discussion
Learning Objectives Activity 1: Brainstorming, question and answer as slides are

presented.
The facilitator asks the participants to mention their understanding
At the beginning of the session of the term malnutrition. The responses on a flip chart and the then
the facilitator is expected to gives the right content as detailed in the session technical notes.
understand the entry level
knowledge of participants
regarding the session content. Session technical notes
At the end of the session, the Malnutrition is the condition that develops when the body does not
participants should be able to: get the right amount of the nutrients it needs to maintain healthy
tissues and organ function.
Identify kinds of malnutrition in
their community
Under Nutrition
Understand causes of the kinds of Under nutrition is a deficiency of food energy or nutrients, which
malnutrition in their community leads to nutrient deficiencies. It is caused by inadequate intake or
poor absorption of nutrients in the body. Acute malnutrition, chronic
Understand the consequences of malnutrition, stunting, wasting, and underweight and micronutrient
malnutrition in the community deficiencies occur because of undernutrition, and they can have
serious consequences on the development and health of infants
Share actions they can take and young children. Undernutrition is one of the leading causes of
to prevent malnutrition among mortality for young children across the globe and is often caused
children and women by an interaction between inadequate dietary intake and frequent
illness.
Over Nutrition
Over nutrition is a condition caused by abnormal or excess fat
accumulation in the body that may lead to health problems and
reduced life expectancy. Overnutrition starts as overweight and if
left uncontrolled may progress to obesity.
3.1 Causes of malnutrition

Malnutrition occurs when a person does not receive nutrients in
the required amounts (less or excess). This can be a result of
several factors and is a result of inadequate food intake and the
health status (immediate causes, which are at an individual level).
These factors in turn are affected by the individual or household’s
access to food, the care available, the availability of suitable health
services and an unhealthy environment (underlying causes). The
resources available in a household and community and how they
are used are issues that influence underlying causes of malnutrition
(see figure below).

Figure 6: showing conceptual framework of malnutrition (UNICEF, 1991)
Conceptual framework for analysing the causes of

malnutrition
Malnutrition,
Outcomes
death & disability
Immediate Inadequate
Disease
causes dietary intake
Underlying Poor water,

Inadequate
causes at Insufficient sanitation &
household / maternal & child
access to FOOD inadequate
family level CARE practices HEALTH services
Quantity and quality of actual resources - human, economic &

organisational - and the way they are controlled
Basic causes at
societal level
Potential resources: environment, technology, people
UNICEF
3.2 Forms of malnutrition

A. Chronic malnutrition
Chronic malnutrition is malnutrition caused by long-term food deprivation or illness. An example is stunting.
Stunting
This refers to a child having short height for their age. It can begin during pregnancy and through infancy (up
to 5 year of age). If not corrected before two years of the child’s age, the effects become irreversible.
Figure 7: Comparison of a
normal and stunted child
(UNICEF 2014)

Consequences of stunting include:
• Delayed motor development
• Poor cognition and educational performance
• Lost productivity and low adult wages
• Excessive weight gain later in childhood
• Increased risk of nutrition-related chronic diseases in adult life
B. Acute malnutrition
Acute malnutrition is a result of short-term lack of food deprivation or illness that results in sudden weight loss
or oedema.
i. Underweight
This refers to a child having a weight that is too low for their age. When severely underweight, the child is weak,
has poor physical stamina and a weak immune system leaving them prone to other infections and illnesses.
ii. Wasting
Wasting refers to a child having a weight that is too low for their height. It is a strong predictor of mortality of
children under 5 years.
C. Micronutrient deficiencies
i. Iron deficiency anaemia
• Iron is required for the synthesis of haemoglobin, which transports oxygen to the cells in our body. It is
required by every growing cell and therefore is essential for child growth and development. It is involved in
energy production, immunity, and regulation of the central nervous system.
• Iron deficiency may lead to iron deficiency anaemia, a condition experienced when the body is not making
enough haemoglobin.
• Signs of iron deficiency anaemia include fatigue, weakness, tiredness, loss of appetite, headaches,
shortness of breath and paleness. Pale skin (especially on palms), pale lips and paleness on the inside of
the bottom eyelid.
• Iron deficiency during early childhood can impair physical and cognitive development.
Signs of anaemia can be seen in the figure 8 below.
Figure 8: clinical signs of anemia (source-UNICEF 2014)

ii. Vitamin A deficiency
Figure below showing Bigot’s spots, whitish • Vitamin A helps keep eyes healthy, promotes vision, and
patchy triangular lesions on the side of the eye. provides protection against infection.
• Vitamin A is needed by the tissues that line our lungs,
Figure 9: Picture showing Bigot’s sport in a person gastrointestinal tract and eyes.
with vit A deficiency (source-UNICEF 2014) • Without adequate vitamin A, these tissues are
susceptible to bacterial invasion; as such, deficiency is
associated with frequent illness and severe deficiency
may result in blindness.
• Signs of vitamin A deficiency include night blindness,
Bigot’s spots and keratomalacia (in order of severity).
• This deficiency is associated with high rates of
respiratory and diarrheal infections.
iii. Iodine deficiency disorder
Figure 10: Picture showing goitre as an advanced

sign of iodine deficiency (source-UNICEF 2014)
• Iodine is essential in the proper functioning of the thyroid
gland, which helps to regulate the body’s use of energy
(metabolism).
• Iodine is essential for physical and mental growth, and it
is particularly important during foetal development.
• Goitre, a swelling of the thyroid gland, is the most
notable symptom of iodine deficiency.
• Severe maternal iodine deficiency can result in
cretinism, whereby the child is born with severe physical
and mental retardation.
• Less severe forms of iodine deficiency in young
children can cause mental deficits such as lower mental
development, lower cognitive function and reduced
ability to focus.
• Goitre is reversible whereas cretinism is irreversible.
Over nutrition using weight and height to calculate a number called

the body mass index (BMI). An adult who has a BMI
Overnutrition is an excess consumption of energy and
between 25 and 29.9 is considered over weight and
nutrients. It can lead to overweight and obesity.
an adult who has a BMI of 30-35 is considered obese
Being overweight or obese increases the likelihood of and an adult with a BMI of 40 or more, or 30 or more.
having diabetes and heart-related diseases like high
BMI is established through dividing weight in kg by
blood pressure.
height (cm) squared.
Overweight and obesity ranges are determined by

