UNIT2:HUMAN NUTRITION AND DIETETICS►

UNIT1:HUMAN NUTRITION AND DIETETICS

  • UNIT1:HUMAN NUTRITION AND DIETETICS

     

     

    Key Unit Competence
    Assist adequately in preparation of a balanced diet to community, family and 

    individuals.

    Introductory activity 1.1

    Observe the Pictures below (A, B, C, D and F) and answer the questions that 

    follow:


    1. What do the above-mentioned pictures (A, B, C, D, E, and F) communicate 
    to you?
    2. Differentiate the pictures A& B, from the picture E
    3. What do you think is the importance of each activity that is being done by 
    the persons in pictures C, D, and F?

    4. According to you, what do you think is the focus of this topic?

    1.1. Breast feeding

    Learning activity 1.1

    Observe the following pictures and respond to questions provided below:


    1. Describe the activities the pictures above pointed out.
    2. Discuss the importance of the ongoing activities in the pictures above 
    (A,B ). 
    3. What do you expect to learn in this lesson?
    4. Use the fundamentals of nursing and nutrition text books taken from the 
    library or internet and find out the advantages of breast feeding for mother 
    and baby, teaching points for breast feeding and contra-indications of 

    breast feeding

    1.1.1. Introduction to breast feeding 

    The breast feeding consists of giving mother’s milk to a newborn, infant, or child. 
    Mature mother’s milk and its precursor, colostrum, are considered the most 
    balanced foods available for normal newborns and infants. Breastfeeding should be 
    initiated immediately after the birth of your child. Breast milk is specifically designed 
    to support optimal growth and development of the newborn, and its composition 
    makes it uniquely superior for infant feeding.
    Exclusive breastfeeding is recommended for the first 6 months of life and should be 
    maintained until weaning is initiated (there are some exceptions: for example, Oral 
    iron drops may be needed before 6 months to support iron stores). Breast feeding 
    is considered adequate to meet the needs of healthy, full-term infants. Even after 
    solid foods are introduced, breastfeeding should continue for at least the first 12 

    months of age.

     1.1.2. Advantages of breastfeeding for the baby

    For the first 2-4 days of a baby’s life, breasts will secrete colostrum, a yellowish 
    fluid rich in proteins. These valuable proteins are essential to the development of a 
    healthy immune system. The protein is easily digested and absorbed by the body, 
    especially by the rapidly developing brain. Colostrum provides factors that promote 
    maturation of the gut and good digestion. Colostrum is the most superior and well 
    designed nutrition for your baby in the first few days of life.
    Breast milk provides superior nutrition to the baby and increases resistance to 
    infections, and therefore fewer incidents of illness and hospitalization. It decreases 
    the risk of lactose intolerance. Breast milk is sterile and easily digested. Breastfed 
    babies experience less nappy rash, they are less likely to develop allergies and 
    experience fewer constipation. Breastfed infants tend to have fewer cavities. 
    Breastfeeding promotes the proper development of baby’s jaw and teeth. 
    Breastfed infants tend to have higher intellectual quotients (IQs) due to good brain 
    development early in life. They benefit emotionally, because they are held more. 
    Breastfeeding promotes mother-baby bonding. In the long term, breastfed babies 
    have a decreased risk of malnutrition, obesity and heart disease compared to 
    formula fed babies.
    Breastfeeding is credited with numerous potential health benefits for the infant, 
    including lower risks of otitis media, upper respiratory tract infection, lower 
    respiratory tract infection, asthma, atopic dermatitis, gastroenteritis, obesity, celiac 
    disease, type 1 and type 2 diabetes, certain types of leukemia, and sudden infant 
    death syndrome. Although many of these benefits are linked to breast feeding for 3 
    months or more, some benefits occur with any duration of breastfeeding, such as 
    the reduced risk of obesity and type 2 diabetes. 
    1.1.3. Advantages of breastfeeding for the mother
    The baby’s sucking causes a mother’s uterus to contract and reduces the flow 
    of blood after delivery. During lactation, menstruation ceases, offering a form of 
    contraception. Mothers who breastfeed tend to lose weight and achieve their 
    pre-pregnancy figure more easily than mothers who bottle feed. Mothers who 
    breastfeed, are less likely to develop breast cancer later in life. Breastfeeding is 
    more economical than formula feeding. There are fewer trips to the doctor and less 
    money is spent on medications. Breastfeeding promotes mother-baby bonding. 
    Hormones released during breast-feeding create feelings of warmth and calm in 
    the mother.
    1.1.4. Teaching points for breastfeeding
    The infant should be allowed to be nursed for 5 minutes on each breast on the first 

    day to achieve letdown and milk ejection. 

    By the end of the first week, the infant should be nursed up to 15 minutes per breast. 
    In the first few weeks of breastfeeding, the infant may be nursed 8 to 12 times 
    every 24 hours. Mothers should offer the breast whenever the infant shows early 
    signs of hunger, such as increased alertness, physical activity, mouthing, or rooting. 
    After breastfeeding is well established, eight feedings every 24 hours may be 
    appropriate. The first breast offered should be alternated with every feeding so 
    both breasts receive equal stimulation and draining. Even though the infant will 
    be able to virtually empty the breast within 5 to 10 minutes once the milk supply 
    is established, the infant needs to nurse beyond that point to satisfy the need to 
    suck and to receive emotional and physical comfort. The supply of milk is equal to 
    the demand the more the infant sucks, the more milk is produced. Infants age 6 
    weeks or 12 weeks who suck more are probably experiencing a growth spurt and 
    so need more milk. Water and juice are unnecessary for breastfed infants in the first 
    6 months of life, even in hot climates. Early substitution of formula or introduction 
    of solid foods may decrease the chance of maintaining lactation. Infants weaned 
    before 12 months of age should be given iron-fortified formula, not cow’s milk. 
    Both feeding the infant, more frequently and manually expressing milk will help to 
    increase the milk supply. Breast milk can be pumped, placed in a sanitary bottle, 
    and immediately refrigerated or frozen for later use. Milk should be used within 24 
    hours if refrigerated or within 3 months if stored in the freezer compartment of the 

    refrigerator.

    1.1.5. Breast feeding technique 

    The breast feeding technique has 3 main parts: effective positioning for the mother, 
    effective positioning for the baby, attaching the baby to the breast. 
    a. Effective positioning for the mother
    A comfortable position is a prerequisite of comfortable breastfeeding. A woman who 
    has recently given birth, especially one new to breastfeeding, may need some help 
    with this. After a caesarean section, or where the perineum is very painful, lying on 
    her side may be the only position a woman can tolerate in the first few days after 
    birth. It is likely that she will need assistance in placing the baby at the breast in this 
    position, because she has only one free hand. When feeding from the lower breast 
    it may be helpful to raise her body slightly by tucking the end of a pillow under her 
    ribs. Once the woman can do this unaided, she may find this a comfortable and 
    convenient position for night feeds, enabling her to get more sleep. Alternatively, 
    the mother may prefer to sit up to feed her baby, it is particularly important that the 
    mother’s back is upright at a right-angle to her lap. 
    Both (arms) lying on her side and sitting correctly in a chair with her back and 
    feet supported enhance the shape of the breast and allow ample room in which to 

    manoeuvre the baby.

    b. Effective positioning for the baby

    The baby’s body should be turned towards the mother’s body so that the baby is 
    coming up to her breast at the same angle as her breast is coming down to the 
    baby. The more the mother’s breast points down, the more the baby needs to be on 
    his back. The advice to have the baby tummy to tummy may be mistakenly taken 
    to imply that the baby should always be lying on his side. However, taking account 
    of the angle of the dangle might be more useful. If the baby’s nose is opposite his 
    mother’s nipple, being brought to the breast with the neck slightly extended, the 
    baby’s mouth will be in the correct relationship to the nipple.
    c. Attaching the baby to the breast
    The baby should be supported across the shoulders, so that slight extension of 
    the neck can be maintained. The baby’s head may be supported by the extended 
    fingers of the mother’s supporting hand or on the mother’s forearm. It may be 
    helpful to wrap the baby in a small sheet (Vancouver wrap), so that his hands are 
    by his side. If the newborn baby’s mouth is moved gently against the mother’s 
    nipple, the baby will open his mouth wide. As the baby drops his lower jaw and 
    darts his tongue down and forward, he should be moved quickly to the breast. The 
    intention of the mother should be to aim the baby’s bottom lip as far away from the 
    base of the nipple as is possible. This allows the baby to draw breast tissue as well 
    as the nipple into his mouth with his tongue. If correctly attached, the baby will have 
    formed a teat from the breast and the nipple.
    The nipple should extend almost as far as the junction of the hard and soft palate. 
    Contact with the hard palate triggers the sucking reflex. The baby’s lower jaw 
    moves up and down, following the action of the tongue. Although the mother may 
    be startled by the physical sensation, she should not experience pain. If the baby 
    is well attached, minimal suction is required to hold the teat within the oral cavity. 
    The tongue can then apply rhythmical cycles of compression and relaxation so that 
    milk is removed from the ducts. The baby feeds from the breast rather than from the 
    nipple, and the mother should guide her baby towards her breast without distorting 
    its shape. The baby’s neck should be slightly extended and the chin in contact with 
    the breast. If the baby approaches the breast, a generous portion of areola will be 
    taken in by the lower jaw, but it is positively unhelpful to urge the mother to try to get 
    the whole of the areola in the baby’s mouth.
    Notes
    Many mothers who have had babies before require as much support with 

    breastfeeding as those who have given birth to their first baby

    Reasons for this include:
    • Previous unsuccessful breastfeeding.
    • Breastfeeding may have gone well last time by chance rather than knowledge.
    • The new baby may behave very differently, or have different needs, from the 
    mother’s previous baby/ babies.
    • The mother may have recently fed (or still be feeding) a toddler and has 
    forgotten quite how much help a new baby requires to breastfeed.
    • Their previous baby may have been born at a time when underpinning 
    information now known to be outdated was thought to be correct.
    1.1.6. Contra indications to breastfeeding
    It may be contraindicated to the mother to breastfeed her child in some cases. For 
    example: Galactosemia in the infant, illegal drug use in the mother, and active 
    tuberculosis. Breast feeding may be also be contraindicated in case of HIV/AIDS – 
    in some countries, the risk of infant mortality from not breastfeeding may outweigh 
    the risk of acquiring HIV through breast milk. The use of certain drugs, such as 
    radioactive isotopes, antimetabolites, cancer chemotherapy agents, lithium, and 

    ergotamine constitute a contraindication during breast feeding. 

    Self-assessment 1.1 

    1. Identify the advantages of exclusive breast feeding of a child until six 
    months? 

    2. Outline the teaching points for breast feeding

    1.2. Formula-feeding

    Learning activity 1.2

    Observe the following pictures and respond to questions given below it

    1.2.1. Formula-feeding
    It may happen that a mother lack or have not enough breast milk for her baby, so 
    it becomes a requirement to search for other sources of nutrients for replacement 
    in order to help the child to achieve normal growth and maintain normal health. 
    A Formula-feeding is a substitute for breast milk that can be used either as an 
    alternative to breastfeeding or as a way of supplementing it. This should include 
    proper amounts of water, carbohydrate, protein, fat, vitamins and minerals. 
    Manufacturers continue to modify their products in an effort to emulate human milk, 
    and although they provide less than the optimal benefits of human milk, they are 
    nutritionally adequate for the first year of life. 
    1.2.2. The three major classes of infant formulas: 
    a) Milk-based formulas prepared from cow milk with added vegetable oils, 
    vitamins, minerals, and iron. These formulas are suitable for most healthy 
    full-term infants.
    b) Soy-based formulas made from soy protein with added vegetable oils (for fat 
    calories) and corn syrup and/or sucrose (for carbohydrate). These formulas 
    are suitable for infants who cannot tolerate the lactose in most milk-based 
    formulas or who are allergic to the whole protein in cow milk and milk-based 
    formulas.
    c) Special formulas for low birth weight (LBW) infants, low sodium formulas for 
    infants that need to restrict salt intake, and “predigested” protein formulas for 
    infants who cannot tolerate or are allergic to the whole proteins (casein and 

    whey) in cow milk and milk-based formulas.

    The standard formula choice is a cow’s milk-based formula, containing skim 
    milk powder, lactose and a variable blend of oils. These formulas are available 
    in two versions: low iron (similar amounts as in human milk, but with much lower 
    bioavailability) or iron-fortified (12 mg elemental iron/l). Use of low iron formulas is 
    one of several risk factors implicated in the incidence of iron deficiency anaemia, 
    the most common nutritional deficiency among infants and toddlers. To provide the 
    best guarantee of normal iron status, the use of iron-fortified formulas, not low iron 

    formulas is recommended.

    Soy-based formulas made from soy protein, vegetable oils and glucose polymers 
    (±sucrose) are available for infants of vegetarian families, infants with galactosaemia 
    or lactose intolerance, or infants with IgE-mediated allergy to cow’s milk protein. Soy 
    formulas are not indicated for low-birth-weight infants, prevention or management 
    of colic, routine treatment of gastroenteritis, or treatment of infants with non
    IgEmediated allergy to cow’s milk protein (i.e. enteropathy or enterocolitis). Recent 
    concerns with respect to the safety of soy formulas are related to their content of 
    phyto-oestrogens. Different factors can lead to a low milk supply during breast
    feeding or contraindicate it – mother’s disease, use same medications, waiting too 
    long to start breast-feeding, not breast-feeding often enough. Sometimes previous 

    breast surgery may affect milk production. 

    1.2.3. Advantages of formula-feeding 

    Time and frequency of feedings: Formula-fed babies usually eat less often than 
    breastfed babies since formula feeds take longer to digest.
    Diet: Formula feeds are very important for a mom who needs to be on a medication 
    that might harm the baby.
    Convenience and Flexibility: Your partner or anyone can feed Your Child at any 
    time without you having to pump, and store breast milk, especially if that isn’t an 
    option. You don’t need to find a private place to nurse in public.
    1.2.4. Disadvantages of formula-feeding
    Lack of antibodies: Formula feeds don’t have the antibodies found in breast milk. 
    As a result, formulas can’t provide to the child with immunity against infection and 
    illness the way breast milk does. 
    Unable to match the complexity of breast milk: Formulas can’t measure up to 
    the complexity of breast milk in the way it changes with baby’s needs.
    There’s a need for planning and organization: Breast milk is always available 
    and at the right temperature, but formula feeds require planning to ensure that you 
    have all the things you need to prepare it. You must make sure you don’t run out of 

    stock to avoid making late-night trips to the store. 

    Also, you must ensure that all the necessary supplies (like bottles and nipples) are 
    clean, easily accessible, and ready to use. You will have to feed the child 8-10 times 
    in 24-hours, so if you’re not organized, you can easily get overwhelmed.
    Formula can be expensive: Baby formula is quite expensive. The most expensive 
    type is ready-to-feed formulas, followed by the concentrated type. The least expensive 
    is the powdered formula. Special formulas, such as soy and hypoallergenic, can 
    cost even more than the ready-to-feed formulas.
    It may cause gassy tummy and constipation: It’s more likely for formula-fed 
    babies to have gassy tummy and constipation than breastfed babies.
    It may increase the risk of infections: Often formulas need to be mixed with 
    water. So if the water is not 100% free of bacteria or other germs, there is a risk of 
    infection, and in the first 12 months, this can lead to serious complications for the 

    baby.

