Handout on Nutrition and Dietetics [NAD 122] for Nursing Students

5. Nutritional Status Assessment of Individuals and Communities

Nutritional status assessment is essential for identifying malnutrition and other nutrition-related health problems. It involves evaluating an individual’s dietary intake, physical health, and biochemical markers. Proper assessment helps health professionals create appropriate interventions to address nutritional deficiencies or excesses.

a. Anthropometry

Anthropometry refers to the measurement of the human body to assess growth, development, and nutritional status.

Common Anthropometric Measurements:

• Body Mass Index (BMI): A measure of body fat based on height and weight.
  • BMI Calculation: BMI = Weight (kg) ÷ Height² (m²).
  • Example: A BMI of less than 18.5 indicates undernutrition, while a BMI over 30 suggests obesity.
• Mid-Upper Arm Circumference (MUAC): Measures muscle mass and fat stores, commonly used to assess malnutrition in children and pregnant women.
  • Example: A MUAC of less than 11.5 cm in children indicates severe acute malnutrition.
• Height-for-Age, Weight-for-Height: Used to assess stunting and wasting in children.
  • Stunting: Low height for age, indicating chronic malnutrition.
  • Wasting: Low weight for height, indicating acute malnutrition.

b. Biochemical Assessment

Biochemical tests analyze blood, urine, or tissue samples to detect nutrient deficiencies or imbalances.

Key Biochemical Markers:

• Hemoglobin Levels: Low levels indicate iron-deficiency anemia.
  • Example: A hemoglobin level below 12 g/dL for women or 13 g/dL for men suggests anemia.
• Serum Vitamin Levels: Deficiencies in vitamins like A, D, and C can indicate malnutrition or specific health issues.
  • Example: Vitamin A deficiency can lead to vision problems and a weakened immune system.

c. Clinical Assessment

Clinical assessment involves examining the body for signs of malnutrition or nutrient deficiencies.

Clinical Signs of Nutritional Deficiencies:

• Pale Skin or Conjunctiva: A sign of iron deficiency or anemia.
• Swollen Gums and Bleeding: Indicates vitamin C deficiency (scurvy).
• Bone Deformities: Can indicate vitamin D deficiency, leading to conditions like rickets in children or osteomalacia in adults.

d. Dietary Assessment

Dietary assessments analyze an individual’s food intake to identify nutritional gaps or excesses.

Methods of Dietary Assessment:

• 24-Hour Dietary Recall: The individual recalls all foods and beverages consumed in the previous 24 hours.
• Food Frequency Questionnaire (FFQ): Assesses how often certain foods are consumed over a given period.
• Food Diary: The individual records everything they eat over a specific timeframe, usually 3–7 days.

Nursing Considerations:

• Nurses should perform thorough assessments, including physical measurements, biochemical tests, and dietary habits, to evaluate an individual’s nutritional status and tailor appropriate interventions.

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6. Malnutrition and the Different Forms of Undernutrition and Overnutrition

Malnutrition occurs when the body does not receive adequate nutrients, leading to health problems. It includes both undernutrition (deficiency of nutrients) and overnutrition (excessive intake of nutrients, leading to obesity and related diseases).

a. Malnutrition

• Undernutrition: Caused by insufficient intake of calories, proteins, vitamins, and minerals. It can lead to conditions such as stunting, wasting, underweight, and micronutrient deficiencies.
  • Overnutrition: Results from excessive caloric intake, often coupled with a sedentary lifestyle. Overnutrition leads to obesity, diabetes, hypertension, and cardiovascular diseases.

i. Types, Causes, and Consequences of Malnutrition

• Stunting: Chronic undernutrition leading to reduced growth in children. It is caused by long-term insufficient nutrient intake.
• Wasting: Acute malnutrition characterized by significant weight loss.
• Underweight: A person who weighs less than the normal range for their age and height due to inadequate nutrition.

ii. Conceptual Framework of Malnutrition

The UNICEF conceptual framework of malnutrition categorizes the underlying causes into three broad areas:

• Immediate Causes: Inadequate dietary intake and disease.
• Underlying Causes: Food insecurity, inadequate care, poor health services, and unhealthy environments.
• Basic Causes: Economic, political, and social factors influencing resource allocation.

iii. Nutrition Situation in Ghana

• Child Malnutrition: Stunting and wasting remain significant public health issues. Micronutrient deficiencies (such as iron, iodine, and vitamin A) are common.
• Overnutrition: Rising rates of obesity and diet-related non-communicable diseases (NCDs) in urban areas due to increased consumption of processed foods and reduced physical activity.

