(PDF) Basic nutrition concepts & nutrition indicators: Training manual for project management unit members

December 2018

Training manual

For Project Management Unit Members

Basic Nutrition Concepts

Nutrition Indicators

&

THE REPUBLIC OF UGANDA

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

December 2018

Training manual

For Project Management Unit Members

Basic Nutrition Concepts

Nutrition Indicators

&

By: Beatrice Ekesa, Deborah Nabuuma,

Samalie Namukose and George Upenytho.

THE REPUBLIC OF UGANDA

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

Table of Contents

4 | Training manual for Project Management Unit Members

According 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 specic information to

situation

Nutrition in Uganda

Training manual for Project Management Unit Members | 5

enable improved farming.

This Guide is therefore designed for use by eld level staff. The guide gives details that are aimed at

enabling the eld 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: eld level staff (Community based

facilitators, Household Mentors and Unit leaders) following the trainings, the eld 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 eld 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 eld extension workers.

This will be measured on number of households reached with the intervention, Number of households

trained by extension eld workers that can implement the recommended practices.

Users of the Guide

This guide it to be used in creating awareness of the eld 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.

6 | Training manual for Project Management Unit Members

Time Topic/Activity Details of topic/Activity Facilitator

8:00 - 8 :15 am

(15 minutes)

Introduction Name, program/project

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

minutes)

Basic Concepts in Nutrition - Denition of food

- Denition of nutrition

- Difference between FS & NS

- Nutrients, Macro and micro

nutrients

- Food groups

9:46 - 10:45 am (1hr) Recommended feeding

practices

Basic food groups basing

on function in body (Energy,

building, protective)

- Standard food groups,

function, sources

15 minutes TEA BREAK

11:00 - 12:00 (1hr) Recommended feeding

practices

- Denition of a balanced diet

- 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 deciencies

Food safety and hygiene -Basic concepts in food safety

and hygiene

LUNCH BREAK

2.00 - 4.00 pm

(2hrs)

Food and nutrition assess-

ment and related indicators

Food intake assessment

House hold food security

indicators

Anthropometry. Clinical signs of

malnutrition.

Management, referral

15 minutes Tea Break

4:15 - 4:30 pm

(15 minutes)

Re-cap Key messages from the

sessions

4:30 - 4.50 pm

(20 minutes)

Way forward How they will mainstream

nutrition into the PRELNOR and

VODP II frame work

4:50 - 5:00pm Closure

Training Program

Training manual for Project Management Unit Members | 7

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

understanding of the concepts below,

What is good nutrition?

What are some of the common nutrient groups?

What are some local food sources of the common nutrient groups?

What is the function or use of these nutrient groups?

(Facilitator asks at least three participants to describe their

understanding of nutrition)

After the participants provide the responses the facilitator

moves forward to provide the right denition and details as

provided in the session technical notes and ensuring there

is great participation and discussion during the process and

welcoming questions and making clarications.

Session technical notes

Nutrition is all about the study of food and how our bodies use it

as fuel for growth, reproduction and maintenance of health.

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, ghting 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.

1.0 Basic Concepts in Nutrition

Learning Objectives

At the beginning of the session

the facilitator is expected to

understand the entry level

knowledge of participants

regarding the session content.

At the end of this session

participants are expected to:

Briey describe what good

nutrition is.

List at least six nutrients found in

foods and their function.

List at least ve local sources of

carbohydrates, proteins, vitamins

and minerals.

Time: 60 minutes

Method: Question / answer

Materials needed: Flip chart, Flip chart board, Marker pens, Block notes

8 | Training manual for Project Management Unit Members

Types of nutrients

Facilitator asks the participants to mention the

types of nutrients they know of and examples of

food items available in their community that are

rich in each of the nutrients listed, let participants

mention as many types as they can. After the

participants provide the responses the facilitator

moves forward to provide the right information

and details as provided in the session technical

notes and ensuring there is great participation and

discussion during the process and welcoming

questions and making clarications.

Session technical notes

1. Macro (big) nutrients

These are nutrients needed in large amounts. They

include:

Carbohydrates (starches, sugars and dietary re).

Fats

Proteins

Water.

2. Micro (small) nutrients

These are needed in small amounts. There are many

of these but the ones most likely to be lacking in the

diet are:

Minerals – iron, iodine, zinc and calcium.

Vitamins – vitamin A, B-group vitamins, folate and

vitamin C.

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.

Nutrients, functions and sources

Time: 40 Minutes

1. Carbohydrates

Carbohydrates provide your body with the fuel it

needs to keep running. Depending on how quickly

they convert to sugar in the body, they can be simple

or complex, carbohydrates are mainly in form of

starches, sugars or ber.

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 ber in carbohydrates makes faeces soft and

bulky and absorbs harmful chemicals, and so helps to

keep the gut healthy. It slows digestion and absorption

of nutrients in meals, and helps to prevent obesity.

Sources of carbohydrates

Main sources of carbohydrates are:

Cereals Starchy roots and tubers

Maize/ maize our

Millet

Sorghum

Rice

Wheat our

Sweet potato

Yam / Taro

Irish potato

Fresh cassava, Cassava our

Plantain, / banana

Figure 1. Examples of carbohydrates.

Training manual for Project Management Unit Members | 9

Requirements

Requirements vary by age, gender, activity, health

status. It is recommended that a person should eat

carbohydrate rich foods 3 or more times a day.

Insufcient intake of carbohydrates results into failure

to meet body energy requirements hence the rate

of growth is reduced as well as body mass (weight)

leading to lack of sufcient energy for metabolism

and work.

Excessive consumption of carbohydrates beyond

what the body requires leads to being overweight

hence increases the risk of ailments like heart disease

and diabetes.

2. Fats and oils

The fats and oils in foods serve many important

functions such as;

Nutrient: Fat supplies essential fatty acids,

which are needed for normal growth of infants

and children and for production of hormone-like

compounds that regulate a wide range of body

functions and keep you healthy.

Transport: Fat carries fat-soluble vitamins (A, D,

E, and K) and assists in their absorption.

Sensory: Fat contributes to the smell and taste

of food.

Texture: Fat helps make foods tender (especially

meats and baked goods).

Satiety: Fat gives food satiety, so you feel full

and satised longer after a meal.

Energy: Fat provides a concentrated source of

calories. This is good if you are travelling long

distances, expending a lot of energy, and carrying

your own food.

In the body, fat has the following roles:

Fats are the body’s main form of stored energy

(important in times of illness and diminished food

intake).

Fats provide most of the energy to fuel muscular

work.

Fat pads internal organs and insulates our bodies

against temperature extremes and damage.

Fats form the major material of cell membranes

(especially brain and nerve cells).

Fats are converted to many important hormones

(including sex hormones).

Fat is a good thing! It’s only when there is too much

of a good thing that it can become problematic.

Requirements

Fat needs are expressed as ‘percent of total energy

needs’. The percent of total energy that should come

from fat in a healthy balanced diet is:

30-40 percent for children on complementary

feeding and up to the age of two years;

15-30 percent for older children and most adults;

for active adults up to 35 percent is acceptable;

At least 20 percent up to 30 percent for women of

reproductive age (15-45 years).

Consuming more fats beyond what the body needs

leads to overweight, and increases the risk of

diseases like heart diseases, high blood pressure

and diabetes.