3.3 Cycle of malnutrition stunted adolescent and later a stunted woman. This
affects her health, productivity, and nutrition. Which
The consequences of malnutrition in an individual
in turn increases the chance that her children will be
can extend to later in life. In addition, the effects
born malnourished. Which continues the cycle. It is
can also affect future generations. This particularly
therefore important that interventions to address and
occurs for women, where their nutrition status affects
prevent malnutrition are taken at each stage of the life
the unborn child. A stunted girl is likely to become a
cycle.
An illustration of the cycle of malnutrition
The Cycle of Undernutrition

PREGNANT WOMEN
Inadequate food Low weight gain
and health care Increased maternal
mortality
INFANTS
ADOLESCENTS ADULT MEN AND Low birth weight High
Stunted growth WOMEN Poor health mortality rate Impaired
Decreased physical Poor productivity in the mental development
capacity work force Increased risk of adult
chronic disease
Inadequate food
CHILDREN and health care
Stunted growth
Impaired immunity Frequent infections
Inadequate food
and health care Reduced mental
capacity
Frequent infections
Copyright 2010, John Wiley & Sons, Inc.
3.4 Prevention of undernutrition • Appropriate water, sanitation and hygiene

practices
• Promotion of exclusive breastfeeding and
continued breastfeeding up to 2 years and beyond • Growth Monitoring and Promotion
• Appropriate complementary feeding practices
At the end of the session, let the facilitator ask
• Supplementation with Vitamin A and iron/folic acid
whether there are any additional questions or
• Immunization and deworming points of clarification. After all clarifications are
made (if any), the facilitator closes the session
• Promotion of maternal nutrition
and mentions the next session and its facilitator.

How to Prevent Malnutrition in Our Keep clean and hygienic
Communities • Use toilets to defecate and throw children’s faces
• Wash hands before food preparation/cooking,
Feeding young children before feeding/eating and after visiting the toilet
• All new born babies should be put on the breast • Keep compounds around the home clean, sweep
within one hour of birth all wastes, faecal matter, droppings of animals
and get rid of stagnant water
• New born babies should be fed only on breastmilk
and not given any other food/drink (like animal • Always have treated water in the home (boiled or
milks, tea, water, soup, porridge, soda, juice, etc.) chlorinated) for drinking. Drink only treated water.
until they are six months old.
• When babies are six months old, they should Seek appropriate health care
continue to be given breast milk AND also fed with
• Attend the clinics (for antenatal, immunization,
other nutritious foods 3 to 4 times daily.
supplementation, deworming, check-ups)
• The foods for young children must contain:
• Immediate treatment of fever (high temperature),
Fruits (like avocado, pawpaw, mangoes, ripe diarrhea, poor (difficult) breathing, poor eating/
bananas) breastfeeding
Vegetables (like mashed dodo/amaranth, • Seek advice on child spacing and family planning
spinach, [young] deep greeny leafs),
Pulses/legumes (like beans, peas, soy), Mitigate emergencies
• Baby porridge should be enriched with avocado, • Prepare savings to build wealth and deter
groundnuts, mukene, ripe sweet bananas, emergencies
• Mashed pumpkin or Irish-potatoes are good foods • Invest in productive assets (livestock, businesses,
for a young child. These foods can be enriched better seeds and farming inputs)
with avocado, groundnuts, mukene, soy flour, • Plant fruits (avocado, papaw, etc) and vegetables
fortified cooking oil, meats) (pumpkin, amaranth, orange fleshed sweet
• Babies should be fed on 1 or 2 snacks between potato, traditional vegetables)
meals (this can include, papaw, orange fleshed
sweet potato, ripe bananas, mangoes, tomatoes. Gender
• Have cohesion in the family to work together and
make decisions together for improved feeding,
health and wealth in the family

4.0 Food safety and hygiene
Time: 60 minutes
Materials needed: Flip chart, Flip chart, board, Marker pens, Block notes

Learning Objectives
Activity 1: Brainstorming, question and answer as slides are
presented.
At the beginning of the session
understand the entry level The facilitator asks the participants to mention their
knowledge and behavior of understanding of the terms mentioned below, writes the
participants in regard to the responses on a flip chart and then gives the right content as
session content. detailed in the session technical notes.
1. Mention any 5 practices related to good personal hygiene.
By the end of the chapter, learners
should be able to: 2. What do you understand by safe storage of food (raw) and
water?
List at least four practices
3. Name three important practices in preparing, cooking and
importance in good personal
storing food safely.
hygiene;
Practice good hygienic during food The facilitator takes 10 minutes to wrap up the session, making
preparation, cooking and storage any clarification needed. Supplement the points they share
with points from the manual if they have not been mentioned

Why foods and drinks must be safe and clean
It is important that the food we eat and the water we drink is clean
and safe. So it is essential to prepare meals in a safe, hygienic
way. If germs get into our foods and drinks, they may give us food
poisoning (resulting, for example, in diarrhea or vomiting). The
people most likely to become sick are young children and people
who are already ill, particularly people living with HIV/ AIDS.
Basic rules of hygiene aim to:

• Prevent germs from reaching foods and drinks. Many germs
come from human or animal faeces. Germs can reach food via:
Dirty hands, flies and other insects, mice and other animals
and dirty utensils
Water supplies if they are not protected from faeces.
• Prevent germs from multiplying in foods and reaching
dangerous levels. Germs breed fastest in food that is warm
and wet (e.g., Porridge), especially if it contains sugar or
animal protein, such as milk.

