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Nutrition For You! A Guide to Nutrition and Health Awareness in Schools, 2005

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2 School Health & Safety Section, ESQID, Ministry of Education

NUTRITION FOR YOU!

A GUIDE TO NUTRITION AND HEALTH

AWARENESS IN SCHOOLS

Written by: Ms. Emma Collins, UNICEF Intern

Edited by: Ms. Aishath Shaaheen Ismail and Hussein Rasheed Moosa

School Health & Safety Section Ministry of Education

Male’ Republic of Maldives

ISBN: 99915-0-561-X



All Rights are reserved by School Health and Safety Section, ESQID, Ministry of

Education, Male’, Maldives. The document may, however, be freely reproduced or

translated, in part or in whole, for educational use only.

Written by: Ms. Emma Collins (UNICEF Intern)

Technical and Professional Support by: Ms. Unni Silkoset (Assistant Program

Officer, UNICEF – Maldives) Ms. Nina Jutila (VSO Volunteer for School Health Unit,

EDC) and Ms. Ella Smith.

Edited & proofread by: Aishath Shaaheen Ismail (Ma. Bougainvilla)

Hussein Rasheed Moosa, MOE

Published by: School Health and Safety Section, ESQID

Ministry of Education,

Male’,

Republic of Maldives

2010

Layout and Design by: Mariyam Maalika Assistant Illustrator, EDC, Maldives

Financial Assistance by:

ISBN: 99915-0-561-X

Printed by: M- Print

Faraway Holidays Private Limited

Male’, Maldives



Foreword

Nutrition is important for our existence, why it is important is not always self-

explanatory. Good nutrition is important for growth and development of the body and

the brain. Nutrition is the power source that enables the body to function properly and

keep its healthy. Nutrition is important for children as their bodies are in the growing

and developing stage. Children who do not take enough food, or take non-nutritious

food, have poor physical and mental development compared to children who take

nutritious food.

Following a series of School Health Assessments conducted in Male’ in September 2002

it was clear that one of the primary gaps in educating children was lack of resources and

knowledge among School Health Assistants and Teachers. Many of the staff who

interviewed in the assessments procedure responded that they need additional

resources and information. Specifically, an information guide for School Health

Assistants, Teachers, Parents and also Students would be of help.

This guide, as a result, is targeted towards those who work with and have a direct

impact in the lives of children and their education. The guide is designed in a way that

can be facilitated by health Personals across the Maldives and those working to expand

and promote health within the country. It is hoped that this guide will prove a useful

resource for all those who read and use it, providing knowledge and encouragement to

make a difference in the community within which they work.

We would like to extend a very special thanks to Ms. Emma Collins, (UNICEF Intern) for

her untiring effort and support rendered in making this document a reality. We owe a

big thanks to Dr. Heidi Brown, Ms. Nina Jutila,( VSO Volunteer), Ms. Unni Silkoset,

(UNICEF Maldives) and Ms. Aishath Shaaheen Ismail for their contributions. Last but not

least, a special thanks goes to Ms. Zahiya Zareer, former Director General, EDC for her

guidance and Support. And also a very special thanks to Dr. M.J. Luna, WHO

Representative to Maldives and other Staffs from WHO Country Office.

Hussain Rasheed Moosa

Senior Co-ordinator, School Health Programmes,



ACKNOWLEDGEMENTS Health and nutrition information and education has made great improvements over the

last few years in the Maldives. However, it is an area which still has far to go in terms of

further developments.

The focus of the guide is targeted towards those working with children as teachers and

school health personnel who can have a direct impact in the education and lives of the

children with which they work.

I am grateful for the following people who have helped me in the various stage of the

development of this booklet:

Ms. Zahiya Zareer former Director General, Educational Development Centre (EDC), Ministry of Education, .

Mr. Hussein Rasheed Senior Co-ordinator, School Health Programmes,

School Health Unit, EDC. Ms. Unni Silkoset Assistant Programme Officer, UNICEF, Maldives Ms. Nina Jutila School Health Officer, School Health Unit, EDC. Ms. Nina Kolbjornsen UNICEF Intern, Educational Development Centre. Mr. Ahmed Salih, Mr. Ahmed Affal and The Health Information and Research Unit, Ministry of Health. Ms. Ella Smit for her professional help, support and guidance. Mariyam Maalika, Assistant Illustrator, EDC. The Staff of School Health Unit, EDC, Ministry of Education. Emma Collins,

UNICEF Intern,

2005



CONTENTS Part 1 Introduction 3

Nutrition throughout the Lifecycle 3

8BNutrition and Health Matters in the Maldives 5

Aims and Objectives of the Guide 7

Who Can Use the Guide? 8

How Do I Use the Guide? 8 Part 2 Nutrition Basics 9 What Are Nutrients? 9 Carbohydrates 11 Fats 12 Proteins 13 Vitamins and Minerals 15

