Chapter 1 NSA
Chapter 1 NSA
Chapter 1 NSA
1.1. Introduction
The science of nutrition is the study of the nutrients and other substances in foods and the
body's handling of them.
Its foundation depends on several other sciences, including agriculture biology,
biochemistry, and others.
Human nutrition is a complex, multifaceted scientific domain indicating how substances in
foods provide essential nourishment for the maintenance of life.
To understand, study, research, and practice nutrition, a holistic integrated approach from
molecular to societal level is needed.
Optimal, balanced nutrition is a major determinant of health.
It can be used to promote health and well-being, to prevent ill-health and to treat disease.
The hundreds of millions of food- and nutrition-insecure people globally, the coexistence
of under - nutrition and over nutrition, and inappropriate nutritional behaviors are
challenges that face the nutritionist of today.
Meal: is an eating occasion that takes place at a certain time and includes specific, prepared food,
or the food eaten on that occasion.
Metabolism; refers to the chemical (metabolic) processes that take place as your body converts
foods and drinks into energy. It’s a complex process that combines calories and oxygen to create
and release energy. This energy fuels body functions
Nutritional requirement: refers to the different nutrients required by the body for energy, growth
and repair, as well as protection from disease. Nutritional requirements differ according to age,
gender, physical activity, height, weight, and health status of the individual. Nutritional status of
an individual person results from nutrient intake, nutrient requirements, and the body’s ability to
digest, use and absorb the nutrients that are ingested.
Balanced Diet: is a diet that contains all the nutrients in the proportion that is optimal for long-
term health and survival.
Nutrients; Chemical substances that are essential to life which must be supplied by food to yield
energy and nutrients for the maintenance of life and the growth and repair of tissues.
Nutrition The scientific study of food and its nutrients; its functions, actions, interactions and
balance in relation to health and disease.
Nutrition sensitive interventions: are interventions or programs that address the underlying
determinants of fetal and child nutrition and development. Food security; adequate carem
giving resources at the maternal, household and community levels; and access to health services
and a safe and hygienic environment are incorporated in nutrition sensitive goals and action.
Nutrition-sensitive agriculture: An approach that seeks to maximize agriculture’s contribution to
nutrition by focusing on the production of nutritious foods, and entails targeting poor households,
promoting gender equality, and providing nutrition education so that household resources are used
to improve household members’ nutrition, especially that of women and young children.
1.3. Nutrient and their functions
Nutrients: are chemical substances obtained from food and used in the body to provide energy,
and regulating agents to support growth, maintenance, and repair of the body's tissues.
In general, based on the amount of nutrient our body needs for metabolism, there are two types of
nutrients: Macronutrients and micronutrients.
Macronutrients: are nutrients required in a large amount and they provide the bulk
energy an organism's metabolic system needs to function.
o Macronutrients include carbohydrates, proteins and fats.
Micronutrients: are nutrients required in a small amount and provide the necessary co-
factors for metabolism to be carried out and include vitamins and minerals.
o Micronutrients are very important for normal growth and maintain health of
human body.
Based on function and source there are six different types of nutrients:
1. Carbohydrates – are what our body burns most often for fuel, much like firewood. They are
used in the body to provide the first source of energy.
e.g, Cereal, grains, legumes, fruits and vegetables are the main source of
carbohydrates.
2. Proteins - are the building blocks of the body tissue, and can also serve as a fuel source.
They build the walls of our body (hair, skin, muscles, etc), just like bricks build our home.
e.g., Meat, egg, poultry, milk, fish and legumes are main source of protein.
3. Fats - are also burned for energy and they give more fuel and are easy for our bodies to store
for later use. Fats have twice as many calories as proteins or carbohydrates.
E.g. this is much like paraffin in our homes; it is stored in a small jug and a little fuel
goes a long way. They also help the body absorb vitamins. Fish, butter, beef, egg,
pork, milk, fruits such as avocado, nuts and soybeans are good source of fat.
3 . Vitamins – are essential for normal growth and health. They are like watchdogs which
protect us from thieves while vitamins in our body protect us from diseases. They are
required in Small quantities in the diet because they cannot be synthesized by the body.
Most vegetables and fruits are good source of vitamins
Based on solubility, there are two types of vitamins:
i. Fat-soluble vitamins:
They are digested and absorbed with the help of fats that are in the diet.
They can be stored in the body for long periods.
They are soluble in fat and this group includes vitamin A, D, E & K
1 Vitamin A – Dark green and yellow fruits and – Needed for strong bones, good
vegetables. vision and healthy skin.