To help families have clean, safe foods and drinks: Preparing food
• Find out about disposal of feaces, hand washing Advise people preparing food to:
practices, the source and storage of water and
ways in which food is prepared. This helps you • Keep food preparation surfaces clean. Use clean,
identify ways in which germs may be reaching carefully washed dishes and utensils to store,
food and water, and foods in which germs may prepare, serve and eat food.
be breeding. • Prepare food on a clean table where there is less
• Suggest practical ways to improve water and food dust.
hygiene. Some of the suggestions listed below
may be relevant and useful. But remember not to • Wash vegetables and fruits with clean/safe water.
overburden families with too much advice. Peel if possible.
• Prevent raw meat, offal, poultry and fish from

touching other foods, as these animal foods often
Clean and safe water contain germs. Wash surfaces touched by these
Advise families to: raw foods with hot water and soap.
• Use safe water, such as treated pipe water, or • Cook meat, offal, poultry and fish well. Meat
water from a protected source, such as a borehole should have no red juices.
or protected well. If the water is not safe, it should
be boiled (rapidly for one minute) before it is drunk • Boil eggs so they are hard. Do not eat raw or
or used in uncooked foods (e.g., fruit juices). cracked eggs.
• Use clean, covered containers to collect and store • Boil milk unless it is from a safe source. Soured
water. milk may be safer than fresh milk.
• Use clean materials to filter your water in need

be. Hygiene around the home
• Use clean utensils to serve and drink water. Advise families to:
• Keep the surroundings of the home free from

animal faeces and other rubbish.
Buying and storing food
Advise families to: • Keep rubbish in a covered bin and empty it
regularly in appropriate places (pits, compost) so
• Buy fresh foods, such as meat or fish, on the day as not to attract flies.
they will eat them. Look for the signs of poor-
quality food. • For easy waste management separate the waste
such as plastic, glass, paper and food/plant
• Cover raw and cooked foods to protect them from remains.
insects, rodents and dust.
• Make compost for the garden with suitable
• Store fresh food (especially foods from animals) waste food, garden rubbish and animal faeces.
and cooked foods in a cool place, or a refrigerator Composting destroys germs in faeces. The
if available. compost pit should be at least partially shaded
and at least 2 feet from a structure like your house
• Keep dry foods such as flours and legumes in a or a fence. It should be at a place convenient
dry, cool place protected from insects, rodents for you to add materials, access to water and
and other pests. good drainage. In addition you should take into
consideration the direction of the wind so that the
• Avoid storing leftovers for more than a few hours
smell or odors doesn’t come to the house.
(unless in a refrigerator). Always store them
covered and reheat them thoroughly until hot and
steaming (bring liquid food to a rolling boil).

Toxins and chemicals Advise people to:
Food and water is unsafe if it contains toxins or • Follow carefully the instructions for using
dangerous chemicals. A toxin called “aflatoxin” is chemicals;
produced by a molds that grows on cereals and
legumes. Eating aflatoxin can make someone • Be strict about keeping chemicals away from
seriously ill. Moulds should be prevented from growing children;
on any food items and this can be done by drying crops
thoroughly and storing them in a dry place. People • Never put food or water into containers that have
should desist from eating moldy foods or giving them been used for chemicals;
to animals but these can be added to compost. • Wash hands after using chemicals, and wash any
Pesticides and other harmful agricultural chemicals foods (e.g., Fruit) that have been sprayed with
may get into food or water and cause poisoning if: them.
• The chemical is not used in the recommended

way; Activity
• The empty containers are used for food or water. Discuss steps that can be taken to put these
recommendations into practice.

5.0 Food and nutrition assessment
Time: 60 minutes
Materials needed: Flip chart, Flip chart, board, Marker pens, Block notes, Height board, MUAC
tapes, Weighing scale
Method: Discussion/question/answer
Learning Objectives
Dietary assessment part I
At the beginning of the session Activity:
understand the entry level The facilitator asks for a volunteer among the participants. The
knowledge of participants in participant shares what they (or their household) consumed the
regard to the session content. day before the training started. Sharing all foods eaten and drunk.
The facilitator probes for in-between meals, and details of the foods
consumed.
participants are expected to:
The facilitator then uses this example to show the participants
Describe the common dietary how to determine the dietary diversity scores whether household
assessment methods and dietary of individual i.e. Minimum dietary diversity score for women.
indicators to measure dietary The facilitator used the food groups discussed earlier and works
adequacy together with the participants to establish whether the example
sites meets the required diversity. About 2-3 other volunteers
Demonstrate ability to use with one describing how they fed their child is done to ensure
common anthropometric understanding on how to determing whether different household
equipment to take accurate members are meeting the required dietary diversity. The session’s
measurements technical notes are used to provide details on the dietary diversity
indicators and make any clarifications needed.
Use a combination of
anthropometric measurements
to determine nutritional status of Session technical notes
individuals
Food intake can be measured in terms of quantity and quality.
However, based on our communities and the capacity of service
providers available, it is difficult to capture quality. We therefore
focus on assessing quality. The quality of the diets is measured
by assessing the diversity of the diets at individual and household
level.
Assessment of dietary diversity is about consumption of a balanced

diet, one that has a variety of different foods from different food
groups one that provides the correct amounts of nutrients needed
by the body to maintain health, growth, and development.
Household dietary diversity score (HDDS)
The household dietary diversity score (HDDS) reflects the economic

ability of a household to access a variety of foods. An increase
in dietary diversity is associated with socio-economic status and
household food security.