Water 31 Nutrition Requirements 32 Healthy Meals 36 Nutrition Requirements at Different Ages 38 Clinical Nutrition 44

Protein Energy Malnutrition 44

Obesity 46 Diabetes 47



Diseases of the Heart and Circulation 49

Iodine Deficiency Disorders 50 Iron Deficiency – Anaemia 50

Eating Disorders 52 Food Safety 54

Part 3 Using Your Knowledge 57 Activity Ideas for Children 58 12B Grades 1-3 58

Grades 4-6 61

13B Grades 7+ 63

Ideas for Schools 65 How to Plan and Hold a Workshop 66

Appendices References



PART 1 INTRODUCTION Nutrition throughout the Lifecycle

The importance of nutrition starts even before we are born. A pregnant woman has a

responsibility to have a healthy diet that meets the requirements of a growing foetus.

Pregnant women also need to ensure that they have a healthy body weight. Being

underweight can increase the risk of having a low birth weight baby and increase the

likelihood of ill health to both the mother and the child. However, it is important not to

be overweight as this can increase the risks of high blood pressure and diabetes during

pregnancy.

Low birth weight (LBW) is defined as weight at birth of less than 2500 grams and is

caused either by intrauterine growth retardation or pre-term deliveries. In developing

countries, most of the LBW babies are caused by growth retardation which means that

they are born undernourished. LBW babies have 40-fold risk of dying in the neonatal

period and 50% greater risk of serious developmental problems where impaired mental



development is the most serious. A low-birthweight infant is thus more likely to be

underweight or stunted in early life.

The consequences of being born undernourished extend into adulthood. Studies from

both developing and industrialized countries suggest a link between foetal undernutrition

and increased risk of various non-communicable diseases like diabetes, high blood

pressure and coronary heart disease later in life.

During infancy and early childhood, frequent or prolonged infections and inadequate

intakes of nutrients - particularly energy, protein, vitamin A, iron and zinc - exacerbate

the effects of foetal growth retardation. Most growth faltering, resulting in underweight

and stunting (low height-for-age), occurs within a relatively short period, from before

birth to about two years of age.

Undernutrition in early childhood has serious consequences. Underweight children tend

to have more severe illnesses, including diarrhoea and pneumonia. There is a strong

association between the severity of underweight and mortality. The capacity to learn

and thrive will also be reduced due to reduced mental development.

A long-standing assumption has been that by school age a child has survived the most

critical period and is no longer vulnerable. However, many of the infectious diseases

affecting preschool children persist into the school years. In addition, rates of

malnutrition are still increasing in many countries. These problems adversely affect

school attendance, performance and learning.

In adolescence, a second period of rapid growth may compensate for early childhood

growth failure, although the potential for catch-up growth is limited. The effects of early

childhood undernutrition on cognitive development and behaviour may not be fully

restored. A stunted girl is thus most likely to become a stunted adolescent and later a

stunted woman. Apart from direct effects on her health and productivity, adult stunting

and underweight increase the chance that her children will be born with low birthweight.

And so the cycle turns…



9BNutrition and Health Matters in the Maldives

The health and nutritional status of children in the Maldives is one, which is in constant

need of improvement as children are torn between the influences of Western cultures

and the practicalities of living in the Maldives where food sources are limited and

unpredictable.

The Health Master Plan 1996-2005 highlights a number of objectives concerning

childhood nutrition. It states that the nutrition programme will “sustain food security and

ensure that people are made aware of the value and importance of a balanced diet”

(Health Master Plan 1996-2005, p 103). The importance of nutritional education is

prioritised and strategies include the identification of “specific nutrition education

projects implemented based on modern techniques of behaviour modification” (Health

Master Plan 1996-2005, p 104). This proposal has been formulated on the basis of these

strategies to meet the stated objectives.

The Multiple Indicator Cluster Survey 2001 (MICS) when examining the nutritional status

of children, states that malnutrition “is mainly due to the lack of a well balanced diet”

(MICS 2001, p 39). The knowledge and awareness of nutritional concerns among

Maldivians are generally poor especially on small community islands where both health

facilities and health workers are lacking.

Under-nutrition continues to be a problem in the Maldives, shown in the high levels of

stunting, wasting and micronutrient deficiencies that are shown in many national reports

and surveys. Despite a reasonably high level of food security, Maldivians suffer due to

the problems that are associated with a limited diet and lack of access to fruits and

vegetables. The geographical nature of the country and its problems with transportation

mean that many communities lack access to good food and nutrition knowledge.

The National Nutrition Strategic Plan aims, amongst others, to improve access to

nutrition and health information and provide guidance on specific nutritional deficiencies

highlighting and increasing the awareness of the values and importance of a balanced



diet. In this way, the problems of children attending school without breakfast, food

choices being limited, and nutrient deficiencies, will be tackled.