3. Proteins

Proteins are the building blocks for muscles, organs

and many of the substances that make up our

bodies. They provide essential amino acids that

the body uses to make muscle tissue. The body

needs proteins and calories every day. Proteins also

facilitate the production of enzymes that govern the

body’s processes such as growth and digestion.

When you don’t get enough of calories and protein

everyday, your body breaks up its own supplies to

make up for the lack of energy. This robs your body of

the calories it needs to stay healthy leading to weight

loss.

10 | Training manual for Project Management Unit Members

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.”

Sources of Proteins

Protein can be found in both animal and

plant foods.

1. Animal sources

• Meats, poultry, sh, 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 2. Example sources of animal protein.

Figure 3. Example sources of plant protein.

Training manual for Project Management Unit Members | 11

Requirements

Requirements vary by age, sex, gender and activity

(see appendix 1) but the general requirement is

approximately 0.75 g per kg of body weight per day.

Not consuming enough protein leads to reduced

growth rate, loss of muscle and build-up of uid in the

body as the body breaks down the muscles to obtain

the protein and energy needed for daily functions. In

children it also leads to retarded growth and protein-

energy malnutrition.

It should also be noted that consumption of

high amounts of animal protein sources that are

accompanied with a lot of fat like meats, milk and

eggs leads to excess consumption of fat which has

negative effects.

4. Vitamins and Minerals

Vitamins include both Fat-soluble (vitamins A, D, E,

and K) and water-soluble (B-group and C vitamins).

Vitamins help the body turn food into energy and

tissues.

There are 13 vitamins in all: vitamin A; the

vitamin B complex, which includes thiamine,

riboavin, niacin, vitamin B6, folic acid, vitamin

B12 pantothenic acid, and biotin; and vitamins C,

D, E, and K.

Minerals are needed for growth and maintenance

of body structures. They also help to maintain

digestive juices and the uids found in and

around cells.

Minerals are not made by plants and animals.

Plants get minerals from water or soil, and

animals get minerals by eating plants or plant-

eating animals.

Vitamins and Minerals are also known as

constructive and protective foods; they help

to build the immune system thus reducing the

occurrence of infections and if they occur the

severity is reduced.

Micronutrients that are in shortest supply and

cause the most micro-nutrient malnutrition

worldwide are: Iodine, zinc, vitamin A, iron and

folate. Lack of vitamin A leads to night blindness,

lack of iron/folate leads to anaemia, lack of

iodine leads to goitre, lack of calcium leads to

weak bones and teeth and lack of zinc leads to

growth retardation and delayed sexual and bone

maturation.

Sources

• 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.

Figure 4. Example sources of vitamins and minerals.

12 | Training manual for Project Management Unit Members

Requirements

Vitamins and minerals are required in small quantities.

Requirements are based on age, sex and activity

level but consumption of a variety of fruits,

vegetables and whole grains.

The best way to make sure we get enough of

each micronutrient and enough bre is to eat a

variety of vegetables and fruits and whole grains

every day.

5. Water

Water just may be the most important nutrient. In fact,

the body is more than half water. You can live without

food for several weeks, but you can go less than a

week without water.

The body needs water to function. It is necessary for

Maintaining body temperature;

Transporting nutrients throughout the body;

Keeping joints moist;

Digesting food;

Ridding the body of waste products.

(Think of the use of water when building a house,

without the water, the cement, sand and concrete will

not be useful.)

Sources

Water;

Fruit Juices;

Soup;

Milk;

Porridge;

Non-caffeinated drinks (caffeinated and alcohol

beverages contain diuretic substances that cause

the body to lose water).

Requirements

1.5 liters/day or 8 glasses a day

Not drinking enough water leads to constipation,

dehydration, dry skin, and build-up of toxins in the

body.

Training manual for Project Management Unit Members | 13

2.0 Recommended feeding practices

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

participants their understanding of the concepts below,

1. What is a balanced diet/meal?

2. Do the different family members (age group and condition) have

the same food needs?

After the participants provide the responses the facilitator

moves forward to provide the right denition and details as

provided in the session technical notes and ensuring there

is great participation and discussion during the process and

welcoming questions and making clarications.

Session technical notes

Balanced meal

A balanced diet provides the correct amounts of food energy and

nutrients needed during the day to cover the dietary requirements of

the person eating it. A balanced diet must be composed of a variety

of different foods from different food groups so that it contains all

the many macronutrients and micronutrients the person needs in

sufcient quantities.

A good meal should contain:

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.

Learning Objectives

At the beginning of the session

the facilitator is expected to

understand the entry level

knowledge and behavior of

participants regarding the session

content.

At the end of this session

participants are expected to:

Know how to plan for a balanced

meal

Understand the food pyramid

concept when planning and

serving meals

Briey describe the main

differences between the food

needs for the different family

members

Time: 60 minutes

Materials needed: Flip chart board, Flip chart, Marker pens, Block notes

14 | Training manual for Project Management Unit Members

+Calcium, Vitamin D

Vitamin B - 12

Supplements

Fats, Oils and Sweets

(use spairingly)

Milk, Youghut and

cheese group (1 glass

of milk / 1 medium

cup youghut)

Vegetables group

The servings for the

day are equivalent

to (Approximately 2

cupped palms cooked

leafy vegetables)

Meat, Poultry, sh, Dry

beans and nuts group

(2 boiled eggs/cooked sh,

meat or chicken / 2 cupped

palms of cooked beans)

Fruits group

(2 medium bananas /

2 medium pieces of

pawpaw, mango)

Water - (2 litres / 6-8 glasses of uid per day) This includes the water, juices or soup taken

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)

Encourage families to use:

Several groups of foods at each meal.

Different vegetables and fruits at different meals

because different vegetables and fruits contain

varying amounts of the different micro-nutrients.

The more colors consumed the better.

Serve meat, poultry, and offal or sh daily if

possible because these foods are the best

sources of iron and zinc (which are often lacking

in diets, especially the diets of young children and

women).

Snacks

Snacks are foods eaten between meals.

Below are examples of foods that make good

snacks

Fresh milk, soured milk, yoghurt, cheese, roasted

groundnuts, soybeans, melon seeds, sesame

seeds, eggs, fried sh, bread, boiled/roasted

maize cob, boiled or roasted cassava, plantain,

yam, sweet potato, bananas, avocado, tomatoes,

mangoes, oranges, pawpaw, passion fruits.

Eating snacks like these is a good way of improving

a diet which may lack food energy and nutrients.

However, frequent eating (snacking) throughout the

day increases the risk of tooth decay, particularly

where oral hygiene is poor. This is particularly true for

articially sweetened snacks that stick to the teeth. It is

better to eat the fruit than make juice as many people

discard the ber in the fruits when making juice.

The Food Pyramid

Although your food intake varies from meal to meal

and from day to day, keeping a balanced view of your

diet is a good idea. The food pyramid (see gure 5) is

meant to be a guideline not rigid set of rules.

Figure 5. The food pyramid.

(Source: Modied from the Food Guide Pyramid; Centre for Nutrition Policy and Promotion CNPP, 2009)

Training manual for Project Management Unit Members | 15

It is healthy to eat more of the foods from the bottom

levels of the pyramid and fewer of those from the top.

The top of the pyramid is for foods that should be

consumed in small quantities because large amounts

are not good for the body.

