COMMUNITY HEALTH NUTRITION

Human beings need food in order to survive. Children and adults a like, need to have certain
elements in the food they eat in order to develop well, prevent diseases and stay healthy. Most
community members in the developing world such as Ghana have little, sometimes no
knowledge in these elements and their food sources. The typical Ghanaian adage “pintin biara ye
omee” which can be translated as “every fullness of the stomach is satisfaction”, can vividly
support the above statement we have made. This notion by many clients, coupled with the
numerous food taboos may be explained as the major factors of malnutrition and other micro-
nutrient deficiency diseases in the country.

Since generally, proper growth and development depends on the type of food one eats, it is
important for the community health nurse to have knowledge about the right sources of food
nutrients in order to impart this to the community members in order to improve their health,
resist infection and prolong their life (King and Burgess, 2004).

The food and drink consumed by man are the raw materials from which the body is built, kept in
good repair and helped to work efficiently in good health.
These foods are broken down by chemical processes into simple substances which are carried
into solution in the blood and absorbed by the tissue cells. The waste products are eliminated
through urine, faeces and sweat.

Nutrition
This is the study of nutrients in food and how they are used by the body. It is concerned with
how food is produced, processed, handled, sold, prepared and eaten as well as what happens to
the food in the body- how it is digested, absorbed and used.

Nutrients
Nutrients are the components of food, which the body uses to build tissues for growth, produce
energy for strength and protecting against infections to keep healthy.
For good health to be achieved through food, a variable number of different food stuff must be
eaten in their right amounts at all times.
Most diseases and conditions that occur in developing countries are as a result of inadequate or
incorrect foods in their proportions.

The three main classes of food

 Energy-giving nutrients, including carbohydrates, fats and oils.
 Body building nutrients, including proteins.
 Protective nutrients, including vitamins and minerals (micro-nutrients).

1. ENERGY-GIVING FOODS
Starch, sugar (carbohydrates) and fats are made of carbon, hydrogen and oxygen elements. When
these elements burn in the cells of the body, they combine with oxygen from the air we breathe
in. They then release energy and change into carbon dioxide and water which we breathe out to
be used for photosynthesis. A substantial amount of energy from sunlight is required to enable
the plant to transform the simple molecules to the more complex carbohydrate molecules. When
carbohydrates are eaten, this process is in effect put into reverse to produce energy for the body.
Energy-giving foods are needed in the body to move muscles, move the body and to keep the
body warm. The various energy-giving foods are classified and described with their individual
specific functions.

A. Carbohydrates
They are normally classified into the following:
a. Monosaccharides (glucose, fructose, galactose)
b. Disaccharides (sucrose, lactose, maltose)
c. Polysaccharides (starch, glycogen, cellulose)
Irrespective of the classification, the formation is still the same. The carbon dioxide in the
atmosphere and the water from the soil are picked up by the plant. These are combined with the
magnesium-containing pigment (chlorophyll) in the plant to form the carbohydrate.

Classification of Carbohydrates
a. Monosaccharides (glucose, fructose, galactose)
These are the simplest carbohydrate CHO) molecules that require no digestion and are
readily absorbed from the gastrointestinal tract directly into the blood stream. They all
contain the same molecules and only differ in the way in which the H and O atoms are
arranged on the carbon atom. It is basically the differences in the arrangement that account
for the different sweetening powers and solubility in them. The source of the
monosaccharides can be found in fruits, vegetables, honey and milk.

b. Disaccharides (sucrose, lactose, maltose)

Two monosaccharides normally combine to form a disaccharide, and a molecule of water
given off.
i. Sucrose: it is a combination of glucose and fructose, found mostly in fruits and
vegetables. When it is consumed it must be broken down to the simple sugars before
the body can use it.

ii. Lactose: it is the main sugar found in milk. Galactose and glucose are
derived from it, thus it must be broken down to galactose and glucose to be used by the
body.
Lactose has three basic functions in the human body:
In the intestines, certain bacteria cause the production of lactic acid from unabsorbed
lactose. This increased acidity creates a medium in which the organism lactobacillus
bifidus grows to produce bifidus factor. This factor helps the infant in preventing the
growth of the less desirable bacteria that cause intestinal putrefaction. The factor is
present in the intestines of breastfed infants, and its absence is one of the disadvantages
of artificial feeding.
 The acid medium created by the formation of the lactic acid increases the permeability of
the intestinal membranes to ions like calcium and other alkaline metals which are needed
for body building.
 An undigested residue of lactose is a major asset because it gives the intestinal normal
peristaltic action. This is because it regulates water in the gastro-intestinal tract, thereby
softening the stools and preventing constipation. Research has also shown that the colon
functions better when there is a reasonable amount of bulk or residue present. This speeds
 the passage of food materials through the gastro-intestinal tract, thus shortening the
‘transit time’ and helping to prevent exposure of the tissues to cancer-causing agents in
the food. They also build lipids like cholesterol and carry them out of the body with the
faeces in order to lower the body lipids concentration, and possibly the risk of artery and
heart diseases as well.
 One other advantage of the cellulose is that, if it is absent in a diet, one has to push hard
when evacuating the bowel contents. The result is that some of the faeces will remain in
the lower gastro-intestinal tract, resulting complications like rectal or colonic cancer.
 It has also been found that dietary fibre tends to reduce hypertension and diabetes, though
the exact mechanism is not yet clearly understood. Lastly, they also exercise the muscles
of the gastro-intestinal tract so that they retain their healthy characteristics of preventing
inflammation.

iii. Maltose: this is the disaccharide found in germinating cereals like maize, millet,
sorghum. It is made up of two molecules of glucose.

c. Polysaccharides (starch, glycogen, cellulose)

For more stable and efficient storage of potential energy, the plant world packs its fuel in
units larger than those mentioned above. They are made up of many molecules of glucose
linked together. The number of glucose units and their arrangement determines the
characteristics of the polysaccharides.
i. Starch: these are stored by plants and granules are covered by insoluble coats and
when it is cooked, the coat breaks off and dissolves.
ii. Glycogen: it is sometimes called ‘animal starch’ because it is the polysaccharide
stored in animal tissues. Although it has many branches structurally, it cannot be
compared to starch. Hence, it can be broken into smaller units or be rebuild as
needed by the body. It is stored in the liver and muscles and when needed for use it
is converted to glucose.
iii. Cellulose: cellulose like starch is made up of more than 3,000 molecules of
glucose held together in long chains. Unlike starch, it does not disperse in water
and is resistant to hydrolysis by acids and enzymes in the human gastro-intestinal
tract. Only herbivorous animals can obtain energy from cellulose since they have
the enzymes to break them down. They are the chief constituents of leaves,
covering of seeds and cereals.

Functions of carbohydrates
1. Source of energy: the primary function of carbohydrates in nutrition is to provide energy.
Although there are other sources of energy supply of the body like proteins and fats,
carbohydrates are also the least expensive sources. However, the availability if the energy
depends on the presence of vitamin B complex and other factors which help with their
metabolism.
Special functions of carbohydrates in the vital organs
i. Liver
 a. a glucose derivative conjugates with certain toxic materials (drugs) to make them
harmless for excretion.
b. The presence of sufficient carbohydrates for energy demands prevents the
channeling of too much protein for this purpose. This protein-sparing action of the
carbohydrates allows the protein to be used for its basic structural purpose of
tissue building.
c. The presence of carbohydrates for energy provision also determines the amount of
fat to be broken down. When the body is called upon to break down fat in the
absence of oxygen, a condition called acidosis occurs due to the products of
incomplete oxidation of fatty acids which are toxic to the body.
ii. Heart
a. The glycogen in the cardiac muscle is an important emergency source of
contractile energy. In a damaged heart, poor glycogen stores or a low
carbohydrate intake may cause cardiac angina.
iii. The brain does not contain any stored supply of glucose hence it depends on the
supply of glucose at any given time from the blood. When the brain is deprived of
energy, it reacts by firing off uncontrolled impulses to give convulsion. It can also
lead to irreversible brain damage if it is deprived of glucose supply for a very long
period.