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b. Undernutrition: Causes, Signs, Symptoms, Prevention, and Management

i. Stunting

• Causes: Chronic malnutrition due to poor maternal health, frequent infections, and inadequate nutrient intake during childhood.
• Signs and Symptoms: Short stature for age, developmental delays, frequent illness.
• Prevention and Management: Adequate nutrition during pregnancy and infancy, breastfeeding promotion, and supplementation with vitamins and minerals.

ii. Acute Malnutrition (Wasting, Kwashiorkor, Marasmus)

• Wasting: Rapid weight loss due to insufficient calorie intake.
• Kwashiorkor: A severe form of protein-energy malnutrition, characterized by edema, an enlarged liver, and skin and hair changes.
• Marasmus: A form of severe undernutrition resulting in extreme thinness and muscle wasting due to a lack of calories and protein.

Prevention and Management: Adequate protein and calorie intake, therapeutic feeding programs, and nutritional counseling for families.

iii. Micronutrient Deficiencies

• Vitamin A Deficiency: Can lead to night blindness and a weakened immune system.
• Iron Deficiency Anemia: Causes fatigue, weakness, and developmental delays in children.
• Iodine Deficiency: Leads to goiter and developmental delays, particularly in pregnant women and children.

Prevention and Management: Supplementation programs, fortification of foods, and dietary diversification.

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7. Community Management of Acute Malnutrition (CMAM)

Community Management of Acute Malnutrition (CMAM) is an approach used in Ghana and other countries to treat children suffering from severe malnutrition at the community level. It ensures timely care without the need for hospitalization unless there are medical complications.

a. Admission Criteria and Procedure

i. Assessment (MUAC, Oedema):

• Children are assessed using Mid-Upper Arm Circumference (MUAC) and checked for bilateral pitting edema. A MUAC of less than 11.5 cm indicates severe acute malnutrition.

ii. Appetite Test:

• An appetite test is performed to evaluate the child’s ability to consume Ready-to-Use Therapeutic Foods (RUTF).

iii. Medical History and Clinical Examination:

• A thorough medical history is taken, and a clinical examination is performed to rule out any medical complications.

iv. Counseling:

• Caregivers are counseled on proper feeding practices, the importance of hygiene, and the need to bring the child for regular follow-up.

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b. Routine Medication

Routine medication is administered to prevent or treat common infections in malnourished children:

• Antibiotics: To prevent infections, as malnourished children are more susceptible.
• Vitamin A Supplementation: To boost immunity and improve vision.

c. Administration of Ready-to-Use Therapeutic Food (RUTF)

RUTF is a nutrient-dense paste that is given to children with severe acute malnutrition. It is energy-rich, fortified with essential nutrients, and does not require refrigeration.

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d. Use of Outpatient Care Action Protocol

CMAM operates based on specific protocols that include regular check-ups, weight monitoring, and the provision of RUTF.

e. Discharge Criteria and Procedure

Children are discharged from the CMAM program when they achieve a healthy MUAC measurement and no longer have medical complications.

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8. Dietary Management of Overnutrition and Diet-Related Non-Communicable Diseases

Overnutrition leads to various health conditions that require dietary interventions for management and prevention. Non-communicable diseases (NCDs) such as diabetes, hypertension, and obesity are linked to poor dietary habits.

a. Diabetes Mellitus

• Dietary Management: Focuses on controlling blood sugar levels through balanced meals containing low glycemic index foods, high fiber, and minimal processed sugars.
  • Example: A diet rich in whole grains, vegetables, and lean proteins can help manage diabetes effectively.

b. Hypertension

• Dietary Management: Low-sodium diets with plenty of fruits and vegetables, whole grains, and lean proteins are recommended.
  • Example: The DASH Diet (Dietary Approaches to Stop Hypertension) emphasizes reducing salt intake and increasing potassium, calcium, and magnesium.

c. Gastric and Duodenal Ulcers

• Dietary Management: Avoid spicy, acidic, and caffeine-containing foods that irritate the stomach lining. A balanced diet with easily digestible foods is advised.

d. Obesity

• Dietary Management: Focuses on reducing caloric intake while increasing physical activity. A diet rich in vegetables, lean proteins, and whole grains is encouraged.
  • Example: Reducing portion sizes and avoiding high-calorie foods such as fast food, sugary drinks, and snacks.

