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Community Nutrition: A Handbook for Health and Development Workers

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 Community nutrition:
a handbook for health and
development workers

Edited by
Ann Burgess, Marlou Bijlsma and Carina Ismael
with
Ann Ashworth

Margaret Atuahene

Ted Greiner

Elizabeth Kamau-Mbuthia

Grace Maina

Joseph Mutuku

Marianne van der Sande

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 Macmillan Education
Between Towns Road, Oxford, OX4 3PP
A division of Macmillan Publishers Limited
Companies and representatives throughout the world
www.macmillan-africa.com
ISBN: 978-0-230-01063-5
Text © Ann Burgess, Marlou Bijlsma and Carina Ismael 2009
Design and illustration © Macmillan Publishers Limited 2009
First published in 2009
All rights reserved; no part of this publication may be
reproduced, stored in a retrieval system, transmitted in any
form or by any means, electronic, mechanical, photocopying,
recording, or otherwise, without the prior written permission
of the publishers.
These materials may contain links for third party websites. We have no control over, and
are not responsible for, the contents of such third party websites. Please use care when
accessing them.
Designed by Andy Magee Design
Typeset by ?????
Illustrated by Lynne Willey
Cover design by Charles Design Associates
Cover photos: Pieter van der Zaag; AMREF © Louise Orton; SIGHT AND LIFE;
Christel Van Den Boogaard

Printed and bound in ???????

2012 2011 2010 2009
10 9 8 7 6 5 4 3 2 1

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 Contents
Preface ......................................................................................................................v
List of Contributors and Acknowledgements............................................................. vi
Introduction .............................................................................................................viii
Key facts to reduce the double burden of malnutrition .............................................. xi

Part 1 Nutrients and foods

1. Nutrients and why we need them .......................................................................2
2. Guidelines for healthy eating .............................................................................11
3. Producing and buying food ..............................................................................20
4. Processing and preparing food .........................................................................29

Part 2 Good nutrition for the household

5. Good nutrition for the household – introduction ................................................36
6. Good nutrition for women .................................................................................39
7. Breastfeeding babies aged 0–6 months............................................................43
8. Feeding young children over 6 months of age ..................................................54
9. Good nutrition for older children, adolescents, men and old people ..................63
10. Feeding sick people at home ............................................................................67

Part 3 Malnutrition
11. Malnutrition and its causes ...............................................................................78
12. Malnutrition through the life cycle – characteristics and dangers .......................84
13. Iron deficiency and anaemia .............................................................................91
14. Vitamin A deficiency disorders ..........................................................................98
15. Iodine, zinc, folate and niacin deficiencies .......................................................103
16. Nutrition-related chronic diseases – introduction .............................................109
17. Hypertension and cardiovascular diseases .....................................................115
18. Obesity and diabetes......................................................................................118

Part 4 Nutrition services

19. Nutrition services – introduction ......................................................................126
20. Assessing and managing malnutrition in young children .................................132
21. Managing malnutrition in older children and adults..........................................141
22. Nutrition in schools .........................................................................................146

Part 5 Planning and improving nutrition activities

23. Implementing nutrition activities ......................................................................154
24. Communication for behaviour change ............................................................163

Appendices
A. Energy and nutrient needs ..............................................................................173
B. Sources of nutrients and household measures ...............................................175
C. Body measurements ......................................................................................184
D. Sources of information ...................................................................................192
Key words and terms ............................................................................................199
Meaning of shortened words .................................................................................203
Index .....................................................................................................................204