However, in addition to the problems of under-nutrition, Maldivians are also facing the

pressure associated with the Western influence. Companies such as Coca Cola, Mars,

Nestle, and Apollo target groups of people especially children and adolescents by

utilizing the fact that these groups of people can be influenced and through advertising

means can be pressurized into choosing to consume junk food rather than making

sensible eating choices.

Dieting is a very common practice among both girls and boys all over the world. The

desire to be thin prompted by what is seen in the media is thrived after in all countries.

It is important that the children and adolescents develop healthy eating habits and

approach dieting in the right way. This is an issue in the Maldives as in most other

countries and improved awareness is needed to allow eating problems to be dealt with

and guidance given to individuals.

Improving diets and preventing under-nutrition is focused around working together to

identify problems and establishing initiatives that will be effective in the community

through the sharing and exchange of knowledge. The more involved the community in

the identification and planning of activities the more effective and sustainable the work

will be in solving specific problems.

The term ‘community’ can be applied not only to large groups of people but can be used

in the context of the school community, local parenting community, families, health

centre patients and government officials. Working together to tackle problems avoids

duplication of ideas and effort and ensures that ideas, skills and information are shared

among a wide range of individuals.



Aims and Objectives of the Guide

The aim of this information guide is to provide those employed in and related to the

health and education sector with a solid background knowledge of nutrition and health

and to make recommendations as to how this knowledge can be used to educate and

raise awareness about issues that are cause for concern in the Maldives.

The objectives of the guide are as follows:

To highlight the nutrition related problems of children that exist in the Maldives

in terms of health and nutrition

To give a basic knowledge of nutrition

To enable users to clearly:

be able to identify a healthy diet

to feel confident about giving advice to others on healthy lifestyles

and nutrition

have a basic understanding of how to communicate health messages

to students

be equipped with activities to be used when teaching nutrition

to identify problems and solutions for the problems that are faced by

individual schools and communities

to make suggestions to programmes that can benefit the school or

community in terms of health and nutrition

To aid the formation of a network of School Health Assistants, Health Workers

and those interested in nutrition and health who can work together and learn

from each other

To enable a greater understanding of professionals working in the field of health

and nutrition through the network, and to have a greater knowledge about

different programmes being conducted in different areas i.e. schools and

communities



Who Can Use the Guide?

The Guide is designed and targeted towards those working as School Health Assistants

and Community or Family Health Workers who require a more detailed knowledge and

understanding of health and nutrition in order to work more effectively.

How Do I Use the Guide?

The Guide is designed to provide basic nutrition information for those working in the

area and also to provide a selection of ideas and activities that could be used in the

communication of this knowledge.

It is divided into two sections, one containing the information and the other activity

ideas, workshop plans and additional information.



0BPART 2 NUTRITION BASICS

What are nutrients?

Nutrients are the substances in food that our bodies need to produce energy, growth

and maintain and repair the body. Nutrients can be grouped into different types:

carbohydrates, fats, proteins, vitamins, minerals and water.

One simple way of approaching nutrition is to think of the body as a car. The car needs

six nutrients to maintain in good condition and they are all equally important.

Figure 1: Your Body Is Like A Car

Carbohydrates and fats

Vitamins

Water

Proteins

Minerals



Nutrient Function in the body Function in the Car

Carbohydrates Provide the energy to work

rapidly. Give glucose to the

brain.

The fuel used for

acceleration and short trips.

Keep the engine running.

Fats Provide energy for strenuous

work. Maintain the body.

The fuel used on long drives.

Keep the car running.

Proteins Build the body. Protect the

body.

The frame of the car.

Protects the car.

Vitamins Help the body and its

systems work properly.

Protect the body

The parts of the car needed

for start up and

maintenance. Keep the car

in shape.

Minerals Aid and maintain correct

functioning of body systems

and protect the body

The accessories of the car

that helps it run smoothly.

Water Vital for life. Required in all

cells and fluids.

The cooling system of the

car. Needed for the car to

work.



Carbohydrates

This group is made up of sugars, starch and dietary fibre.

Sugar is the simplest form of carbohydrate. There are many different types of sugar that

are found in different types of food. Sugar is found naturally in foods such as milk, fruit

and vegetables but is added to jams, soft drinks, biscuits, cakes and sweets.

Sugars are simple molecules that are digested and absorbed easily by the body.

Starch is made up of chains of glucose sugar molecules. Starches are more complex

molecules that are broken down by the body into glucose before they can be digested.

Starch foods must be cooked before they can be eaten. When cooked with water

starchy food absorbs the water and swells.

Starch products include potatoes, bread, rice, pasta, taro, wheat, and millet.