    Self-assessment 1.2

    1. Identify the major classes of infant formulas.
    2. Explain the disadvantages of formula feeding. 

    3. What are the advantages of three major classes of infant formulas?

    1.3. Supplementary feeding

    Learning activity 1.3

    Observe the following pictures and answer the given questions

    1.3.1.Vitamin and mineral supplementation 

    With the exception of vitamins D and K, human milk from well-nourished mothers 
    provides all the nutrients required for the first four to six months of life. Routine 
    administration of intramuscular vitamin K at birth has eliminated vitamin K deficiency. 
    Commercial infant formulas are fortified with vitamins and minerals; therefore, 
    supplements are unnecessary.
    a. Vitamin D
    Human milk contains very little vitamin D. Therefore, an additional source is 
    recommended for exclusively breast-fed infants who may not be exposed to sunlight. 
    Vitamin D needs will be met from occasional exposure to small amounts of sunlight, 
    or prophylactic supplementation with 200 IU (5 μg) vitamin D/day. Infants at risk for 
    vitamin D deficiency and the development of nutritional rickets are those who are 
    dark-skinned, exclusively breast-fed, living at high northern or southern latitudes, 
    or weaned to vegetarian diets. Naturally occurring dietary sources of vitamin D are 
    rare (liver, oily fish), while only milk and margarine may be fortified with vitamin D in 
    some countries. With increasing use of sunscreen and avoidance of sun exposure 
    due to the risks of skin cancer, the potential for vitamin D deficiency may be higher.
    b. Iron deficiency
    Iron deficiency is most common among infants between the ages of 6 and 24 months. 
    The major risk factors for iron deficiency anemia in infants relate to socioeconomic 
    status and include the early consumption of cow’s milk, inadequate funds for 
    appropriate foods, and poor knowledge of nutrition. Other high-risk groups include 
    low birth weight and premature infants and older infants who drink large amounts 

    of milk (1liter/day) or juice and eat little solid food. The importance of preventing 

    rather than treating anaemia has been accentuated by findings that iron deficiency 
    anaemia may be a risk factor for developmental delays in cognitive function and 
    that this delay is irreversible with iron therapy and persists into early childhood.
    Strategies for the prevention of iron deficiency anaemia
    In order to prevent iron deficiency anaemia the baby should be exclusively breast
    fed during the first 4–6 months, then there will be the introduction of iron-fortified 
    infant cereal, other iron-rich foods (e.g. strained meats) and enhancers of iron 
    absorption (vitamin C, e.g. fruit) from 6 months. There is a need of using iron
    fortified formula for infants weaned early from the breast or formula fed from birth. 
    The introduction of unmodified cow’s milk should be delayed until at least 9–12 
    months of age. 
    c. Fluoride
    Fluoridation of the water supply has proven to be the most effective, cost-efficient 
    means of preventing dental caries. In areas with low fluoride levels in the water 
    source, fluoride supplements are recommended. 
    The increased availability of fluoride (fluoridated water, foods or drinks made with 
    fluoridated water, toothpaste, mouthwashes, and vitamin and fluoride supplements) 
    has resulted in an increasing incidence of very mild and mild forms of dental fluorosis 
    in both fluoridated and non-fluoridated communities. 
    This sign of excess fluoride intake has led to modifications in fluoride recommendations 
    including later introduction and lower doses of fluoride supplements, and caution 
    to parents of young children to use small amounts, and discourage swallowing of 
    toothpaste. Dental fluorosis has not been shown to pose any health risks and while 
    there may be mild cosmetic effects, the teeth remain resistant to caries.
    d. Cow’s milk
    The use of unmodified cow’s milk before 9–12 months of age is not recommended. 
    In comparison to human milk and iron fortified formula, cow’s milk is higher in 
    nutrients such as protein, calcium, phosphorus, sodium, and potassium and 
    significantly lower in iron, zinc, ascorbic acid, and linoleic acid. Nutrients in solid 
    foods emphasize these excesses and deficiencies, so that cow’s milk-fed infants 
    receive a higher renal solute load and are at greater risk of eating an unbalanced 
    diet. In particular, the risk for iron depletion and iron deficiency anaemia is higher 
    because the iron content of cow’s milk is low and not readily bioavailable and its 
    absorption may be impaired by the high concentrations of calcium and phosphorus 
    and low concentration of ascorbic acid in cow’s milk. In addition, intestinal loss of 
    (blood) iron in the stool is associated with Cow’s milk-feeding in the first six months 

    of life. Whole cow’s milk (3.3% butterfat) continues to be recommended for the

    second year of life. Two percent milk may be an acceptable alternative provided 
    that the child is eating a variety of foods and growing at an acceptable rate. 

    Table 1.3. 1 Nutrient content of human milk, formula, and cow’s milk per liter


    Self-assessment 1.3

    1. Explain how to prevent iron deficiency anemia to an infant during the 
    weaning period? 
    2. Identify the nutrients which are highly found in cow’s milk in comparison 
    to human milk and iron fortified formula? 
    3. Which foods should be emphasized in order to avoid excesses and 
    deficiencies resulting from cow’s milk as supplementary food during 

    weaning period

    1.4. Childhood special considerations

    Learning activity 1.4

    Observe the pictures below


    1. What message do you get from each of the above-mentioned pictures?
    2. Compare the pictures A and B in terms of the activities that are being 
    done and their importance.

    3. What do expect to study in this lesson?

    1.4.1. Special considerations for childhood 

    Childhood is usually regarded as the period between 2 and 10 years. The linear 
    growth of pre-pubertal children occurs at a relatively constant rate of about 6 cm 
    per year. The median heights and weights of girls and boys are very similar. In 
    average, they increase from 87 cm and 12 kg at age 2 years, to 137 cm and 32 kg 
    at 10 years. 
    Children are a potentially vulnerable group since they are entirely dependent upon 
    parents or caregivers for all nutritional needs. Inadequate intakes of energy and 
    essential nutrients may compromise growth and development to an extent which 
    may have lasting consequences.
    However, in most relatively affluent societies where a wide variety of foods are 
    available, growth and development usually occur quite satisfactorily without detailed 
    dietary advice. Obesity, rather than under-nutrition, is the major nutrition-related 
    disorder. An important consideration is that eating habits determined in childhood 

    may be important determinants of chronic disease in later life. 

    1.4.2. Calories and Nutrients

    Total calorie needs steadily increase during childhood, although calorie needs per 
    kilogram of body weight progressively fall. The challenge in childhood is to meet 
    nutrient requirements without exceeding calorie needs.
    1.4.3. Eating Practices
    As children get older, they consume more foods from non -home sources and have 
    more outside influences on their food choices. School, friends’ houses, childcare 
    centers, and social events present opportunities for children to make their own 
    choices beyond parental supervision.
    Children who are home alone after school prepare their own snacks and, possibly, 
    meals.
    The ideal of children eating breakfast, dinner, and a snack at home, with a nutritious 
    brownbag or healthy cafeteria lunch at school, is not representative of what most 
    children are eating. Children who eat dinner with their families at home tend to have 
    higher intakes of fruits, vegetables, vitamins, and minerals and lower intakes of 
    saturated and trans-fatty acids, soft drinks, and fried foods. Family meals promote 
    social interaction and allow children to learn food-related behaviors. Parents should 
    provide and consume healthy meals and snacks and avoid or limit empty-calorie 
    foods. 
    1.4.4. Nutrients of Concern
    Important concerns during childhood include excessive intakes of calories, sodium, 
    and fat, especially saturated fat. Nutrients most likely to be consumed in inadequate 
    amounts are calcium, fiber, vitamin E, magnesium, and potassium. The percentage 
    of children with usual nutrient intakes below the Estimated Average Requirement 
    (EAR) tends to increase with age and is greater among females than males. It is 
    recommended to children who consume less than1 L/day of vitamin D–fortified milk 

    takes a supplement of 400 IU/day.

    Self-assessment 1.4

    1. Identify nutrients which are excessively consumed by children and those 
    which are consumed in inadequate amounts. 
    2. What would you recommend to parents/care givers for promoting the 
    good eating habits of children?
    3. What nutrients should be mostly recommended for promoting the growth 

    of children

    1.5. Special considerations and nutritional disorders in 

    adolescence

    Learning activity 1.5

    Observe the pictures below and answer the questions given below:

    1.5.1. Introduction

    During adolescence physiological age is a better guide to nutritional needs than 
    chronological age. Energy needs increase to meet greater metabolic demands of 
    growth. Daily requirement of protein also increases. Calcium is essential for the 
    rapid bone growth of adolescence, and girls need a continuous source of iron to 
    replace menstrual losses. Boys also need adequate iron for muscle development. 
    Iodine supports increased thyroid activity, and use of iodized table salt ensures 
    availability. B-complex vitamins are necessary to support heightened metabolic 
    activity.
    Many factors other than nutritional needs influence the adolescent’s diet, including 
    concern about body image and appearance, desire for independence, eating at 
    fast-food restaurants, peer pressure, and fatty diets. Nutritional deficiencies often 
    occur in adolescent girls as a result of dieting and use of oral contraceptives. 
    Skipping meals or eating meals with unhealthy choices of snacks contributes to 
    nutrient deficiency and obesity.
    Fortified foods (nutrients added) are important sources of vitamins and minerals. 
    Snack food from the dairy and fruit and vegetable groups are good choices. To 
    counter obesity, increasing physical activity is often more important than restricting 
    intake. 
    The onset of eating disorders such as anorexia nervosa or bulimia nervosa often 
    occurs during adolescence. Recognition of eating disorders is essential for early 
    intervention. Sports and regular moderate-to-intense exercise necessitate dietary 
    modification to meet increased energy needs for adolescents.
    Carbohydrates, both simple and complex, are the main source of energy, providing 
    55% to 60% of total daily kilocalories. Protein needs increase to 1 to 1.5 g/kg/day. 
    Fat needs do not increase. Adequate hydration is very important. Adolescents need 
    to ingest water before and after exercise to prevent dehydration, especially in hot, 
    humid environments. Vitamin and mineral supplements are not required, but intake 
    of iron-rich foods is required to prevent anemia.
    Parents have more influence on adolescents’ diets than they believe. Effective 
    strategies include limiting the amount of unhealthy food choices kept at home, 
    encouraging smart snacks such as fruit vegetables or string cheese, and enhancing 
    the appearance and taste of healthy foods.
    The ways to promote healthy eating include making healthy food choices more 
    convenient at home and at fast-food restaurants; and discouraging adolescents 
    from eating while watching television.
    Malnutrition at the time of conception increases risk to the adolescent and her fetus. 

    Most teenage girls do not want to gain weight. Counseling related to nutritional

    needs of pregnancy is often difficult, and teens tolerate suggestions better than rigid 
    directions. The diet of pregnant adolescents is often deficient in calcium, iron, and 
    vitamins A and C. Prenatal vitamin and mineral supplements are recommended.
    1.5.2. Nutritional disorders in adolescence 
    Adolescence is a stressful time for most young people. They are unexpectedly faced 
    with numerous physical changes, an innate need for independence, increased work 
    and extracurricular demands at school, in many cases jobs, and social and sexual 
    pressures from their peers. For many teens, such stress can cause one or more of 
    the following problems: anorexia nervosa, bulimia.
    a. Anorexia Nervosa
    Anorexia nervosa, commonly called anorexia, is a psychological disorder 
    characterized by an obsessive desire to lose weight by refusing to eat. It is more 
    common to women than men. It can begin as early as late childhood, but usually 
    begins during the teen years or the early twenties. 
    It causes the adolescent to drastically reduce calories, causing altered metabolism, 
    which results in hair loss, low blood pressure, weakness, amenorrhea, brain 
    damage, and even death.
     The causes of anorexia are unclear. Someone with this disorder (an anorexic) 
    has an inordinate fear of being fat. Some anorexics have been over-weight and 
    have irrational fears of regaining lost weight. Some young women with demanding 
    parents perceive this as their only means of control. Some may want to resemble 
    slim fashion models and have a distorted body image, where they see themselves 
    as fat even though they are extremely thin. Some fear growing up. Many are 
    perfectionistic overachievers who want to control their body. It pleases them to deny 
    themselves food when they are hungry.
     These young women usually set a maximum weight for themselves and become 
    an expert at “counting calories” to maintain their chosen weight. They also often 
    exercise excessively to control or reduce their weight. If the weight declines too far, 
    the anorexic will ultimately die.
    Treatment requires the following:
    Development of a strong and trusting relationship between the client and the health 
    care professionals involved in the case. The adolescent should learn and accepts 
    that weight gain and a change in body contours is normal during adolescence. 
    There is need to focus on nutritional therapy so that the adolescent understand the 
    need for both nutrients and calories and how best to obtain them. Individual and 
    family should be counselled in order to make sure that the problem is understood 
    by everyone. Close supervision should be done by the health care professional. For 

    achieving the desired results, there is need of time and patience from all involved.

    b. Bulimia

    Bulimia is a syndrome in which the adolescent alternately binges and purges by 
    inducing vomiting and using laxatives and diuretics to get rid of ingested food. 
    Bulimics are said to fear that they cannot stop eating. They tend to be high 
    achievers who are perfectionistic, obsessive, and depressed. They generally lack 
    a strong sense of self and have a need to seem special. They know their binge–
    purge syndrome is abnormal but also fear being overweight. This condition is more 
    common among women than men and can begin any time from the late teens into 
    the thirties.
    A bulimic usually binges on high-calorie foods such as cookies, ice cream, pastries, 
    and other forbidden foods. While eating, the binge can take only a few moments or 
    several hours—until there is no space for more food. It occurs when the person is 
    alone. Bulimia can follow a period of excessive dieting, and stress usually increases 
    the frequency of binges.
    Bulimia is not usually life-threatening, but it can irritate the oesophagus and cause 
    electrolyte imbalances, malnutrition, dehydration, and dental caries.
    Treatment usually includes limiting eating to mealtimes, portion control, and close 
    supervision after meals to prevent self-induced vomiting. Diet therapy helps teach 
    the adolescent basic nutritional facts so that he or she will be more inclined to treat 
    the body with respect. Psychological counselling will help to understand his or her 
    fears about food. Group therapy also can be helpful.
    Both bulimia and anorexia can be problems that will have to be confronted 

    throughout the client’s life

    Self-assessment 1.5

    1. Identify the most required nutritional needs during adolescence age.
    2. What are the factors (other than nutritional needs) that influence the 
    adolescent diet?
    3. What are the characteristics of anorexia nervosa? 
    4. What are the requirements for the treatment of anorexia nervosa? 
    5. Describe the characteristics of an adolescent suffering from bulimia. 

    6. Discuss the management of bulimia.

    1.6. Special nutrition in pregnancy

    Learning activity 1.6


    1. What are you seeing on the pictures A and B? 
    2. Describe the activities which are being done on the pictures A and B.
    3. What do you think may be the title of today’s lesson? 

    4. What do you think is the role of each food presented on picture C?

    1.6.1. Balanced diet

    A balanced diet is essential for the good health of a pregnant mother and her baby. 
    Eating well will provide nutrients that are needed by the mother and her baby. A 
    healthy diet will also help ensure a healthy weight gain, ensure get the key vitamins 
    and minerals needed, and reduce the risk of pregnancy complications.

    Poor nutrition during pregnancy and unhealthy lifestyle behaviors during pregnancy 

    increase the risk of developing nutrient deficiencies, birth defects and pregnancy 
    complications, it causes also low birth weight in infants and decreases chances of 
    survival. Maternal underweight is associated with an increased risk of premature 
    birth and maternal overweight is associated with a higher frequency of premature 
    birth, higher Caesarean section rates and increased risk of neural tube defects. A 
    healthy diet and regular physical activity may reduce the risk of negative pregnancy 
    outcomes associated with underweight and overweight. Many women mistakenly 
    believe that during pregnancy they need to “eat for two” (mother and baby).
    The energy requirements of pregnancy are related to the mother’s body weight and 
    activity. The quality of nutrition during pregnancy is important, and food intake since 
    the first trimester includes balanced portions of essential nutrients with emphasis 
    on quality. Protein intake throughout pregnancy needs to increase to 60 g daily, 
    which represents an increase from 46g/d in non-pregnant states. Protein is essential 
    for the growth and development of fetus. In other words, this increase reflects a 
    change to 1.1g of protein/kg/day during pregnancy from 0.8g of protein/kg/day for 
    non-pregnant states. 
    The pregnant women should eat two to three portions of protein rich foods every 

    day including lean meat, poultry, seafood, eggs, legumes, tofu, nuts and seeds.