Abnormalities of carbohydrate metabolism

There are several pathological conditions that cause difficulties in utilizing carbohydrates.
i) Diabetes in which there is not enough insulin for the uptake of glucose by the B cells
and this creates hyperglycaemia.
ii) Lack of enzymes convert galactose to glucose in the liver. Galactose will therefore,
appear in abnormal quantities in the blood leading to a condition called
galactosaemia, which is characterized by vomiting, mental retardation, and weight
loss.
iii) Lactose intolerance – certain persons do not have the enzyme to convert lactose to
glucose. They exhibit signs of diarrhea, flatulence and abnormal cramps caused by
the osmotic effect of undigested lactose in the lower gastro-intestinal tract, or the
production of organic acids and carbon dioxide in the fermentation of lactose by the
gastro-intestinal tract organisms.
iv) Atherosclerosis – there is evidence that high intake of sucrose is associated with high
incidence of atherosclerosis possibly through its effects in stimulating high blood
triglyceride levels.

Summary of Functions of Carbohydrate

 It supplies energy to the body
 Provides heat and keeps the body warm
 The fibre in carbohydrates makes the faeces bulky and soft and causes peristaltic
movement and so prevents constipation
 It nourishes the brain and keeps it active
 Glycogen is stored in the muscles as an emergency source of energy
B. FATS AND OILS
They are compounds of glycerin and fatty acids. Different fats do have different acids. Fats are
derived from animal and plant sources.
1. Animal sources – all fatty meat and fish, milk and cheese.
2. Vegetable sources – oil from all kinds of nuts including groundnut, palm nut, coconut,
cashew nut, shear nut, soya beans and ‘agushi’ among others

Functions of Fat in the Body

i) Source of energy- Each gramme of fat (animal, vegetable, either liquid or solid),
provide 9 kilocalories of energy which is about twice the energy produced by either
carbohydrate or protein (high caloric value).
ii) Satiety value- The presence of fat in the duodenum stimulates the release of a
hormone in the stomach which in turn inhibits hunger contraction, therefore keeping
the body satisfied for a longer period.
iii) Carrier of fat soluble vitamins (A, D, E, K) - They serve as carriers or precursors for
the above vitamins. Hence elimination of fat from the diet leads to a decrease intake
of the nutrients. Anything that interferes with the absorption or utilization of fat such
as obstruction of the bile duct, depresses the availability of these fat soluble vitamins.
iv) Sources of essential fatty acids – Vegetable sources of fat contain a polyunsaturated
fatty acid (linoleic acid) which cures dermatitis and restores growth. It cannot be
synthesized by the body so vegetable fat is the only source of it for its important
functions in the body
v) Palatability - Many substances responsible for flavours and aromas of food are fat
soluble. This fat contributes to the acceptance of the meals. It has also been suggested
that fat in a diet stimulates the flow of digestive enzymes.
vi) Mechanical functions - Fat provides a general padding for the vital organs and nerves
which holds them in position (heart, kidneys and liver) to prevent physical trauma.
vii) The stored fat beneath the skin acts as a non-conductor and prevents excessive
radiation or loss of body heat, and also cushions the body against injury.
Undesirable effects of fats in the body
1. Plagues which are soft liquid accumulations deposit on the inner walls of the arteries and
as they enlarge, the artery walls lose their elasticity and the passage narrows. Again, the
arteries become rough, hence clotting of blood occurs. This clot may travel along the
system until it reaches an artery too small to allow its passage. The tissue fed by this
particular artery will not get enough oxygen and nutrients. If such a clot lodges in an
artery of the heart, we say the person has a heart attack, but if it is in the brain it is called
stroke (cerebro-vascular accident).
2. During a prolong period of food deprivation, fat stores makes a contribution to the energy
needs of the body. However, this kind of energy (ketones) has disadvantages because the
brain nerve cells cannot use it. Hence, it has to be complimented with glucose. The net
result is that these tissues will be left atrophied, weak and eventually lose their functions
or die.
3. Fatty acids do not oxidize readily as sugar in the body. When the body is called upon to
burn fat in the absence of carbohydrates, a condition called acidosis occurs due to the
products of incomplete oxidation of fatty acids which are toxic to the body.
 4. After eating a meal high in fat, the lipids increase more rapidly than the tissues can utilize
or store, thus causing a temporary hyperlipemia which tends to hasten blood clotting.
5. It also serves as deposits under the skin to protect against injury. However, too much
deposit results in obesity and may lead to a variety of diseases.
Summary of Functions of Fats and Oils
 They give energy which is more than twice in calorie than carbohydrates
 They are needed for the formation of nerve sheath for protection of nerves
 They make the diet more palatable
 They have good satiety value
 They are needed for fat-soluble vitamins to be absorbed and utilized.
 They protect other vital organs in the body such as the heart, kidney from physical trauma

2. BODY-BUILDING FOODS
Body-building foods consist of proteins. The body uses protein elements called amino acids to
build new tissues and repair worn out ones.

PROTEINS
They are the most complex of foodstuffs. They are made up of carbon, oxygen, hydrogen,
nitrogen, sulphur and phosphorous. They are the only foodstuff that has an element of nitrogen.
They made up of about 20 amino acids and each protein contains only a few of them. Among the
amino acids, 10 are essential in that, they cannot be built up by the body itself. The remaining
amino acids are non-essential because they can be made in the human body cells from other
amino acids.

Certain animal protein sources such as eggs, milk, meat, offal, milk, cheese, fish, poultry, but it
contains all of them in good proportions (first class proteins). Plant protein sources such as all
kinds of legumes and nuts, contain second class proteins. Hence the first class animal protein
sources are advisable to be included in a diet. However, soya beans contain more protein than
other beans, and the protein is more complete (King and Burgess, 2004).

Sources of protein
Animal Plant
Eggs Pulse foods (groundnut, all types of beans and soya beans )
Meat Some constituents of cereals (maize, millet, Guinea corn, sorghum and
Milk Rice.
Fish

Functions of Protein
a. Essential for growth - The chief use of protein is to provide building materials for
the body. This is because no other foodstuff contains the nitrogenous component essential for
the making of a living cell. The amino acids are carried in the blood to all parts of the body
for this purpose. If these amino acids are not available, there will be a loss of total body
protein, thus resulting in weight loss.

b. Formation of essential body compounds - These include the following:

 1. Hormones like insulin, adrenaline, thyroxine, are protein substances.
2. All enzymes are protein substances.
3. Haemoglobin has a protein component.

c. Maintenance of body neutrality - They are considered buffers reacting with both
acids and bases. Their presence in the blood helps to prevent the accumulation of too much
acid or alkaline, either of which would interfere with normal body function.

d. Stimulation of antibody formation - The antibodies which fight infection, are

protein substances. Since a specific antibody is needed in response to a particular infective
agent, the need for protein is extensive. Consequently, those on low protein diet are
susceptible to infection.

e. Regulation of water balance in the body - Since plasma protein cannot penetrate
the capillary membranes, it remains in the bloodstream. When oncotic pressure exerted by
the plasma proteins exceeds the lowered hydrostatic pressure, the fluid is drawn back into the
blood.

In protein deficiency, the plasma albumen level drops reducing the oncotic pressure to the point
where the fluid is not drawn back and it accumulates in the interstitial spaces. Hence, oedema is
the first sign of protein deficiency.

