TOPIC 11. PREVENTING AND MANAGING MALNUTRITION

NUTRITION NOTES

Undernourished children

Weigh young children regularly and advise on feeding: a healthy child is a growing child

Most children are at greatest risk of malnutrition from the age of about six months (when they are growing fast and breastmilk alone cannot cover nutrient needs) until they are 2-3 years old (when growth slows and they can feed themselves).

Families and health workers can find out if children are well nourished or malnourished by weighing them regularly and plotting their weights on growth charts (see Figure 14). A child may:

gain weight at the healthy rate, which means the child is almost certainly eating well and is healthy;
gain weight too slowly or not gain any weight, which signals that something is wrong. The child may be sick and/or not eating enough;
lose weight, which is a very dangerous sign. The child is not eating enough and is almost certainly ill;
gain weight faster than the healthy rate, which probably means the child is catching up weight lost during an illness but can also mean that the child has a health problem that could lead to obesity.

A child is severely malnourished if there is:

severe wasting (thinness) and/or;
oedema of both feet.

These children are dangerously ill and need in-patient treatment immediately. Make sure they are kept warm and fed while travelling to hospital.

Undernourished children need frequent nutrient-rich meals

Health workers need to work with the family of a malnourished child to:

find out why the child is not growing well. Discuss the feeding pattern (amount, variety and frequency of meals), appetite, behaviour and illnesses; examine the child for infections or other medical conditions; try to find the underlying causes (e.g. family food shortages; poor feeding practices; child receives insufficient care). See Introduction, page 9;
plan together how to help the child. A family will need to:

- feed the child better. This may mean increasing breastfeeding, improving complementary feeding, feeding more frequently and/or giving more attention during meals (see Topics 6 and 7). Discuss family beliefs on child feeding and blocks to better feeding (e.g. lack of resources, such as food, cash, time or cooking facilities). Then decide together which improved feeding practices the family is able and willing to adopt;

- take the child for treatment if sick and learn how to prevent childhood infections in the future.

Figure 14. Checking that children are growing well by weighing them often

Health workers should monitor undernourished children’s weights closely. If a family is unable to provide a healthy, balanced diet for a child, you may need to give food (enrol the child in a supplementary feeding programme) and micronutrients (e.g. vitamin A and iron) for a while. This must not prevent you from helping the family decide how they can feed the child better. Sometimes a family should be referred to a social worker, agricultural field worker or other community service to help deal with underlying reasons for poor nutrition.

Iron deficiency and anaemia

(also see Introduction, page 9)

Advise anaemic people to eat iron-rich diets and give iron supplements if needed

Signs of anaemia are:

low haemoglobin (<13 g/dL in men, <12g/dL in non-pregnant women and older children, <11 g/dL in pregnant women and young children and <11.5 g/dL in children aged 5-11 years);
pale palms and inner eyelids.

The main causes of anaemia are:

lack of iron. This is often the commonest cause but other nutritional causes include lack of folate, vitamin B₁₂ and vitamin A;
malaria, hookworm infection, other infections (such as HIV/AIDS), heavy bleeding and sickle-cell disease.

People with anaemia:

need to know how to improve their diets so they get more iron. Improving diets means eating more iron-rich foods (especially meat, offal, poultry and fish) and foods such as fruit that increase iron absorption (see Box 6 in Topic 1). Appendix 1, Tables 1 and 3, list useful sources of iron.
often need to be prescribed iron supplements and sometimes folate (as folic acid) and other micronutrient supplements - in addition to a good diet. Help people to understand that they must take supplements regularly and for as long as prescribed. Explain the side effects of iron supplements, such as indigestion (which is overcome by taking supplements together with food) and black stools;
may need treatment for other causes of anaemia, such as hookworm infection, malaria or other parasitic diseases, including schistosomiasis.

Treat all causes of anaemia

Explain to people with anaemia, or their families, how to prevent anaemia in the future by:

having a diet rich in iron (and vitamin C, if the iron mainly comes from foods of plant origin). Iron supplements may be needed at certain times, such as during pregnancy, but these should never replace a good diet;
preventing hookworm infection, malaria and other causes of anaemia.

Vitamin A deficiency disorders

(also see Introduction, page 9)

Find out which vitamin A-rich foods are available and promote their use

Lack of vitamin A in the diet weakens the immune system, often causing people (especially children) to become ill and die. If the deficiency is severe, the eye is affected. One of the first eye signs is night blindness (inability to see at dusk and in dim light). There is likely to be a vitamin A deficiency problem in the area if the death rate for children under age 5 years is high (i.e. >50 deaths per 1 000 live births) and/or if many women were night blind during their last live pregnancy (i.e. at least 5 percent).

Families can prevent vitamin A deficiency by:

eating foods rich in vitamin A (see Appendix 1, Tables 1 and 3). This is the best and only sustainable way to prevent vitamin A deficiency. In order to absorb vitamin A from plant foods well, the meal should contain some fat or oil. If people are unable to obtain a vitamin A-rich diet, it may be necessary to:

- promote foods fortified with vitamin A (e.g. some oils and fats) if they are available and offer good value for money;

- give vitamin A supplements to young children and to women within six weeks of giving birth according to national protocols. High doses of vitamin A supplements should never be given to any woman who could be pregnant because they may harm the unborn baby;

- take children for routine immunizations to prevent infections such as measles. Children with measles often become vitamin A-deficient.

If there are eye signs of vitamin A deficiency, such as night blindness or conjunctival or corneal xerosis (dryness), the person needs urgent medical attention and vitamin A supplements.