    1.6.2. Calcium
    Calcium intake is especially critical in the third trimester, when fetal bones are 
    mineralized. It is especially important for the growth of strong bones. It’s important to 
    consume adequate amounts of calcium in pregnancy to support the musculoskeletal, 
    nervous, and circulatory systems. Pregnant women who do not consume sufficient 
    amounts of calcium are at greater risk of developing osteoporosis later in life. 
    Pregnant and lactating women need 1000 mg of calcium per day. Pregnant teens 
    need 1300 mg of calcium per day. Foods rich in calcium include dairy products such 
    as milk, yoghurt, and cheese. Plant sources include tofu, green leafy vegetables 
    and fortified foods. 
    1.6.3. Iron
    Iron needs to be supplemented to provide for increased maternal blood volume, 
    fetal blood storage, and blood loss during delivery. However, by focusing on eating 
    a variety of iron-rich foods, you should be able to get all the iron you need from 
    foods. Foods high in iron include red meat such as beef, lamb and eggs, lean beef 
    and poultry. Plant sources include spinach, and whole grain cereals, dark green, 
    leafy vegetables, citrus fruits. Iron from plant sources is less readily absorbed by 
    the body than those from animal foods. Iron absorption can be increased from plant 
    sources by eating them with foods rich in vitamin C, like fruits and vegetables. 

    1.6.4. Folic acid

    Folic acid intake is particularly important for deoxyribonucleic acid (DNA) synthesis 
    and the growth of red blood cells. Inadequate intake can lead to fetal neural tube 
    defects, anencephaly, or maternal megaloblastic anemia. Sources of folic acid 
    include, but not limited to liver, nuts, dried beans, lentils and eggs.
    1.6.5. Special consideration 
    Prenatal care usually includes vitamin and mineral supplementation to ensure daily 
    intakes; however, pregnant women should not take additional supplements beyond 
    prescribed amounts. On the other hand, alcohol use during pregnancy can cause 
    physical and neuro-developmental problems, such as mental retardation, learning 
    disabilities, and fetal alcohol syndrome. A high caffeine intake is associated with 

    low birth weight (LBW) but not with birth defects or preterm birth.

    Self-assessment 1.6

    You are requested to help a pregnant woman who came to your Health Center for 
    antenatal care in 1st term of pregnancy, which kind of foods you will recommend 

    to her during the remaining period.

    1.7. Maternal Diet during lactation

    Learning activity 1.7

    Observe the pictures below

    Nutritional needs during lactation are based on the nutritional content of breast milk 
    and the energy “cost” of producing milk. Compared with pregnancy, the need for 
    some nutrients increases, whereas the need for other nutrients falls. The healthy 
    diet consumed during pregnancy should continue during lactation.
    The lactating woman needs 500 kcal /day above the usual allowance because 
    the production of milk increases energy requirements. Protein requirements during 
    lactation are greater than those required during pregnancy. The recommended 
    daily allowance for protein during lactation is an additional 25 g/day. The need for 
    calcium remains the same as during pregnancy (that is 1000mg/day). Lactating 
    teens need 1300 mg of calcium per day.
    Requirements of many micronutrients increase compared to pregnancy, with the 
    exception of vitamins D and K, calcium, fluoride, magnesium, and phosphorus. As 
    such, it is recommended that women to continue to take a prenatal vitamin daily 
    while they are breastfeeding
    There is an increased need for vitamins A and C. Daily intake of water-soluble 
    vitamins (B and C) is necessary to ensure adequate levels in breast milk. 
    For many vitamins and minerals, requirements during lactation are higher than 
    during pregnancy. In general, an inadequate maternal diet decreases the quantity 
    of milk produced, not the quality. The exceptions are thiamin, riboflavin, vitamin 
    B6, vitamin B12, vitamin A, and iodine: prolonged inadequate maternal intake of 
    these nutrients reduces their amount in breast milk and may compromise infant 
    nutrition. While maternal supplements can correct inadequacies, there are no 
    consistent recommendations concerning the use of supplements during lactation. 
    Women are encouraged to obtain nutrients from food, not supplements; however, 
    iron supplements may be needed to replace depleted iron stores, not to increase 
    the iron content of breast milk. 
    Another nutritional consideration during lactation is fluid intake. It is suggested 
    that breastfeeding mothers drink a glass of fluid every time the baby nurses and 
    with all meals. Thirst is a good indicator of need except among women who live in 
    a dry climate or who exercise in hot weather. Fluids consumed in excess of thirst 
    quenching do not increase milk volume. 
    In reality, breastfeeding is not always associated with return to preconception 
    weight, and some women actually gain weight during lactation. 
    Other considerations concerning maternal diet and breast milk are as follows:
    Highly flavored or spicy foods may impact the flavor of breast milk but need only 
    be avoided if infant feeding is affected. Some babies are irritated by spicy foods, 

    but others are fine with it

    So, it is best to lessen the number of spices in food for lactating mother, if she 
    notices her baby being uncomfortable with it. 
    Caffeine, alcohol, and drugs are excreted in breast milk and should be avoided. 
    Consistent evidence shows that when a lactating mother consumes alcohol, it easily 
    enters breast milk and results in reduced milk production. There is no scientific 
    evidence to support alcohol consumption during lactation. An occasional drink of 
    alcohol may occur, but women should not breastfeed for at least 4 hours afterward. 
    The lactating mother should be aware that caffeine enters breast milk. Maternal 
    intake should be moderate, such as the equivalent of one to two cups of coffee 
    daily. 
    Chocolate is rich in theobromine, and when eaten, has a similar effect to that of 
    caffeine. Though people love having chocolate, they should cut down the quantity 

    while breastfeeding.

    Some babies could be intolerant to cow milk. When the mother drinks cow milk or 
    has dairy products, then the allergens that have entered the breast milk irritate the 
    baby. After consuming dairy products, if the baby shows symptoms like colic and 

    vomiting, it means that the intake of the dairy products should stopped for a while.

    The smell of garlic can affect the smell of breast milk. Some babies hate it while 
    others like it. Therefore, garlic may be stopped if the baby is uncomfortable while 
    nursing. Some babies might fuss or grimace at the breast when they encounter 
    the strong smell of garlic. Until you wean your baby, avoid peanuts, especially if 
    your family has a medical history of allergies to peanuts. Peanuts allergic proteins 
    might pass to the produced breast milk, and then reach the baby. 
    If you consume fish or any other foods having high mercury content, then this will 
    appear in the breast milk. When breast milk has high levels of mercury, it might 
    affect the neurological development of your baby. A lactating mother should not 
    consume fish more than twice a week. It is best to avoid fish that has high mercury 

    completely.  

    If you had broccoli for dinner the previous day, then you should not be surprised 
    when your baby has gassy problems the next day. Other gassy foods like onions, 
    cabbage, cauliflower, and cucumber should be avoided while breastfeeding in 
    case the baby doesn’t tolerate them. Citrus fruits are an amazing source of Vitamin 
    C, but this can irritate the baby’s stomach due to their acidic components. As their 
    gastrointestinal tract is immature, they’re unable to deal with these acid components, 
    resulting in fussiness, diaper rashes, spitting up, and more. The mother doesn’t 
    have to remove citrus fruits completely from her diet, though. Having one grapefruit 
    or orange daily is fine. But if she decides to cut them out completely, then she 

    should have other vitamin C-rich foods like pineapples, papayas, and mangoes.

    Self-assessment 1.7

    1. Identify the maternal diet recommended during lactation period. 

    2. What will you discourage to eat or drink during lactation period? 

    1.8. Special geriatric nutritional needs

    Learning activity 1.8

    Observe the following pictures

    1. What does each of the pictures A, B, C, and D communicate to you?
    2. Identify the groups of foods included in picture A and their importance.

    3. What do you expect to learn from this lesson?

    Nutrition plays an important role in health maintenance, rehabilitation, and 
    prevention and control of disease. When dealing with nutritional issues, nurses 
    who work with older adults must consider the following: (1) the basic components 
    of a well-balanced diet for older adults; (2) how the normal physiologic changes of 
    aging change nutritional needs; (3) how the normal physiologic changes of aging 
    may interfere with the purchase, preparation, and consumption of nutrients; and 
    (4) how cognitive, psychosocial, and pathologic changes commonly seen in aging 
    impact one’s nutritional status.
    Nutrition and aging
    Nutritional needs do not remain static throughout life. Like other needs, older 
    adults’ nutritional needs are not exactly the same as those of younger individuals. 
    An understanding of older adults’ nutritional needs is essential for providing good 
    nursing care. Good nutrition practices play a vital role in health maintenance and 
    health promotion. Good eating habits throughout life promote physical wellness 
    and mental well-being. Inadequate nutrition and fluid intake can result in serious 
    problems such as malnutrition and dehydration. Poor nutrition practices can 
    contribute to the development of osteoporosis and skin ulcers, and can complicate 
    existing conditions, such as cardiovascular disease and diabetes mellitus.
    Good eating habits developed early in life promote health in old age. Older adults 
    are at risk for nutritional problems because of changes in physiology including 
    changes in body composition, gastrointestinal tract, metabolism, central nervous 
    system, renal system, and the senses. There are also changes in income, changes 
    in health, psychosocial changes, and memory loss (senile dementia), which may 
    include forgetting to eat. Other changes include sensory changes, and physical 
    problems like weakness, gouty arthritis and painful joints.
    Some elderly people have difficulty getting adequate nutrition because of age 
    or disease related impairments in chewing, swallowing, digesting and absorbing 
    nutrients. Age-related gastrointestinal changes that affect digestion of food and 
    maintenance of nutrition include changes in the teeth and gums, reduced saliva 
    production, atrophy of oral mucosal epithelial cells, increased taste threshold, 
    decreased thirst sensation, reduced gag reflex, and decreased esophageal 
    and colonic peristalsis. Their nutrient status may also be affected by decreased 
    production of chemicals to digest food (digestive enzymes), changes in the cells of 
    the bowel surface and drug–nutrient interactions. 
    The presence of chronic illnesses (e.g., diabetes mellitus, end-stage renal disease, 
    cancer) often affects nutrition intake. Adequate nutrition in older adults is affected 
    by multiple causes such as lifelong eating habits, ethnicity, and socialization. It is 
    also affected by income, educational level, and physical functional level to meet 

    activities of daily living (ADLs), loss, dentition, and transportation.

    Adverse effects of medications cause problems such as anorexia, gastrointestinal 
    bleeding, xerostomia, early satiety, and impaired smell and taste perception. 
    Cognitive impairments such as delirium, dementia, and depression affect ability to 
    obtain, prepare, and eat healthy foods.
    Some elderly people demonstrate selenium deficiency, a mineral important for 
    immune function. Impaired immune function affects susceptibility to infections and 
    tumors (malignancies). Vitamin B6 helps to boost selenium levels, so a higher 
    intake for people aged 51–70 is recommended.
    Nutritional interventions should first emphasize healthy foods, with supplements 
    playing a secondary role. Although modest supplementary doses of micronutrients 
    can both prevent deficiency and support immune functions, very high dose 
    supplementation (example, high dose zinc) may have the opposite effect and result 
    in immune-suppression. Therefore, elderly people also need special attention with 
    regard to nutritional care.
    Older adults represent a heterogeneous population that varies in health, activity, 
    and nutritional status. Generalizations about nutritional requirements are less 

    accurate for this age group than for others. 

    Generally, Calorie needs decrease with age; attributed in large part to progressive 
    decreases in physical activity (a decrease in physical activity directly lowers calorie 
    expenditure. Indirectly, a decrease in physical activity leads to a loss of lean body 
    mass).
    Requirements for older people increase for calcium and vitamin D. For example, 
    in order to reduce the risk for age related bone loss and fracture, the requirement 
    for vitamin D is increased from 200 IU/day to 400 in individuals of 51–70 years 
    of age and to 600 IU/day for those over 70 years of age. The equivalent of three 
    glasses of milk is needed to meet calcium requirement in older adults. Calcium 
    supplements may be necessary to achieve the recommended amount. Other 
    nutrients important for bone health include vitamin A, vitamin K, magnesium, vitamin 
    C, and phytoestrogens. 
    Older adults need to obtain their Recommended Dietary Allowance (RDA) for 
    vitamin B12 from the synthetic form found in supplements or fortified foods. The 
    dietary Reference Intakes (DRIs) for sodium decreases due to the decrease in 
    calorie requirement. The RDA for iron in women decreases when menses stops. 
    Generally, older adults do not consume enough vitamin E, magnesium, fiber, 
    calcium, potassium, and probably vitamin D. They should be encouraged to eat 
    more whole grains, dark green and orange fruits and vegetables, legumes, and milk 
    and milk products.

    Screening for nutritional problems is appropriate for all older adults and in all settings. 

    Screening is essential so that timely nutrition intervention can be instituted. Weight 
    loss is the most effective dietary strategy against osteoarthritis. The benefits of 
    weight loss and exercise combined are greater than when either method is used 
    alone. Benefits include improvements in physical function and quality of life. 
    Even interventions begun late in life can slow or stop bone loss characteristic of 
    osteoporosis.
    Sarcopenia is the loss of muscle mass and strength that occurs with aging. It is 
    not inevitable and can be reversed with resistance training and adequate protein 
    intake. To build muscle in older adults, more protein than the RDA may be required.
    The treatment of obesity in older adults is not without risk. Weight loss can be 
    counterproductive if it comes from a loss of muscle and bone, not fat. For many 
    older adults, malnutrition presents more of a risk than overweight. A heart healthy 
    diet may help reduce the risk of Alzheimer disease (AD) and coronary heart disease 
    (CHD).
    Pressure ulcers increase the need for calories, protein, and other nutrients. 
    Increasing nutrient density without increasing the volume of food served may be the 
    most effective method of delivering additional nutrients. Between-meal supplements 

    may also be needed to maximize intake.

    Self-assessment 1.8

    1. What are the negative effects that result from poor nutrition practices of 
    older people?
    2. Why older adults are at risk for nutritional problems?
    3. Discuss the food components and their sources that should be emphasized 
    in the diets of older Adults. 
    1.9. Food security and availability
    Learning activity 1.9

    1.9.1.Introduction to Food security and availability

    The concept of food security means that the need for households to have both 
    physical and economic access to the national food supply is fulfilled. The household 
    food security exists when all the people living in the household have physical, 
    social and economic access to sufficient, safe and nutritious food at all times. It 

    should meet their dietary needs and food preferences for an active and healthy life

    Food security is more than simply access to enough food to prevent death by 
    starvation. The current understanding of food security accordingly emphasizes the 
    quality of the diet – on the need for dietary diversity and for food that supplies the 
    micronutrients necessary to create and sustain health. 

    1.9.2. Levels of food and nutrition security

    An individual’s food security – at house level, is the final step in a sequence of food 
    production and distribution, from the availability of food globally and nationally to 
    access to food at the household level. Global food availability refers to the total 
    amount of food that is produced globally. Currently, global food availability would 
    be more than adequate to meet the energy needs of the entire world’s people if the 

    provision of food was equally distributed. 

    National food availability refers to the amount of food available for consumption 
    by a country’s population. This supply of food consists of total agricultural production 
    (cash crops, livestock, and food crops), net food imports (imports minus exports), 
    food aid, and food stocks. A country is self-sufficient if it is able to produce 100% (or 

    more) of its national food requirements

    1.9.3. Household Food Security: 

    Sufficient amounts of food may be available at the national level, but people must 
    have both physical and economic access to this food. Unless they are able to 
    generate enough food on their own to provide a balanced diet, they must be able 
    to reach a place where food is available. National food security is a prerequisite 
    but no guarantee of household food security. Household food security includes the 

    following:

    (1) Households need physical access to a place where food is available. 
    Households typically obtain food through producing their own crops or livestock for 
    consumption, purchasing from markets, receiving food as a transfer from relatives, 
    members of the community, the government, or foreign donors, and gathering in the 
    wild. Physical availability of food relates to local production, agricultural productivity, 
    and the ability of markets to deliver food to consumers and agricultural inputs to 
    farmers. In developing countries, availability through local food production is often 
    affected by low agricultural productivity, seasonality, and inadequate adoption of 

    appropriate technologies.