Summary of Functions of Proteins

 They are needed for growth of tissue cells from birth until growth stops
 They are important for repairs and renewal of tissues which are constantly undergoing
wear and tear
 They are needed for the formation of enzymes, hormones, antibodies, antitoxins
 They regulate water balance in the body

3. PROTECTIVE FOODS
Protective foods include vitamins and minerals, which are also called micro-nutrients. They are
needed in the body to resist and fight infection and to recover from infections.

Vitamins
Vitamins are organic substances essential to good health. With the exception of vitamin D, they
are not synthesized by the body and must be obtained from the diet. They are normally present in
small quantities in food stuff. However, they can be made synthetically today. They are required
in minute traces daily to play a part in metabolic reactions of the body often as regulators or
components of enzyme systems.

They are divided into two groups

a. the fat soluble – vitamin – A, D, E and K
b. the water soluble – vitamin B complex and C
Vitamin A
Form - It is fat soluble and enters the body in two forms-retinol and carotene:
a. Retinol – it is present in animal fats, red palm oil, cheese, eggs and milk.
b. Carotene – this substance is found in carrots, green vegetables, all yellow and red fruits.
This is a precursor of vitamin A, and man can turn the carotene present in the food into
vitamin A within the body. In order to preserve the vitamin A in oil, it should not be
boiled for long.
Functions of Vitamin A
1. Vision - the ability of the eye to adapt to changes in light is dependent upon the presence
of a light-sensitive pigment called visual purple in the rods of the retina which is made up of
protein (opsin) and the vitamin A compound (retinene).

When light hits the retina in the dark, the visual purple splits into two compounds. There is
normally enough retinene in the pigment layer behind the rods which comes to combine with
the opsin to form the visual purple again. When the body is deficient in vitamin A, less
retinene is available for the formation of visual purple and it leads to night blindness.
The cornea is also affected. The lachrymal gland fails to secrete or the duct is blocked. The
reason is that the gland has to form the secretion. Consequently, the cells of the cornea which
are deprived of these secretions begin to slough and eventually rupture. This is termed
keratomalacia. As the condition progresses, infections set in and pus is formed (Bitot’s
Spots). This progresses to xerosis conjunctivae and to xerophthalmia in the advanced stages.

2. Health of Epithelial Tissues - It maintains the healthy functioning of the epithelial tissues of
the skin from the mucous membrane lining the eyes, gastro-intestinal, respiratory and genito-
urinary tracts. These cells secret mucous and it is Vitamin A which helps to synthesize the normal
constituent of mucus. Without this, they keratinize, that is, they become dry and flat. When this
happens the following changes occur:

a. Eyes: the cornea dries up, hardens and progresses to blindness(xerophthalmia )

b. Respiratory tract: the villa in the salivary glands dry, mouth dries and is open to invading
organisms.
c. Gastro-intestinal tract: no mucous so no digestion
d. Genito-urinary tract- there is no epithelium for protection and so results in urinary tract
infections.
e. Skin: as the skin becomes dry and scaly, pigmented popular eruptions may appear around
the hair follicles called follicular hyperkeratosis.

3. Growth. – An animal deprived of vitamin A will cease to grow. Bones fail to grow in length
and the remodeling process slows down. Since there is no change in the growth of the
nervous tissues, there may be pressure on the brain whose growth is not affected by the
vitamin A deficiency. This leads to paralyses that affect the extremities.
4. Teeth - There are specialized epithelial cells surrounding the tooth buds in a child called
ameloblasts, for forming the enamel structure of the developing tooth. Inadequate vitamin A
produces faulty enamel forming epithelial cells which impairs the structure of teeth.

5. Thyroid gland:
 Studies with radioactive iodine gave shown that vitamin A deficiency reduces the rate of
thyroxin formation and that goiter has been shown to occur more in people whose diet is
deficient in vitamin A
6. Reproduction – it is for normal reproduction in rats. Its deficiency may lead to infertility.

VITAMIN B 1 (THIAMINE)
This vitamin is not stored in the body so a deficiency can develop quickly, and any excess
intake is lost in the urine, it is essential for carbohydrate metabolism and controls the
nutrition of nerve cells.
Sources include - pork (highest value), kidneys, livers, eggs, yeast whole cereals not polished
and legumes.

Functions of Thiamine
In order to utilize energy from glucose, the body changes it to pyruvite acid, and thiamine
combines with other enzymes to form energy which muscles depend greatly on. When there
is lack of thiamine then the pyruvite acid accumulates and is toxic to the body.

Causes of Deficiency of Thiamine

1. The vitamin is on the outer coat of cereals and those who often take cereals that are polished
are bound to have low intake of thiamine.
2. Poor absorption: this applies to those with gastro-intestinal problems such as diarrhea which
do not allow the absorption of the vitamin to be possible.
3. Excessive demand: its demand is normally increase during certain periods, like pregnancy
and lactation hence there is the need to increase its intake during this period to prevent.
4. Over washing of cereals: the vitamin is water soluble, hence if cereals are washed several
times thiamine is lost.

Clinical Manifestations of the Deficiency of Thiamine

In the sub clinical stages, the individual manifest general weakness of the body, constipation
anorexia, and the calf muscles become tender. As time goes on it manifests clinical beriberi.
The types of beriberi are the wet, dry and infantile.

a) Wet Beriberi
Due to lack of vitamin B1, carbohydrates are incompletely metabolized and there is an
accumulation of lactic acid and pyruvic acid in the body fluids. Hence, these metabolites
cause dilatation of the peripheral blood vessels. This may cause fluid to leak out through
the capillaries, causing oedema. To maintain circulation, the heart rate has to increase
exerting pressure on it. As the condition progresses there is enlargement of the right side
of the heart leading to biventricular congestive heart failure (only one ventricle) as well
as pulmonary congestion. The patient then manifests pitting oedema, dyspnoea,
palpitation and extended neck veins.

b) Dry Beriberi
The effect is on the peripheral nerves of the legs and arms, this leads to polyneuropathy.
There is a degeneration of the myelin sheath which leads to numbness with bilateral and
symmetrical burning sensation. There is also tickling sensations on the feed. The knee
 and ankle jerk becomes sluggish. As the condition progresses, there is a wasting of the
muscles of the feet and hands resulting in a characteristic foot and wrist drop. Eventually,
he loses sense of position (ataxia) or even paralysis if not treated.

c) Infantile Beriberi
It occurs mostly in young children who are not getting enough of the vitamin through
breastfeeding. The reason may be that the mother is also not getting enough of the
vitamin in her diet. Such a child blots up due to edema. If the child cries the sound is not
heard but only the emotion. The child also develops gastro-intestinal problems. As the
cells of the smooth muscles and the secretary glands can not receive enough energy from
glucose due to its deficiency, anorexia, indigestion, gastric agony, result. Like the wet
beriberi, the heart muscle weakens due to lack of energy and a cardiac failure can result
from that.
Mental depression and confusion is relieved by thiamine hence it is called Morale
Vitamin. People on low thiamine intake show pronounced mood changes.

The deficiency of thiamine occurs basically in rice eating areas where there is a lot of
polishing of rice. It is also destroyed at high temperature. The vitamin is easily destroyed by
alkaline and preservation. Since it is water-soluble, when washing rice, it should take a very
short period.

RIBOFLAVIN (VITAMIN B2)

It is found in the same foods as thiamine and is also reduced by milling and washing. It can
also be destroyed by sunlight, hence green vegetables that are exposed to direct sunlight have
little of it. Its storage is limited in the body although some amounts are found in the liver and
kidney.