Vitamin B: helps to maintain healthy skin and a well-functioning nervous system. Vitamin B
also help to convert carbohydrates into energy.
Vitamin C or ascorbic acid: is needed for building the connective tissue that holds body
cells together. Vitamin C is essential for healthy teeth, gums and blood vessels. It also helps
the body to absorb iron. The Vitamin C deficiency will result in scurvy. Citrus fruits are good
sources of vitamin C.
5. Minerals – are nutrients such as iron, calcium, iodine, zinc and magnesium that are
important for normal body growth and health. Animal and plant food sources provide most
of the essential minerals. Iron (Fe), Iodine (I), Zinc (Zn), Calcium (Ca) and Prosperous (P)
are some examples of minerals.
S.No Mineral Source Function
6. Water - is needed for most body functions, including maintenance of health and
integrity of every cell in the body.
1.4. Food groups and their sources
Most people, particularly those with a low income, consume only one or two types of
mostly staple foods.
Consumption of diversified foods is important for health, proper growth and development
of children and adolescents.
There are a number of food classifications containing five, six, seven and ten food groups
according to different literature.
The basis for the classification is mainly on the nutritional needs of population group.
Here in this chapter we will see the six food group classification which is adopted from FAO food
group classification
i. Staples: This food groups are basic sources of energy. Foods in this category include cereal
grains such as sorghum, millet, maize, barley, oats, wheat, teff, rice and starchy roots (inset,
cassava, sweet potato and potato).
ii. Legumes and nuts: This group includes beans, lentils, peas, chickpeas, ground nuts and soya
beans. Apart from soybean and groundnut, which is also rich in oils and fats, they provide mainly
protein and are important for growth, repair and body building.
iii. Animal source foods: All foods in this group are of animal origin such as meat, poultry, eggs,
milk and milk products and fish. They provide protein, fats, vitamins and minerals. They help the
child to grow, have strong bones and be health.
iv. Vegetables: This group includes green leafy and yellow and orange vegetables such as
cabbage, kale, green pepper, pumpkin, onion, tomato, carrot, spinach, cauliflower, lettuce, celery,
cucumber, eggplant, brocoli, and others such as mushroom. They provide mostly vitamins,
minerals and water. Vegetables also contain natural indigestible fibers that are necessary for
proper digestion and healthy bowl movement.
v. Fruits: They include citrus fruits (oranges, lemons and mandarins), bananas, papaya, mango,
avocado, pineapple, apple, guava, watermelon, grapes, peach, sweet melon and many other
indigenous fruits. Fruits provide mostly carbohydrates, vitamins, minerals and water.
vi. Fats: This group includes fats from plant and animal origin. Fats and oils from plants are
oilseeds (soybean, linseed, and groundnut). Fats provide an additional energy, essential fatty acids
and fat-soluble vitamins.
There are foods unclassified in this food groups and not desired for diet diversification. These are
mainly processed foods such as biscuits, various kinds of sweets and alcohol. Industrial food
processing in most cases refines or modifies natural foods and makes them nutrient dense by
removing natural components like fibers. They also have more undesired nutrients like salt, sugar
and fats in excess to enhance their flavor and taste for market purpose.
The conceptual framework for food and nutrition security is helpful in disaggregating the related
concepts of food security and nutrition security at both household and individual levels.
Food security: the condition when all people, at all times, have physical and economic access
to sufficient, safe and nutritional food to meet their dietary needs and food preferences for an
active and healthy life.
Nutrition Security: The condition when all people have ongoing access to the basic elements
of good nutrition, i.e., a balanced diet, safe environment, clean water, and adequate health care
(preventive and curative), and the knowledge needed to care for and ensure a healthy and active
life for all household members.
Food security is defined as the availability and the access of food to all people;
whereas nutrition security demands the intake of a wide range of foods which
provides the essential needed nutrients.
While food security is about access to a certain quantity of food, nutrition security
considers food quality.
Food and Nutrition security: Food and nutrition security exists when all people at all times have
physical, social and economic access to food, which is consumed in sufficient quantity and quality
to meet their dietary needs and food preferences, and is supported by an environment of adequate
sanitation, health services and care, allowing for a healthy and active life.
The overlap between food and nutrition security is shown in Figure 1.2.
1.6. Malnutrition
1.6.1. Definition and basic concepts of malnutrition
Malnutrition refers to abnormal nutrition condition, both under-nutrition and over
nutrition.
While majority of developed countries suffer from problems related over-nutrition,
developing countries suffers from the double burden of under-nutrition and over-
nutrition.
Malnutrition is currently considered the leading cause of child mortality.