Contents iii

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 Preface
A few years ago we were approached by
Professor David Morley, founder of Teaching-
aids at Low Cost, about producing a low-cost
reader-friendly book dealing with the emerging
problem of chronic diseases. After consult-
ing colleagues in Africa and elsewhere, it was
agreed that there was a need for a new book
on all aspects of community nutrition. Previous
books were becoming outdated and there were
many health and development professionals,
especially in rural areas, who were unable to
access information via the internet.
This book is written primarily for people work-
ing at district and community levels, however,
we hope it will be useful to those studying or
teaching community nutrition as well as those
who have a keen interest in the subject.
The book has been written jointly by the three
of us. Carina has considerable and very recent
practical experience working with communi-
ties in Mozambique, Marlou is intrigued by the
discrepancy between knowing what works and
what is actually achieved in the field of nutrition
and how to bring the two together, and Ann’s
main interest is in encouraging the exchange
of information, ideas and practical experiences
between development professionals in different
parts of the world.
To ensure the reliability and validity of the facts
presented we have consulted colleagues at
xxxxxxxxxx_fm.indd v
the forefront of nutritional developments and
have visited east and west Africa to get first-
hand information on national programmes and
to clarify needs. Carina has liaised with other
community nutritionists to check the material
and to ensure that what is being included is rel-
evant, useful and reader-friendly for our target
users. Our co-contributors, as listed on the title
page, have supported us in their own area of
expertise, and Liz Paren at Macmillan guided
our efforts.
We believe that a publication such as this can
be enhanced immensely by the provision of
plenty of good illustrations so we would like
to thank our artist Lynne Willey and others
at Macmillan Education for the figures as
well as the many generous individuals and
organisations that have allowed us to use their
artwork and photographs in order to achieve
this.
Now our book is born, it has become your
book! We hope you find it useful. Please tell
us what you think by writing to: c/o Macmillan
Education, Between Towns Road Oxford OX4
3PP, UK. Alternatively, we can be contacted by
email on the following addresses:
annpatriciaburgess@yahoo.co.uk
marloubijlsma@yahoo.co.uk
carinaismael@hotmail.com.
Preface v
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 Contributors
Ann Burgess, Nutrition Consultant, Scotland
Marlou Bijlsma, Nutrition Consultant, The Netherlands
Carina Ismael, Nutritionist, Mozambique
Professor Ann Ashworth, London School of Hygiene and
Tropical Medicine, UK (Chapter 8 and part of Chapter 20)
Dr Margaret Atuahene, School of Public Health, University
of Ghana (Chapters 16–18)
Dr Ted Greiner, Professor of Nutrition, College of Human
Ecology, Hanyang University, Seoul, Korea (Chapter 7)
Joseph Mutuku, graduate student Wageningen University,
formerley with Micronutrient Initiative, Kenya (Chapter 13)
Dr Marianne van der Sande, National Institute for Public
Health and the Environment, The Netherlands (Chap-
ters 16–18)
Dr Elizabeth Kamau-Mbuthia, Department of Human
Nutrition, Egerton University, Kenya
Grace Maina, Nutrition Consultant, Kenya
also
Dr Maria Nnyepi, Senior Lecturer Nutrition, University of
Botswana
Phyllis Moraa Oyugi, Nutrition Consultant, Kenya and
working with GOAL Malawi
Acknowledgements
The following colleagues gave advice and answered our
many questions:
Dr Margaret Akinyi Wagah, Lecturer/National Coordinator
RENEWAL Kenya, Kenyatta University, Kenya; Dr Anirban
Chatterjee, UNICEF, New York; Fortunata Chuwa,
Nutritionist, Tanzania; Dr Phil Harvey, Johns Hopkins
University, USA (affiliated with the A2Z Micronutrient
Project); Dr Peggy Henderson, CAH, WHO, Geneva;
Sister Hillu and the counselling team of the Kilimanjaro
Christian Medical Centre, Tanzania; Eddie Laswai, Cook,
Tanzania; Professor Daniel N Lantum, Regional Coordina-
tor for Africa; Professor Joyce Kinabo, Sokoine University,
Morogoro, Tanzania; Pamela Morrison, International Lacta-
tion Consultant, UK; Elizabeth Macha, UNICEF Country
Office, Tanzania; Anna Mswata, Senior Nursing Officer
and Nutritionist, Mount Meru Regional Hospital, Arusha,
Tanzania; Caroline Muchobia, Gertrudes Garden
Children’s Hospital, Nairobi, Kenya; Dr Mark Myatt,
Consultant Epidemiologist, Institute of Ophthalmology,
University College London, UK; Rosemary Ngaruro, Chief
Nutritionist, Ministry of Health, Kenya; Stacia Nordin,
Sustainable Food Adviser, Lilongwe, Malawi; Professor
Wilna Oldewage-Theron, Vaal University of Technology,
South Africa; Dr Gideon Orio and Faith Juma, Elerai West-
End Medical Centre, Arusha, Tanzania; Dr Felicity Savage,
vi Community Nutrition
xxxxxxxxxx_fm.indd vi
Centre for International Health and Development, UCL,
UK; Dr Andrew Seal, Centre for International Health and
Development, UCL, UK; Dr Emily Siegel, Helen Keller
International, USA (affiliated with the A2Z Micronutrient
Project); Terry Wefwafwa and other officers of the Nutrition
Association of Kenya.
Before the book was commissioned we also consulted:
Dr Peter Glasauer, FAO, Rome; Dr Robert Mwadime,
FANTA Project, Uganda; Noreen Prendiville, Chief,
Nutrition Section, UNICEF Kenya Country Office; Dr Peter
Ngatia, Betty Rabar and Robina Biteyi, African Medical
and Research Foundation, Kenya; Louise Sserunjogi,
Nutrition Consultant, Kampala, Uganda; Professor Pauline
MN Kuzwayo, Department of Human Nutrition and Dietet-
ics. University of Limpopo, Medunsa Campus, South
Africa; Dr Kirstin Thompson and Dr Robert Beaglehole,
WHO, Geneva.
We give special thanks to Professor David Morley who
encouraged us to prepare this book and to Liz Paren
and others at Macmillan Education for their help and
encouragement.
Very many other people have contributed indirectly to
this book – we have gathered ideas from colleagues from
Africa and other parts of the developing world. We have
read their articles, books and newsletters. We have worked
with and been motivated by health and other development
staff working with communities. We want to thank you all.
We would also like to thank the following people and
organisations for generously allowing us to use their
photographs and drawings:
• African Medical and Research Foundation (AMREF) for
Figures 19a (also used on the cover), 20b, 20c, 23a, C4
and C5.
• Christel Van Den Boogaard for Figure 19d (1) [if used]
and a cover photograph.
• David Gifford for Figure 14a.
• Emergency Nutrition Network (ENN) for Figure 7e from
Infant Feeding in Emergencies Module 2. Overhead
figure IFE 2/15.
• Food and Agriculture Organization of the United
Nations (FAO) for Figures 0c, 2b, 3d, 4b, 6a, 10c, 11b,
20c and 24h from Family Nutrition Guide.
• International Centre for Diarrhoeal Disease Research,
Bangladesh (ICDDR,B) for Figures 15c and 20d.
• SIGHT AND LIFE for Figure 14b and a cover
photograph.
• Stacia Nordin (editor) and Carmen Aspinall (artist) for
Figure 2d from Low Input Food and Nutrition Security:
5/5/09 6:43:21 PM
 Growing and Eating More, Malawi: World Food
Programme, 2005.
• Tearfund UK for Figures 3b and 4a.
• University Research Co., LLC. USA/Quality Assurance
Project (URC/QAP), Tanzania for Figures 7a, 7b, 7c, 7d,
8b and 8e from the Integrated Set of HIV and Infant
Feeding Job Aids for use in PMTCT and ANC Infant-
Feeding Counseling.
• Valid International for Figures 9b and 20e.
• World Health Organization (WHO) for Figure 13b;
Figures C1, C2 and C3.
• Peter van der Zaag for Figures 19d (2) [if used] and 22e
and a cover photograph.
Also thanks to Marie McGrath (ENN) and Peggy
Koniz-Booher (URC/QAP) for their special help in
providing illustrations from their organisations, and to
Wilna Oldewage-Theron for the ‘story’ in Figure 18b.
We adapted illustrations from: United Nations System
Standing Committee on Nutrition (SCN News No. 32) for
Figure 0b; Curriculum Development Centre, Zambia/FAO
Basic Education Course on Nutrition Education Pupil’s
Book Grade 2 for Figure 10c the Nutrition Department,
Ministry of Health, Mozambique for Figure 8d; Family
Health International’s Strategies for an Expanded and
Comprehensive Response to a National HIV/AIDS Epi-
demic by P.R. Lamptey et al. for Figure 24a and AMREF
Community Nutrition for Eastern Africa for Figures 12c,
21b and 23a.
Macmillan publications provided the following
illustrations: Figure 19c from Nutrition Handbook For
Community Workers In The Tropics by Caribbean Food
and Nutrition Institute (CFNI) and Figure 24e from
Communicating Health by John Hubley. Figure 24b was
adapted from Communicating Health and Figure 12a
from Setting Up Community Health Programmes by
Ted Lankaster.