Functions of Riboflavin
1. One of the riboflavin enzymes remove the amino group (NH2 ) from certain amino acids ,
hence rendering them useful to the body
2. It acts as a co-enzyme of the flavor-proteins which transfers hydrogen to cytochrome to
form energy during tissue oxidation
3. It is needed for the good health of tissues which come from the ectodermal regions such as
the skin, eye, nerves, and so on.
4. It is also needed for general growth since it is basically needed for protein metabolism

Clinical Effects of Riboflavin Deficiency

The signs of the deficiency are not very clear. However, long term deficiencies may manifest the
following:
1. Mouth: the angles of the mouth may be pale and cracked forming angular stomatitis. The
lips may also swell and cuts appear in the middle of the lips with blood oozing out
(cheilosis). The tongue becomes swollen, painful and there is loss of papillae (glossitis).
2. Eyes: the deficiency of riboflavin also causes vascularization of the cornea of the eye.
The reason is that the lacrimal gland washes the cornea frequently with its secretions
(tears). These tears contain riboflavin which carries oxygen to supply the cornea.
 However, if there is not enough riboflavin in the tears, the vessels of the cornea move
towards it, resulting in vascularization.
3. Genitalia: in males there are scaly, greasy eruptions around the scrutum (scrotal
dermatosis). In the females, they are found around the vulva causing vulvitis.
4. In children: it causes stunted growth.
5. Nasolabial folds: the scaly skin folds may also be seen at the nose, mouth and back of the
ear as white patches.

NITCOTINIC ACID / NICOTINAMIDE / NIACIN / VITAMIN B3

Two forms of niacin exist. Plant sources have the vitamin in acid form (nicotinic acid), but in
animal tissues it is in the amide form (nicotinamide).
It is contained in good protein food such as fish, meat, egg groundnuts, yeast, beans and whole
cereals. Highly milled grains, maize and starchy roots are poor sources. Maize contains small
amount of nicotinic acid.
This double effect makes the prevalence of pellagra high in areas where the people take kenkey
without fish. Thus pellagra is normally termed the disease of ‘maize eating groups’.

Functions of Niacin
Niacin is important in various metabolic functions like any of the B groups and act as co-
enzymes. These enzymes take part in oxidation and reduction actions of the cells. Hence, all
living tissues will require this enzyme. They also take part in pyruvite, lipids and protein
metabolisms.

In sub-clinical cases, there is weakness of the body, irritability and burning sensation of the
tongue.

Clinical Manifestation of Pellagra (3 Ds)

1. Dermatitis- areas exposed to the sun develop rashes. These rashes are symmetrically
dispersed i.e. both hands are affected. It can also affect the face and neck. At times it cuts
across the neck.
2. Diarrhoea - due to changes in the gastro-intestinal tract and inflammation, there is a
painful tongue, sore mouth, abdominal pain and diarrhoea. At times blood and mucus can
be seen in stools.
3. Dementia - due to the involvement of the nerves, the power of concentration slows and
there is loss of memory. If the deficiency is severe one goes into a delirium and has
hallucinations. It may also lead to exaggerate knee jerk because the spinal cord is
involved and degenerative changes have taken place. This can culminate in the loss of
sensation and a state of ataxia.

VITAMIN C (ASCORBIC ACID)

Vitamin C is water soluble, and it is found in fresh fruits (oranges, grapefruit, lemons, wild
fruits, green vegetables, salad leaves, cabbage, and potatoes. It is readily destroyed by heat;
hence some fresh fruits or salad should be included in the daily diet. Since cooking for a long
time reduces the contents of vitamin C, vegetables should be cut and boiled for only 10 – 15
minutes.
Functions of Vitamin C
It has the following functions in the body:
1. Formation of collagen: collagen is a substance that binds cells together. It is synthesized
from many amino acids such as hydroxyproline. It is made from the conversion of praline
to hydroxyproline, which depends on the presence of vitamin C. It is also needed in the
formation of collagen for strong bones
2. Utilization of iron and calcium: the absorption of iron from the intestinal tract is
facilitated by the presence of vitamin C. It also prevents the precipitation of calcium as an
insoluble complex.
3. Utilization of folic acid: the conversion of the inactive form of folic acid to the active
form (the citrovorum factor) is speeded up by vitamin C. It is in this way that vitamin C
is effective in preventing megaboblastic anaemia of infancy.
4. Healing of wounds: There is a high need for vitamin C in the healing of wounds where
new connective tissues are mainly collagen, must be formed. There are report that
vitamin C can combat infections in cases of burns, and heal quickly when given ascorbic
acid.

Vitamin C deficiency leads to a condition known as scurvy.

Clinical features of scurvy.
1. Gingivitis - the gums are swollen partially in the region of the papillae between the teeth.
These may be also extensive that they project beyond the biting surface of the teeth and
almost completely conceal them. The swollen gums bleed on the slightest touch. There is
associated infection which gives an offensive odour.
2. Spontaneous bleeding from the skin – there is weakness of the walls of the capillaries
leading to bleeding through the orifices, bruising of the skin and petechiae.
3. Bones – there is oedema at the long bone which may cause swelling at the ends of the
long bones, giving them the shape of a club.
4. Hair – the hair becomes brittle especially the hairs on the thighs and arms, termed the
‘corkscrew’ hair.
5. Teeth - the teeth become loose and infected.
6. Anaemia - the constant loss of blood leads to microcytic anaemia

VITAMIN D (CALCIFEROL)
Vitamin D is fat soluble and is found with vitamin A in small amounts in animal fat provided the
animal has been in the sun. It is made in the skin by the action of ultraviolet rays. It can also be
produce synthetically.

Functions of Calciferol (Vitamin D)

a. Absorption of calcium and phosphorous - it makes the cell membranes more permeable
to calcium, but not phosphorous. However, in the intestines, calcium is bound to the
phosphorous as calcium phosphates. Hence both of them can be absorbed by the body.
b. Calcification - After the absorption of calcium and phosphorous through the intestinal
wall, vitamin A continues to work in partnership with calcium and phosphorous in the
calcification aspects of bone formation.
 c. Renal phosphate clearance - it affects the kidney’s handling of phosphorous. When there
is a deficiency of vitamin D, the parathyroid hormone influences the kidney to excrete
more phosphates than normal.

d. Citrate metabolism – it helps in citrate metabolism. Citrate is an organic acid involved in

the mobilization of minerals from the bone tissues and removal of calcium from the
blood. This keeps the level of calcium in the blood constant

Vitamin D deficiency
In infants it causes rickets and ostoemalacia in adults. It is commonest in children. The causes
of the deficiency are varied: -
i) Lack of vitamin and calcium in diet
ii) Renal diseases (renal oeteodystrophy) which speeds its excretion from the body
iii) Excessive demand during stress, pregnancy and lactation
iv) In cultures where clothes are worn all the time. This does not allow the sunrays to
change all provitamin into the vitamin d.
v) Malabsorption syndrome or fatty diarrhoea in which the vitamin cannot be absorbed
in the gastro-intestinal tract.

Clinical Manifestations
a. Head - The bones of the cranium become soft and if pressed they go down and up. The
middle of the skull is depressed and the fontanelles are not properly closed. This is an
early sign in children
b. Legs and arms - the epiphyseal ends of the legs and arms are not well calcified and as the
child begins to sit or walk, the epiphyses are pulled out of position and deformities
develop in different planes leading to ‘bowed and knocked’ knees. In view of the
muscular weakness, when the child is sitting he attempts to support his trunk with his
outstretched hand. This causes knobbing deformity at the wrists.
c. Ribs – the joints between the ribs become enlarged and there is undue protrution of the
sternum known as Pigeon chest. Later, bending of the ribs occur which interferes with
normal expansion of the chest during respiration.
d. Spine - The gradual curving of the spine may lead to kyphosis (hump back) or lordosis.
e. Muscles - weak and flabby muscles make the child slow to sit or walk. If the serum
calcium level is very low, pathological conditions like tetany, carpo-pedal spasms and
convulsions may occur.