Assessment of household dietary diversity involves After establishing the different foods consumed, the
finding out the different foods consumed by the foods are grouped into 10 food groups.
household over a period of 24 hours. This covers
only foods consumed at home and excludes foods Consumption of foods from any 5 food groups and
purchased and eaten outside the home. After above indicates meeting minimum dietary diversity.
establishing the different foods consumed, the foods Food groups are: 1. All starchy staples; 2. Beans peas;
are grouped into the respective food groups. For 3. Nuts and seeds; 4. Dairy; 5. Flesh foods (meats); 6.
measuring household dietary diversity, 12 standard Eggs; 7. Vitamin A rich dark green leafy vegetables;
food groups are used as listed below. Consumption 8. Other vitamin A rich vegetables and fruits; 9. Other
of 3 or less food groups is considered low dietary vegetables; 10. Other fruits.
diversity, consumption of between 4-5 food groups
is considered moderate dietary diversity while
consumption of more than 6 food groups is considered Children dietary diversity
high dietary diversity.
i. Minimum meal frequency (MMF)
Food groups are: Cereals; White roots & tubers, and
bananas; Fruits; Vegetables; Meat and meat products; This is a proxy for the child’s energy requirements
Eggs; Fish; Milk and milk products; Legumes, nuts and and is based on how much energy the child needs
seeds; Oils or fats; sweets and sugars; condiments, whether breast fed or not.
spices and other beverages.
Breastfed children are considered to be fed with a
minimum meal frequency if they receive solid, semi
Individual dietary diversity score (IDDS) sold or soft foods at least twice a day (6-8 months) or
at least 3 times a day (9-23 months)
Individual dietary diversity scores aim to reflect nutrient
adequacy. An increase in individual dietary diversity Non-breastfed children aged 6-23 months are
score is related to increased nutrient adequacy of the considered to be fed with a minimum meal frequency
diet. Individual scores are preferable to household if they receive solid, semi sold or soft foods at least 4
scores because they provide more specific reflection times a day
of the quality of the diet and status of nutrition.
It is measured as a proportion of breastfed and non-
When assessing individual dietary diversity, the foods breastfed children 6–23 months of age who receive
consumed by the individual over a 24-hour period are solid, semi-solid, or soft foods (but also including
established. This included all food eaten or drunk both milk feeds for non-breastfed children) the minimum
at home and away from home. After establishing the number of times or more.
different foods consumed, the foods are grouped into
the respective food groups. 12 food groups are used,
Calculation of the proportion of women with minimum
similar to those for household dietary diversity above.
dietary diversity
Consumption of 3 or less food groups is considered
low dietary diversity, consumption of between 4-5
food groups is considered moderate dietary diversity
while consumption of more than 6 food groups is Breastfed children 6-23 months of age
considered high dietary diversity. who received solid, semi-solid or soft foods the minimum number of times or more during the previous day
Breastfed children 6-23 months of age
Dietary diversity of women Non-breastfed children 6-23 months of age

who received solid, semi-solid or soft foods or milk feeds the minimum number of times or more during the previous day
Minimum Dietary Diversity Score for Women Non-breastfed children 6-23 months of age
(MDDS-W)
ii. Minimum dietary diversity (MDD)
The Minimum Dietary Diversity Score for Women is a
This indicator looks at food groups a child eats.
food group diversity indicator that has been shown to
This indicator is a measure for adequate macro and
reflect an additional key dimension of diet quality that
micronutrients and diet variety other than breastmilk.
is micronutrient adequacy. The foods consumed over
a 24-hour period are established including all food Their diet is assessed based on 8 food groups. If a child
eaten or drunk both at home and away from home. eats at least four or more food groups, it is assumed

that the child has met his/her dietary diversity. receive a minimum acceptable diet (apart from breast
milk). This indicator measures both the minimum
Food groups are: grains, roots and tubers (millet, feeding frequency and minimum dietary diversity, as
cassava, potatoes, rice, yams); eggs; legumes & nuts appropriate for various age groups. If a child meets
(beans, ground nuts, peas, Soya bean); fresh foods the minimum feeding frequency and minimum dietary
(meat, fish, poultry, organ meats); Vitamin A rich fruits diversity for their age group and breastfeeding status,
& vegetables (Carrots, mangoes, pawpaw) and other then they are considered to receive a minimum
fruits and vegetables (banana, passion fruits, jack acceptable diet. Minimum is considered as follows:
fruit, pineapple).
- 2 times for breastfed infants (6-8months
It is measured as a proportion of children 6–23 months
of age who receive foods from 4 or more food groups - 3 times for breastfed children (9-23months)
(the number of children 6-23 months who receive
foods from 4 or more food groups divided by the total - 4 times for non-breastfed children/infants
number of children aged 6-23 months). Meal is defined as any solid. Semi-solid or liquid food
Calculation of the proportion of children with minimum
given to the child alone or within a composite dish
dietary diversity
within the previous day.
Children 6-23 months of age who received foods from ≥ 4 food groups during the previous day
Children 6-23 months of age
iii. Minimum Acceptable Diets (MAD)
Proportion of children 6–23 months of age who
This composite indicator will be calculated from the following two fractions:
Breastfed children 6-23 months of age who had at least

the minimum dietary diversity and the minimum meal frequency during the previous day
Breastfed children 6-23 months of age
Non-breastfed children 6-23 months of age who received at least 2 milk feedings and had at least the minimum
dietary diversity not including milk feeds and the minimum meal frequency during the previous day
Non-breastfed children 6-23 months of age
Dietary diversity indicators all foods and beverages consumed in preceding

24 hours/previous day and records
Dietary assessment is a process of evaluating what
people eat by using one or several intake methods. 2. Dietary history which is about usual food intake
including meal patterns, common foods and food
The assessment includes asking the client about groups
eating patterns like quantity of food eaten at each
meal, food groups eaten each day. There are different 3. Direct observation where she mentioned that
methods of assessing diet which include; intakes are watched and recorded The facilitator
then explains Food consumption indicators and
1. The 24-hour recall where the facilitator mentioned how they are measured.
that you asks client/caregiver to recall and describe