The Food Pyramid as a guide helps to promote

the 3 basic rules for a healthy diet:

• Variety

• Balance

• Moderation

Variety means that you must include many different

foods from each level of the Food Pyramid because

no single food can supply all of the nutrients that your

body needs on a daily basis. This can help to expand

your food choices. It is best to eat foods of all colours.

The more colours and textures in your daily meals, the

better range of nutrients you’ll get. You can choose to

vary different foods in a day or aim to vary different

foods across a whole week.

Balance means that you must eat the right amounts

of foods from all levels of the Food Pyramid each day.

This way you will get all the calories and nutrients you

need for proper growth and development.

Moderation means that you are careful not to eat too

much of any one type of food.

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

enough food to supply the extra energy, protein,

vitamins and minerals needed by the growing fetus

or baby during breastfeeding. Her meals must be

balanced.

Early initiation of breastfeeding (within the rst 30

minutes of delivery) whether at hospital, at home,

or at the midwife’s, and give colostrum to the baby.

Colostrum protects infant from disease by providing

the infant’s rst vaccine

Exclusive breastfeeding of all children below 6

months of age. Breast milk provides all the nutrients

needed to satisfy huger and promote growth

No other foods or drinks should be given to children

below 6 months of age. This reduces infections and

diarrhoea

Children at 6 months and above should be given a

balanced diet in addition to the breast milk. These

foods should not be too thin as they will not provide

enough nutrients.

Continue breast feeding up to at least 2 years of

age even as you provide other foods

If a child is sick, encourage them to eat and

drink, even if they have little appetite. Increase

breastfeeding frequency, provide more uids (water,

juice, soup)

Ensure the diet includes foods rich in protein,

vitamin A and iron to ensure the child’s growth

Obtain vitamin A supplementation for children under

5 years from the health centre

Deworm all children every 6 months starting at 2

years

Ensure that children are fully immunized and keep

the health card/book safely

Use iodized salt in the home for the whole family.

Iodine promotes physical development and

prevents miscarriages

Have a backyard garden with different green leafy

vegetables to provide the vegetables needed by the

family throughout the year

Important nutrition points to remember

16 | Training manual for Project Management Unit Members

3.0. Malnutrition

Method: Presentations and discussion

Activity 1: Brainstorming, question and answer as slides are

presented.

The facilitator asks the participants to mention their understanding

of the term malnutrition. The responses on a ip chart and the then

gives the right content as detailed in the session technical notes.

Session technical notes

Malnutrition is the condition that develops when the body does not

get the right amount of the nutrients it needs to maintain healthy

tissues and organ function.

Under Nutrition

Under nutrition is a deciency of food energy or nutrients, which

leads to nutrient deciencies. It is caused by inadequate intake or

poor absorption of nutrients in the body. Acute malnutrition, chronic

malnutrition, stunting, wasting, and underweight and micronutrient

deciencies occur because of undernutrition, and they can have

serious consequences on the development and health of infants

and young children. Undernutrition is one of the leading causes of

mortality for young children across the globe and is often caused

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 inuence underlying causes of malnutrition

(see gure below).

Learning Objectives

At the beginning of the session

the facilitator is expected to

understand the entry level

knowledge of participants

regarding the session content.

At the end of the session, the

participants should be able to:

Identify kinds of malnutrition in

their community

Understand causes of the kinds of

malnutrition in their community

Understand the consequences of

malnutrition in the community

Share actions they can take

to prevent malnutrition among

children and women

Time: 60 minutes

Materials needed: Photos of children with different clinical signs of malnutrition

Training manual for Project Management Unit Members | 17

Figure 6: showing conceptual framework of malnutrition (UNICEF, 1991)

Figure 7: Comparison of a

normal and stunted child

(UNICEF 2014)

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.

Conceptual framework for analysing the causes of

malnutrition

Malnutrition,

death & disability

Inadequate

dietary intake

Outcomes

Immediate

causes

Basic causes at

societal level

Underlying

causes at

household /

family level

Insufcient

access to FOOD

Inadequate

maternal & child

CARE practices

Quantity and quality of actual resources - human, economic &

organisational - and the way they are controlled

Potential resources: environment, technology, people

UNICEF

Poor water,

sanitation &

inadequate

HEALTH services

Disease

18 | Training manual for Project Management Unit Members

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 deciencies

i. Iron deciency 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 deciency may lead to iron deciency anaemia, a condition experienced when the body is not making

enough haemoglobin.

• Signs of iron deciency 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 deciency during early childhood can impair physical and cognitive development.

Signs of anaemia can be seen in the gure 8 below.

Figure 8: clinical signs of anemia (source-UNICEF 2014)

Training manual for Project Management Unit Members | 19

Figure below showing Bigot’s spots, whitish

patchy triangular lesions on the side of the eye.

Figure 9: Picture showing Bigot’s sport in a person

with vit A deciency (source-UNICEF 2014)

• Vitamin A helps keep eyes healthy, promotes vision, and

provides protection against infection.

• Vitamin A is needed by the tissues that line our lungs,

gastrointestinal tract and eyes.

• Without adequate vitamin A, these tissues are

susceptible to bacterial invasion; as such, deciency is

associated with frequent illness and severe deciency

may result in blindness.

• Signs of vitamin A deciency include night blindness,

Bigot’s spots and keratomalacia (in order of severity).

• This deciency is associated with high rates of

respiratory and diarrheal infections.

• 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 deciency.

• Severe maternal iodine deciency can result in

cretinism, whereby the child is born with severe physical

and mental retardation.

• Less severe forms of iodine deciency in young

children can cause mental decits such as lower mental

development, lower cognitive function and reduced

ability to focus.

• Goitre is reversible whereas cretinism is irreversible.

ii. Vitamin A deciency

iii. Iodine deciency disorder

Figure 10: Picture showing goitre as an advanced

sign of iodine deciency (source-UNICEF 2014)

Over nutrition

Overnutrition is an excess consumption of energy and

nutrients. It can lead to overweight and obesity.

Being overweight or obese increases the likelihood of

having diabetes and heart-related diseases like high

blood pressure.

Overweight and obesity ranges are determined by

using weight and height to calculate a number called

the body mass index (BMI). An adult who has a BMI

between 25 and 29.9 is considered over weight and

an adult who has a BMI of 30-35 is considered obese

and an adult with a BMI of 40 or more, or 30 or more.

BMI is established through dividing weight in kg by

height (cm) squared.

20 | Training manual for Project Management Unit Members

3.3 Cycle of malnutrition

The consequences of malnutrition in an individual

can extend to later in life. In addition, the effects

can also affect future generations. This particularly

occurs for women, where their nutrition status affects

the unborn child. A stunted girl is likely to become a

stunted adolescent and later a stunted woman. This

affects her health, productivity, and nutrition. Which

in turn increases the chance that her children will be

born malnourished. Which continues the cycle. It is

therefore important that interventions to address and

prevent malnutrition are taken at each stage of the life

cycle.