Clients should be advised to take diets rich in whole milk, cream, eggs and tablets containing
vitamin D.

Summary of Functions of Vitamins

 Vitamin A is required for the eye to adapt to changes in light
 Vitamin A also helps to keep the eyes and skin healthy
 Vitamin D helps with the absorption and utilization of calcium and phosphorous
 It is also associated with growth and development of bones
 Vitamin D helps develop the fertility of animals including man
 Vitamin K helps in blood clotting
  Vitamin C aids in wound healing and also keeps capillaries, bones and teeth healthy
 Vitamin B1 (thiamine) stimulates appetite and controls fluid balance in the body
 Vitamin B2 (riboflavin) helps to keep the skin and eyes healthy
 Vitamin B3 (nicotinic acid, niacin helps in the metabolism of fat and protein.
 Folic acid is essential for the development of red blood cells
 Vitamin B12, like folic acid is essential for the development of red blood cells

MINERALS
Minerals are inorganic compounds. They are forms of micro-nutrients, most of which are
contained in foods in a natural form.
The mineral ions are found in tissue fluids around cells and also inside the cells. The tissue
contains most of the potassium magnesium and phosphate ions.

CALCIUM
Of all the minerals in the body calcium occurs in the greatest amount. It is found principally in
the bones and teeth and in the case of the teeth, contributes to the hardness and resistance to
decay.

Source of calcium
The richest sources of calcium are animal sources as, milk and milk products, whole fish, kidney,
meat, snails, crustaceans (shrimps, crabs and lobsters) eggs and liver. Plant sources include
beans, green leafy vegetables.

Deficiency of calcium
When the calcium intake falls below the minimum requirement, it leads to softening and
weakening of the bones and teeth. In children the weakened condition of the bones is referred to
as rickets and is associated with growth retardation.

IRON
Iron is an essential component in our body. It is involved in the transfer of oxygen in blood
which is of great importance to our survival.
A deficient supply of iron therefore is a very common cause of anaemia which is initially mild
and moderate in degree. If the supply is gravely deficient for a long period, a severe degree of
anaemia may develop which may lead to fatal results.

Sources of iron
Among the richest animal sources of iron are beef, liver, egg yolk and land snails. Plant sources
of iron include whole wheat, all kinds of dark green vegetables, onions, okro, coconut, and
‘bedru’.

Functions of Iron
1. It is an essential constituent of haemoglobin and is responsible for the red colouring of
blood.
2. It is necessary for the transportation of oxygen to the tissues.
Deficiency of iron
Deficiency of iron may be due to insufficient iron intake in the diet, loss of blood through
menstruation or delivery, worm infestation, and severe malaria. Deficiency leads to iron
deficiency anaemia. This is discussed fully under micro-nutrient deficiency disorders.

FOLIC ACID / FOLATE

Folic acid has been shown to be essential for the development of red blood cells.

Sources of Folic acid

Rich sources of folic acid include liver and kidney, fresh dark green vegetables, fish, beans and
ground nuts.

Functions of Folic acid

1. It is needed for proper growth.
2. It develops healthy red blood cells.

Deficiency of Folic acid

1. It causes a type of anaemia called megaloblastic anaemia.
2. Destruction of red blood cells is faster in sickle cell anaemia and malaria.

IODINE
Iodine is essential for the formation of the thyroid gland hormones such as thyroxine, which is
needed in the body for proper growth and development.

Sources of iodine
The amount of iron in the plant foods depend on whether or not, iodine was present in the soil in
which the plant was grown. Vegetables grown in iodine rich soil will be good sources of iodine.
Sea fish eaten with the head and iodized salt in the diet are also good sources.

Functions of iodine
1. Iodine is required for normal physical and mental development.
2. It is required by the thyroid gland for the production of thyroxine.

Deficiency of iodine
1. If sufficient iodine is not available for the formation of thyroxine the thyroxine the thyroid
gland enlarges in an effort to maintain its normal output of hormone and gives rise to a
swelling in the neck. This condition is known as goiter.
2. Deficiency of iodine during pregnancy and infancy results in a failure of physical and mental
development of the child, a condition sometimes known as cretinism.
3. Abortions can also result during pregnancy.

FLUORIDE
Sources
The chief source of fluoride is in the form of fluoride in drinking water. Small quantities of it can
be found in foods especially in tiny fish which bones can be eaten. Some tooth pastes also
contain fluoride.
Functions of fluoride
1. Fluoride helps in the formation of bones and teeth.
2. It is necessary for the prevention of dental carries.

Deficiency
The absence of fluoride in the diet will lead to dental carries.
Note that, too much of fluoride causes a condition known as fluorosis.
ZINC
Zinc is an anti-oxidant which is needed to destroy free radicals to prevent tissue damage during
infection.
Sources of zinc
Sources of zinc include meat, chicken, fish, whole grain cereals and legumes. There is substantial
amount of zinc in breast milk which is well absorbed.

Functions of zinc
. Zinc is needed in the body for proper growth and development in children.
2. It is also needed to heal wounds and fight diseases in both children and adults.

Deficiency of zinc -Lack of zinc is usually due to general poor diet. Deficiency results in:
1. Slow growth and development.
2. Slow sexual development in boys.
3. Slow healing of wounds.
4. Mental changes such as apathy.
5. Skin changes
6. It may also cause persistent diarrhoea.

Summary of Functions of Minerals

 Calcium helps make teeth strong and healthy
 Iron is responsible for the red colouring of the blood and necessary for the transportation
of oxygen

Major nutritional problems in Ghana

In Ghana, the major nutritional deficiency conditions include:
1. Kwashiorkor
2. Marasmus
3. Obesity
4. Micro-nutrient deficiencies- iron, iodine and vitamin A.

KWASHIORKOR
This is a condition which results where the child is given foods which are rich in carbohydrates
but lack protein. The incidence of this condition is high during the second year of the child’s life,
usually during complementary feeding, or when he is put off the breast.

Factors that contribute to Kwashiorkor

1. Social factors:
 a.Ignorance: the parents might have the foodstuff but lack knowledge in nutrition. Hence
they only aim at satisfying the child’s hunger. Also during complementary feeding when
the food given to the child is not rich in protein but high in carbohydrates due to
ignorance as to functions and sources of food nutrients.
b. Food habits: in the indigenous Ghanaian cultures, there is poor intra-family food serving
where more protein is consumed by the adults, while the children get less protein but
more carbohydrates. There are also varied taboos with unquestionable reasons in which
children are not allowed to eat meat, eggs, as described in chapter four.
c.Economic factors: there are also prevailing economic factors which prevent the parents
from providing enough protein for their children. In an attempt to meet the economic
needs of the family, most nursing mothers stop breast feeding their children early and
leave them in the care of younger people who may not have time to feed the children
well. Another economic factor is increasing spending of income. If there is too much
spending immediately after wages have been paid on expensive items leaving a little
amount for the rest of the family, especially for the feeding of the children. Poverty also
makes people buy cheap food stuff which usually tend to be more or only carbohydrates.
d. Infection: during complementary feeding, the child is normally exposed to infectious
agents because the feeds and the feeding and cooking utensils may be contaminated.
These agents compete for the few nutrients the child takes.
e.Short birth intervals: the period between the birth of a child and the subsequent siblings
affects the nutritional status of that child since he will not get enough breast milk before
the next pregnancy. The child is put off the breast prematurely without nutritious
substitutes.