    (2) Regardless of the source of food, households must have the means to acquire 
    appropriate foods. Economic access therefore refers to the affordability of food 
    to the consumer. The majority of people worldwide, including those in low-income 
    countries, obtain at least part of their food through markets. Households’ ability to 

    purchase food depends on the households’ income and the price of food.

    The factors that affect either food prices or household income influence the people’s 
    ability to buy food. 
    (3) Socio-political access: Various social and political factors affect household 
    food security. Households in developing countries may, for example, have unequal 
    access to food because of unequal social conditions and exclusionary practices. 

    Social conflict can also threaten the food access of affected people.

    The causes of food and nutrition insecurity all relate to either insufficient national 
    food availability or insufficient access to food by households and individuals.
    Several global risks can potentially impact the availability of food at the national level. 
    These include high and volatile food prices, financial and economic shocks, climate 
    change, and epidemic outbreaks of human disease and crop and livestock disease. 
    Other factors may be: the general social, economic, and political environment 
    prevailing at national level; the presence of natural shocks or conflict; the quality of 
    commercial and trade policies; the commitment of the political leadership to hunger 
    reduction; and the prevalence of institutions that enable participation of women 
    and marginal groups in decision-making processes that affect their future. The 
    food insecurity at the household level include shocks in production (e.g., harvest 
    failure), market (e.g., lost employment), or household expenditure (e.g., emergency 

    medical costs resulting in less money available for food). 

    Other factors may include, but not limited to the following reasons: rapid 
    population growth (It is not always easy to purchase food for large numbers of 
    family members), conflict and/or civil war (interfere with production, marketing 
    and distribution), and extreme production fluctuation. They include also limited 
    or lack of employment, lower level of saving, high rate of natural erosion and/
    or natural disasters, poor health and sanitation     which may lead to the increased 
    morbidity, mortality and reduced productivity due to illness, deforestation leads 
    to high top soil erosion and poor soil fertility. It will lead to decreased rainfall and 

    dryness.

    1.9.5. Consequences of household food insecurity

    The body’s response to chronic hunger and malnutrition is a decrease in body size. 
    In small children this is known as stunting, or stunted growth, and is indicated by 
    low weight for height. This process starts as the baby is growing in the uterus, if the 
    mother is malnourished, and continues until approximately the third year of life. It 
    leads to higher infant and child mortality, with rates increasing significantly during 

    famines. 

    Once stunting has occurred, improved nutritional intake later in life cannot reverse 

    the damage. Premature failure of vital organs occurs during adulthood.

    For example, a 50-year-old individual might die of heart problems because their 
    heart suffered structural defects during early development. Stunted individuals 
    suffer a far higher rate of disease and illness than those who have not undergone 
    stunting. Severe malnutrition in early childhood often leads to defects in mental 
    development. Chronic food insecurity will lead to poor growth, slower development, 
    low educability, school absenteeism or dropout, and increased morbidity and 
    decreased survival impacting on the socioeconomic development through several 

    generations.

    1.9.6. Community-based Actions to address food and nutrition 

    insecurity

    Community-based interventions to improve household food availability and dietary 
    diversity are considered sustainable solutions to address household food and 
    nutrition insecurity in developing countries. In these interventions, household 
    food availability is increased through local production, thereby increasing the 
    household’s access to diverse and micronutrient-rich foods. Such programs can 
    also lead to reduced household poverty, improved nutritional status of household 
    members, and potentially empower women. 
    Food-based strategies at the community level generally focus on the production 
    of nutritious food for household consumption. These strategies have the potential 
    for income generation, provided that households produce a surplus and have easy 
    access to markets at which to sell their harvest. Economically viable post-harvest 
    products could further enhance market possibilities for locally produced crops. 
    To ensure that the gardening activities translate into improved dietary quality, 
    home-gardening projects need to include a strong nutrition education and behavior 
    change component. Various entry points can be used for nutrition education 
    and promotions. The best choice of intervention depends on the nature and 
    the magnitude of the problem. A situation assessment prior to the intervention 
    will indicate which elements of food insecurity are involved and who is affected. 
    Analysis of the underlying causes of food and nutrition insecurity should be the core 
    of any sustainable intervention that aims to prevent recurrence and does not create 

    dependency.

    Self-assessment 1.9 

    1. Identify the levels of food security.

    2. What are the causes of food insecurity?

    1.10. Food contamination and spoilage

    Learning activity 1.10


     1. Name the items in the pictures A, B, C, D, E and F and indicate the place 
    where they are
    2. What is happening on picture C and F? What do you think will be the 

    result?

    Bacteria are a major source of microbial contamination of food (i.e., the undesired 
    presence in food of harmful microorganisms or the harmful substances they 
    produce). Viruses, parasites and fungi are also able to contaminate food and cause 

    foodborne illnesses in humans

    1.10.1.Routes for food contamination

    Microorganisms can enter food through different routes including the followings:
    Air and dust: Microorganisms are found everywhere in our environment. Many 
    types of microbes can be found in air and dust, and can contaminate food at any 
    time during food preparation or when food is left uncovered.
    Soil, water and plants: Many microorganisms present in soil and water may 
    contaminate foods. Microorganisms also grow on plants and can contaminate food 
    if care is not taken to remove them by washing or inactivate them by cooking.
    Gastrointestinal tract: The intestines of all humans and animals are full of 
    microorganisms, some of which are beneficial but others are pathogenic. Bacterial 
    pathogens such as Salmonella, Campylobacter and Escherichia coli are common 
    examples.
    Animals: Many foodborne microorganisms are present in healthy animals raised 
    for food, usually in their intestines, hides, feathers, etc. Meat and poultry carcasses 
    can be contaminated during slaughter by contact with small amounts of intestinal 
    contents. For example, in animals slaughtered in rural communities without any 
    safety measures, microorganisms present in the animals’ intestines can easily 
    contaminate the meat. 
    Food handlers: The term food handler can be applied to anyone who touches or 
    handles food, and this includes people who process, transport, prepare, cook and 
    serve food. The presence of microorganisms on the hands and outer garments 
    of food handlers reflects the standard of hygiene in the environment and the 
    individuals’ personal hygiene.
    Food utensils: Food utensils are cutting boards, knives, spoons, bowls and other 
    equipment used in food preparation, which may become contaminated during food 
    processing and preparation. For example, in families where there is no access to 
    running water, the food utensils may not be properly cleaned, stored and handled, 
    and may become a major route of food contamination.
    Cross-contamination of food is the transfer of harmful microorganisms between 
    food items and food contact surfaces. Prepared food, utensils and surfaces may 
    become contaminated by raw food products and microorganisms. These can be 
    transferred from one food to another by using the same knife, cutting board or other 
    utensil without washing it between uses. 
    A food that is fully cooked can become re-contaminated if it touches raw foods or 
    contaminated surfaces or utensils that contain pathogens. 
    Unsafe temperature: An unsafe temperature for food storage is a major factor in 
    food contamination. Many microorganisms need to multiply to a very large number 

    before enough are present in food to cause disease in someone who eats it.

    Poor personal hygiene: Poor personal hygiene of food handlers is another major 
    factor in food contamination. The most important contaminants of food are the 
    microorganisms excreted with faeces from the intestinal tract of humans. These 
    pathogens are transferred to the food from faecal matter present on the hands. 
    Pests: Foods can be damaged and also contaminated by pests. Many stored 
    grains are lost through the damage done by pests, including termites (mist), beetles, 
    locusts, cockroaches, flies and rodents such as rats and mice. Pests can damage 
    and contaminate foods in various ways, such as boring into and feeding on the 

    insides of grains, or tunneling into stems and roots of food plants.

    1.10.2. Prevention of food contamination

    To prevent contamination, food production and preparation operations need to be 
    carefully controlled, in order to avoid exposing them to microbial, chemical and /or 

    physical food contamination. 

    In order to prevent microbial food contamination people have to have a habit of 
    hand washing before and during food preparation. Attention also needs to be given 
    to possible chemical contamination of food. Food can be contaminated through 
    the misuse or mistaken handling of chemicals, including pesticides, bleach and 
    other cleaning materials. All chemicals (detergent, disinfectant, sanitiser) used in 
    the food preparation area should be removed before food preparation begins, to 
    prevent any chemical contamination of the food. Physical contaminants include 
    stones, pieces of glass, and metal. Physical contamination can occur at any stage 
    of the food chain: for example, stones, bones, twigs, pieces of shell or foreign 
    objects can enter food during handling and preparation. These materials should 
    be removed, if possible, for example by sieving or picking out the items with clean 

    fingers.

    1.10.3. Food spoilage

    Microbial spoilage is caused by microorganisms like fungi and bacteria. They spoil 
    food by growing in it and producing substances that change the color, texture and 
    odor of the food. Eventually the food will be unfit for human consumption. Spoilage 
    may be physical or chemical.
    Physical spoilage is due to physical damage to food during harvesting, processing 
    or distribution. The damage increases the chance of chemical or microbial spoilage 
    and contamination because the protective outer layer of the food is bruised or 
    broken and microorganisms can enter the foodstuff more easily. 
    Chemical spoilage: in this case chemical reactions in food are responsible for 
    changes in the color and flavor of foods during processing and storage. Foods are 
    of best quality when they are fresh, but after fruits and vegetables are harvested, 
    or animals are slaughtered, chemical changes begin automatically within the foods 

    and lead to deterioration in quality. Fats break down and become rancid (smell 
    bad), and naturally-occurring enzymes promote major chemical changes in foods 

    as they age

    1.10.4.Factors influencing food spoilage
    The factors that can increase or delay the process of food spoilage include its water 
    content, environmental conditions, packaging and storage. The amount of water 
    available in a food can be described in terms of the water activity. No matter whether 
    food is fresh or processed, the rate of its deterioration or spoilage is influenced by 
    the environment to which it is exposed. The exposure of food to oxygen, light, 
    warmth or even small amounts of moisture can often trigger a series of damaging 
    chemical and/or microbial reactions. Changing the environment can help to delay 
    spoilage (e.g. storing foods at low temperatures).
    Packaging helps to protect food against harmful contaminants in the environment 
    or conditions that promote food spoilage including light, oxygen and moisture. The 
    type of packaging is a key factor in ensuring that the food is protected. Packaging 
    of foods in cans, jars, cartons, plastics or paper also serves to ensure food safety if 
    it is intact, because it provides protection against the entry of microorganisms, dust, 

    dirt, insects, chemicals and foreign material. 

    General measures for keeping food safe and clean in the household
    Safe food-preparation practices should be respected. People have to observe the 
    following measures for keeping food safe and clean in the household:
    1. Hands should always be clean whenever food is handled. Hot water and 
    soap should be used to wash hands after going to the bathroom, before 

    handling cooked foods, and after handling raw food. 

    2. A person who is ill should not prepare food. 
    3. During food preparation, contact between hands and the mouth, nose, or 
    hair should be avoided. Likewise, coughing and sneezing over foods are 
    forbidden. Tissues or handkerchiefs should be used to prevent contamination. 
    4. Tasting food with fingers and utensils used during preparation is not advised, 
    even if the cooking temperature is very hot.
    5. Buy fresh foods on the day of consumption when possible, or use before the 
    expiry date (if indicated).
    6. Do not buy foods with any of the danger signs 
    7. Frozen food should be thawed in a refrigerator, not put in warm water or left 
    out to thaw.
    8. Store foods at the right temperature and covered.
    9. Eat meals as soon as possible after preparation.
    10. Use clean covered containers for fetching water.
    11. Use a safe water supply, or else boil all water before use.
    12. Wash hands with soap and water before food preparation, before eating 
    meals, and after touching animals, dirty areas, or soil or after visiting the 
    bathroom.
    13. Keep food covered.
    14. Cook food thoroughly or to the correct internal temperature.
    15. Wash all food preparation and eating utensils thoroughly with water and 
    soap before use.
    16. Wash all fruit and vegetables before peeling or eating.
    17. Do not cough, spit, or touch the body during food preparation.
    18. Keep rubbish bins closed at all times.

    19. Keep animals away from food preparation areas.

    Self-assessment 1.1 0

    1. Describe at least 5 routes of contamination of foods

    2. Identify the general measures for preventing food spoilage? 

    1.11. Food preservation and storage

    Learning activity 1.11

    Observe the pictures below:


    1. What do pictures A and B communicate to you?

    2. What do you expect to learn from this lesson?

    1.11.1. Food preservation
    Food preservation refers to the different techniques that are applied to food to 
    prevent it from spoiling. The science behind food preservation involves either: (1) the 
    destruction of micro-organisms responsible for causing food spoilage; (2) reducing/
    eliminating the water (moisture) content from food; and (3) altering the temperature 
    and other conditions that favor the growth of food microorganisms, and thereby 
    retarding microbial growth and replication (thus delaying food spoilage). Simple 
    household food preservation techniques are the following:
    a. Drying
    A number of foods (fruits, vegetables, tubers-cassava, and potatoes) which cannot 
    be stored for long in their fresh state without spoiling can be preserved by drying. 
    Before drying, there should be enough sunshine and foods should be sliced in 
    small pieces for them to dry faster. Dried fruits can be eaten in their dry state (e.g. 
    dried jackfruit), vegetables and potatoes need to be cooked by boiling in water 

    while dried cassava can be ground into flour and used later

    b. Smoking
    Smoking meat and fish is a highly recommended method for prolonging their 
    storage life. The fish is first cooked over a high fire and then smoke-dried in one to 
    five days (and nights) over a low fire. Fresh-dried fish keeps for up to a week, while 
    hard-dried fish (keeping fish in salt for several weeks) keeps for several months.
    c. Salting
    Salting is a simple food preservation method that can be used to prolong the shelf 
    life of food for a few days. When added to foods, salt takes out moisture and retards 
    microbial growth and replication.
    d. Boiling
    Boiling of foods kills food microbes. Perishable foods can be boiled, cooled and 

    kept in clean containers and then used within a day.

    1.11.2. Food storage 
    Storing food in the right way can be a great help in ensuring a household’s food 
    security. Food storage broadly refers to the different means through which food can 
    be kept for longer periods without the food spoiling. The shelf life of a food is the 
    length of time a food remains safe and fit for human consumption. It is essential to 
    store food properly to ensure the following: food remains in good condition for as 
    long as possible. Food is protected from flies, dust and other organisms that can 
    spoil and/or contaminate food. Food is protected from organisms like insects and 

    rats that eat and spoil food. 

    a. Category of foods
    Foods should be stored differently on the basis of how fast they will spoil. Foods 
    can be categorized into 3 groups: 
    • Perishable foods (e.g., eggs, milk, and cream, fresh meat and raw fish) have 
    the shortest shelf life and must be used within a few days. These should be 
    stored in a clean cool place. In the absence of refrigerators, such foods can 
    be placed in clean containers, saucepans or pots. The containers can then 
    be placed in a basin of cold water covered with a clean piece of cloth. In all 
    circumstances, milk and meat should be consumed within 2 days.
    • Semi-perishable foods (e.g., bread, cakes, grain, fresh fruit and vegetables): 
    Breads and cakes should be stored in a bread bin or tin. Fruit and vegetables 
    may be stored in a rack or basket. When put in storage, care should always 
    be taken to remove and discard the particular foods that start showing signs 
    of spoilage so as to avoid cross-contamination. 
    • Non-perishable foods: e.g., dry, bottled and tinned foods can be stored in a 

    cupboard on their own or in airtight containers. 