Household Food Insecurity and access Scale Activity:
(HFIAs); The aspect of food insecurity measured
by HFIES is a condition by which people are unable After explaining minimum meal frequency, minimum
to access food and the severity of food insecurity dietary diversity and minimum acceptable diets for
condition is manifested by certain food related children, the facilitator presents the following children
experiences and behaviours. in different households. All children are 1 year old and
are breast fed. And below are the number of meals
HFIES can be assessed using a set of questions and number of food groups they consumed.
below
The facilitator reviews the refine points for each of
these indicators for the example as shown in the table
No. Occurrence Questions
The facilitator then asks the participants if the
1 In the past four weeks, did you worry that your minimum meal frequency, minimum dietary diversity,
household would not have enough food?
and minimum acceptable diets have been met for
2 In the past four weeks, were you or any house- each of the children. Placing an X or √ (for yes or no)
hold member not able to eat the kinds of foods
you preferred because of a lack of resources?
Table showing child dietary diversity score
3 In the past four weeks, did you or any household
exercise
member have to eat a limited variety of foods
due to a lack of resources
Minimum Minimum Minimum
4 In the past four weeks, did you or any household meal dietary acceptable diet
member have to eat some foods that you really frequency diversity
did not want to eat because of a lack of resourc-
es to obtain other types of foods? Reference 3 times a 4 food Has both
day groups minimum meal
frequency,
member have to eat a smaller meal than you
minimum dietary
felt you needed because there was not enough
diversity
food?
6 In the past four weeks, did you or any house- 1 2 (No) 4 (yes) No
hold member have to eat fewer meals in a day
because there was not enough food? 2 3 (yes) 3 (no) No
7 In the past four weeks, was there ever no food 3 4 (yes) 3 (no) No
to eat of any kind in your household because of
lack of resources to get food? 4 3 (yes) 5 (yes) Yes

member go to sleep at night hungry because
there was not enough food?
5.2 Anthropometric assessment
member go a whole day and night without eating
anything because there was not enough food?
Time: 60 Minutes

5.1 Household food security indicators and
measurement Activity:
Time: 20 minutes After nutrition indicators and after the introduction of

the section on anthropometric indicators
Materials needed: Weighing scale, Height board, Facilitator requests for 5 Participants to volunteer,
MUAC tapes and each volunteer is allocated a measurement.
Facilitators take 10 minutes teaching the volunteers
Method. Presentation and discussion how to take the respective measurements. Volunteers
take 10 minutes to practice taking the measurements.

The activity allows participants to cover the It is based on the 8 questions shown below.
anthropometric measurements, how they are
made and how the results are interpreted .The Table showing questions used to assess
measurements to be taken will include: household food insecurity
1. MUAC 1 Worry that you would not have enough food

because of a lack of food, money or other
2. Weight resources?
3. Height
2 Not able to eat healthy and nutritious food
4. Length because of a lack of food, money or other
resources?
Each group then takes 5 minutes to present how to
3 Eat a limited variety of food because of a lack of
take the measurements to the rest of the participants.
food, money or other resources?
The rest of the participants then take 15 minutes
4 Skip a meal because of a lack of food, money or
practicing the other measurements. other resources?
Following this, the facilitator takes 10 minutes 5 Eat a smaller meal than you felt you needed
explaining the growth charts and how to plot the because of a lack of food, money or other
measurements to determine the nutrition status resources?
(stunting, underweight). Participants are given the
examples below to practice how to plot and interpret 6 Have no food to eat of any kind in your household
of a lack of resources to get food?
the results. (participants are asked to give the status;
therefore the facilitator does not mention whether the 7 Were hungry but not able to eat of a lack of
sample children below are stunted, underweight or resources to get food?
normal). Note those at risk of malnutrition, moderately
malnourished, severely malnourished, and normal 8 Go a whole day without eating anything at all
because of a lack of resources to get food?
1. Stunted child: (i) a girl, 11 months old, with a
length of 66 cm. (ii) a boy, 1 year and 2 months
old, 68cm
The answers are placed on a scale of severity of food
2. Normal height for age child: (i) a girl, 1 year and 8 insecurity as shown below:
months old, 79cm. (ii) a boy, 9 months, 73.5cm Mild food insecurity Severe food insecurity
3. Underweight child: (i) a boy, 6 months, 6kg. (ii) a Uncertainty regarding

ability to obtain food
Compromising on food
quality and variety
Reducing food quantities,
skipping meals
Experiencing
hunger
girl, 1 year and 10 months, 7.4kg
4. Normal weight for age child: (i) a boy, 1 year and

3 months 8.3kg. (ii) a girl, 1 year, 9.6kg
Household hunger scale (HHS)
Session technical notes Most appropriate to use in areas of substantial

food insecurity essentially a behavioural measure,
Household food insecurity experience scale (HFIES) captures more severe behaviours. It is based on 3
main questions:
This indicator gives a measure of access to food at
the level of individuals or households. It measures • Was there ever no food to eat of any kind in your
severity of food insecurity based on people’s house because of lack of resources to get food?
responses to questions about constraints on their
ability to obtain adequate food. • Did you or any household member go to sleep
at night hungry because there was not enough
food?

• Did you or any household member go a whole Technical session notes
day and night without eating anything because
there was not enough food? Anthropometry is the measurement of the human
body’s physical dimensions. The measures are used
to establish the nutrition status of individuals and
For each of the questions one asks how often the populations.
occurrence was observed: never (0 times), rarely (1
or 2 times), sometimes (3-10 times, and often (more
than 10 times). Height / length
One can either choose to use the HFIES or the HHS 1) Height
based on the context. This measurement is taken for children two years
and above and/or for those greater than 85 cm.
The following as steps for taking accurate height
Nutrition status assessment measurements
1. Time: 60 Minutes • Set the measuring board vertically on a stable

level surface.
2. Method: Presentations and discussion and
demonstrations • Remove the child’s shoes and any head-covering.
• Place the child on the measuring board, standing

Activity: upright in the middle of the board.
The facilitator introduces the section on nutrition • The child’s heels and knees should be firmly
status assessment. The facilitator explains that pressed against the board by the assistant while
good nutrition care starts with good assessment the measurer positions the head and the cursor.
of the nutritional status. The facilitator explains The child’s head, shoulders, buttocks, knees and
various methods of assessment which include; heels should be touching the board.
anthropometry, dietary, clinical and biochemical
methods. The facilitator then gives introductory • Read and announce the measurement to the
paragraph about several methods, biochemical nearest 0.1cm.
and anthropometric and scope of this manual in
• Record and repeat the measurement to the
relation to the projects
measurer to make sure it has been correctly
Participants form 2 groups, and each group is heard
allocated 2 measurements. Facilitators take 10
minutes teaching the groups how to take the
respective measurements. Groups take 10 minutes
to practice taking the measurements.