Clinical Features
1. Growth retardation: the child is normally shorter than normal due to lack of proteins
to build the tissues.
2. Oedema: there is oedema which starts with the swelling of the feet and progressively
involves the whole legs, hands and the face. The face is normally round giving a ‘moon
face’ appearance which is an important early sign of kwashiorkor. This oedema is present
because of the lack of serum protein in the blood (hypproteinaemia).
3. Gastro-intestinal disturbance: the mouth and lips become sore and there is loss of
appetite which may result in anaemia. The stools become loose containing undigested
food particles, which is offensive and some times watery.
4. Emotional changes: the child is often dull, miserable and apathetic. He is not attracted
to happening around him.
5. Skin changes: the skin is hypopigmented (becomes lighter in colour). The skin peels off
(flaky paint dermatosis) which can give rise to ulcers under the skin especially on the
legs, behind and around the ear.
6. Hair changes: the hair changes to reddish-brown, silky, straighter than normal and is
easily pulled out.
7. Liver enlargement: in severe cases there may be enlargement of the liver as a result of
fatty changes.
Figure 8.1 A Two and Half Year Old Child with Severe Kwashiorkor

MARASMUS
The word marasmus is a Greek word meaning ‘wasting’. It occurs when there is too little food
intake than the body requires. It occurs when children are fed with a diet which is grossly
deficient in energy to meet the requirement of the rapidly growing children. It occurs mostly
during the first year of life when for some reason the child does not get enough breast milk, and
other foods are also inadequate. It is thus a disease of starvation.

Factors that Contribute to Marasmus

1. Failure of breastfeeding: this could result from factors like the death of the mother
which deprives the child of breast feeding. Again, the children could be abandoned by their
mothers, in such instances foster mothers cannot provide the child with enough food. Some
mothers also refuse to breastfeed for fear of having sagging breast. Another reason for the
failure of mothers to breastfeed their children is unplanned pregnancies which compel them
to wean the child prematurely.
2. Breast diseases: this is applicable to mothers who do not produce enough breast milk
due to advanced age, nutritional reasons and psychological reasons. Other pathological
conditions that prevent adequate production of breast milk include abscesses of breasts,
inverted nipples and cracked nipples.
3. Bottle feeding: it contributes greatly to the incidence of marasmus. This is associated
with the poor hygiene ways in handling the bottles, thereby introducing infective agents into
the child. The advertisements of manufactured baby foods also influence some mothers to
resort to using them to feed their babies. However, most of the mothers cannot read the
instructions on the containers, and so do not mix them in the required proportion.
4. Economic constrains: due to poverty, the child is given over diluted feeds depriving
him of enough food to satisfy his needs (under-feeding).
5. Unhygienic preparation of feeds causing diarrhea which interferes with the absorption
of food.
6. Prolonged breastfeeding without the introduction of other foods after six months leads
to inadequate intake of food required by the body.
 Clinical Features of Marasmus include:
Constipation: occurs due to little intake of food.
Anaemia: may be present due to insufficient intake of food to give the necessary nutrients.

Given too quickly the nutrients may overload the intestines and other tissues which can cause
heart failure and other serious problems and the child may die.

Figure 8. 2 An Eighteen Month old Child with Severe Marasmus

General Management of Protein-Energy Malnutrition

The management of severe protein-energy malnutrition (PEM) may take a long time to achieve
recovery.
Children with severe protein-energy malnutrition are likely to die. They need careful treatment
usually in hospital at least for a while. Even after treatment with special foods and drugs, some
of them may die. Some of those who recover may relapse and become malnourished again.
The treatment of severe malnutrition begins with medical treatment, hydration, treatment of
infestation and keeping the body at a normal temperature. When the child is severely
malnourished, the intestinal walls become thin and unable to digest and absorb food normally.
The tissues of the body are not able to work and to use nutrients in the normal way.
The child is then given milk feeds to begin with, and the weight gain usually slows. A child with
oedema should lose weight at first as he looses oedema fluids, but his appetite, mental state and
general condition should improve. When the child begins to take in food when infections and
other problems are treated, the intestinal walls begin to recover.
As nutrients begin to reach the tissues, the cells also recover and start to work normally again.
This process of early recovery takes time depending on how quickly the infections and other
problems are controlled.
During this stage the child must be fed in small amounts, but frequently. If too much food is
given too quickly the food may overload the intestines and other tissues which can cause heart
failure and other serious problems, and the child may die.
As the child’s cells recover, they become able to use nutrients to rebuild lost tissues. The child’s
appetite increases and the process of ‘catch-up growth’ begins. During this phase, the child can
be given plenty of food with concentrated energy and nutrients.
When the child has regained lost weight and returned to normal weight-for-height, the weight
gain slows down. The child should now be eating family foods, but grow at normal rate.
At this stage, the management of the child’s condition can be continued either at home or
nutrition rehabilitation centre, depending on the strength and ability of the family.

Nutritional Rehabilitation Centres

They are areas set up to manage malnourished children. There are two types:
a. Day care nutritional rehabilitation centres
b. Residential nutritional rehabilitation centres

a. Day Care Nutritional Rehabilitation Centres: this is a centre that handles those with
moderate protein-energy malnutrition on daily basis. The child is brought to centre by the
mother every morning, roughly five to six times in a week. The facilities used there are similar
to those used by the mother in her home. She is helped to prepare the food and feed the child.
They also use local cooking utensils and local food stuff to prepare the food for the child. In
addition to that, they are taught personal and environmental hygiene. The mothers ultimately
get to understand that the child’s condition is caused by the food only, so when she is
discharged she would practice what she has learned.
b. Residential Nutritional Rehabilitation: the severely malnourished child and the mother are
admitted and the mother prepares the meals and feeds the child under supervision of trained
personnel. The mother and child are kept in the institution until the child’s condition
improves. The principles are the same as in day care institutional centres.

It is the role of the nurse in the community to supervise the care of malnourished children and
their families in the home. She assesses the home environment, as well as the social and cultural
factors that might have contributed to the illness and counsels accordingly

Advantages of nutritional rehabilitation centres

1. Health education of mothers on various topics: the mothers get to know the ‘magic’ in
using diet in treating malnutrition. This would motivate them to prevent future relapses.
The mother’s are also taught to own backyard gardens which can supplement their
nutritional needs during the dry season. They are also taught trades like weaving, pottery
making, and sewing, while they are there to earn additional income.
2. Training of other health personnel: health personnel can go there to appreciate the
cases and learn more about the signs and symptoms and management of malnutrition..
3. Survival: mothers who stayed the course went home with a healthy live child.
4. Aids recovery: the presence of the mother gives a psychological satisfaction to the child
which aids a speedy recovery.

Disadvantages of nutritional rehabilitation centres

1. There is a social stigma for those who send their children there as being poor. However,
to minimize this problem, they are referred to as mother craft centres.
 2. There is also the possibility of the cross-infection of communicable diseases in the centre
if good personal hygiene is not maintained.
3. They require additional staff and equipment of the health service, therefore more strain
on the government.

Prevention of malnutrition
A number of factors if taken seriously can ease the problems of malnutrition as below:
a. Establishment of nutritional rehabilitation centres: these are areas that are set up to
deal with malnourished to them for management and advice as described above.
b. Health education in nutrition: this should be directed to parents on the importance of
breastfeeding and a good inter-family distribution of food. It should also be extended to
school health education. All children should be taught the importance of a balanced diet.
c. Health education on family planning: the parents should be made to understand that
spacing of births gives more time to be spent on each child in order to prevent
malnutrition. It also enables them have an ideal family size that can be managed and
catered for well.
d. Health education on immunization: most of the nutritional conditions are precipitated
by conditions like measles and whooping cough. In view of this, parents should be
encouraged to immunize their children.
e. Government intervention: the government should try to develop local complementary
foods like weanimix and soya beans at cheaper prices for the parents to afford. Apart
from this, the agriculture officers should research into quicker maturing foods for the
farmers.