    The recommended storage conditions for foods often vary; the variations even 
    differ for the same foods depending on the freshness or dryness of the particular 
    food. The following are the further food categories and their storage methods:
    b. Storage of cereals, bread, flour, and rice:
    Bread needs to be stored in its original package at room temperature. It should 
    be used within 5 to 7 days or else it will grow moulds (a sign of spoilage). Cereals 
    - depending on the quantities and level of dryness - may be stored at room 
    temperature in tightly closed containers to keep out moisture and insects. Properly 
    dried cereals packaged in sacs can be stacked on racks in a dedicated food store. 
    Due attention should be taken to keep out rats that normally feed on stored food. 
    Grain raw rice can be stored in closed containers at room temperature and used 
    within one year. Once cooked, rice should be eaten immediately in the absence of 
    refrigeration.
    c. Storing fresh vegetables:
    Proper storage of fresh vegetables helps to maintain their quality and retain nutrient 
    value. Most fresh vegetables need to be stored under low temperatures in areas 
    which are neither humid nor damp. If available, fresh vegetables can be stored in 
    a clay pot fridge. 
    d. Storing fresh fruits:
    All fresh fruits generally need to be stored in a cool area, preferably in a clay pot 
    fridge. Fruits have a tendency to either be contaminated by other foods and or to 
    absorb odors from other foods. They therefore need to be kept separately.
    e. Storing milk and milk products:
    Milk is a highly perishable food and yet very nutritious. To prolong its shelf life, milk 
    should never be left at room temperature for a long time as it spoils quickly. Care 
    must be taken to keep milk in clean covered containers that should be left to stand 
    in a cool place. Unrefrigerated milk should be used within a day.
    f. Storing meat and fish:
    Meat (including poultry), fish, eggs and milk are the best sources of proteins in 
    the human diet. Given their high protein and moisture content, these products are 
    highly perishable. It is for this reason that these products will spoil faster than others 
    - however well prepared and stored. One big contributor to the faster spoilage of 
    fresh cuts of meat is the fact that these usually contain spoilage bacteria on the 
    surface that can grow quickly, producing slime and causing spoilage after a few 
    days. Meat should be prepared and eaten within 24 hours of purchase/slaughter.
    Thinly cut pieces of meat are more susceptible to spoilage given the larger surface 
    area for bacterial action. Meat and meat products should be used within a few days. 
    If the meat cannot be used within a day, it is advisable to dry, smoke or salt it before 

    storing it

    Like meat, fresh fish should be eaten immediately. Never store fish in water as this 
    leads to loss of nutrients from the fish. In order to store fish for longer, it should be 
    smoked.
    g. Storing Root Tubers (Cassava, Sweet Potatoes):
    Most root tubers may not be stored well for long after harvest; however, root tubers 
    keep longer than other vegetables, fruits, meat, milk, etc. When tubers will not be 
    prepared within a few days, care should be taken to avoid bruising them. 
    Cassava tubers can also be piled into plenty and watered daily to keep them fresh 
    or coated with a paste of mud to preserve their freshness. They can keep for about 
    4-7 days.
    Un-bruised sweet potatoes can be kept in a cool, dry place for up to 4-7 days. Care 
    should be taken to remove any developing buds.

    Self-assessment 1.11

    1. Describe 4 simple household food preservation techniques
    2. Explain the storage methods of the following food categoriessada) Storage 
    of cereals, bread, flour, and rice; (b) Storing fresh vegetables (c) Storing 
    fresh fruits (d) Storing milk and milk products (e) Storing meat and fish (f) 

    Storing Root Tubers (Cassava, Sweet Potatoes).

    1.12. Food habits

    Learning activity 1.12

    Observe the pictures below:



    As humans need to fit into society, it follows naturally that people often adopt a 
    dietary practice to demonstrate a sense of belonging. For example, people of the 
    African diaspora may choose to eat African foods on certain occasions or at parties 
    as an expression of ethnic identity. Food can be linked to status, and this is plainly 
    seen when people’s dietary habits change as they move up the socio-economic 
    hierarchy. They tend to go beyond mere consumption of basic essential items 
    for survival to the purchase and intake of more expensive and indeed unusual 
    forms of diet that are prestigious and can adequately “match” their status. Foods 
    that are considered within their own culture as “food for the poor” are consciously 
    excluded from the daily diet as these could “taint” their achieved social position. In 
    general, eating with particular people connotes social equality with those people – 
    many societies regulate who can dine together as a means of establishing class. 
    Moreover, a gendered dimension is seen in some cultures where women and 

    children eat apart from men.

    1.12.1.Conservatism of Cuisine

    Another aspect of the culture-food interaction is the concept of “conservatism of 
    cuisine.” Although what people eat is based in part on what has traditionally been 
    available to them, food habits are also culturally defined. Thus, some food items, 
    although edible and nutritious, remain taboo among certain population groups. In 
    essence, what determines consumption of a particular food is not only its availability 

    (and our ability to purchase it) but, importantly, its cultural acceptability

    Food preferences, while sometimes purely personal, are strongly determined by 
    culture and tradition: what is considered acceptable as food is dictated to a large 
    extent by cultural norms. This explains why people are often reluctant to try foods 
    that are unfamiliar to them and why they tend to be conservative in their choice of 

    cuisine.

    1.12.2. Food Taboos
    A food taboo refers to the act of abstaining from certain foods by reason of culture 
    or religion. Food taboos dictate what may or may not be eaten, and by whom, at 
    what periods certain foods may or may not be eaten, and which foods can or cannot 
    be eaten together. Cultural guidelines may also exist regarding how a particular 
    crop is to be harvested or how a certain type of animal is to be slaughtered, cooked, 
    and served. For example, in most Western cultures, the idea of eating dog or horse 
    meat is unacceptable, as is the thought of eating insects, which are considered a 
    delicacy in some cultures. 
    Food taboos can also be tied to the reproductive cycle. Pregnant women, for 
    example, may be allowed to eat certain foods but not others. Cultural values and 
    beliefs can also affect infant feeding practices, including the practice of breast
    feeding, in ways that may have either a positive or negative impact on a child’s 
    nutritional status. For example, in some cultures, mothers are told that a child with 
    diarrhoea should abstain from food in order to “cleanse” the belly. Another widely 
    held belief in some cultures is that colostrum is “dirty” and should be discarded, and 
    a baby should therefore not be suckled until the “white milk” appears.
    1.12.3. Etiquette
    Proper etiquette for serving and eating food also shows great variation between 
    different cultures. In many cultures, only the right hand may be used for eating, 
    because the other hand (the left) is, culturally, not suitable, as it is designated for 
    sanitation purposes. While meals must be eaten silently in some cultures, in others 
    mealtimes are looked forward to as a period for family discussion and interaction. In 
    considering all these possibilities, it should be accepted that there are no absolute 
    right or wrong food habits, as conclusions can only be made within the perspective 
    of one’s own culture – provided that the food habits in question are of nutritional 

    benefit to the consumers.

    Self-assessment 1.12

    1. What does a food taboo refer to?

    2. Give 2 examples of food etiquette

    1.13. Factors affecting the choice of food

    Learning activity 1.13

    Observe the following pictures and answer the questions mentioned below


    1. What do pictures A and B communicate to you?
    2. How would you organize your meal plate in order to be healthy?
    3. Use library books of nursing nutrition or internet and write short notes on the 
    physical/environmental, physiological, social, economic, psychological, 

    religious and cultural factors influencing food choices

    Why do people eat what they eat? Food is necessary to sustain life and health, but 
    people eat certain foods for many reasons other than good health and nutrition, 
    although these are important factors. Eating behaviors develop from cultural, 
    societal, and psychological patterns. These patterns, reflecting food habits that 
    have been transmitted from preceding generations, are the heritage of any given 
    ethnic group. They may be influenced by interactions with other groups, so that 
    some intermingling of patterns is inevitable, but modifications are worked into 
    the total structure over long periods of time and are acceptable only if they fit the 
    existing customs.
    Food patterns reflect a people’s social organization, including their economy, 
    religion, beliefs about the health properties of foods, and attitudes about family. 
    Great emotional significance is attached to the consumption of certain foods.
    1.13.1.Biological food needs
    The biological food needs of a person throughout the life cycle have one requirement. 
    The food consumed must provide essential chemical substances – nutrients which 
    the body can digest, absorb, and metabolize. To maintain life and health, the 
    nutrients must reach the cells. 
    Adequate nutrient intake depends on many factors, including age, sex, activity, 
    size, and individual variations. The amounts of required nutrients may vary, but the 
    types and kinds of nutrients established as being essential to life and health will 
    remain the same throughout life. Research may add other, as yet unrecognized, 

    essentials as scientific investigation progresses.

    1.13.2. Cultural development of food habits
    Each particular society that identifies itself with a common denominator (e.g., 
    ethnicity, religion, geographic location, and lifestyle) has its own unique cultural 
    food pattern.
    Culture involves much more than the major and historic aspects of a person’s 
    communal life (e.g., language, religion, politics, location). It also develops from all 
    of the habits of everyday living and family relationships, such as preparing and 
    serving food. In a gradual process of conscious and unconscious learning, cultural 
    values, attitudes, customs, and practices become a deep part of individual lives. 
    Although part of this heritage may be revised or rejected as adults, people are 
    ultimately responsible for shaping their own lives and passing traditions on to the 

    subsequent generations as they see fit. 

    Food habits are among the oldest and most deeply rooted aspects of a culture. An 
    individual’s cultural background largely determines what is eaten as well as when 
    and how it is eaten. All types of customs, whether rational or irrational or beneficial 
    or injurious, are found in every part of the world. Many foods take on symbolic 
    meanings related to major life events (e.g., birth, death, weddings). From ancient 
    times, ceremonies and religious rites involving food have surrounded certain 
    events and seasons. Food gathering, preparing, and serving have followed specific 
    customs, many of which remain intact today.
    Many different cultural food patterns are part of family and community life. These 
    patterns have contributed special dishes or modes of cooking to people eating 
    habits. Older members of the family use traditional foods more regularly, with 
    younger members of the family using them mainly on special occasions or holidays.
    Nevertheless, traditional foods have strong meanings and bind families and cultural 
    communities in close fellowship. Individual tastes and geographic patterns will vary, 
    but general food patterns are connected with culture and have a strong influence 
    on how people eat.
    Assumptions about dietary patterns cannot be made, but knowledge of the variety 
    of unique traditional foods provides a rudimentary understanding of the range of 
    possible food choices. Such an understanding of various cultural food patterns is 

    valuable when providing dietary guidance as a health care professional.

    1.13.3. Religious Aspects
    Food plays different, important roles in many religious faiths and practices. These 
    roles are usually rigid and tenaciously held by the adherents of the faiths. Then again, 
    these roles may vary within a faith or philosophy. For instance, most Buddhists are 
    vegetarians so as to avoid killing animals. Some Buddhists avoid meat and dairy 
    products, while others only avoid beef. 
    Many Hindus are vegetarian but this is not obligatory. Muslims follow a list of 
    foods that are allowed (halal, Arabic for “permitted” or “lawful”) and those that are 
    prohibited (haram), such as pork and alcohol. 
    Christian practices vary by denomination and sect. While Catholic and Orthodox 
    Christians observe several feast and fast days during the year, most Protestants 
    observe only Easter and Christmas as feast days and don’t follow ritualized fasting. 
    Some Christians do not drink alcohol, including many members of various Protestant 
    churches. Seventh Day Adventists avoid both caffeinated and alcoholic beverages, 

    and they are vegetarians.

    1.13.4. Social effects
    In any society, social groups are largely formed by factors such as economic status, 
    education, residence, occupation, and family. Accordingly, values and practices 
    differ among groups. Subgroups also develop on the basis of region, religion, age, 
    sex, social class, health issues, special interests, ethnic backgrounds, politics, and 
    other common traits such as group affiliations.
    Food habits, like any other form of human behavior, are gradually established with 
    influences from every direction. 
    Food is a symbol of acceptance, warmth, and friendliness in social relationships. 
    People tend to accept food or food advice readily from friends, acquaintances, and 
    people who they view as trusted authorities. This guidance is especially strong in 
    family relationships.
    Food habits that are closely associated with family sentiments often stay with 
    people throughout their lives. During adulthood, certain foods may even trigger a 
    flood of childhood memories and are valued for reasons apart from any nutritional 
    importance.
    1.13.5. Psychological influences
    Understanding dietary patterns begins with the recognition of the psychological 
    influences that are involved. Many of these psychological factors are rooted in 
    childhood experiences. For example, when a child is hurt or disappointed, parents 
    may offer a cookie or a piece of chocolate to distract the child. Then, when adults 
    feel hurt, they may turn to similar comfort foods to help them cope. Certain foods, 
    especially sweets and other pleasurable flavors, stimulate “feel good” body 
    chemicals in the brain called endorphins that give a mild “high” that may actually 
    help ease pain.
    1.13.6.Food and psychosocial development
    From infancy to old age, emotional maturity grows along with physical development. 
    At each stage of human growth, food habits are part of both physical and psychosocial 
    development. For example, a 2-year-old toddler who is taking his first steps toward 
    eventual independence from his parents may learn to control his parents through 
    food by refusing to eat at meal times or otherwise being a demanding eater. 
    Psychologists believe that food neo-phobia may also be involved. This normal 
    developmental trait may be an instinct from the evolutionary past that protected 
    children from eating harmful foods when they were just becoming independent from 

    their mothers.

    1.13.7. Marketing and environmental Influences
    Food habits are also manipulated by television, radio, magazines, and other media 
    messages. Influences from peers, availability of convenience items, marketing 
    at the local grocery store, and many other factors of persuasion may sway the 
    decision-making process for food choices throughout life. Advertising strategies 
    that make use of brand mascots and cartoon media characters on food packages 
    greatly impact children’s eating patterns by increasing the preference for products. 
    Marketing trends and media also influence what a culture views as beautiful and 
    such provocations may dictate food choices, meal composition, lifestyle, and bodyimage expectations.
    1.13.8.Economic Influences
    Economics is a very strong factor in the determination of food consumption. The 
    costs of producing, transporting, and distributing food determine how much and 
    what types of food are available. Lack of money affects not only the prices that 
    people can pay for food but also the kinds of storage facilities they can afford 
    to have within the household. Poor people often must buy cheap foods in small 
    quantities and purchase items that do not require special storage facilities such as 
    freezers or refrigerators.
    The cost of transportation may prohibit going to a large market, where volume 
    purchases permit cheaper prices. Poverty is sometimes classified as a subculture 
    in our society, and different attitudes and adaptations about foods emerge from 
    this class than those found in the middle or upper classes. Nurses should have an 

    extensive knowledge of these differences.

    Self-evaluation 1.13

    Analyze your eating patterns. Be as objective as possible. Answer the following 
    questions about your behaviors.
    1. What are the determining factors in the way you eat?
    2. What are the determining factors in the amount you eat?

    3. What determines your likes and dislikes?

    1.14. Protein-energy malnutrition

    Learning activity 1.14

    See the following images and attempt the questions that follows


    1. Differentiate the persons in picture A and B based on their physical 
    characteristics?
    2. Describe the hair of the person in Picture B
    3. What do you expect to learn from this lesson?

    1.14.1. Introduction
    An appropriately nourished individual is well equipped to resist disease, recover 
    from illness, reach an optimal fitness level and enjoy a better quality of life.
    Malnutrition is a common problem worldwide. Malnutrition encompasses the 
    inadequacy of any nutrient in the diet. It includes under–nutrition (in people with 
    a limited or restricted food intake) and over-nutrition associated with excessive 
    food intake.
    The consequences of malnutrition include an increased risk of diseases and 
    death, poor productivity of the malnourished individuals as well as poor academic 
    performance and loss of attendance of children from school. Other consequences are 
    poverty perpetuation (a vicious circle) and an intergenerational cycle of malnutrition. 
    Death from protein-energy malnutrition and other nutritional deficiencies occurs 
    within 60 to 70 days of total starvation in normal weight adults, but over a shorter 
    period of time in those who are already malnourished. Depletion of nutrient stores 

    also occurs more rapidly in the ‘metabolically stressed patient’.