Figure 12. Measuring the height in children below 2 years of age.(source: Modified from multiple indicator cluster surveys)
Headpiece firmly on head
Measure on knees
Head on chin
Shoulders level
Child’s hands
and arms at side
Left hand on
knees; knees
together
against board
Right hand on shins

heels against back and
base board
Assistant on knees
Line
of sight
Questionnaire and pencil on

clipboard on floor or ground

1) Length • Allow the measurer to place his/her hands on the
child and firmly hold the child’s knees together
This measurement is taken for children below two while pressing down. The soles of the feet should
years of age and/or for those who are less than 85 cm be flat on the foot piece, toes pointing up at right
or unable to stand. angles.
• Place the measuring board horizontally on a flat, • The measurer should immediately remove the
level surface. child’s feet from contact with the footboard with
one hand while holding the footboard securely in
• Remove the child’s shoes and any head covering.
place with the other.
• Place the child so he/she is lying down and face
• Read and record the measurement as shown in
up in the middle of the board.
diagram above
• Allow the assistant to hold the sides of the child’s
head and position the head until it is touching the
head board.
Figure 13.Figure 2.Measuring the length of a child below 2 years of age.(source: Modified from multiple indicator cluster surveys)
MEASURE
ON KNEES ASSISTANT
ON KNEES
3
2
ARMS COMFORTABLY
STRAIGHT 5
HAND ON KNEES OR SHINS:

LEGS STRAIGHT
8
FEET FLAT
AGAINST
9
FOOT PIECE 5 HAND CUPPED OVER EARS:
HEAD AGAINST BASE OF BOARD
LINE OF SIGHT CHILD FLAT ON BOARD

PERPENDICULAR TO 6
BASE OF BOARD 7
1
QUESTIONNAIRE AND PENCIL ON CLIPBOARD
ON FLOOR OR GROUND

Weight Age
Because of its complexity and proneness to mistakes, The age should be recorded as accurate as possible
taking the measurement need to be trained on how to so that the correct cut off can be used to determine
use the equipment and that there is a need to do more nutrition status.
than 1 measurement to catch any errors.
The age can be determined from official documents
(health card, immunization card, and birth certificate).
If official documents are not available, use a local
Taking weight of a child on a floor scale. calendar of events to determine the month and year
of birth.
1. Place the electronic scale on a flat, level surface
If a child’s length or height is less than 110 cm or if the
2. Check and readjust the weight reading to zero
child cannot touch his/her ear with the opposite hand
3. Undress the child by extending the arm over the head, he/she should be
treated as under 5 years.
4. Make him/her stand on the middle of the scale’s
surface
Using the weight, height, and age measurements
5. When the child is settled and the weight reading is
stable record the weight to the nearest 100g. Make The age of the child, together with the weight and
sure that nobody holds the child during weighing height are used to determine if the child is well
and that the child stands freely without holding nourished, under or over nourished.
onto anything
Stunting: height and age
6. Read and announce the value from the scale. The
Underweight: weight and age
assistant should repeat the value for verification
and record it immediately Wasting: weight and height
The above measurements are compared against

Taking weight of a child on a floor scale with an WHO Child Growth Standards to determine the status
adult of the child
1. Place the electronic scale on a flat, level surface
Charts
2. Check and readjust the weight reading to zero
There are different charts, and different charts for
3. Undress the child
assessing stunting, underweight, and wasting; for
4. Ask the caregiver to stand on the scale’s surface boys and girls; and for different ages.
in the middle and record their weight to the nearest
For each chart, a child has normal height for age or
100g when the caregiver is settled and the weight
weight for age or weight for height, if their results are
reading is stable. This is the weight of the adult
plotted between the 2 and -2 lines.
5. Zero the scale using the appropriate button
If the results are plotted below the -2 line, they are
6. Hand the child to the caregiver when the scale stunted, underweight or wasted.
reads 0kg
If their results are below the -3 line, they are severely
7. When the caregiver is settled with the child and the stunted, underweight or wasted.
weight reading is stable record the weight to the
nearest 100g. This is the weight of the child.

assistant should repeat the value for verification
and record it immediately.

Figure showing weight for age growth chart for girls aged 0 to 2 years
Z-scores Index Cut off Indication

The results can be analysed using tables or software Wasted Less the -2 Wasted
to establish the score for each child. If the score is Less than -2 and Moderately
below -2, it means the child is malnourished. Weight for
more than or wasted
Age
equal to -3
Table 4: Interpretation of Z score
≤-3 Severely wasted
Index Cut off Indication
Stunting Less the -2 Stunted
Height for Less than -2 and Moderately Mid Upper Arm Circumference (MUAC)
Age more than or stunted MUAC tape is used to screen for wasting among
equal to -3 children and women. The tape has three colors: The
≤-3 Severely stunted red indicates the child has severe acute malnutrition.
Underweight Less the -2 Underweight The yellow indicates the child has moderate acute
malnutrition. The green indicates the child has normal
Less than -2 and Moderately
Weight for nutritional status.
more than or underweight
Age
equal to -3
≤-3 Severely
underweight

Figure 14: Measuring MUAC of a young child (Source-UNICEF 1991)
How to measure MUAC
Ask the mother/caregiver to remove any clothing that may cover

STEP 1: the child’s less active arm. If the child can stand and it is possible,
the child should stand erect and sideways to the measurer.
STEP 2:
Bend the arm at 90. Estimate the midpoint of the upper arm
by locating the tip of the shoulder and tip of the elbow.
STEP 3:
Straighten the child’s arm and wrap the tape around the arm at
the midpoint. Make sure the numbers are right side up. Make
sure the tape is flat around the skin.