The information in this book has been checked and is believed to be accurate at the time of going to press.
However, the authors, contributors and publishers accept no legal responsibility for mistakes or omissions.
We advise you to check guidelines, especially drug doses, and to follow national guidelines.

Preface vii

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 Introduction
We have written this book to provide up-to- » The high cost of foods and fuel due partly to
date reliable information on nutrition and its climate change.
disorders. If you are a nutritionist, a health
In addition, undernutrition and micronutrient
professional or other development professional
deficiencies are still leading causes of poor
working at community or district level this book
pregnancy outcomes, mother and young child
is for you. It should also be useful if you are
deaths, slow growth, learning difficulties, poor
studying or teaching nutrition.
school performance, low work productivity and
Why is a new book necessary? decreased immunity. Together under- and over-
nutrition put an enormous economic burden on
A new book is necessary largely because of
the families, communities and countries they
new nutritional challenges in resource-poor
affect. One of the aims of this book is to help
countries (see Figure 0a). These include:
you understand and deal with these old and
» The special food needs of people living with new problems.
HIV.
In this book we focus on recommendations
» Feeding babies born to HIV+ mothers.
rather than background information. Also we
» The increasing prevalence of chronic condi-
have not dealt with topics such as nutrition
tions such as obesity, cardiovascular disease
in emergencies, nutritional care of inpatients,
and diabetes that are linked to changing
nutrition surveys or nutrition training. We
diets and lifestyles.