An illustration of the cycle of malnutrition

ADOLESCENTS

Stunted growth

Decreased physical

capacity

The Cycle of Undernutrition

Inadequate food

and health care

Inadequate food

and health care

Inadequate food

and health care

Frequent infections

PREGNANT WOMEN

Low weight gain

Increased maternal

mortality

INFANTS

Low birth weight High

mortality rate Impaired

mental development

Increased risk of adult

chronic disease

ADULT MEN AND

WOMEN Poor health

Poor productivity in the

work force

CHILDREN

Stunted growth

Impaired immunity

Reduced mental

capacity

3.4 Prevention of undernutrition

• Promotion of exclusive breastfeeding and

continued breastfeeding up to 2 years and beyond

• Appropriate complementary feeding practices

• Supplementation with Vitamin A and iron/folic acid

• Immunization and deworming

• Promotion of maternal nutrition

• Appropriate water, sanitation and hygiene

practices

• Growth Monitoring and Promotion

At the end of the session, let the facilitator ask

whether there are any additional questions or

points of clarication. After all clarications are

made (if any), the facilitator closes the session

and mentions the next session and its facilitator.

Training manual for Project Management Unit Members | 21

How to Prevent Malnutrition in Our

Communities

Feeding young children

• All new born babies should be put on the breast

within one hour of birth

• New born babies should be fed only on breastmilk

and not given any other food/drink (like animal

milks, tea, water, soup, porridge, soda, juice, etc.)

until they are six months old.

• When babies are six months old, they should

continue to be given breast milk AND also fed with

other nutritious foods 3 to 4 times daily.

• The foods for young children must contain:

Fruits (like avocado, pawpaw, mangoes, ripe

bananas)

Vegetables (like mashed dodo/amaranth,

spinach, [young] deep greeny leafs),

Pulses/legumes (like beans, peas, soy),

• Baby porridge should be enriched with avocado,

groundnuts, mukene, ripe sweet bananas,

• Mashed pumpkin or Irish-potatoes are good foods

for a young child. These foods can be enriched

with avocado, groundnuts, mukene, soy our,

fortied cooking oil, meats)

• Babies should be fed on 1 or 2 snacks between

meals (this can include, papaw, orange eshed

sweet potato, ripe bananas, mangoes, tomatoes.

Keep clean and hygienic

• Use toilets to defecate and throw children’s faces

• Wash hands before food preparation/cooking,

before feeding/eating and after visiting the toilet

• Keep compounds around the home clean, sweep

all wastes, faecal matter, droppings of animals

and get rid of stagnant water

• Always have treated water in the home (boiled or

chlorinated) for drinking. Drink only treated water.

Seek appropriate health care

• Attend the clinics (for antenatal, immunization,

supplementation, deworming, check-ups)

• Immediate treatment of fever (high temperature),

diarrhea, poor (difcult) breathing, poor eating/

breastfeeding

• Seek advice on child spacing and family planning

Mitigate emergencies

• Prepare savings to build wealth and deter

emergencies

• Invest in productive assets (livestock, businesses,

better seeds and farming inputs)

• Plant fruits (avocado, papaw, etc) and vegetables

(pumpkin, amaranth, orange eshed sweet

potato, traditional vegetables)

Gender

• Have cohesion in the family to work together and

make decisions together for improved feeding,

health and wealth in the family

22 | Training manual for Project Management Unit Members

4.0 Food safety and hygiene

Method: Presentations and discussion

Activity 1: Brainstorming, question and answer as slides are

presented.

The facilitator asks the participants to mention their

understanding of the terms mentioned below, writes the

responses on a ip chart and then gives the right content as

detailed in the session technical notes.

1. Mention any 5 practices related to good personal hygiene.

2. What do you understand by safe storage of food (raw) and

water?

3. Name three important practices in preparing, cooking and

storing food safely.

The facilitator takes 10 minutes to wrap up the session, making

any clarication needed. Supplement the points they share

with points from the manual if they have not been mentioned

Session technical notes

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, ies 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.

Learning Objectives

At the beginning of the session

the facilitator is expected to

understand the entry level

knowledge and behavior of

participants in regard to the

session content.

By the end of the chapter, learners

should be able to:

List at least four practices

importance in good personal

hygiene;

Practice good hygienic during food

preparation, cooking and storage

Time: 60 minutes

Materials needed: Flip chart, Flip chart, board, Marker pens, Block notes

Training manual for Project Management Unit Members | 23

To help families have clean, safe foods and drinks:

• Find out about disposal of feaces, hand washing

practices, the source and storage of water and

ways in which food is prepared. This helps you

identify ways in which germs may be reaching

food and water, and foods in which germs may

be breeding.

• Suggest practical ways to improve water and food

hygiene. Some of the suggestions listed below

may be relevant and useful. But remember not to

overburden families with too much advice.

Clean and safe water

Advise families to:

• Use safe water, such as treated pipe water, or

water from a protected source, such as a borehole

or protected well. If the water is not safe, it should

be boiled (rapidly for one minute) before it is drunk

or used in uncooked foods (e.g., fruit juices).

• Use clean, covered containers to collect and store

water.

• Use clean materials to lter your water in need

be.

• Use clean utensils to serve and drink water.

Buying and storing food

Advise families to:

• Buy fresh foods, such as meat or sh, on the day

they will eat them. Look for the signs of poor-

quality food.

• Cover raw and cooked foods to protect them from

insects, rodents and dust.

• Store fresh food (especially foods from animals)

and cooked foods in a cool place, or a refrigerator

if available.

• Keep dry foods such as ours and legumes in a

dry, cool place protected from insects, rodents

and other pests.

• Avoid storing leftovers for more than a few hours

(unless in a refrigerator). Always store them

covered and reheat them thoroughly until hot and

steaming (bring liquid food to a rolling boil).

Preparing food

Advise people preparing food to:

• Keep food preparation surfaces clean. Use clean,

carefully washed dishes and utensils to store,

prepare, serve and eat food.

• Prepare food on a clean table where there is less

dust.

• Wash vegetables and fruits with clean/safe water.

Peel if possible.

• Prevent raw meat, offal, poultry and sh from

touching other foods, as these animal foods often

contain germs. Wash surfaces touched by these

raw foods with hot water and soap.

• Cook meat, offal, poultry and sh well. Meat

should have no red juices.

• Boil eggs so they are hard. Do not eat raw or

cracked eggs.

• Boil milk unless it is from a safe source. Soured

milk may be safer than fresh milk.

Hygiene around the home

Advise families to:

• Keep the surroundings of the home free from

animal faeces and other rubbish.

• Keep rubbish in a covered bin and empty it

regularly in appropriate places (pits, compost) so

as not to attract ies.

• For easy waste management separate the waste

such as plastic, glass, paper and food/plant

remains.

• Make compost for the garden with suitable

waste food, garden rubbish and animal faeces.

Composting destroys germs in faeces. The

compost pit should be at least partially shaded

and at least 2 feet from a structure like your house

or a fence. It should be at a place convenient

for you to add materials, access to water and

good drainage. In addition you should take into

consideration the direction of the wind so that the

smell or odors doesn’t come to the house.

24 | Training manual for Project Management Unit Members

Toxins and chemicals

Food and water is unsafe if it contains toxins or

dangerous chemicals. A toxin called “aatoxin” is

produced by a molds that grows on cereals and

legumes. Eating aatoxin can make someone

seriously ill. Moulds should be prevented from growing

on any food items and this can be done by drying crops

thoroughly and storing them in a dry place. People

should desist from eating moldy foods or giving them

to animals but these can be added to compost.