STEP 4:
Inspect the tension of the tape on the child’s arm.
Make sure the tape has the proper tension and is not
too tight or too loose. Repeat any step as necessary.
STEP 5:
When the tape is in the correct position on the arm with correct
tension, observe the colour code the child’s MUAC is in. [Or
read the measurement to the nearest 0.1 cm.]
STEP 6:
Immediately record the measurement and colour code
Table 5: Understanding the MUAC results
MUAC tape Meaning RECOMMENDATION

Colour
RED • Child has severe acute malnu- • Referral to the nearest healthcare facility immediately
trition and high risk of death if
• Follow-up (in 3 days) to ensure the child has been
they have another disease
taken to the health facility
• Needs immediate healthcare
• Come to measure MUAC again after 2 weeks
YELLOW Child has moderate acute mal- • Advise to have all diseases and infections treated
nutrition and risk of becoming
• If child is < 2 years to continue breastfeeding
severely malnourished
• Encourage them to feed the child a balanced diet
• Comeback to measure MUAC again after one month
GREEN Child is growing well • Advise the caregiver to continue with healthy feeding
the baby: three meals a day, 2 snacks, and feed on
fruits, vegetables, milk


Table 6. Cut-off points for screening in the community for SAM and MAM using MUAC
Group Severe acute malnutrition Moderate acute Normal

(SAM) malnutrition (MAM)
Infants and children 6
˂11.5 cm ≥11.5 to ˂12.5 cm ≥12.5 cm
months to ˂5 years
Children 5 ˂ 10 years ˂13.5 cm ≥13.5 to ˂14.5 cm ≥14.5 cm
Adults 18 years and older ˂19.0 cm ≥19.0 to ˂22.0 cm ≥22.0 cm
Pregnant women or ˂19.0 cm ≥19.0 to ˂22.0 cm ≥22.0 cm
mothers with infants up to 6
months
Elderly people 60 years and ˂16.0 cm ≥16.0 to ˂18.5cm ≥18.5 cm
older
Oedema Measuring oedema
Oedema is a build-up of fluids in the tissues causing • Apply normal thumb pressure on both feet
abnormal swelling of the hands and feet or other • Count the numbers 101, 102, 103 to estimate
body parts. The body requires nutrients for various three seconds without using a watch
processes that lead to normal fluid balance. Oedema
caused by malnutrition has to occur in both limbs at • Check if a shallow print persists on both feet
the same time. • If the print persits in both feet, it implies the child
has nutritional odema (pitting oedema) and is
severely malnourished
Figure 15.assessment of bilateral oedema (UNICEF 1991)
Recommendations
The existing government health structures can be
• If no oedema is found (0): Advise the caregiver to
used, starting with a referral to the village health worker
continue with healthy feeding the baby
Community Health Extension Workers (CHEWs) are
• If oedema is found, the child should be referred to individuals within the community who are equipped to
a health facility. further refer the child to the appropriate health facility.
The participants and the project management team
• Follow-up to ensure the child went for healthcare
can also be guided to develop an appropriate referral
and reporting system.
Referral of malnourished children
It is important that the malnourished children identified
are referred to a health facility.

Sign/signals (or complaints) Nutritional Recommendation
abnormality
Swollen body, loss of appetite, Severe acute Where edema is Severity RECOMMENDATION
(may have a disease like diar- malnutrition found
rhoea): May have brownish thin No edema Advise the caregiver to continue
hair with healthy feeding the baby
0
(three meals, snacks, fruits,
Check for oedema vegetables, milk)
Oedema is only Child likely kwashiorkor Should
found below the be referred to a health facility.
ankle (pitting pedal
odema) Advise mother to increase
+ frequency of breastfeeding and
feeding.
1: Apply normal thumb pressure on
both feet: count the numbers 101, Follow-up to ensure the child
102, 103 to estimate three seconds went for healthcare
without using a watch). 2: Check--a Pitting odema but Must immediately refer (or even
shallow print persists on both feet below the knee ++ escort the child to a health
implies the child has nutritional provider)
odema (pitting oedema).
The odema is
Follow-up same day or following
generalised (found
day
also on the face
+++
hands etc) Repeat assessment for oedema
after 7 days
Vitamin A • Refer to a healthcare provider

deficiency
• Provide fruits (papaw, avocado) every day and mangoes
during the season
• Provide plenty of traditional vegetables cooked with little oil
• The child go for vitamin A supplementation every 6 months
Hitting things when walking in the

twilight, poor vision.
Check for eye dryness, Bigot’s
spots (whitish patchy triangular le-
sions on the side of the eye)
Swelling on the front of the neck: Iodine • Advise to use only iodized salt in the house
Goitre deficiency
• You could refer to the healthcare provider.
disorder
Visible severe • Referral to the nearest healthcare facility immediately
wasting
• Follow-up (in 3 days) to ensure the child has been taken to
the health facility
• Come again after a month to reassess

Anthropometric equipment needed
Height: height boards Weight: weighing scales MUAC: MUAC tapes
Taking the Weight-for-Height/Length Taking the weight of a caregiver with child using
electronic scales:
Because of its complexity and proneness to mistakes,
Weight-for-Height/Length the persons taking the 1. Place the electronic scale on a flat, level surface.
measurement need to be trained on how to use the 2. Check and readjust the weight reading to zero.
equipment and that there is a need to do more than 1
3. Undress the child.
measurement to catch any errors.
4. Ask the caregiver to stand on the scale’s surface
Weight-for-Height implies the following steps:-
in the middle and record their weight to the nearest
Taking the height or length 100g when the caregiver is settled and the weight
Calculating the weight for height/length percentages reading is stable
5. Hand the child to the caregiver.
Taking the weight of a child/adolescent using 6. When the caregiver is settled with the child and
electronic scales: the weight reading is stable record the weight to
the nearest 100g.
1. Place the electronic scale on a flat, level surface.
2. Check and readjust the weight reading to zero. assistant should repeat the value for verification
and record it immediately.
3. Undress the child.
4. Make him/her stand on the middle of the scale’s

surface. Adults body mass index (BMI)
5. When the child is settled and the weight reading A quite different anthropometric index is used
is stable record the weight to the nearest 100g. to measure acute protein-energy malnutrition
Make sure that nobody holds the child during (sometimes called “chronic energy deficiency”) in
weighing and that the child stands freely without adults). This is the body mass index (BMI) unlike
holding onto anything. weight-for-height in children, you divide weight by
height, or rather, and you divide weight in kilograms
6. Read and announce the value from the scale. The by the square of height in meters:
assistant should repeat the Value for verification
and record The cut-off point defining malnutrition is the same for
all adults, regardless of their age, height, or sex:
7. Record it immediately.