According to Vlok (1994), obesity is the most important condition in affluent societies, and that,
rise in privilege among them usually leads to less physical activity as well as the consumption of
richer diets.
Obesity is excessive development of fat throughout the body than the body requires. A person is
said to be obese when his weight does not correspond to his height (Body Mass Index). It is
usually a state of gross mass excess.

Causes of Obesity
1. The cause of obesity is the intake of calories in excess of the body’s requirement for
energy. The excess energy is converted to fat and deposited in the body. Excessive intake
of fatty foods and refined sugars are mostly enjoyed by the affluent as a prestigious.
2. Eating in-between the normal meal times also contributes to the development of obesity.
3. Some obese people claim it runs in their families, that is, genetic. But from our
experience of supervising different types of families with problems, including those with
obese clients, and not from any empirical point of view, the behavioural factor which is
handed on in the family, remains the strongest than genetic, if it is.
4. Socially, in this part of the world people especially women are admired and adored when
they look fat. When this is not controlled, such people easily become obese.
Children are sometimes obese because of the following reasons.
 They eat more calories than the body uses. The reasons are the same as in adults. They may
eat too much energy foods or take too little time exercises or both.
 A child who is overweight becomes less active, so he may become more obese when he
grows older.
 Children at greater risk of being obese are those from richer families who eat many sweets
and fatty foods and those who are overfed on formula (King and Burgess, 2004).

Effects of obesity
1. King and Burgess, 2004 also described the effects of obesity as:
2. As the child grows, patches of fat build up in the lining of the arteries making them
narrow.
3. A clot of blood forms when there is a patch of atheroma and blocks the artery completely.
4. When an artery in the brain is blocked and may lead to paralysis.
5. Due to the above, they have a shorter life span.
6. Obesity also interferes with the action of insulin and is one of the factors that contribute
to diabetes.
7. They may disfigure resulting embarrassment and lack of confidence.
Management and Prevention of obesity
The management of obesity is mainly behavioural change in eating and activity levels. The same
principles are also employed in its prevention. These include:
 Avoidance of formula foods for children as much as possible
 Children’s foods should contain a lot of fibre and not too fat or sugar
 Children should be discouraged from eating too much sweets and ice-cream
 The diet should contain a lot of fibre to help promote a sense of fullness to prevent eating
more.
 Reduction in the amount of calorie foods eaten.
 People should be encouraged to do regular exercising by running, playing football, jogging,
dancing and so on.

MICRO-NUTRIENT DEFICIENCIES
Micro-nutrients have been discussed under vitamins and minerals, but the following are worth
mentioning again because they have become the focus priority of the Ministry of Health. These
include iron, vitamin A and iodine deficiency disorders.

NUTRITIONAL ANAEMIA
Nutritional Anaemia is a condition in which there is decrease amount of haemoglobin in the red
blood cells. This substance is carried inside red blood cells to give its colour and transport
oxygen to all parts of the body. Therefore, anaemia will occur if each of the red blood cells
contains too little haemoglobin or if the number of red cells is low. Anaemia is one of the causes
of deaths in childhood, and one of the commonest conditions affecting children and women,
especially pregnancy women in Ghana.

Causes of Nutritional Anaemia

There are many causes of anaemia which may be multiple at any given time or situation, or have
a single cause.
 1. Anaemia in children can begin when mothers have anaemia before or during pregnancy, and
the infant is born with low iron stores. Iron is stored in the liver, spleen, and bone marrow.
When these stores are used up and not replenished either through iron absorbed from food,
or through iron given in the form of drops or tablets, anaemia develops.
2. Anaemia is often caused by an excess loss of iron through bleeding from menstruation, child
birth or accidents.
3. During infection with the parasites, the parasites invade and destroy the red blood cells.
This situation reduces the number of the red blood cells to cause anaemia.
4. Parasitic worms such as the hookworm also suck the blood of the individual when he is
infested.
5. Deficiencies of folic acid, vitamin A, vitamin C, vitamin B-12, and various minerals which
must be present for proper absorption of iron, can also cause anaemia.
6. Only a small percentage of the iron in food is actually absorbed by the body. For it to be
absorbed, it must be in a special form. However, substances, such as phytates in whole
grains, and tannins in tea, prevent iron absorption. Iron deficiency is common when the diet
is mostly grains or starchy roots. Even small levels of iron deficiency in a person affects
absorption. The more severe the deficiency the higher the rate o absorption of the nutrient.
Clinical signs and symptoms
While some anaemia gives rise to special signs such as painful swollen fingers as in sickle cell
anaemia, it usually shows the following general signs and symptoms.
1. There is a feeling of un-wellness and tiredness or lack or energy.
2. Paleness of the lips, finger nails and toe nails, the palms of the hands, the tongue and the
conjunctivae.
3. He may feel nausea or have poor appetite.
4. As the condition progresses, there is a rapid heart rate, a weak soft pulse, and rapid
respiration.
5. Cyanosis and cardiac failure with oedema and enlarged liver are present.
6. When there is haemolysis, it shows as a yellowish discolouration of the eyes.

Effects of Anaemia
Management
1. Breast milk contains low levels of highly absorbable iron that is sufficient until about six
months of age. After that, iron supplements should be given to infants every six months
until they are five tears of age to maintain normal iron status.
2. Infants born with low birth weights should take supplemental iron starting at two months
of age.
3. There should be increased intake of foods containing iron.
4. Iron supplementation should be given to pregnant women. Folate is also given to help
with the absorption of iron.
Iron deficiency is often worse by blood loss from the gut caused by feeding infants with formula
or other forms of animal milk, or in young children and women by infection.
Treatment
For treatment of anaemia refer to the previous lessons on vitamins and minerals.

NIGHT BLINDNESS
Night blindness is a condition in which a person finds it difficult to see in dim light. This is
followed by the presence of tiny white patches on the conjunctiva (white part of the eye). These
white patches are called Bitot’s spots. At later stages the conjunctiva dries out and looses its
shiny nature. This is known as xerosis. There is later on a softening of the cornea leading to a
breakdown of the eye ball.

Causes of night blindness

Night blindness is causes by vitamin A deficiency in the body. This is mainly due to inadequate
vitamin A in the diet. Sometimes, inability of the body to absorb the vitamin due to disease or
other conditions may lead to the deficiency.

You should never attempt to treat any person you suspect to be suffering from night blindness.
The condition you think is night blindness may be something else. Refer to appropriate personnel
where the eyes would be examined and correct diagnosis is made.

Prevention
Though you may be able to treat xerophthalmia, you can prevent the disease by giving dietary
advice. You should advice pregnant women to eat foods rich in vitamin A. this helps to build up
stores of vitamin A in the liver of the foetus. You should also advice mothers to include green
leafy vegetables or yellow orange fruits in the weaning foods for the child. These are locally
available, cheap and are known to be rich sources of vitamin A. It is important to give education
on this condition to all relevant groups to create awareness and to help them make informed
choices.

IODINE DEFICIENCY DISORDERS (IDD)

Iodine is needed in the body in very small amounts but the lack of it can cause a lot of serious
physical and social problems. IDD has recently gained international recognition and all efforts
are being made to prevent further occurrence of the diseases. The sources of iodine, its functions
in the body as well as the causes of iodine deficiency disorders have been discussed earlier in
this chapter.