Pesticides and other harmful agricultural chemicals

may get into food or water and cause poisoning if:

• The chemical is not used in the recommended

way;

• The empty containers are used for food or water.

Advise people to:

• Follow carefully the instructions for using

chemicals;

• Be strict about keeping chemicals away from

children;

• Never put food or water into containers that have

been used for chemicals;

• Wash hands after using chemicals, and wash any

foods (e.g., Fruit) that have been sprayed with

them.

Activity

Discuss steps that can be taken to put these

recommendations into practice.

Training manual for Project Management Unit Members | 25

5.0 Food and nutrition assessment

Method: Discussion/question/answer

Dietary assessment part I

Activity:

The facilitator asks for a volunteer among the participants. The

participant shares what they (or their household) consumed the

day before the training started. Sharing all foods eaten and drunk.

The facilitator probes for in-between meals, and details of the foods

consumed.

The facilitator then uses this example to show the participants

how to determine the dietary diversity scores whether household

of individual i.e. Minimum dietary diversity score for women.

The facilitator used the food groups discussed earlier and works

together with the participants to establish whether the example

sites meets the required diversity. About 2-3 other volunteers

with one describing how they fed their child is done to ensure

understanding on how to determing whether different household

members are meeting the required dietary diversity. The session’s

technical notes are used to provide details on the dietary diversity

indicators and make any clarications needed.

Session technical notes

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 difcult 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) reects 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.

Learning Objectives

At the beginning of the session

the facilitator is expected to

understand the entry level

knowledge of participants in

regard to the session content.

At the end of this session

participants are expected to:

Describe the common dietary

assessment methods and dietary

indicators to measure dietary

adequacy

Demonstrate ability to use

common anthropometric

equipment to take accurate

measurements

Use a combination of

anthropometric measurements

to determine nutritional status of

individuals

Time: 60 minutes

Materials needed: Flip chart, Flip chart, board, Marker pens, Block notes, Height board, MUAC

tapes, Weighing scale

26 | Training manual for Project Management Unit Members

Assessment of household dietary diversity involves

nding out the different foods consumed by the

household over a period of 24 hours. This covers

only foods consumed at home and excludes foods

purchased and eaten outside the home. After

establishing the different foods consumed, the foods

are grouped into the respective food groups. For

measuring household dietary diversity, 12 standard

food groups are used as listed below. 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 considered

high dietary diversity.

Food groups are: Cereals; White roots & tubers, and

bananas; Fruits; Vegetables; Meat and meat products;

Eggs; Fish; Milk and milk products; Legumes, nuts and

seeds; Oils or fats; sweets and sugars; condiments,

spices and other beverages.

Individual dietary diversity score (IDDS)

Individual dietary diversity scores aim to reect nutrient

adequacy. An increase in individual dietary diversity

score is related to increased nutrient adequacy of the

diet. Individual scores are preferable to household

scores because they provide more specic reection

of the quality of the diet and status of nutrition.

When assessing individual dietary diversity, the foods

consumed by the individual over a 24-hour period are

established. This included all food eaten or drunk both

at home and away from home. After establishing the

different foods consumed, the foods are grouped into

the respective food groups. 12 food groups are used,

similar to those for household dietary diversity above.

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

considered high dietary diversity.

Dietary diversity of women

Minimum Dietary Diversity Score for Women

(MDDS-W)

The Minimum Dietary Diversity Score for Women is a

food group diversity indicator that has been shown to

reect an additional key dimension of diet quality that

is micronutrient adequacy. The foods consumed over

a 24-hour period are established including all food

eaten or drunk both at home and away from home.

After establishing the different foods consumed, the

foods are grouped into 10 food groups.

Consumption of foods from any 5 food groups and

above indicates meeting minimum dietary diversity.

Food groups are: 1. All starchy staples; 2. Beans peas;

3. Nuts and seeds; 4. Dairy; 5. Flesh foods (meats); 6.

Eggs; 7. Vitamin A rich dark green leafy vegetables;

8. Other vitamin A rich vegetables and fruits; 9. Other

vegetables; 10. Other fruits.

Children dietary diversity

i. Minimum meal frequency (MMF)

This is a proxy for the child’s energy requirements

and is based on how much energy the child needs

whether breast fed or not.

Breastfed children are considered to be fed with a

minimum meal frequency if they receive solid, semi

sold or soft foods at least twice a day (6-8 months) or

at least 3 times a day (9-23 months)

Non-breastfed children aged 6-23 months are

considered to be fed with a minimum meal frequency

if they receive solid, semi sold or soft foods at least 4

times a day

It is measured as a proportion of breastfed and non-

breastfed children 6–23 months of age who receive

solid, semi-solid, or soft foods (but also including

milk feeds for non-breastfed children) the minimum

number of times or more.

Calculation of the proportion of women with minimum

dietary diversity

ii. Minimum dietary diversity (MDD)

This indicator looks at food groups a child eats.

This indicator is a measure for adequate macro and

micronutrients and diet variety other than breastmilk.

Their diet is assessed based on 8 food groups. If a child

eats at least four or more food groups, it is assumed

Breastfed children 6-23 months of age

who received solid, semi-solid or soft foods the minimum number of times or more during the previous day

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

Breastfed children 6-23 months of age

Non-breastfed children 6-23 months of age

Training manual for Project Management Unit Members | 27

that the child has met his/her dietary diversity.

Food groups are: grains, roots and tubers (millet,

cassava, potatoes, rice, yams); eggs; legumes & nuts

(beans, ground nuts, peas, Soya bean); fresh foods

(meat, sh, poultry, organ meats); Vitamin A rich fruits

& vegetables (Carrots, mangoes, pawpaw) and other

fruits and vegetables (banana, passion fruits, jack

fruit, pineapple).

It is measured as a proportion of children 6–23 months

of age who receive foods from 4 or more food groups

(the number of children 6-23 months who receive

foods from 4 or more food groups divided by the total

number of children aged 6-23 months).

Calculation of the proportion of children with minimum

dietary diversity

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

receive a minimum acceptable diet (apart from breast

milk). This indicator measures both the minimum

feeding frequency and minimum dietary diversity, as

appropriate for various age groups. If a child meets

the minimum feeding frequency and minimum dietary

diversity for their age group and breastfeeding status,

then they are considered to receive a minimum

acceptable diet. Minimum is considered as follows:

- 2 times for breastfed infants (6-8months

- 3 times for breastfed children (9-23months)

- 4 times for non-breastfed children/infants

Meal is dened as any solid. Semi-solid or liquid food

given to the child alone or within a composite dish

within the previous day.

Breastfed children 6-23 months of age who had at least

the minimum dietary diversity and the minimum meal frequency during the previous day

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

This composite indicator will be calculated from the following two fractions:

Breastfed children 6-23 months of age

Non-breastfed children 6-23 months of age

Dietary diversity indicators

Dietary assessment is a process of evaluating what

people eat by using one or several intake methods.

The assessment includes asking the client about

eating patterns like quantity of food eaten at each

meal, food groups eaten each day. There are different

methods of assessing diet which include;

1. The 24-hour recall where the facilitator mentioned

that you asks client/caregiver to recall and describe

all foods and beverages consumed in preceding

24 hours/previous day and records

2. Dietary history which is about usual food intake

including meal patterns, common foods and food

groups

3. Direct observation where she mentioned that

intakes are watched and recorded The facilitator

then explains Food consumption indicators and

how they are measured.