    1.14.2.Protein-energy malnutrition

    Protein-energy malnutrition (PEM) is the inadequate intake of protein, mainly seen 
    in developing countries. Within a hospital setting in developed countries, protein 
    energy malnutrition may be due to poor nutritional intake in alcohol misusers or in 
    those suffering from anorexia nervosa. It may be seen in some conditions, because 
    of an inability either to adequately absorb nutrients, such as with Coeliac disease, 
    or to utilize that which is absorbed, such as in cirrhosis. Protein loss can occur 
    following excessive losses of protein in the urine, such as in nephritic syndrome or 
    other renal disorders, and in acute surgical trauma or burns, owing to catabolism. 
    Finally, increased utilization and therefore protein intake requirements occur in 
    fevers and hyperthyroidism.
    Malnutrition can occur in the hospital setting, particularly in older patients who are in 
    hospital for a number of weeks, owing to poor attention to their nutritional needs, for 
    example lack of nutrition screening, food left out of the patient’s reach, not providing 
    appropriate assistance to eat or drink etc.
    Kwashiorkor and Marasmus are serious diseases of Protein Energy Malnutrition 
    (PEM) which develop in young children between 1-3 years of age. They are due to 
    (a) an inadequate diet, that is a diet lacking in proteins and calories and (b) Infections 

    such as diarrhea, measles, bronchitis which lead the child into malnutrition. 

    1.14.3. Kwashiorkor
    Kwashiorkor is a form of malnutrition caused by protein deficiency in the diet, 
    typically affecting young children.
    a. Causes of Kwashiorkor
    The main cause of kwashiorkor is not eating enough protein or other essential 
    vitamins and minerals.
    b. Sign and symptoms
    The Signs and symptoms of kwashiorkor are: change in skin and hair color (to 
    a rust color) and texture, fatigue, diarrhea, loss of muscle mass, failure to grow 
    or gain weight, edema (swelling) of the ankles, feet, and belly; damaged immune 
    system, which can lead to more frequent and severe infections; irritability; flaky 
    rash and shock.
    c. Prevention and treatment
    Prevention, is mainly done through health education of the parents about nutrition 
    and breastfeeding; exclusive breastfeeding for the first 6 month is the best; children 
    should breastfeed up to at least 2 years and the food is introduced slowly from 
    6 months starting from the soft ones; Immunization, family planning and early 

    treatment of any disease.

    Curative:

    a) Hospitalization.
    b) Rehydration: by oral fluids & solution to maintain electrolytes. In severe cases 
    blood transfusion (10ml/kg) may be prescribed.
    d. Complications
    Kwashiorkor results in: muscle wasting, a low serum albumin resulting in peripheral 
    edema (which may make the muscle wasting less obvious) and fatty liver with 
    hepatomegaly. There is also a reduction in immunity and infections may also be 
    present. It is usually seen in children and so there is also growth retardation. All 
    these features are reversible with an adequate protein intake: 
    1. Secondary immune deficiency.
    2. Sever water & electrolytes disturbances.
    3. Hypoglycemia.
    4. Hypothermia.
    5. Heart failure: due to severe anemia, septicemia or due to over hydration 
    during treatment.
    6. Bleeding tendency: due to low vit. K.
    7. Blindness due to sever vit.A deficiency.
    8. Mental retardation: if Kwashiorkor occurs before 6 months of life.
    1.14.4.Marasmus
    Definition 
    It is due to both protein and energy deficiencies; it can occur in anyone with severe 
    malnutrition but usually occurs in children. 
    Clinical manifestations: it is characterized by the classic features of starvation, 
    including: growth reduction, absence of body fat (loss of sub-cutaneous fat, and 
    marked wasting of muscles (the child is reduced to “skin and bones”).
    Treatment:
    1) Preventive: as mentioned in Kwashiorkor.
    2) Curative:
    • Treatment of causes. b) Treatment of complications.
    • Diet: Increase calories & protein (of high biological value).
    • Increase vitamins & minerals. Vegetables & fruit.

    • Parental fluid & blood transfusion.

    • Antibiotics & anti diarrhea drugs.

    Complications:
    • Hypothermia.
    • Hypoglycemia.
    • Infection.
    • Gastro enteritis & dehydration.
    • Edema: Marasmic Kwashiorkor.
    • Bleeding tendency

    • Congestive heart failure.

    1.14.5.Marasmus Kwashiorkor
    Definition: This form of edematous Protein Energy Malnutrition (PEM), combines 
    clinical characteristic of Kwashiorkor and Marasmus. 
    Clinical signs
    The main features are the edema of Kwashiorkor, with or without its skin lesions, 
    and muscle wasting, loss of subcutaneous fat of Marasmus. Biological features 
    of both Marasmus and kwashiorkor are seen, but alterations of severe portion 
    deficiency usually predominate.
    Kwashiorkor and marasmus affect not only the physical growth but also mental 
    development of the child. They can also cause death. 
    Protein Energy Malnutrition need to be prevented by means of:
    • Proper antenatal care of mothers, because a healthy mother give birth to a 
    healthy baby.
    • Promotion of breast feeding.
    • Proper weaning of the child.
    • The child should be given nutrition supplement starting around the age 6 
    months as breast milk alone is not sufficient to sustain the growth of the child. 
    Nutritional supplements can be easily prepared at home using low-cost foods 
    that are locally available. They are foods such as cereals, millets, ground nuts 
    and sugar. Proper use of these supplements helps in preventing malnutrition 
    during the weaning period.
    • Nutrition education of the mother.
    • Immunization of the child against child hood diseases.
    • Food hygiene practices to prevent infections.

    • Economic development to decrease poverty.

    • Improved environmental sanitation.
    • Nutrition and health education.
    • Family planning.
    Main three lines in treatment of Protein Energy Malnutrition (PEM):

    1) Rehydration 2) Medication 3) Provide of adequate nutrition.

    Nursing care plan to PEM:

    Nursing diagnosis:

    1. Imbalanced nutrition less then body requirements related to lack of parents 
    knowledge, economic factors, and inability to absorb nutrition or inadequate 
    food intake.
    2. Deficit fluid volume related to diarrhea & vomiting.
    3. Subnormal body temperature caused by loss of body heat related to loss 
    subcutaneous fats.

    4. Risk for infection related to malnutrition, decrease immunoglobulin.

    The usual approach to treatment
    1. First phase is the stabilization phase (24-48 Hours): correction of dehydration 
    and antibiotic therapy to control infection
    2. Second phase (an additional week to 10 days): continued antibiotic therapy 
    And initial diet administration: to provide maintenance requirements of 
    energy and protein (75 cal/ kg/24hrs and 1 gm /kg /24hrs). Lactose free milk 
    may be initially given, followed by humanized milk. Correct the electrolyte & 
    vitamin deficiency
    3. Third phase: The child’s appetite is returning and the infections are usually 
    under control. A diet provide up to 150 kcal/ kg/24hrs and 4 gm /kg /24hrs 
    of protein. Iron therapy. Blood transfusion is required in case of anemia, 

    serious infection and bleeding tendency (15- 20 ml/kg).

    Self-assessment 1.14 

    1. Differentiate Kwashiorkor from Marasmus in terms of their clinical features, 

    prevention and nursing management

    1.15. Specific vitamin deficiencies

    Learning activity 1.15

    Observe the image below


    Vitamins and minerals are essential nutrients in human body because they act in 
    concert, they perform hundreds of roles in the body. They help shore up bones, 
    heal wounds, and bolster your immune system. They also convert food into energy, 
    and repair cellular damage. Their deficiencies affect the whole-body function. Their 
    main food sources include vegetables and fruits, food from animals (eggs, meat, 

    milk, etc).

    1.15.1.Vitamin A deficient 
    The absorption of vitamin A is related to fat absorption in the gut, and requires 
    protein for synthesis. Therefore, a deficiency of fat, protein or a gut-related illness 
    can result in vitamin A deficiency. Deficiency results in growth reduction and visual 
    problems. Xerophthalmia may occur in vitamin A deficiency and is characterized 
    by conjunctivitis, abnormal and severe dryness of the surface of the cornea and 
    conjunctiva.
    Bitot’s spots (white, soft deposits on the conjunctiva) and night blindness may also 
    occur. Where a deficiency exists, there may be a reduction in immunity. 
    In a previously adequately nourished individual, there are usually enough stores of 
    vitamin A within the liver to last approximately nine months, so it is not unusual for 

    patients to present late in chronic illness.

    Good dietary sources of vitamin A (and beta-carotene, a precursor to vitamin 
    A) include: carrots, oily fish, liver and liver products. They also include fortified 
    margarine and fat spreads, fish liver oils, dairy products (milk, cheese, cream and 
    butter), egg yolks, peaches, apricots and mangoes, tomatoes and red peppers and 

    dark-green leafy vegetables (such as spinach).

    1.15.2.Vitamin B1 (thiamine) deficiency
    Vitamin B1 deficiency may be seen in individuals who abuse alcohol, although it is 
    present in many foodstuffs, vitamin B1 is not present in alcohol. In addition, the body 
    does not store vitamin B1, as it is a water-soluble vitamin. Thiamine is mainly required 
    during the metabolism of carbohydrates, fat and alcohol. Diets high in carbohydrate 
    require more thiamine than diets high in fat. The deficiency is commonly known as 
    beriberi. ‘Dry beriberi’ refers to the development of neurological problems, such as 
    Wernicke’s encephalopathy (ataxia, confusion, nystagmus and sixth cranial nerve 
    palsy), peripheral and motor neuropathy. ‘Wet beriberi’ refers to the development 
    of neurological problems with additional heart failure. The problems are reversible 
    if sufficient thiamine is given, intravenously if necessary.
    Sources of thiamine: Thiamine is not evenly distributed in cereal grains – most of 
    it is present in the outer ‘germ’ layer. Other good sources include: yeast and yeast 
    extract, wholegrain cereal foods, pork, nuts and pulses.

    Many breakfast cereals are fortified with thiamine.

    1.15.3.Vitamin B2 (riboflavin)
    Vitamin B2 is water-soluble and is found in small amounts in many foods. However, 
    levels rapidly decrease under serious illness or with the intake of some drugs, 
    for example amitriptyline, imipramine, chlorpromazine or oral contraceptives. A 
    deficiency of riboflavin results in lesions on the muco-cutaneous surfaces of the 
    mouth (angular stomatitis, atrophic lingual papillae and magenta tongue), cracked, 
    bleeding lips and glossitis. Itchy perineum and hair loss may be seen. There may 
    also be neurological sequelae with photophobia and ataxia.
    Riboflavin deficiency is often accompanied by iron deficiency – possibly as a result 
    of impaired absorption.
    Good dietary sources of riboflavin include: yeast and yeast extract, liver and offal 
    meats, green, leafy vegetables, eggs, milk and dairy products and cereals and 

    cereal products.

    1.15.4.Vitamin C (ascorbic acid)
    Vitamin C is water-soluble and easily destroyed in cooking. It is biochemically active 

    in collagen synthesis, iron absorption and in immunologic function. Therefore, not

    surprisingly, a deficiency in vitamin C, better known as ‘scurvy’, is characterized by 
    swollen, bleeding gums, wiry hair, anaemia and a predisposition to infections, and 
    easy bruising. People with poor diets devoid of fresh food, and those with increased 
    vitamin C requirements, such as cigarette smokers or post-operative patients, are 
    likely to have suboptimal levels. Owing to its role in collagen synthesis, adequate 
    vitamin C is essential for wound healing.
    Good dietary sources of vitamin C include:
    • Fruits and fruit juices (particularly citrus fruits, strawberries, kiwi fruit, berries, 
    currants and guava)
    • Some green vegetables (such as green peppers, broccoli, cabbage and spring 

    greens); however, significant losses can occur during storage and cooking

    Self-assessment 1.15 

    1. Discuss the physical characteristics of the people with the following 
    vitamin deficiency: Vitamin A, B1 (thiamine), B2 (riboflavin) and C
    2. What are the good dietary sources of the following vitamins: Vitamin A, 

    B1 (thiamine), B2 (riboflavin) and C

    1.16. Specific mineral deficiencies

    Learning activity 1.16

    See the picture A and B mentioned below:

    1. Find out the types of foods displayed in picture A
    2. Characterize the health status of the lady in picture B
    3. What do you think may be the consequences of lacking the foods in 

    picture A in human body organism?

    1.16.1. Folic acid

    Folic acid is the parent molecule of a large number of derivatives collectively known 
    as ‘folates’. The role of folic acid is also known in preventing neural tube defects 
    in early pregnancy. In deficiency states, it causes megaloblastic anaemia, atrophic 
    tongue and growth retardation.
    Deficiency is most likely to occur as a result of:
    • Mal absorption (e.g., in coeliac disease): The use of certain drugs interferes 
    with folic acid metabolism (notably methotrexate to treat rheumatoid arthritis 
    and anticonvulsants used in the treatment of epilepsy).
    • Cell proliferation: Some disease states can cause an increase in cell 
    proliferation (e.g., leukaemia).
    Good dietary sources of folates include: liver, green vegetables, yeast extract, 

    pulses and some fruits (oranges and orange juice).

    1.16.2.Zinc
    A deficiency in zinc may occur in patients who require long-term administration of 
    parenteral or enteral feeding, if they have high requirements, with only standard 
    amounts being provided. There are very small body stores of zinc; so, problems 
    can arise if it is not present within the diet on a regular basis. Conditions which 
    predispose people to zinc deficiency are related to:
    • Reduced intake (perhaps associated with an eating disorder)
    • Reduced absorption/bioavailability (owing to an inhibitor, such as a highphytate diet)
    • Increased losses (such as in diarrhoea or excessive vomiting)
    • Increased requirement associated with growth (also in pregnancy/lactation) 
    and are Secondary to conditions such as alcoholism.
    Deficiency results in poor hair quality and hair loss. Changes in the skin result 
    in crusty lesions around the nose and mouth, followed by fingers, toes and the 
    perineal area. The patient may go on to develop diarrhoea, mental confusion and 
    depression. There is also an increased susceptibility to infections, as zinc has a 
    critical role in immune-competence.
    Zinc deficiency in childhood results in stunted growth. Zinc is also thought to play a 
    role in taste acuity, and a loss of taste (hypogeusia) may result from zinc deficiency.
    Zinc has a critical role in protein synthesis and in structural proteins; hence, a 
    deficiency may impair wound healing. It has been postulated that zinc is related 
    to appetite, as it is not unusual to have a loss of appetite with subclinical zinc 

    deficiency.

    Good dietary sources of zinc include: red meat, fish and shellfish, milk and milk 
    products, poultry, and eggs. Other sources of zinc include bread and cereal products, 

    green, leafy vegetables and pulses, although these all have a lower bioavailability.

    1.16.3.Iron
    Iron is an essential component of haemoglobin and myoglobin, with its major 
    function being that of carrying oxygen. Many enzymes contain or require iron, 
    and it is required for many metabolic processes. In contrast to other minerals, no 
    mechanism exists in the body to excrete iron, therefore body levels of iron are 
    regulated by absorption. Iron deficiency results in a reduced ability to transport 
    oxygen around the body. This can have many harmful effects on cardiovascular 
    and respiratory systems, brain and muscle function, and wound healing.
    Both a deficiency and excess of iron are associated with an increased susceptibility 
    to infection. Iron deficiency, with or without anemia, results in a wide range of 
    defects in immune function.
    Good dietary sources of iron include: 
    • Red meat, liver and offal, poultry and fish (contain smaller amounts)
    • Cereal products and fortified breakfast cereals; these can contribute significant 
    amounts of non haem iron, but this is less well absorbed than iron from meat 
    products (haem iron).
    • Other good sources of non-haem iron include green leafy vegetables, dried 
    fruit, pulses, nuts and seeds.
    Having a good source of vitamin C (for example fruit or fruit juice) with foods that 
    contain non haem iron can enhance the absorption of iron. Tannins and phytates 
    can inhibit the absorption of non-haem iron.
    Iron and zinc compete for absorption, which is why it can be a disadvantage for 
    people to self-supplement with either of these nutrients unless there is a proven 

    deficiency and they are under medical supervision.