The global community is urging for prevention of under-nutrition in children by focusing
on the 1000 days nutrition interventions- the period from pregnancy to the first two years
of life.
If under-nutrition occurs during this period, the damage on child physical and cognitive
development will be irreversible.
1. Under nutrition
I) Protein- energy malnutrition (PEM)
Protein-Energy Malnutrition (Macronutrient Deficiency) is currently the most important
nutritional problem in developing countries including our country Ethiopia.
Failure to grow adequately is the first and most important manifestation of protein
energy malnutrition.
It can be due to long-term or short term food shortages and infections.
The term protein energy malnutrition is used to describe both the moderate and the sever
forms of under-nutrition.
o Moderate (mild) PEM: It is manifested mainly as poor physical growth in
children. Stunting, underweight, and wasting are manifestations of child growth
failure due to mild/moderate PEM.
o Sever PEM: Kwashiorkor (petting oedema) and nutritional marasmus (severe
wasting) are manifestations of sever PEM, and often lead to death of many
children.
Stunting; is a malnutrition condition reflected by inadequate linear growth of a child.
It is referred to as chronic malnutrition.
Stunted children are too short for their age.
Stunting develops over a long period of time as a result of inadequate dietary intake, and
repeated infections.
It is irreversible physical and cognitive damage and the child will become mentally less
developed adult.
The impacts of malnutrition can be reflected at the individual, household, and community
level.
Children and mothers usually suffer the most because many nutrients are critical for
normal growth and development.
Malnutrition in pregnant mothers causes intra-uterine growth retardation of the fetus
leading to low weight at birth and lower chance of survival. Impacts of malnutrition are
described below:
1) Susceptibility to mortality (death)
Stunting and other forms of under-nutrition are clearly a major contributing factor to child
mortality, disease and disability.
Specific nutritional deficiencies such as vitamin A, iron or zinc deficiency also increase
risk of death.
Nutrition interventions are of two types. These are Nutrition specific intervention and
Nutrition sensitive intervention.
1) Nutrition specific interventions; are interventions or programs that address the
immediate determinants of fetal and child nutrition and development. Adequate
food and nutrient intake, feeding, care giving and parenting practices, and low
burden of infectious diseases are among the main nutrition specific interventions.
The major areas of action are
Adolescent, preconception, and maternal health and nutrition
Maternal dietary or micronutrient supplementation
Promotion of optimum breastfeeding
Complementary feeding and responsive feeding practices and stimulation
Dietary supplementation
Diversification and micronutrient supplementation or fortification for
children
Treatment of severe acute malnutrition
Disease prevention and management
Nutrition in emergencies
The above nutrition sensitive and specific activities are summarized in to core intervention
areas and presented in detail as follows.
1. Life Cycle Approach to Nutrition
The life cycle of human beings originates from a fertilized egg, which develops into a
fetus that is eventually born as a baby. A baby develops into a child, transitions
through the wonderful phase of adolescence, becomes an adult, and then advances into
old age and eventually death.
A person’s stage of life influences their health and nutritional requirements.
Investing in nutrition throughout the life cycle will have both short term and long-term
economic and social significance.
i. Pre-conception nutrition
Human reproduction is the result of a complex and interrelated genetic, biological,
environmental and behavioral process.
Given favorable states of health, these processes occur smoothly in females and males
and set the stage for successful reproduction.
However, less than optimal states of health, brought about by conditions such as acute
under- nutrition or high levels of alcohol intake, can disrupt these finely tuned
processes and diminish reproductive capacity.
The following are important measure that a women planning to be pregnant needs to
take care of.
1. Achieve health body weight: among the critically important factor for improved pregnancy
outcome is maternal body weight.
2. Use iodine fortified salt
3. Consume diversified diet from at least five different food groups
4. Take folic acid supplementation every day if you are planning for pregnancy to lower your
risk of folic acid deficiency.
5. Stop smoking and drinking alcohol.
Optimal nutrition for the mother and for the child during this time can have a
profound impact on the child's growth and development and reduce disease risk, as
well as protect the mother's health.
Under-nutrition during pregnancy, is among the major determinant of stunting and
can lead to restricted growth which later results in neurological problems, poor school
achievement, low-skilled employment, and reduced productivity during adulthood
which cannot deliver good care of their own children, thus contributing to the
intergenerational transmission of poverty and malnutrition.
Promote and support good maternal nutrition during pregnancy and lactation
Meeting women's nutrient requirements is key as nutrient needs increase during
pregnancy and lactation.