28 | Training manual for Project Management Unit Members

Household Food Insecurity and access Scale

(HFIAs); The aspect of food insecurity measured

by HFIES is a condition by which people are unable

to access food and the severity of food insecurity

condition is manifested by certain food related

experiences and behaviours.

HFIES can be assessed using a set of questions

below

No. Occurrence Questions

1 In the past four weeks, did you worry that your

household would not have enough food?

2 In the past four weeks, were you or any house-

hold member not able to eat the kinds of foods

you preferred because of a lack of resources?

3 In the past four weeks, did you or any household

member have to eat a limited variety of foods

due to a lack of resources

4 In the past four weeks, did you or any household

member have to eat some foods that you really

did not want to eat because of a lack of resourc-

es to obtain other types of foods?

5 In the past four weeks, did you or any household

member have to eat a smaller meal than you

felt you needed because there was not enough

food?

6 In the past four weeks, did you or any house-

hold member have to eat fewer meals in a day

because there was not enough food?

7 In the past four weeks, was there ever no food

to eat of any kind in your household because of

lack of resources to get food?

8 In the past four weeks, did you or any household

member go to sleep at night hungry because

there was not enough food?

9 In the past four weeks, did you or any household

member go a whole day and night without eating

anything because there was not enough food?

5.1 Household food security indicators and

measurement

Time: 20 minutes

Materials needed: Weighing scale, Height board,

MUAC tapes

Method. Presentation and discussion

Activity:

After explaining minimum meal frequency, minimum

dietary diversity and minimum acceptable diets for

children, the facilitator presents the following children

in different households. All children are 1 year old and

are breast fed. And below are the number of meals

and number of food groups they consumed.

The facilitator reviews the rene points for each of

these indicators for the example as shown in the table

The facilitator then asks the participants if the

minimum meal frequency, minimum dietary diversity,

and minimum acceptable diets have been met for

each of the children. Placing an X or √ (for yes or no)

Table showing child dietary diversity score

exercise

Minimum

meal

frequency

Minimum

dietary

diversity

Minimum

acceptable diet

Reference 3 times a

day

4 food

groups

Has both

minimum meal

frequency,

minimum dietary

diversity

1 2 (No) 4 (yes) No

2 3 (yes) 3 (no) No

3 4 (yes) 3 (no) No

4 3 (yes) 5 (yes) Yes

5.2 Anthropometric assessment

Time: 60 Minutes

Method: Presentations and discussion

Activity:

After nutrition indicators and after the introduction of

the section on anthropometric indicators

Facilitator requests for 5 Participants to volunteer,

and each volunteer is allocated a measurement.

Facilitators take 10 minutes teaching the volunteers

how to take the respective measurements. Volunteers

take 10 minutes to practice taking the measurements.

Training manual for Project Management Unit Members | 29

The activity allows participants to cover the

anthropometric measurements, how they are

made and how the results are interpreted .The

measurements to be taken will include:

1. MUAC

2. Weight

3. Height

4. Length

Each group then takes 5 minutes to present how to

take the measurements to the rest of the participants.

The rest of the participants then take 15 minutes

practicing the other measurements.

Following this, the facilitator takes 10 minutes

explaining the growth charts and how to plot the

measurements to determine the nutrition status

(stunting, underweight). Participants are given the

examples below to practice how to plot and interpret

the results. (participants are asked to give the status;

therefore the facilitator does not mention whether the

sample children below are stunted, underweight or

normal). Note those at risk of malnutrition, moderately

malnourished, severely malnourished, and normal

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

2. Normal height for age child: (i) a girl, 1 year and 8

months old, 79cm. (ii) a boy, 9 months, 73.5cm

3. Underweight child: (i) a boy, 6 months, 6kg. (ii) a

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

Session technical notes

Household food insecurity experience scale (HFIES)

This indicator gives a measure of access to food at

the level of individuals or households. It measures

severity of food insecurity based on people’s

responses to questions about constraints on their

ability to obtain adequate food.

It is based on the 8 questions shown below.

Table showing questions used to assess

household food insecurity

1 Worry that you would not have enough food

because of a lack of food, money or other

resources?

2 Not able to eat healthy and nutritious food

because of a lack of food, money or other

resources?

3 Eat a limited variety of food because of a lack of

food, money or other resources?

4 Skip a meal because of a lack of food, money or

other resources?

5 Eat a smaller meal than you felt you needed

because of a lack of food, money or other

resources?

6 Have no food to eat of any kind in your household

of a lack of resources to get food?

7 Were hungry but not able to eat of a lack of

resources to get food?

8 Go a whole day without eating anything at all

because of a lack of resources to get food?

The answers are placed on a scale of severity of food

insecurity as shown below:

Mild food insecurity Severe food insecurity

Uncertainty regarding

ability to obtain food

Compromising on food

quality and variety

Reducing food quantities,

skipping meals

Experiencing

hunger

Household hunger scale (HHS)

Most appropriate to use in areas of substantial

food insecurity essentially a behavioural measure,

captures more severe behaviours. It is based on 3

main questions:

• Was there ever no food to eat of any kind in your

house because of lack of resources to get food?

• Did you or any household member go to sleep

at night hungry because there was not enough

food?

30 | Training manual for Project Management Unit Members

• Did you or any household member go a whole

day and night without eating anything because

there was not enough food?

For each of the questions one asks how often the

occurrence was observed: never (0 times), rarely (1

or 2 times), sometimes (3-10 times, and often (more

than 10 times).

One can either choose to use the HFIES or the HHS

based on the context.

Nutrition status assessment

1. Time: 60 Minutes

2. Method: Presentations and discussion and

demonstrations

Activity:

The facilitator introduces the section on nutrition

status assessment. The facilitator explains that

good nutrition care starts with good assessment

of the nutritional status. The facilitator explains

various methods of assessment which include;

anthropometry, dietary, clinical and biochemical

methods. The facilitator then gives introductory

paragraph about several methods, biochemical

and anthropometric and scope of this manual in

relation to the projects

Participants form 2 groups, and each group is

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.

Technical session notes

Anthropometry is the measurement of the human

body’s physical dimensions. The measures are used

to establish the nutrition status of individuals and

populations.

Height / length

1) Height

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

measurements

• Set the measuring board vertically on a stable

level surface.

• Remove the child’s shoes and any head-covering.

• Place the child on the measuring board, standing

upright in the middle of the board.

• The child’s heels and knees should be rmly

pressed against the board by the assistant while

the measurer positions the head and the cursor.

The child’s head, shoulders, buttocks, knees and

heels should be touching the board.

• Read and announce the measurement to the

nearest 0.1cm.

• Record and repeat the measurement to the

measurer to make sure it has been correctly

heard

Training manual for Project Management Unit Members | 31

Headpiece rmly 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

Assistant on knees

Right hand on shins

heels against back and

base board

Line

of sight

Questionnaire and pencil on

clipboard on oor or ground

Figure 12. Measuring the height in children below 2 years of age.(source: Modied from multiple indicator cluster surveys)

32 | Training manual for Project Management Unit Members

1) Length

This measurement is taken for children below two

years of age and/or for those who are less than 85 cm

or unable to stand.

• Place the measuring board horizontally on a at,

level surface.

• Remove the child’s shoes and any head covering.