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9. Methods of Food Supply, Storage, Preparation, and Distribution and How These Contribute to Health and Disease

The methods of food supply, storage, preparation, and distribution are critical components of public health and nutrition. Poor practices in any of these areas can lead to malnutrition, foodborne diseases, and increased vulnerability to health issues.

a. Methods of Food Supply

The availability and access to food play a significant role in determining nutritional status, especially in low-resource settings like rural Ghana.

i. Food Availability:

• Seasonality: Certain foods, especially fruits and vegetables, are only available during specific seasons. Seasonal availability can limit access to nutritious foods at certain times of the year.
  • Example: In rural areas, yam, cassava, and maize are staple crops that may be in abundance after the harvest season but scarce during off-seasons.

ii. Food Security:

• Food Security: Exists when all people have physical, social, and economic access to sufficient, safe, and nutritious food. In food-insecure regions, individuals may suffer from malnutrition due to insufficient access to nutritious foods.
  • Example: Food insecurity in regions affected by drought or floods can result in widespread malnutrition due to crop failure.

b. Food Storage

Proper storage of food ensures that nutrient value is retained and contamination is prevented.

i. Storage Techniques:

• Cold Storage: Refrigeration and freezing help preserve perishable foods such as meat, dairy, and vegetables, preventing spoilage.
• Dry Storage: Cereals, grains, and dried legumes should be stored in cool, dry places to avoid mold and insect infestation.

ii. Effects of Poor Storage:

• Poor storage practices, such as improper refrigeration or exposure to pests, can lead to the contamination of food and result in diseases such as food poisoning.
  • Example: Aflatoxins, toxic substances produced by fungi, can contaminate improperly stored grains and cause liver damage or cancer when consumed over long periods.

c. Food Preparation

The way food is prepared plays a crucial role in its nutritional value and safety.

i. Cooking Methods:

• Boiling, Steaming, and Grilling: These methods help retain most of the nutrients in foods while reducing the risk of contamination.
  • Example: Steaming vegetables retains water-soluble vitamins such as vitamin C and folate, compared to frying which may reduce their nutrient content.
• Frying and Overcooking: High-fat cooking methods and overcooking can reduce the nutrient content of food and introduce harmful substances such as trans fats or acrylamide.
  • Example: Deep frying fish can reduce its healthy omega-3 fatty acid content while increasing unhealthy fat levels.

d. Food Distribution

Equitable food distribution ensures that all populations, particularly vulnerable groups, have access to nutritious food.

i. Distribution Networks:

In Ghana, both formal markets and informal vendors play significant roles in food distribution. In rural areas, limited infrastructure and transportation challenges can restrict access to fresh produce, leading to reliance on processed or less nutritious foods.

ii. Impact on Health:

• Inadequate distribution networks in rural or underserved areas can lead to food deserts, where residents lack access to healthy, affordable food options, increasing the risk of malnutrition and diet-related diseases.

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10. Factors that Influence Food Consumption Habits in Ghana

Food consumption habits in Ghana are shaped by a variety of factors, including cultural traditions, socioeconomic status, food availability, and personal preferences. Understanding these factors helps health professionals design interventions that promote healthy eating practices.

a. Factors Influencing Food Consumption

i. Food Availability, Access, and Utilization:

• Availability: The types of food available in a given region influence dietary patterns. In rural Ghana, starchy foods like yam, cassava, and maize are staples due to their wide availability.
• Access: Socioeconomic status often determines access to a variety of foods. Higher-income individuals may have access to a more diverse diet that includes fruits, vegetables, and proteins, while lower-income households may rely heavily on starchy foods.

ii. Food Security:

Food security, or the reliable access to sufficient nutritious food, directly impacts food consumption habits. In food-insecure areas, individuals may prioritize filling, calorie-dense foods over nutrient-dense options.

iii. Food Habits:

Cultural and religious practices heavily influence food choices in Ghana. For example, certain groups may avoid pork or beef for religious reasons, while others may rely on specific staples like fufu or banku in their daily meals.

iv. Storage:

The capacity to store foods, particularly perishables, affects consumption. In areas with limited refrigeration, fresh fruits, vegetables, and meat may be consumed less frequently, contributing to less balanced diets.

b. Menu Planning and Budgeting

Planning meals and managing household food budgets are essential skills for promoting balanced diets, particularly in low-income households.

i. Menu Planning:

• A well-planned menu should include a variety of food groups, with an emphasis on fruits, vegetables, lean proteins, and whole grains.
  • Example: A balanced meal might include yam or rice (carbohydrate), leafy greens (vegetable), and fish or beans (protein).

ii. Budgeting:

• Budgeting helps households allocate funds for nutritious food without exceeding their financial limits. It involves prioritizing essential items and minimizing the purchase of processed foods or expensive imported products.