    Self-assessment 1.16

    1. Discuss the consequences resulting from the lack of the following minerals 
    in human body: folic acid, zinc, and iron

    2. What are the good dietary sources of (a) folic acid, (b) zinc and (c) iron

    1.17. Over-nutrition conditions

    Learning activity 1.17

    Observe the pictures below:


    1. What does each of the pictures A, B, C, and D communicate to you?
    2. Identify the groups of foods included in picture A and their importance.

    3. What do you expect to learn from this lesson?

    Over-nutrition overview
    Over-nutrition is a growing health problem globally. Obesity often coexists with 
    under-nutrition in developing countries and is a complex condition, with serious 
    social and psychological dimensions, affecting virtually all ages and socio-economic 

    groups.

    The reproductive risks of over-nutrition or obesity include infertility or difficulty with 
    conception, gestational diabetes, hypertension (pregnancy-induced), premature 
    birth, and increased rates of caesarean section, as well as a birth weight of greater 
    than 4000 grams. Overweight and obesity are important risk factors for most of 
    the chronic disorders. Indeed, there is a strong interrelationship between many of 
    chronic disorders and risk factors. 
    Early identification by means of nutritional screening, dietary treatment, and 
    monitoring of obese pregnant women as part of standard prenatal care may affect 

    outcomes for the mother and infant.

    Overweight is defined as having a BMI that is more than 25. It is related to an 
    excessive body weight, not necessarily excessive body fat. Muscle, bone, fat, and 
    water all contribute to body weight. Obesity, on the other hand, is defined as having 
    a BMI ≥30, a condition characterized by excess accumulation of body fat.
    Overweight and obesity are important risk factors for most of the chronic disorders. 
    Indeed, there is a strong interrelationship between many of chronic disorders and 

    risk factors. 

    1.17.1.The Causes of Obesity 
    Obesity is a completely unnatural human condition. Dozens of studies from around 
    the world have convincingly shown that obesity is absent when people eat the 
    traditional diet for their region. The disorder appeared when people began to adopt 
    a more modern, Westernized lifestyle. 
    A major factor leading to obesity is reduced physical activity. This occurs as a 
    result of the combination of urbanization and labor-saving machinery. A few decades 
    ago, the majority of people in developing countries lived in villages and engaged in 
    agricultural work or other occupations that require much physical labor. Over recent 
    decades, many tens of millions have relocated to cities. Most jobs today require far 
    less expenditure of energy. At the same time, thanks to the availability of cars and 

    buses, people today typically walk much less than people used to.

    Another major cause of obesity is the widespread availability of highly palatable, 
    energy-dense food (i.e., high quantity of kcal per gram). A large amount of 
    accumulated evidence demonstrates how such food leads to excess intake of food 
    energy – in other words, over-nutrition. Such foods have four key features: a high 
    fat content, high refined sugar content, low fiber content, and a high energy density.
    These features of the modern, Western diet should not be viewed singly: they act 
    synergistically.
    Let us start with dietary fat. The majority of human studies indicate that a high-fat 
    diet     induces excessive energy intake and hence weight gain. The next heavy factor 

    in the obesity epidemic is sugar. In particular, sugar-sweetened beverages have a 

    similar effect on energy balance as does dietary fat: consuming these drinks leads 
    to spontaneous overconsumption of food. With respect to weight control fruit juices, 
    as far as is known, have no advantage over soft drinks.
    Another important dietary component with respect to obesity is fibre. Fibre has the 
    opposite action in the body of sugar and fat; the presence of fibre in foods tends to 
    induce satiation (a feeling of fullness), thereby bringing about a halt to eating. This 
    can be illustrated by comparing a slice of whole wheat bread, a slice of white bread, 
    and 170 mL of cola drink (about half a tin). They each have 170 kcal. Compared 
    with whole wheat bread, the white bread has only half as much fiber, and cola is 
    lacking of fiber altogether. This difference is clear when these foods are eaten: 
    white bread can be eaten more quickly than whole wheat bread and produces less 
    satiation. The cola can be consumed even more quickly and produces minimal 
    satiation.
    The role of fiber in retarding the development of obesity is supported by strong 
    epidemiologic evidence. Detailed comparisons have been made between the 
    satiating effects of the major components of food. In general, fat has the least 
    satiating action, next is carbohydrate, then protein, while fiber has the most.

    An important factor that determines the satiating ability of a particular food is its 
    energy density. Foods with more concentrated energy (more kcal per gram) have 
    less satiating power (i.e., little appetite satisfaction relative to energy consumed), 
    and they are therefore more likely to lead to overconsumption of food energy. This 
    may be a major reason why food fat causes weight gain: because fat has more 
    than twice as much energy per gram as either protein or carbohydrates, fat-rich 
    foods tend to be energy dense. Conversely, foods with high water content have a 
    low energy density and can therefore satiate the appetite before much food energy 
    has been consumed. Many types of fruit and vegetables, such as apples, melon, 
    carrots, and cabbage, have high water content and are therefore particularly good 
    at satisfying the appetite. 
    We can summarize as follows: Doughnuts and biscuits (cookies) are a mixture of 
    fat, sugar, and refined flour, with a minimal content of water and fiber. They are the 
    type of food that readily causes people to overeat and become overweight. In stark 
    contrast, no one ever became overweight by eating too many carrots or by drinking 
    too much tomato soup! 
    One more factor deserves mention in a discussion of the causes of obesity is portion 
    sizes. These have been steadily expanding for the past 40 years. For example, 
    plates in restaurants are significantly larger now than they were a few decades ago. 
    In the case of bottle sizes for cola drinks, these are now three or four times larger. 

    This is potentially important because evidence shows that when people have more 

    food placed in front of them, they eat more. This problem appears to be additive 
    when combined with increased energy density. 
    An accepted wisdom concerning obesity is that most people who try to lose weight 
    fail, and of those that do lose weight, most regain it. By comparison, avoiding obesity 

    in the first place is a much easier goal to accomplish. 

    1.17.2.Complications of Obesity

    Obesity significantly increases mortality and morbidity. It is associated with a wide 
    variety of comorbidities, including diabetes, hyperlipidemia, fatty liver disease, 
    obstructive sleep apnea, gastro-esophageal reflux disease, vertebral disk disease, 
    osteoarthritis, and increased risk of certain cancers. Abdominal obesity, part of 
    the metabolic syndrome, increases the risk of coronary heart disease and type 
    2 diabetes. Obesity increases the risk of complications during and after surgery 
    and the risk of complications during pregnancy, labor, and delivery. Higher body 
    weights are associated with higher mortality from all causes. Obesity increases the 
    risk of complications during and after surgery and the risk of complications during 
    pregnancy, labor, and delivery. Higher body weights are associated with higher 
    mortality from all causes.
    Obesity presents psychological and social disadvantages. In a society that 
    emphasizes thinness, obesity leads to feelings of low self-esteem, negative self
    image, depression, and hopelessness Negative social consequences include 
    stereotyping; prejudice; stigmatization; social isolation; and discrimination in social, 
    educational, and employment settings.
    1.17.3.The Treatment of Obesity 
    A lifestyle approach that includes nutrition therapy, physical activity, and behavior 
    modification is the basis of comprehensive weight management. Pharmacotherapy 
    and surgery may be used in conjunction with lifestyle interventions, based on the 
    individual’s body mass index (BMI) and the presence of comorbidities.
    Attempts to lose weight (i.e., body fat) usually achieve little success. It is important 
    that people wishing to lose weight have realistic goals. An appropriate goal is to 
    lose between 200 and 900 grams per week, or 10% of body weight over 6 months. 
    Setting more ambitious goals is a recipe for disappointment. Moreover, rapid weight 
    loss increases the probabilities of later regaining the weight. Many overweight people 
    dream of achieving a shape that requires losing 30% of their weight. When they fail 
    to achieve this, they feel they have failed. In reality, losing 10% of body weight is a 
    success because it results in significant improvement to long-term health, such as 
    a decrease in blood pressure or blood cholesterol, or an improvement in ability to 
    walk quickly. 
    The first step in losing weight is the adoption of an energy-reduced diet. An 

    appropriate target is to cut energy intake by 500 to 1000 kcal per day.

    It is of prime importance to recognize the major causes of obesity and put these 
    into reverse. In other words, a person should follow a healthy lifestyle that includes 
    a diet that has a generous content of fiber-rich foods, is moderate in fat, is low 
    in sugar, and has a low energy density. 
    Exercise is especially important. There is much evidence that achieving weight 
    loss – and long-term avoidance of weight regain – requires around 60 or 90 minutes 
    of exercise every day, such as walking at a brisk pace. If the intensity is greater, 
    as in the case of jogging for example, then the time required is reduced to 30 
    to 45 minutes per day. One of the secrets for losing weight is to engage in high 
    levels of physical activity (approximately 1 hour per day), eating a low-calorie, low
    fat diet, eating breakfast regularly, self-monitoring weight, and maintaining a 
    consistent eating pattern     across weekdays and weekends. Moreover, weight 
    loss maintenance may get easier over time; after individuals have successfully 
    maintained their weight loss for 2 to 5 years, the chance of longer-term success 
    greatly increases.

    Here are additional rules that are helpful for people trying to lose weight:

    1. Eat small portions.
    2. Eat breakfast every day.
    3. If a person wishes to have sweet-tasting beverages, then replace sugar with 
    synthetic sweeteners.
    4. Avoid buying foods that encourage overeating, and don’t have the “wrong” 
    foods easily accessible. If you can’t resist chocolate, then keep chocolate 
    out of easy reach.
    5. Stay away from buffets or other locations where overeating is made easy.
    6. Try to identify factors that trigger overeating. For example, many people 
    react to stress by overeating. Reducing stress is one example of changing 
    behavior so that overeating is avoided.
    7. Buy a pedometer. These devices count the number of steps walked. An 
    appropriate goal is 10,000 steps per day.
    8. Join a group that actively supports weight loss, increased fitness, and 
    healthful eating. This could be, for example, a commercial organization or a 
    group of friends.
    9. Eating at regular, frequent intervals may help prevent extreme hunger and 
    reduce the risk of binge eating. Meal patterns should be individualized.
    10. Measure weight frequently, 
    11. Watching TV for a limited period of time, 
    12. Nletting a small weight gain become a big weight gain, and

    13. Pharmacotherapy is adjunctive therapy in the treatment of obesity. Drugs 

    are not effective in all people, and they are only effective for as long as they 
    are used.
    14. Surgery to promote weight loss therapy involves limiting the capacity of the 
    stomach. Gastric bypass also circumvents a portion of the small intestine to 
    cause mal absorption of calories. Both types effectively promote weight loss 
    but are tools, not magic strategies.
    15. Bariatric surgeries require lifelong changes in eating behaviors to ensure 
    continued success. The postsurgical diet progresses from clear liquids to 
    pureed food to a soft diet. Small, frequent meals are necessary to avoid 
    overstretching the pouch. Sugars are avoided to decrease the risk of dumping 
    syndrome. Nutritional deficiencies are a lifelong risk, requiring preventative 
    supplementation.

    16. Perhaps most important of all: be determined!

    Self-assessment 1.17

    1. What are the complications that result from obesity?

    2. Discuss the dietary management of obesity?

    1.18. Assessment of nutritional status of a client

    Learning activity 1.18

    Observe the pictures below:



    Nutritional assessment is a systematic process used for collecting client’s nutrition 
    information, interpreting them in order to make decisions about the nature and cause 
    of nutrition related health issues that affect the person. Nutritional assessment 
    focus on the interpretation of anthropometric, biochemical (laboratory), clinical and 
    dietary data to determine whether a person or groups of people are well nourished 
    or malnourished (over-nourished or undernourished). Nutritional assessment can 
    be done using the ABCD methods. These refer to the following:
    A: Anthropometry; B. Biochemical methods; C: Clinical methods; D: Dietary methods
    The type of data needed for health and diet history is subjective and involves 
    interviews and food records. The accuracy of both approaches depends on the 
    skill of the interviewer and the client’s memory, perception, and cooperation. It 
    is important that the interviewer learn something about the client’s life and the 
    factors that influence his or her eating habits (such as money, storage facilities, 

    transportation, and ethnicity).

    1.18.1.Anthropometric assessment
    Anthropometry is the measurement of the size, weight, and proportions of the body. 
    Common anthropometric measurements include weight, height, MUAC, head 
    circumference, skinfold and body mass index (BMI).
    a. Weight
    Weighing is usually the first step in anthropometric assessment and a prerequisite 
    for finding weight-for-height z-score (WHZ) for children and BMI for adults. Weight 
    is strongly correlated with health status. Unintentional weight loss can mean 
    poor health and reduced ability to fight infection. Low pre-pregnancy weight and

    inadequate weight gain during pregnancy are the most significant predictors of 

    intrauterine growth retardation and low birth weight.
    b. Height
    Measuring length or height requires a height board or measuring tape marked in 
    centimeters (cm). Measure the length for children who are under 2 years of age 
    or less than 87 cm long. Measure height for children of 2 years and older who are 
    more than 87 cm tall and for adults.
    c. The head circumference (HC)
    HC is the measurement of the head along the supra orbital ridge (forehead) 
    interiorly and occipital prominence (the prominent area on the back part of 
    the head) posterior. It is measured to the nearest millimeter using flexible, non
    stretchable measuring tape around 0.6cm wide. HC is useful in assessing chronic 
    nutritional problems in children under two years old as the brain grows faster during 
    the first two years of life.
    d. Mid-Upper Arm Circumference (MUAC)
    MUAC is the circumference of the left upper arm measured at the mid-point between 
    the tip of the shoulder and the tip of the elbow, using a measuring or MUAC tape. 
    MUAC measurements in millimeters (mm) are more accurate than measurements 
    in cm. Use MUAC to measure all pregnant women and women up to 6 months 
    postpartum. MUAC is not currently recommended for infants under 6 months and 
    should not be used to assess nutritional status in people with edema.
    e. Skinfold measurement
    Skinfold measurement is a technique to estimate how much fat is on the body. It 
    involves using a device called a caliper to lightly pinch the skin and underlying fat in 
    several places. This quick and simple method of estimating body fat requires a high 
    level of skill to get accurate results. The seven skin sites for skinfold measurement 
    are the followings: triceps, chest/pectoral, midaxillary, subscapular, suprailiac, 
    abdominal, and thigh.
    f. Body Mass Index (BMI)
    BMI is an anthropometric indicator based on weight to-height ratio. It is used to 
    classify malnutrition in non-pregnant/non-postpartum adults. BMI is not an accurate 
    indicator of nutritional status in pregnant women or adults with edema. 

    BMI=Weight (Kg)/Height2 (m)

    1.18.2. Clinical methods

    In this part the nurse will assess clinical signs and symptoms that might indicate 
    potential specific nutrient deficiency. Special attention is given to organs such as 
    skin, eyes, tongue, ears, mouth, hair, nails, and gums. Clinical methods of assessing 
    nutritional status involve checking signs of deficiency at specific places on the body 
    or asking the patient whether they have any symptoms that might suggest nutrient 

    deficiency.

    1.18.3.Biochemical assessment
    Biochemical assessment means checking levels of nutrients in a person’s blood, 
    feces, urine or other tissues that have a relationship with the nutrient. Laboratory 
    test results provide to health care professionals useful information about medical 

    problems that may affect appetite or nutritional status.