• Place the child so he/she is lying down and face

up in the middle of the board.

• Allow the assistant to hold the sides of the child’s

head and position the head until it is touching the

head board.

• Allow the measurer to place his/her hands on the

child and rmly hold the child’s knees together

while pressing down. The soles of the feet should

be at on the foot piece, toes pointing up at right

angles.

• The measurer should immediately remove the

child’s feet from contact with the footboard with

one hand while holding the footboard securely in

place with the other.

• Read and record the measurement as shown in

diagram above

Figure 13.Figure 2.Measuring the length of a child below 2 years of age.(source: Modied from multiple indicator cluster surveys)

MEASURE

ON KNEES

3

2

5

8

9

6

7

1

ASSISTANT

ON KNEES

ARMS COMFORTABLY

STRAIGHT

HAND ON KNEES OR SHINS:

LEGS STRAIGHT

HAND CUPPED OVER EARS:

HEAD AGAINST BASE OF BOARD

QUESTIONNAIRE AND PENCIL ON CLIPBOARD

ON FLOOR OR GROUND

CHILD FLAT ON BOARD

LINE OF SIGHT

PERPENDICULAR TO

BASE OF BOARD

FEET FLAT

AGAINST

FOOT PIECE

Training manual for Project Management Unit Members | 33

Weight

Because of its complexity and proneness to mistakes,

taking the measurement need to be trained on how to

use the equipment and that there is a need to do more

than 1 measurement to catch any errors.

Taking weight of a child on a oor scale.

1. Place the electronic scale on a at, level surface

2. Check and readjust the weight reading to zero

3. Undress the child

4. Make him/her stand on the middle of the scale’s

surface

5. When the child is settled and the weight reading is

stable record the weight to the nearest 100g. Make

sure that nobody holds the child during weighing

and that the child stands freely without holding

onto anything

6. Read and announce the value from the scale. The

assistant should repeat the value for verication

and record it immediately

Taking weight of a child on a oor scale with an

adult

1. Place the electronic scale on a at, level surface

2. Check and readjust the weight reading to zero

3. Undress the child

4. Ask the caregiver to stand on the scale’s surface

in the middle and record their weight to the nearest

100g when the caregiver is settled and the weight

reading is stable. This is the weight of the adult

5. Zero the scale using the appropriate button

6. Hand the child to the caregiver when the scale

reads 0kg

7. When the caregiver is settled with the child and the

weight reading is stable record the weight to the

nearest 100g. This is the weight of the child.

8. Read and announce the value from the scale. The

assistant should repeat the value for verication

and record it immediately.

Age

The age should be recorded as accurate as possible

so that the correct cut off can be used to determine

nutrition status.

The age can be determined from ofcial documents

(health card, immunization card, and birth certicate).

If ofcial documents are not available, use a local

calendar of events to determine the month and year

of birth.

If a child’s length or height is less than 110 cm or if the

child cannot touch his/her ear with the opposite hand

by extending the arm over the head, he/she should be

treated as under 5 years.

Using the weight, height, and age measurements

The age of the child, together with the weight and

height are used to determine if the child is well

nourished, under or over nourished.

Stunting: height and age

Underweight: weight and age

Wasting: weight and height

The above measurements are compared against

WHO Child Growth Standards to determine the status

of the child

Charts

There are different charts, and different charts for

assessing stunting, underweight, and wasting; for

boys and girls; and for different ages.

For each chart, a child has normal height for age or

weight for age or weight for height, if their results are

plotted between the 2 and -2 lines.

If the results are plotted below the -2 line, they are

stunted, underweight or wasted.

If their results are below the -3 line, they are severely

stunted, underweight or wasted.

34 | Training manual for Project Management Unit Members

Figure showing weight for age growth chart for girls aged 0 to 2 years

Z-scores

The results can be analysed using tables or software

to establish the score for each child. If the score is

below -2, it means the child is malnourished.

Table 4: Interpretation of Z score

Index Cut off Indication

Stunting

Height for

Age

Less the -2 Stunted

Less than -2 and

more than or

equal to -3

Moderately

stunted

≤-3 Severely stunted

Underweight

Weight for

Age

Less the -2 Underweight

Less than -2 and

more than or

equal to -3

Moderately

underweight

≤-3 Severely

underweight

Index Cut off Indication

Wasted

Weight for

Age

Less the -2 Wasted

Less than -2 and

more than or

equal to -3

Moderately

wasted

≤-3 Severely wasted

Mid Upper Arm Circumference (MUAC)

MUAC tape is used to screen for wasting among

children and women. The tape has three colors: The

red indicates the child has severe acute malnutrition.

The yellow indicates the child has moderate acute

malnutrition. The green indicates the child has normal

nutritional status.

Training manual for Project Management Unit Members | 35

STEP 1:

STEP 2:

STEP 3:

How to measure MUAC

Figure 14: Measuring MUAC of a young child (Source-UNICEF 1991)

Ask the mother/caregiver to remove any clothing that may cover

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.

Bend the arm at 90. Estimate the midpoint of the upper arm

by locating the tip of the shoulder and tip of the elbow.

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 at around the skin.

36 | Training manual for Project Management Unit Members

STEP 4:

STEP 6:

STEP 5:

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.

Immediately record the measurement and colour code

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.]

Table 5: Understanding the MUAC results

MUAC tape

Colour

Meaning RECOMMENDATION

RED • Child has severe acute malnu-

trition and high risk of death if

they have another disease

• Needs immediate healthcare

• Referral to the nearest healthcare facility immediately

• Follow-up (in 3 days) to ensure the child has been

taken to the health facility

• Come to measure MUAC again after 2 weeks

YELLOW Child has moderate acute mal-

nutrition and risk of becoming

severely malnourished

• Advise to have all diseases and infections treated

• If child is < 2 years to continue breastfeeding

• 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

Training manual for Project Management Unit Members | 37

Oedema

Oedema is a build-up of uids in the tissues causing

abnormal swelling of the hands and feet or other

body parts. The body requires nutrients for various

processes that lead to normal uid balance. Oedema

caused by malnutrition has to occur in both limbs at

the same time.

Measuring oedema

• Apply normal thumb pressure on both feet

• Count the numbers 101, 102, 103 to estimate

three seconds without using a watch

• Check if a shallow print persists on both feet

• If the print persits in both feet, it implies the child

has nutritional odema (pitting oedema) and is

severely malnourished

Recommendations

• If no oedema is found (0): Advise the caregiver to

continue with healthy feeding the baby

• If oedema is found, the child should be referred to

a health facility.

• Follow-up to ensure the child went for healthcare

Referral of malnourished children

It is important that the malnourished children identied

are referred to a health facility.

The existing government health structures can be

used, starting with a referral to the village health worker

Community Health Extension Workers (CHEWs) are

individuals within the community who are equipped to

further refer the child to the appropriate health facility.

The participants and the project management team

can also be guided to develop an appropriate referral

and reporting system.