Minimum Dietary Diversity Score for Women House Hold Hunger Scale (HHS); this focuses on
(MDDS-W): Is a food group diversity indicator that has the food quantity dimension of food access and does
been shown to reflect one key dimension of diet quality not measure dietary quality. It can be used to monitor
especially micronutrient adequacy. Ten food groups prevalence of hunger over time, assess food security
are considered here namely; 1. All starchy staples; situation, monitor and evaluate the impact of ant
2. Beans peas; 3. Nuts and seeds; 4. Dairy; 5. Flesh hunger policies and programs, provide information
foods (meats); 6. Eggs; 7. Vitamin A rich dark green for early warning of nutrition and food security
leafy vegetables; 8. Other vitamin A rich vegetables surveillance. This involves asking 3 main questions:
and fruits; 9. Other vegetables; 10. Other fruits.
Consumption of foods from any 5 food groups and • Was there ever no food to eat of any kind in your
above indicated meeting minimum dietary diversity. house because of lack of resources to get food?
The household dietary diversity score (HDDS) is • Did you or any household member go to sleep at
meant to reflect, in a snapshot form, the economic night hungry because there was not enough food?
ability of a household to access a variety of foods.
The increase in dietary diversity is associated • Did you or any household member go a whole day
with socio-economic status and household food and night without eating anything because there
security (household energy availability). To measure was not enough food?
household dietary diversity, 12 standard food groups.
Consumption of less than 4 food groups is considered For each question one asks how frequently that
low dietary diversity, consumption of between 4-5food happened.
groups is considered moderate dietary diversity while
HHS should therefore not be used as a standalone
consumption of more than 6 food groups is considered
measure of food security but instead as one of the tools
high dietary diversity.
to measure complimentary aspects of food insecurity
Individual dietary diversity scores aim to reflect (such as anthropometric data, House hold income and
nutrient adequacy. Studies in different age groups have expenditure, Food production and consumption and
shown that an increase in individual dietary diversity House hold and individual dietary diversity.
score is related to increased nutrient adequacy of the
diet.

6.0 Action plans for PMU members
Time: 60 minutes
Materials needed: Flip chart, Flip chart, board, Marker pens, Block notes
Activity:
Learning Objectives The facilitator introduces the session and its objective (10
minutes).
Participants are grouped according to their projects
participants are expected to: Each of these groups takes 30 minutes to discuss:
Identify operational frame work for 1) Current operational framework for extension service provision
extension service provision 2) Identification of nutrition related indicators that can be assessed
in the current framework as a way of mainstreaming nutrition
Identify nutrition related indicators
that can be assessed in the 3) Tools required to mainstream nutrition (what kind of job aids
current frame work as a way of would be require)
main streaming nutrition.
4) Action plans to mainstreaming nutrition activities
Identify tools that are required to
mainstream nutrition
Groups take 10 minutes to present their results
The facilitator takes 15 minutes to wrap up the session
Current operational framework for extension service provision

Visits; what is done, frequency, details, who does what
Mainstreaming nutrition into the extension service provision

framework
Identification of nutrition related indicators that can be assessed in

the current framework
Identification of tools required to mainstream nutrition. For example,

what kind of job aids.
Development of action plans

Development of action plans to mainstream nutrition related
activities.

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Book · December 2018

Beatrice Ekesa Deborah Nabuuma

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Nutritional status assessment View project

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Basic Nutrition Concepts

By: Beatrice Ekesa, Deborah Nabuuma,

Basic Nutrition Concepts

By: Beatrice Ekesa, Deborah Nabuuma,

Nutrition situation in Uganda 5

1.0 Basic Concepts in Nutrition 8

Nutrients, functions and sources 9

2.0 Recommended feeding practices 14

The Food Pyramid 15

3.1 Causes of malnutrition 17

3.2 Forms of malnutrition 18

3.3 Cycle of malnutrition 21

3.4 Prevention of undernutrition 21

4.0 Food safety and hygiene 23

5.0 Food and nutrition assessment 26

Dietary diversity indicators 27

Nutrition status assessment 31

6.0 Action plans for PMU members 42

4 | Training manual for Project Management Unit Members

Training manual for Project Management Unit Members | 5

Users of the Guide

Overview of the Training Guide

6 | Training manual for Project Management Unit Members

Time Topic/Activity Details of topic/Activity Facilitator

Training manual for Project Management Unit Members | 7

Method: Question / answer

Activity: (using a flip chart, ask at least three participants their

Nutrition comprises the process of providing the nutrients needed

Food is any substance (solid, semi-solid, or liquid) taken into the

Good nutrition is important for:

8 | Training manual for Project Management Unit Members

2. Micro (small) nutrients Maize/ maize flour Sweet potato

Whether or not a food is a good source of a nutrient

Training manual for Project Management Unit Members | 9

10 | Training manual for Project Management Unit Members

Protein can be found in both animal and

Figure 3. Example sources of plant protein.

• Soy products (tofu, tempeh, soy milk,

• There are also small amounts of

• Plant sources of protein are considered

• Soy protein is the one exception--it is

Training manual for Project Management Unit Members | 11

Sources Figure 4. Example sources of vitamins and minerals.

• Orange vegetables, such as orange

12 | Training manual for Project Management Unit Members

The best way to make sure we get enough of Water;

Training manual for Project Management Unit Members | 13

Activity: (using a flip chart, the facilitator asks at least three

14 | Training manual for Project Management Unit Members

Figure 5. The food pyramid.

Fats, Oils and Sweets +Calcium, Vitamin D

Milk, Youghut and Meat, Poultry, fish, Dry

Vegetables group Fruits group

Training manual for Project Management Unit Members | 15

Important nutrition points to remember

Good nutrition during pregnancy and appropriate

Pregnant women should receive ante-natal care