Types of iodine deficiency disorders

The types of iodine deficiency disorders include:
a. Goitre
Goiter is an enlargement of the thyroid gland in the neck. In its severe form it is characterized
by swelling of the gland. Goitre is much more common in women than men because their
requirement for iodine is higher. This is because, the demand for essential nutrients by
women increase as a result of menstruation, pregnancy and lactation.
The Consequences of goiter include:
 Pressure on the neck, trachea and larynx making breathing difficult
 Social problems like disfiguring of the appearance of an individual
 Death from surgical complications
  Low productivity

b. Hypothyroidism
This means the thyroid gland works below its normal level of functioning and therefore does
not produce enough thyroid hormones. Low level of thyroid hormones in blood leads to
sluggishness, dry skin, inability to tolerate cold conditions and constipation. In very young
children, it produces not only this feature but also mental growth retardation because the
thyroid hormones are essential for normal development of the body.

c. Cretinism
Cretins have retarded mental and physical development of the body. They are often deaf and
dumb. Some are never able to walk properly. You may find a cretin in an area where IDD is
very common.

d. Reproductive Failure
Women in very severely iodine deficient areas have more miscarriages, still birth and other
problems related to reproduction than women in iodine sufficient areas. Continued
miscarriages endanger the health of women and especially in marriage.

e. Death During childhood

Iodine deficiency kills children because it lowers resistance to fight infection.

Prevention and Control of IDD

Food grown in iodine deficient soil cannot provide enough iodine for the population and
livestock. This means that if an area is iodine deficient, IDD, cannot be eliminated by changing
dietary habits or eating certain kinds of foods grown in the area. The correction can be achieved
by providing iodine from external sources such as:
i. Periodic supplementation of deficient population with iodized capsules.
ii. Fortifying commonly eaten food such as salt with iodine.

In Ghana production of iodized salt is being encouraged. Most manufacturers are now fortifying
salt produced with iodine. The problem however is that, iodized salt is much more expensive
than ordinary salt. This is compelling most consumers to buy the cheaper non-iodated salt. A law
exists but needs to be enforced to make it mandatory for every salt producer to produce iodized
salt.

DIET DURING PREGNANCY AND LACTATION

Diet in Pregnancy
Investigation of the diet of pregnant women has shown that an adequate diet is a factor of
fundamental importance in ensuring a normal, pregnancy and labour. Poor diet is associated with
an increased incidence of complications such as maternal and infant mortality and still birth. The
weight of the infant at birth is influenced by maternal nutrition. Low birth weight is expected in
malnourished mothers and infants with low birth weight have a much greater risk of dying, as
mentioned earlier.
It is therefore prudent for the community nurse to ensure pregnant women are given practical
instructions about what foods they should eat and why they should eat them.
At the beginning of pregnancy, the intake of foods rich in vitamins and mineral must be
increased. This is to protect the mother from infectious diseases and also for proper development
of the foetus. During antenatal clinics, clients are given iron, multivitamins and folic acid tablets
which should be taken daily. It is therefore necessary that all pregnant women attend antenatal
clinic for at least four times before they deliver. Their haemoglobin level should be checked.
Practical examples should be given, regarding diet, taking into account the foods that are locally
available, affordable and equally nutritious.

Foods rich in protein, iron, calcium and vitamin A are important during pregnancy and are also
advised to take iron supplements in the form of ferrous sulphate. It is particularly important to
increase iron intake during the last trimester since this is the period the foetus will be storing iron
in its liver for use in the first few days of its extra-uterine life. Foods rich in calcium and fruits
should also be increased during the last six months of pregnancy.

Women who are well developed physically and enjoy good health are more likely to have
successful pregnancies than those who are poorly developed or sickly.

Dietary Management of Anaemia in Pregnancy

Anaemia is common in child-bearing women and particularly in multiparous of the lower income
group. Many are anemic before they become pregnant, so it is essential that the condition is
diagnosed at the beginning of pregnancy and treated effectively.

Anaemia most usually arises from an inadequate intake of iron, folic acid or vitamin B12 or a
combination of these.

Diet during Lactation

During the delivery of an infant hospital conditions, woman may lose up to a litre of blood. The
majority of women in Ghana have their babies at home and persons assisting them in delivery
may not be able to minimize blood loss. During the weeks after delivery the women should
replace the blood lost. The protein, iron and other nutrients contained in blood must be supplied
in her diet. The rule now is for every mother to put the baby to the breast soon after delivery, and
continue to breastfeed exclusively for six months, and continue to breastfeed along side
complementary foods for at least two years.

It is therefore necessary that throughout the lactation period the nursing mother require her
normal diet with additional proteins, calcium, calories and vitamins. An ample fluid intake is
required. She must also eat at regular intervals, as well as be encouraged on all other measures
that would promote lactation as discussed in chapter four.
It must be remembered that the survival of the breastfeeding baby depends largely on the health
and nutritional state of his mother.

Feeding of an Elderly Person

Where the elderly are concerned the maintenance of an adequate standard of nutrition may
present special difficulties. There is a tendency among old people to become apathetic and lose
interest in food. Physical infirmities may make shopping and food preparation difficult especially
where the old man or woman is living is living alone.
Another problem is that their body processes have naturally slowed down and hence their body
does not require as much energy as before.
It is known that some old people remain very active but regardless of their mode of life, they will
all still require the nutrients they previously needed to lead a healthy life. There may be
insufficient money to spend on food. Old people cling to eating habits which has been
established over many years and do not easily adopt new ideas. An additional problem of old
people is that they may have lost most of their teeth and find it difficult to chew their food. In
such instances minced or soft food can be given where they have lost their teeth.
An effective approach to the subject of diet planning for the elderly necessitate a sympathetic
understanding of such problems.
When giving food, it should be light and easily digestible. In most cases it may be necessary to
include more roughage to avoid constipation.
Excessive weight gain should be avoided in elderly and where there is weight gain it should be
controlled.

Where the amount of money available for the purchase of food is strictly limited it is important
to supervise them to spend on food before other things. Advice should be given on the buying of
food items which are nutritious.

The most expensive food items such as meat, egg or fish may not be necessary if there is
inadequate money. The community health nurse can support by educating the family to find
alternative food items. Food recommended for the elderly should also be easy to prepare. Milk
intake should be encouraged to provide enough calcium. Intake of both water and fat soluble
vitamins should be increased and a lot of vegetables should be included in elderly patients’ diets.

Vegetarianism
According to Helman and Dornton-Hill as cited in Bullough and Bullough (1990), vegetarianism
remains a fairly popular practice with nontraditional groups. These are persons who are already
vegetarians, those who have recently become vegetarians and those who have alternative
lifestyles and philosophies.
There are three types of vegetarians:
1. Pure vegetarian – one who live wholly or principally on vegetable foods and avoids any
form of animal food.
2. A person who eats only grains, fruits and vegetables.
3. Lacto-ovo vegetarian – one who avoids meat but consumes egg, milk and milk products as
well as grains, fruits an vegetables.

The community health nurse should bear in mind that some of these forms of vegetarians, if not
all, are found in the country. Diets of these type in a child needs to be based on adequate
assessment and counseling by the community health nurse.
i. Their protein sources need to be varied to ensure adequate amounts of
essential amino acids, since the amino acids in one food can supplement those in another.
ii. A diet that is devoid of all animal food is deficient in vitamin B12,
supplementation is therefore essential.
iii. Iodine can be obtained by using iodized salt.
 The above discussion on community health nutrition, based on different stages and situations in
life show clearly that, the education on diet should shift from the traditional mode of asking
every client to take all kinds of nutrient sources of foods, but should try to have social and
medical a background, as well as the health state of each client before effective education on diet
can be given.