    Table 1.18 3 Blood tests useful for determining nutritional status

    Many parameters are useful in assessing nutrition status, including anthropometric, 
    laboratory, physical, and historical data. These data form the basis for interpreting 
    nutrient needs and determining how they will be met. Each client’s individual needs 
    in all the areas must be considered. The Needs can change as people change—
    aging, recovering from diseases, or adopting different lifestyles are some of the 
    important changes that require different nutritional patterns.
    1.18.4.Dietary methods
    Assessing food and fluid intake is an essential part of nutrition assessment. It 
    provides information on dietary quantity and quality, changes in appetite, food 
    allergies and intolerance, and reasons for inadequate food intake during or after 
    illness. 
    The first methods use is called 24-hour recall. This technique is used to quantify 
    or assess the average dietary intake. The patient is asked to remember in detail 
    every food and drink consumed along the previous 24 hours. It may be repeated 
    on several occasions in order to count day to-day variation in intake. The nurse will 
    ask the patient to remember what they ate or drank for a specified period of time 
    or activities. 
    The second method for dietary assessment is food frequency questionnaire which 
    provide information that establishes usual dietary intake. It is designed to obtain 
    information on overall dietary quality rather than nutrient composition and intake. 
    The food frequency questionnaire examines how often someone eats certain foods, 
    and sometimes the size of the portions. It consists of a list of foods and a selection 
    of options relating to the frequency of consumption of each of the foods listed (e.g., 
    times per day, daily, weekly, monthly).
    Another way to do dietary assessment is called food group questionnaire which 
    focus on showing clients’ pictures of different food groups (often available from 
    national nutrition authorities) and ask whether they ate or drank any of those foods 
    the previous day.
    a. Weighed food records
    The 7-day weighed food record is frequently regarded as the “gold standard” against 
    which other methods are compared, because it uses many days of recording –
    which is more likely to capture the usual intake of an individual – and provides 
    exact measures for portion sizes. Prior to consumption, subjects or investigators 
    are required to weigh each item of food and drink. A detailed description of the food 
    (individual ingredients, brand name, method of preparation, etc.) and its weight are 
    recorded.
    b. Estimated food records
    Estimated food records are similar to weighed food records, the difference being the 
    way in which individuals or investigators quantify food intake. Intake is estimated, 
    rather than weighed, and then converted into amounts that can be used to calculate 
    food and nutrient intake
    c. Household food surveys
    A number of surveys are meant to collect information about dietary intake at the 
    household level. This method has been used to monitor long-term dietary intake 
    and provide information on food expenditure and food and nutrient intake trends 

    over a period of time.

    Examples of questions that are used for nutrition history
    1. How many meals and snacks do you eat each day?
     Meals------------- Snacks-----------------
    2. How many times a week do you eat the following meals away from home? 
    Breakfast-------- Lunch---------- Dinner
    What type of eating places do you frequently visit? Fast food Diner?cafetaria 
    Restaurant---- other---------
    3. On average, how many pieces of fruit or glasses of juice do you eat or drink 
    each day?
     Fresh fruit-----------------juice ---------------
    4. On average, how many servings of vegetables do you eat each day? ------
    ----
    5. On average, how many times a week do you a high-fiber breakfast cereal? 
    ------
    6. How many times a week do you eat red meat (beef, lamb, veal) or pork?---
    -------
    7. How many times a week do you eat chicken or turkey?-------
    8. How many times a week do you eat or shellfish?--------
    9. How many hours of television do you watch every day?---------
     Do you usually snack while watching television? Yes----No----
    10. How many times a week do you eat desserts and sweets?------

    11. What types of beverages do you usually drink? How many servings of each 

    do you drink a day?
    Water---- Milk: Alcohol:
    Juice---- Whole milk:---- Beer-----------
    Soda------ 1%milk---------- Wine----------
    Diet soda ------ skim milk-------- hard liquor---
    Sports drinks .......
    Ice tea-------

    Iced tea with sugar------

    Self-assessment 1.18

    1. What are the common anthropometric measurements? 
    2. Identify the clinical signs and symptoms of nutritional deficiencies based 
    on physical examination of the following organs:
    a. Skin, hair, and mucous membranes
    b. Eyes
    c. Abdomen
    3. What are the laboratory tests and acceptable limits that are useful for 
    determining malnutrition problems relating to the following nutrients?
    a. Carbohydrate
    b. Iron

    c. Calcium

    1.19. Oral feeding

    Learning activity 1.19

    1. What do you see on pictures A and B?
    2. Differentiate pictures A and B in terms of the activities that are being 
    performed.

    3. What do you expect to learn from this lesson?

    Nutrition is a basic component of health that affects a patient’s rate of recovery 
    from short-term and chronic illness, surgery, and injury. The lack of attention to a 
    patient’s nutritional status leads to malnutrition. 
    Associate nurse collaborates with a variety of health care professionals regarding 
    the nutritional health of patients and participate in nutritional screenings and 
    assessments. He/she also assess and help patients with feeding and identify 
    patients at risk for difficulty swallowing and aspiration during feeding.
    Nutritional screening must be completed within 24 hours of admission to a hospital, 
    within 14 days of admission to a long-term care facility, or within a facility-defined 
    period of time in ambulatory and home care settings.
    Hospitalized patients receive a number of different oral diets that require a health 
    care provider’s order. A therapeutic diet treats many illness and disease states. A 
    regular diet can be modified in two ways: quantitatively or qualitatively. Qualitative 
    diets include modifications in consistency, texture, or nutrients such as clear or full 
    liquid. Quantitative diets include modifications in number or size of meals served or 
    amounts of specific nutrients such as six small feedings or calorie diets. You can 
    supplement any diet with oral nutrition supplements. You prepare a patient so he or 
    she can be comfortable and not interrupted during a meal.
    Helping adults with oral nutrition requires time, patience, knowledge, and 
    understanding. Most people eat without assistance. For other people assistance 
    is required to get food from the plate and into the mouth. When they are ill, many 
    patients require assistance either to feed themselves or, if necessary, to be fed by 
    another person if unable to eat independently.
    Altered dentition, improperly fitted dentures, oral lesions or infections, or diseases 
    causing impaired digestion limit the types and consistencies of foods tolerated. 
    Hemiplegia, fractured arm, quadriplegia, debilitating illness, or generalized 
    weakness limits self-feeding ability and appetite.
    Equipment for oral feeding:
    • Stethoscope and tongue blade for assessment
    • Washcloths and towels

    • Tongue blade

    • Adaptive utensils as necessary for self-feeding
    • Oral hygiene supplies

    Table 1.19 1 Implementation of oral feeding



    Self-assessment 1.19 

    1. What is the rational for putting the patient in high-Fowler’s position during 
    oral feeding?
    2. Why should the associate nurse or family talk with patient during meal?

    3. What is the required equipment for oral feeding?

    1.20. Nasogastric tube feeding

    Learning activity 1.8

    Observe the pictures below:


    1. What information do you get from the above pictures?
    2. Describe the activities that are being done in pictures B, C, and D 
    mentioned above.

    3. What do expect to be the today’s lesson?

    In order to help patients who are not able to swallow, a nasogastric tube is required. 
    Nasogastric tube feeding is a method for providing nutrients to patients who are not 
    able to meet their nutritional requirements orally. As a rule, candidates for enteral 

    nutrition must have a sufficiently functional gastrointestinal (GI) tract to absorb nutrients.

    1.20.1. Indications for Nasogastric tube feeding

    Indications for Nasogastric tube feeding include the following:
    • Situations in which normal eating is not safe because of high risk for aspiration: 
    Altered mental status, swallowing disorders, impaired gag reflex, dependence 
    on mechanical ventilation, certain esophageal conditions (strictures, or 
    dysmotility), and delayed gastric emptying – inability to safely and adequately 
    consume oral intake. 
    • Clinical conditions that interfere with normal ingestion or absorption of 
    nutrients or create hypermetabolic states: Surgical resection of oropharynx, 
    proximal intestinal obstruction or fistula, pancreatitis, burns, and severe 
    pressure ulcers.
    • Short-term feeding (< 6 weeks) with functional gastrointestinal tract
    • Conditions in which disease or treatment-related symptoms reduce oral 
    intake: Anorexia, nausea, pain, fatigue, shortness of breath, or depression. 
    1.20.2.Advantages and disadvantages for Nasogastric tube 
    feeding
    Advantages
    It is easy to place and remove tube. It uses stomach as reservoir. It can use 
    intermittent feedings. Dumping syndrome is less likely than with naso-intestinal (NI) 
    feedings.
    Disadvantages
    It is contraindicated for clients at high risk for aspiration. It is potentially irritating 
    to the nose and esophagus. It may be removed by uncooperative or confused 
    patients. It is not appropriate for long-term use. It is unaesthetic for patient.
    1.20.3. Technique of nasogastric feeding
    a. Preparation
    Before starting feeding procedure, the nurse will have to prepare him/herself as 
    follow: 
    • Wear clean uniform (dress or gown)
    • Tie hair properly
    • Remove watch and jewelry
    • Wash hands
    • Be aware of food reactions, its side effects and its interactions with the 
    treatment at hand.

    • Check patient’s medical prescription

    The next step will be the assessment: 
    • Identify the patient. 
    • Assess patient’s clinical status to determine potential need for tube feedings, 
    decreased level of consciousness, nutritional deficits, head or neck surgery, 
    facial trauma, or impaired swallow, patient’s ability to understand and cooperate,
     physical and psychological condition.
    • Assess patient for food allergies.
    • Perform physical assessment of abdomen, including auscultation for bowel 
    sounds before feeding.
    • Obtain baseline weight and review serum electrolytes and blood glucose 
    measurement. 
    • Assess patient for fluid volume excess or deficit, electrolyte abnormalities, 
    and metabolic abnormalities (e.g., hyperglycemia).
    • Verify health care provider’s order for type of formula, rate, route, and 
    frequency.
    • Check expiration date of feed and check for damage
    The preparation of patient will focus on: 
    • Respect of patient’s privacy
    • Evaluate the patient’s ability to understand and co-operate
    • Inform and explain the patient/family: objective, procedure, etc. of care
    • Get patient’s consent 
    Equipment
    • Trolley or disinfected tray
    • A container with liquid or semi liquid food at room temperature or a disposable 
    feeding bag, tubing, or ready-to-hang system
    • 50-60mL or larger “Janet” Syringe
    • Clean gloves 
    • Protection for the patient
    • A cup of clean water to rinse the catheter
    • Clean gauze / tissue to wipe the patient’s mouth, if necessary
    • Stethoscope
    • Kidney dish
    • Enteral infusion pump for continuous feedings if applicable
    • pH indicator strip (scale 0.0 to 11.0)
    • Document (file) for recording the frequency and administered quantity
    • Prescribed enteral formula

    b. Implementation

    1. Identify patient using two identifiers (i.e., name and birthday or name and 
    account number) according to agency policy. Compare identifiers with 
    information on patient’s identification bracelet.
    2. Perform hand hygiene. Apply clean gloves
    3. Obtain formula to administer: Verify correct formula and check expiration 
    date; note condition of container. Provide formula at room temperature.
    4. Prepare formula for administration:
    a) Use aseptic technique when manipulating components of feeding system 
    (e.g., formula, administration set, connections).
    b) Shake formula container well. Clean top of canned formula with alcohol swab 
    before opening it.
    c) For closed systems, connect administration tubing to container. If using open 
    system, pour formula from brick pack or can into administration bag (see 
    illustration).
    5. Open roller clamp and allow administration tubing to fill. Clamp off tubing 
    with roller clamp. Hang container on intravenous (IV) pole.
    6. Place patient in high-Fowler’s position or elevate head of bed at least 30 
    degrees (preferably 45 degrees). For patient forced to remain supine, place 
    in reverse Trendelenburg’s position.
    7. Verify tube placement. Observe appearance of aspirate and note pH 
    measure.
    8. Check gastric residual volume (GRV) before each feeding (for bolus and 
    intermittent feedings) and every 4 to 6 hours (for continuous feedings): 
    – Draw up 10 to 30mL air into syringe and connect to end of feeding tube.
    – Inject air into tube. Pull back slowly and aspirate total amount of gastric 
    contents.
    – Return aspirated contents to stomach unless volume exceeds 250mL. 
    – Do not administer feeding when a single GRV measurement exceeds 500mL 
    or when two measurements taken 1 hour apart each exceed 250mL. 
    – Flush feeding tube with 50mL of water
    9. Before attaching feeding administration set to feeding tube, trace tube to its 

    point of origin. Label administration set, “Tube Feeding Only.”

    Intermittent gravity drip:
    – Pinch proximal end of feeding tube and remove cap. Connect distal end of 
    administration set tubing to feeding tube and release tubing.
    – Set rate by adjusting roller clamp on tubing or attach tubing to feeding pump. 
    Allow bag to empty gradually over 30 to 45 minutes. 
    Label bag with tubefeeding type, strength, and amount. Include date, time, and initials.
    – Change bag every 24 hours.
    Continuous drip method:
    a) Connect distal end of administration set tubing to feeding tube as in Step 10a.
    b) Thread tubing through feeding pump; set rate on pump and turn on. 
    10.Advance rate of tube feeding gradually, as ordered.
    11. Flush tubing with 30mL water every 4 hours during continuous feeding, before 
    and after an intermittent feeding. Have registered dietitian recommend total 
    free water requirement per day and obtain health care provider’s order.
    12. When patient is receiving intermittent tube feeding, cap or clamp end of 
    feeding tube when not being used.
    13. On completion of feed, flush the tube with 10-20 CC of water or until the tube 
    is clear (or volume as recommended on dietetic regimen). The plunger must 
    be used for flushing to achieve optimum flushing of the tube and prevent 
    blockage.
    14. Close the clamp on the NG tube then disconnect the syringe and recap the 
    feeding port.
    15. Wipe the mouth
    c. Completion of the procedure
    • Position the patient comfortably and appropriately
    • Arrange personal effects of the patient and put them within reach.
    • Thank the patient for his or her collaboration
    • Eliminate waste
    • Dispose of supplies and perform hand hygiene 
    • Provide a health education related to the patient’s health condition
    • Wash hands
    • Record and sign the administration of food on the monitoring document by 
    providing clear specifications as follows: feeding hour, administered quantity, 

    patient’s reactions, and possible residues.

    Self-assessment 1.20

    1. What are the indications for nasogastric tube feeding?
    2. Within the skills laboratory, prepare the material for nasogastric tube 
    feeding. By using simulation mannequin (model), perform nasogastric 

    feeding with respect of all recommended steps. 

    End unit assessment 1

    1) Recommendation for protein during pregnancy is: 
    a. 60 g daily
    b. 14 g daily
    c. 32 g daily
    d. 75 g daily
    2) It is recommended that pregnant women get at least 1000mgs/day of ..., 
    to help build healthy bones for mother and baby.
    a. Calcium
    b. Folic acid
    c. Iron
    d. Thiamine
    3) Reduces the risk of birth defects of the brain and spinal cord; referred to 
    as the “neural tube”
    a. Calcium
    b. Folic Acid
    c. Potassium
    d. Fiber

    4) Which supplement helps prevent anemia and supports the baby’s growth 
    and development
    a. zinc
    b. vitamin D

    c. DHA

    d. iron
    5) Discuss the factors that influence eating habits to promote a healthy 
    lifestyle
    6) Discuss the different nutritional disorders found in children aged less than 

    five years and their management

    7) Explain the specific diets for management of the adolescents with 
    Anorexia nervosa and Bulimia
    8) Explain how to prevent iron deficiency anemia to an infant?
    9) What nutrients should be mostly recommeded for promoting the growth 
    of children
    10) What will you discourage to eat or drink to a lactating Woman?
    11) Discuss the food components and their sources that should be emphasized 
    in the diets of older Adults.
    12) What are the causes of food insecurity?
    13) Identify the general measures for preventing food spoilage
    14) Describe 4 simple household food preservation technique
    15) Explain the storage methods of fruits; vegetables; cereals, milk, sweet 
    and potatoes.
    16) Discuss shortly the food habits
    17) What are the cultural factors affecting food choices
    18) Differentiate Kwashiorkor from Marasmus in terms of their clinical features, 
    prevention and management.
    19) What are the clinical characteristics of the people with the following 
    vitamin deficiencies: vitamin A and C
    20) What are the good dietary sources of the following vitamins: Vitamin A; 
    B1 (thiamine); and C
    21) What are the good dietary sources of (a) folic acid (b) iron (c) Zinc? 
    22) Discuss the dietary management of obesity
    23) What are the common anthropometric measurements?
    24) What is the rational for putting the patient in high fowler’s position during 
    oral feeding?

    25) What are the indications for nasogastric tube feeding?












    UNIT2:HUMAN NUTRITION AND DIETETICS►