Overweight and obesity

Overweight and obese people need less energy-rich foods, a healthy, balanced diet and more exercise

Overweight and obesity (being too fat) are other kinds of malnutrition; in both, the weight is ‘too high’ in relation to the person’s height. Box 18 shows how to determine if an adult’s weight is normal.

BOX 18 · BODY MASS INDEX

We use the Body Mass Index (BMI) to decide if an adult has a normal weight or is underweight, overweight or obese. BMI = weight (kg) divided by height (m)². For example, if a woman weighs 50 kg and is 1.5 m tall, her BMI is 50/(1.5 × 1.5) = 22. Referring to the BMI below, 22 classifies her in the normal weight group.
Weight group	BMI
Underweight	less than 18.5
Normal weight	18.5-24.9
Overweight	25-29.9
Obese	30 and over

People who are overweight or obese are at risk of heart disease, hypertension and stroke, diabetes, certain types of cancers and gallbladder disease. It is most dangerous if a person has a ‘fat waist’ (the waist is large compared to the hips).

People put on weight when they eat more food energy than they use. This usually is the case when people’s normal lives (and work) do not involve much physical activity and their meals contain large amounts of energy-rich foods, such as fats and oils.

Although sugar is not a particularly energy-rich food (see page 21), people who are, or at risk of becoming, overweight or obese should limit the amount they eat. Sugary foods are often rich in fats and they encourage overeating because they are sweet and therefore attractive to many people.

While overweight and obesity is normally seen as a problem of excessive food energy intake only, some health workers do not know that overweight people often also suffer from micronutrient deficiencies (in particular, vitamins A, E and C, and some B-group vitamins) because they often eat poor, unbalanced diets. This is important to note in order to advise overweight and obese people correctly (see Box 19). Not only do they need to reduce their energy intake (and/or increase their physical activity level), but they also must have healthy, balanced diets.

Obesity is a complicated, difficult-to-treat condition in which social norms and values (e.g. fat people are seen as rich people), and psychological factors also play an important role. This makes it more difficult to persuade people to change what they eat and to change their activity level.

BOX 19 · PREVENTING AND MANAGING OVERWEIGHT AND OBESITY

How to help people prevent overweight and obesity

Explain the risks and causes of overweight and obesity.
Encourage people to be more physically active whenever possible (at work, play, sports). For example, to walk vigorously for at least 1/2 hour every day or to dig or dance for at least 1/2 hour three times a week.
Give advice on:

- what to eat - plenty of fresh fruits and vegetables; lean, instead of fatty meat and fish; wholemeal cereals and pulses;

- what not to eat - fatty and sugary foods and alcoholic drinks (e.g. 1 litre of beer provides about a tenth of a man’s energy needs per day). Fat should supply only about a third of the energy needs; this can only be met if foods rich in fat are eaten only in smaller amounts. Remember that most of the fat in the diet is often ‘hidden’ in foods like meat, groundnuts, milk and fried foods. The fat in plant foods and fish is usually healthier than fat in meat and milk (see Box 4 in Topic 1).

How to help fat people lose weight

Explain that:

- increasing physical activity is essential because regular exercise lowers the risk of heart disease even if there is no weight loss;

- overweight and obese people must eat less food, especially less high-energy foods and drinks (i.e. fatty and sugary foods/drinks) at each meal. Water, instead of sugary beverages is the better choice. It is also important to eat only when hungry (e.g. avoid eating meals or snacks while watching TV). People who want to lose weight need a diet containing a variety of foods, especially plenty of vegetables and fresh fruits. Advise them to reduce the amount of beer they drink and to stop eating fatty or sugary snacks; recommend fresh fruits instead.

- it is safer to lose weight gradually on a low-energy healthy, balanced diet than on a special slimming diet.

It is difficult for most overweight and obese people to lose weight. They need frequent, sympathetic encouragement. Never laugh at or be rude about obese people - these are serious conditions that need your help.

SHARING THIS INFORMATION

Before sharing this information with families, you may need to:

1. Find out. What the common types and causes of malnutrition are, including overweight and obesity. Which types of families are most affected. What the local names and beliefs for poor growth, anaemia, vitamin A deficiency and obesity are. What type of treatment and care is given to people with different types of malnutrition by families and health workers.

2. Prioritize. Decide which information is most important to share with different groups, families or individuals.

3. Decide whom to reach. For example: parents and other caregivers of malnourished children; malnourished adults and their relatives; health staff and volunteers helping at clinics and with community-based growth monitoring activities.

4. Choose communication methods. For example: group discussions with community groups and at clinics; feeding demonstrations; individual counselling at clinics and homes.

Examples of questions to start a discussion
(choose only one or two questions that deal with the information families need most)

If many local young children are growing slowly

How can we find out if our children are growing too slowly?

Why do some children grow too slowly?

How can we help these children and their families?

What feeding advice should we share with the families of undernourished young children?

If many children and women have anaemia

Is anaemia (use local name) a problem in this place?

Do you know what causes anaemia? Emphasize the important local causes.

How can we prevent anaemia caused by hookworm, malaria, a poor diet?

Which local foods are rich in iron? How can we improve the amount of iron we absorb from food (see Topic 1, page 19)?

If many people have vitamin A deficiency disorders

What is vitamin A? What happens if a child or adult does not get enough vitamin A?

How can we prevent vitamin A deficiency disorders?

Which local foods are rich in vitamin A?

If many people are overweight or obese

Which health problems are linked to overweight and obesity?

How can we prevent ourselves from becoming overweight?

How can overweight and obese people lose weight? Is it easy?