Figure 15.assessment of bilateral oedema (UNICEF 1991)

Table 6. Cut-off points for screening in the community for SAM and MAM using MUAC

Group Severe acute malnutrition

(SAM)

Moderate acute

malnutrition (MAM)

Normal

Infants and children 6

months to ˂5 years ˂11.5 cm ≥11.5 to ˂12.5 cm ≥12.5 cm

Children 5 ˂ 10 years ˂13.5 cm ≥13.5 to ˂14.5 cm ≥14.5 cm

Children 10 ˂ 15 years ˂16.0 cm ≥16.0 to ˂18.5 cm ≥18.5 cm

Children 15 ˂ 18 years ˂18.5 cm ≥18.5 to ˂21.0 cm ≥21.0 cm

Adults 18 years and older ˂19.0 cm ≥19.0 to ˂22.0 cm ≥22.0 cm

Pregnant women or

mothers with infants up to 6

months

˂19.0 cm ≥19.0 to ˂22.0 cm ≥22.0 cm

Elderly people 60 years and

older

˂16.0 cm ≥16.0 to ˂18.5cm ≥18.5 cm

38 | Training manual for Project Management Unit Members

Sign/signals (or complaints) Nutritional

abnormality

Recommendation

Swollen body, loss of appetite,

(may have a disease like diar-

rhoea): May have brownish thin

hair

Check for oedema

1: Apply normal thumb pressure on

both feet: count the numbers 101,

102, 103 to estimate three seconds

without using a watch). 2: Check--a

shallow print persists on both feet

implies the child has nutritional

odema (pitting oedema).

Severe acute

malnutrition

Where edema is

found

Severity RECOMMENDATION

No edema

0

Advise the caregiver to continue

with healthy feeding the baby

(three meals, snacks, fruits,

vegetables, milk)

Oedema is only

found below the

ankle (pitting pedal

odema)

+

Child likely kwashiorkor Should

be referred to a health facility.

Advise mother to increase

frequency of breastfeeding and

feeding.

Follow-up to ensure the child

went for healthcare

Pitting odema but

below the knee ++

Must immediately refer (or even

escort the child to a health

provider)

Follow-up same day or following

day

Repeat assessment for oedema

after 7 days

The odema is

generalised (found

also on the face

hands etc) +++

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)

Vitamin A

deciency

• Refer to a healthcare provider

• 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

Swelling on the front of the neck:

Goitre

Iodine

deciency

disorder

• Advise to use only iodized salt in the house

• You could refer to the healthcare provider.

Visible severe

wasting

• Referral to the nearest healthcare facility immediately

• Follow-up (in 3 days) to ensure the child has been taken to

the health facility

• Come again after a month to reassess

Training manual for Project Management Unit Members | 39

Taking the Weight-for-Height/Length

Because of its complexity and proneness to mistakes,

Weight-for-Height/Length the persons taking the

measurement need to be trained on how to use the

equipment and that there is a need to do more than 1

measurement to catch any errors.

Weight-for-Height implies the following steps:-

Taking the height or length

Calculating the weight for height/length percentages

Taking the weight of a child/adolescent using

electronic scales:

1. Place the electronic scale on a at, level surface.

2. Check and readjust the weight reading to zero.

3. Undress the child.

4. Make him/her stand on the middle of the scale’s

surface.

5. When the child is settled and the weight reading

is stable record the weight to the nearest 100g.

Make sure that nobody holds the child during

weighing and that the child stands freely without

holding onto anything.

6. Read and announce the value from the scale. The

assistant should repeat the Value for verication

and record

7. Record it immediately.

Taking the weight of a caregiver with child using

electronic scales:

1. Place the electronic scale on a at, level surface.

2. Check and readjust the weight reading to zero.

3. Undress the child.

4. Ask the caregiver to stand on the scale’s surface

in the middle and record their weight to the nearest

100g when the caregiver is settled and the weight

reading is stable

5. Hand the child to the caregiver.

6. When the caregiver is settled with the child and

the weight reading is stable record the weight to

the nearest 100g.

7. Read and announce the value from the scale. The

assistant should repeat the value for verication

and record it immediately.

Adults body mass index (BMI)

A quite different anthropometric index is used

to measure acute protein-energy malnutrition

(sometimes called “chronic energy deciency”) in

adults). This is the body mass index (BMI) unlike

weight-for-height in children, you divide weight by

height, or rather, and you divide weight in kilograms

by the square of height in meters:

The cut-off point dening malnutrition is the same for

all adults, regardless of their age, height, or sex:

Anthropometric equipment needed

Height: height boards Weight: weighing scales MUAC: MUAC tapes

40 | Training manual for Project Management Unit Members

Minimum Dietary Diversity Score for Women

(MDDS-W): Is a food group diversity indicator that has

been shown to reect one key dimension of diet quality

especially micronutrient adequacy. Ten food groups

are considered here namely; 1. All starchy staples;

2. Beans peas; 3. Nuts and seeds; 4. Dairy; 5. Flesh

foods (meats); 6. Eggs; 7. Vitamin A rich dark green

leafy vegetables; 8. Other vitamin A rich vegetables

and fruits; 9. Other vegetables; 10. Other fruits.

Consumption of foods from any 5 food groups and

above indicated meeting minimum dietary diversity.

The household dietary diversity score (HDDS) is

meant to reect, in a snapshot form, the economic

ability of a household to access a variety of foods.

The increase in dietary diversity is associated

with socio-economic status and household food

security (household energy availability). To measure

household dietary diversity, 12 standard food groups.

Consumption of less than 4 food groups is considered

low dietary diversity, consumption of between 4-5food

groups is considered moderate dietary diversity while

consumption of more than 6 food groups is considered

high dietary diversity.

Individual dietary diversity scores aim to reect

nutrient adequacy. Studies in different age groups have

shown that an increase in individual dietary diversity

score is related to increased nutrient adequacy of the

diet.

House Hold Hunger Scale (HHS); this focuses on

the food quantity dimension of food access and does

not measure dietary quality. It can be used to monitor

prevalence of hunger over time, assess food security

situation, monitor and evaluate the impact of ant

hunger policies and programs, provide information

for early warning of nutrition and food security

surveillance. This involves asking 3 main questions:

• Was there ever no food to eat of any kind in your

house because of lack of resources to get 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 day

and night without eating anything because there

was not enough food?

For each question one asks how frequently that

happened.

HHS should therefore not be used as a standalone

measure of food security but instead as one of the tools

to measure complimentary aspects of food insecurity

(such as anthropometric data, House hold income and

expenditure, Food production and consumption and

House hold and individual dietary diversity.

Training manual for Project Management Unit Members | 41

6.0 Action plans for PMU members

Activity:

The facilitator introduces the session and its objective (10

minutes).

Participants are grouped according to their projects

Each of these groups takes 30 minutes to discuss:

1) Current operational framework for extension service provision

2) Identication of nutrition related indicators that can be assessed

in the current framework as a way of mainstreaming nutrition

3) Tools required to mainstream nutrition (what kind of job aids

would be require)

4) Action plans to mainstreaming nutrition activities

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

Identication of nutrition related indicators that can be assessed in

the current framework

Identication 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.

Learning Objectives

At the end of this session

participants are expected to:

Identify operational frame work for

extension service provision

Identify nutrition related indicators

that can be assessed in the

current frame work as a way of

main streaming nutrition.

Identify tools that are required to

mainstream nutrition

Time: 60 minutes

Materials needed: Flip chart, Flip chart, board, Marker pens, Block notes

42 | Training manual for Project Management Unit Members

THE REPUBLIC OF UGANDA

Basic nutrition concepts & nutrition indicators: Training manual for project management unit members

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