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11. Nutrition Interventions and Policies in Ghana

Ghana has implemented various nutrition interventions aimed at addressing malnutrition, improving public health, and promoting healthy dietary practices. These interventions are supported by both government and international organizations, such as the World Health Organization (WHO) and UNICEF.

a. Promotion of Optimal Breastfeeding Practices

• Exclusive Breastfeeding (EBF): The government promotes EBF for the first six months of life, followed by the introduction of complementary foods. This practice ensures that infants receive adequate nutrition and antibodies to protect them from infections.

b. Promotion of Complementary Feeding

• Complementary feeding refers to the introduction of nutrient-dense foods to infants at six months, while continuing breastfeeding. This ensures that infants transition smoothly from breast milk to a varied diet, providing all necessary nutrients for growth.

c. Promotion of Improved Hygiene and Sanitation (WASH)

• WASH initiatives aim to improve water, sanitation, and hygiene practices, which are essential for preventing diseases and ensuring proper nutrition.
  • Example: Safe water access and proper sanitation prevent diarrhea and other waterborne diseases, which can impair nutrient absorption and lead to malnutrition.

d. Vitamin A Supplementation

• Vitamin A supplementation programs provide high-dose vitamin A capsules to children aged 6–59 months to prevent deficiencies that can cause blindness and weaken the immune system.

e. Zinc Supplements for Diarrhea Management

• Zinc supplementation is an effective intervention to reduce the severity and duration of diarrhea in children, which can prevent dehydration and malnutrition.

f. De-worming

• Regular de-worming campaigns are conducted to reduce the prevalence of intestinal parasites that compete for nutrients and impair children’s growth.

g. Iron-Folic Acid Supplementation for Pregnant Women

• Pregnant women are provided with iron and folic acid supplements to prevent anemia, which is common during pregnancy and can lead to complications such as preterm delivery or low birth weight.

h. Salt Iodization

• Salt iodization is a public health strategy aimed at preventing iodine deficiency, which can cause goiter and cognitive impairment, particularly in children.

i. Fortification of Staple Foods

• Staple foods such as flour and cooking oil are fortified with vitamins and minerals (e.g., iron, vitamin A) to prevent widespread micronutrient deficiencies.
  • Example: Fortified flour ensures that bread and other baked goods provide essential nutrients that might otherwise be lacking in the diet.

j. Treatment of Moderate and Severe Acute Malnutrition

• Ready-to-Use Therapeutic Foods (RUTF): Used to treat severe acute malnutrition in children, RUTF provides high-energy, nutrient-dense food to promote rapid recovery.

k. Promotion of Healthy Diets and Lifestyles

• Public health campaigns encourage Ghanaians to adopt healthier dietary practices, such as reducing the consumption of processed foods, increasing fruit and vegetable intake, and engaging in regular physical activity.

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12. Approaches Used to Implement Nutrition Interventions in Ghana

a. Use of Essential Nutrition Actions (ENAs)

ENAs are integrated into healthcare services at various contact points (e.g., antenatal care, immunization clinics) to promote essential nutrition practices, such as breastfeeding, complementary feeding, and micronutrient supplementation.

b. Integrated Management of Neonatal and Childhood Illnesses (IMNCI)

IMNCI is a holistic approach that integrates nutrition interventions with other health services to improve child survival, growth, and development.

c. Community- and Facility-Based Infant and Young Child Feeding

These programs educate caregivers about proper feeding practices for infants and young children, ensuring they receive adequate nutrition during critical stages of growth.

d. Growth Monitoring and Promotion

Growth monitoring involves regular measurement of a child’s growth to detect malnutrition early and intervene promptly.

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13. The Role of the Dietician/Nutritionist in the Health Team

Dieticians and nutritionists play a vital role in managing patients’ dietary needs and providing guidance on nutritional interventions. Their responsibilities include:

• Assessing Nutritional Status: Evaluating patients’ dietary habits, anthropometry, and biochemical markers.
• Developing Nutritional Plans: Creating individualized dietary plans for patients with specific health conditions (e.g., diabetes, hypertension).
• Counseling and Education: Providing nutritional education to patients and families on healthy eating habits, food choices, and meal planning.

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14. The Role of the Nurse/Midwife in Nutrition Education and Counseling

Nurses and midwives are on the frontlines of patient care and play a critical role in promoting good nutrition. Their roles include:

• Nutritional Assessments: Nurses perform assessments to identify malnutrition and other dietary concerns in patients.
• Counseling: Nurses educate patients on the importance of a balanced diet, portion control, and how to manage diet-related health conditions.
• Monitoring: Nurses monitor patients’ progress, ensuring that dietary interventions are effective in promoting health and preventing complications.

This Nutrition and Dietetics Handout, in line with the Ghana Nurses and Midwifery Council (NMC) Curriculum, covers essential aspects of nutrition, from the role of nutrients in health and disease to the implementation of nutrition interventions in Ghana. Understanding the importance of nutrition and effective dietary management helps nurses and healthcare professionals improve patient outcomes by preventing and managing malnutrition and diet-related diseases.