Engagement of fathers, grandmothers, and other community influencers to assure that
pregnant and lactating women receive adequate food and support are very much
important.
So it is important to make sure that the following key interventions are addressed to
ensure optimal maternal nutrition during pregnancy and lactation.
During pregnancy & lactation provide
- Iron/Folic Acid supplementation
- Treatment & prevention of malaria
- Increase food intake
one extra meal each day during pregnancy
two extra meals each day during lactation
De-worming during pregnancy
Vitamin A Supplementation within 45 days of delivery
Promote and support optimal infant and young child feeding (IYCF)
The following important IYCF and care practices need to be applied for optimal child
nutrition.
Immediate initiation of breastfeeding after birth (within one hour of delivery)
Exclusive breastfeeding for the first 6 months of life (no other food than breast milk)
Starting at 6 months appropriate complementary feeding (e.g., divers diet) together with
continued breastfeeding to 2 years or beyond
o Complementary food needs to be prepared from at least four of the six food groups to
ensure adequate macro and micro nutrient intake
o Increase number of feedings with age, Increase density & quantity with age
Adequate care and feeding of sick children to prevent both acute malnutrition and
stunting
o Increase frequency of breast feeding and complementary food during times of child
illness
o After recovery, provide the baby with good amount of food for catch-up growth
Ensure water, sanitation and hygiene practice
2) Nutrition-sensitive agriculture
It is a food-based approach to agricultural development that puts nutritionally rich
foods, dietary diversity, and food fortification at the heart of overcoming
malnutrition and micronutrient deficiencies.
Food-based approaches include food production, dietary diversification and food
fortification, as sustainable strategies for improving nutrition.
This approach stresses the multiple benefits derived from enjoying a variety of foods,
recognizing the nutritional value of food for good nutrition, and the importance and
social significance of the food and agricultural sector for supporting rural livelihoods.
The overall objective of nutrition-sensitive agriculture is to make the global food
system better equipped to produce good nutritional outcomes.
The Ethiopian Ministry of Agriculture and Natural Resource produced National
Nutrition Sensitive agriculture strategy to direct and lead the sector’s agricultural
practices to be nutrition sensitive.
Nutrition sensitive agriculture works in three main ways to contribute for improved
nutrition
1 . Making food more available and accessible:
Increasing agricultural production makes more food available and affordable, which
improves both the health and the economic status of the community.
Sustained income growth in turn has a sizeable effect on reducing malnutrition.
2. Making food more diverse and production more sustainable:
Increasing diversity in food production and promoting sustainable production practices
like conservation agriculture, water management and integrated pest management can
improve nutrition levels without depleting natural resources.
Family farming, home gardens and homestead food production projects can make a
wider variety of crops available at the local level.
3. Making food itself more nutritious:
Fortification (Bio-fortification, Agronomic bio- fortification and artificial fortification)
can prevent micronutrient deficiencies by enhancing micronutrient content in foods
through processing, plant breeding and improved soil fertility.
Strategic Objective # 1: To leverage nutrition into agriculture and livestock sector policies,
strategies, programs and work plans at all level
Strategic Objective # 5: Ensure women and youth empowerment and gender equality
Gender has been reported as the cause and also consequence for hunger and malnutrition
and also associated with higher levels of acute and chronic under-nutrition.
So addressing the issue of cultural and traditional hurdles and also making women to be
at the center of nutrition related interventions both in the rural and urban settings is an
important measure to improve maternal and child nutrition.
3. Caring practice
Care practice specifically focuses on the care given to mothers and children
for improved nutritional outcome.
Caring practices such as breastfeeding, appropriate complementary feeding, as
Well as hygiene and health seeking behaviors support good nutrition.
These practices can be severely disrupted in various conditions like during high
burden of work on the mother which could limit the time that she needs to spend
caring for herself and her baby.
4. Water, Sanitation and Hygiene
In 2014, an estimated 159 million children under five years of age were stunted,
and 50 million were wasted around the world.
Based on WHO 2015 report 2.4 billion individuals lack access to improved
sanitation and 663 million lack accesses to a protected water source.
The report showed that more often communities affected by under-nutrition also
have limited access to safe water and sanitation.
There are evidence based interventions which are proven to work in improving
nutrition of individuals implemented along with other intervention measures.
These WASH interventions include use of improved water supply, safe
household water management treatment and storage, improved household toilets
or latrines, and hand washing with soap.
Keeping food safe through safe handling, preparation and storage and prevention
of contamination is among the important measures which need to be addressed
all the time.
In Ethiopia WASH is one of the major areas of intervention for improved health
and nutritional status.