In the world:
37% are anaemic
35% are at risk of iodine deficiency
20% are at risk of zinc deficiency
12% have too little to eat
34% are overweight
8% are obese
3% have diabetes

In ‘developing’ countries:
17% newborns have a low birthweight
Among children aged under 5 years:
31% are stunted
27% are underweight
10% are thin
Undernutrition contributes to more than half of
deaths of children aged under 5 years
25% have vitamin A deficiency
18% women have vitamin A deficiency
50–60% of pregnant women are anaemic

Figure 0a: Nutrition challenges in the world today

Sources: Food and Nutrition Bulletin 28/1 Supp 2007 PS174; Population Reference Bureau
www.prb.org; World Health Organization www.who.int

viii Community Nutrition

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 Figure 0b: Malnutrition is a worldwide problem (SCN News #32 adapted)

cover food security rather briefly although
we list several materials on this subject in
Appendix D.
What we can do
There are plenty of cost-effective actions that
many of us can take to improve nutrition where
we live and work. We hope this book will moti-
vate and help you to:
» Analyse the nutrition situation and design
actions to deal with food insecurity nutrition
disorders in your area.
» Counsel on key nutrition messages on feed-
ing and caring for the family – especially dur-
ing pregnancy and the first two years of life.
» Make special efforts to reach the most vul-
nerable households and individuals in your
communities.
» Use culturally sensitive, effective and inter-
esting methods of communication.
» Recognise, prevent and manage all types of
malnutrition.
» Lobby for policies and programmes that
alleviate poverty and inequality, improve
household food security and improve the
education and status of all, especially
women and girls.
» Integrate nutrition activities into health,
food, educational and other development
programmes.

Eating well and being well nourished is essential for a long, active and happy life. Good nutri-
tion starts in the womb. Well-nourished women are likely to have well-nourished babies. Well-
nourished babies are likely to thrive, develop physically and mentally to their full potential, and
are less likely to have chronic diseases in adult life. Well-nourished school children and ado-
lescents have the best chance of learning well and getting a good job. Well-nourished adults
can work more productively; well-nourished older people are likely to be healthy and active
and are at less risk of chronic disease.

Introduction ix

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 We know that malnourished households must
be equal partners in development programmes
if there is to be lasting improvement in nutri-
tion. These households must be involved with
conceiving, planning, implementing, monitoring
and evaluating community-based activities. To
be able to work with and help these families we
must first understand their food-related beliefs,
habits and desires as well as their socio-
economic situations and family structures.
It is the parents and carers in needy house-
holds who are directly responsible for providing
more food and better meals, preventing sick-
ness and caring for the young, old and sick. To
do this, they need information, skills, services
and resources. We may need to help them to:
» Develop the skills and confidence to iden-
tify, analyse and deal with family nutrition
disorders.
» Use the resources they already have in a
more efficient way.
Figure 0c (© FAO)
x Community Nutrition
xxxxxxxxxx_fm.indd x
» Access additional resources, services and
information.
Nutrition is an immense and exciting subject.
Researchers discover new information every
day, so this book will eventually become out-
dated. With this in mind, Appendix D lists
details of websites and newsletters where
updated information can be found in the future.
We know that many of you face challenging
situations in your daily work. We hope that this
handbook will make your job a little easier and
will help you to counsel and support the house-
holds in your communities and districts.
The many contributors to this book who are
working in Africa and elsewhere have gener-
ously shared their knowledge and experiences.
Those of you working in the community and
district are also in an excellent position to find
out ‘what works’. So we hope you will also
share your experiences and ideas with us and
with others.
5/5/09 6:43:24 PM
 Key facts to reduce the double burden
of malnutrition
» Healthy families eat a variety of foods, exercise regularly and drink
plenty of safe water.
» Fruits and vegetables are high in micronutrients and antioxidants.
» Meat and organ meats are the best sources of iron.
» Using iodised salt prevents iodine deficiency.
» Gardening is one way to improve family diets.
» Starting breasfeeding within 1 hour of birth helps to prevent deaths
of newborn babies.
» Most babies should have no other food or drink except breastmilk
until they are 6 months old.
» The best milk for non-breastfed babies under 6 months is infant
formula.
» Babies need other foods in addition to breastmilk when they are
6 months old.
» Young children should attend clinics regularly for growth monitoring,
supplements and immunisations.
» Adolescents grow fast and need three healthy meals and some
snacks each day.
» Pregnancy during adolescence is dangerous for the girl and her
baby.
» Mothers who are well nourished before and during pregnancy are
likely to have healthy babies.
» Pregnant women need extra food, particularly iron-rich foods.
» Keeping a healthy weight, eating a healthy diet and being active
helps to prevent chronic diseases.
» Eating well and taking regular exercise helps old people to stay
healthy and active.
» Washing hands thoroughly before handling food helps to prevent
infections.
» Sick people need extra food to fight infections and aid recovery.
» ARV (antiretroviral) treatment is most effective when people eat well.

Key facts to reduce the double burden of malnutrition xi

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