Dietary fibre is the term given to a number of complex carbohydrates, which cannot be

digested. Fibre is found primarily in the cell walls of plants. These starches pass through

the small intestine and are broken down by bacteria in the large intestine before being

excreted from the body together with other waste products.

Fibre helps to prevent constipation, and can prevent heart disease as it alters cholesterol

levels in the blood. Fibre is important in keeping the digestive tract healthy and working

properly. However, fibre can reduce the absorption of minerals such as iron and zinc.

Sources of fibre are fruit, vegetables, beans and whole-grains.

Carbohydrates have important functions in the body.

1. They provide energy

U1 gram of carbohydrate provides 16kJ or 4 Kcal



2. If carbohydrates are lacking, protein will be used for energy by

the body and wasting (acute malnutrition) can occur as protein is

used for energy rather than its growth and repair functions

3. Fibre can reduce blood cholesterol levels, and prevent heart

disease

4. Fibre can reduce the risk of cancer

Fats

Fats are made up of chains of fatty acids. Fatty acids can be either saturated or

unsaturated. Saturated fats are solid at room temperature and include butter, lard, and

ghee. Unsaturated fats are liquid at room temperature and are mainly vegetable and

animal based oils.

Functions of fat in the diet;

1. The most energy dense source in the diet

U1 gram of fat provides 37kJ r 9 Kcal

2. They are an essential component of cell membranes

3. They are needed for the absorption and function of vitamin A, E, D,

and K

4. Essential fatty acids are needed for cell membranes and nerve tissue

5. Fat makes meals more tasty and satisfying

Rich sources of fat are oils, meat products, butter, margarine, fish, nuts, soya beans,

potato crisps and chocolate.

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Fat is an important nutrient in the diet. However, it is important to regulate fat intake. A

diet high in saturated fat is associated with high blood cholesterol levels, which can lead

to coronary heart disease.

It is recommended that no more than 35% of total energy intake comes from fat, with

no more than 10% from saturated fat.

Proteins

Proteins are complex molecules made up of chains of smaller molecules called amino

acids. These are the primary building blocks of the body. Chains of amino acids together

form proteins. When proteins are eaten and digested they are broken down into their

amino acids, which are then absorbed and used to build new tissues.

E D

C

F

A B

B

E

Amino Acids

= Proteins

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Proteins are needed to build and maintain muscle, blood, skin and bones together with

tissues and organs of the body. They also make hormones and enzymes and provide

energy.

Good sources of protein are:

Fish

Meat

Dhal curries

Beans

Eggs

Milk

Cheese

Yoghurt

Protein is found in a wide variety of animal and plant based foods, however, the amount

and quality of the protein varies. The quality of the protein depends on the amino acids

that are present. Amino acids can be classified into essential and non-essential amino

acids. Essential amino acids cannot be made by the body, thus they are required from

the diet.

If a food contains more than one of the essential amino acids required by the body it is

said to be of high biological value. If low in essential amino acids it is said to be of low

biological value. In general, animal sources of protein have a higher biological value

than plant sources.

However, proteins can complement each other if eaten together and thus give a meal of

high biological value. This complementary function of proteins plays an important role in

meeting people’s nutritional requirements.




Vitamins and Minerals

Vitamins and minerals are called micronutrients. They are needed in much smaller

amounts than protein, fat and carbohydrate but are essential for good nutrition. They

help the body work properly and stay healthy. Some minerals also make up part of

many of the body's tissues, for example, calcium and fluoride are found in bones and

teeth and iron is found in the blood. Without vitamins and minerals your body will fail to

function properly and diseases occur.

Vitamins

Vitamins are complex substances that are needed in small amounts for specific body

processes. Only a few milligrams are needed per day but vitamins are essential to

health. Most vitamins cannot be made by the body and so are required from the diet. If

vitamin requirements are not met due to a poor diet or medical condition specific

symptoms will appear and a deficiency disease may develop.

Vitamin A is needed for building and maintaining healthy tissues throughout the

body, particularly eyes, skin, bones and tissues of the respiratory and digestive tracts. It

is also very important for effective functioning of the immune system. Vitamin A

deficiency can lead to poor night vision, severe eye diseases and in severe cases

permanent blindness. This occurs mainly in undernourished children, especially those

with measles and other infections. Vitamin A deficiency can also lead to increased illness

and death from infections.

Vitamin A is found in two forms; as retinol in animal food sources and carotenoids in

plant sources. Carotenoids are converted to retinol by the body. The most common

carotenoid is beta-carotene.

A



Retinol is found in breast milk, liver, eggs, and milk. Foods rich in carotene include

carrots, dark green leafy vegetables, deep yellow and orange sweet potatoes, pumpkins,

mangoes, papaya and red palm oil. Vitamin A is not found in oranges.

Vitamin B complex consists of 8 individual B vitamins, which have a unique

structure and function in the human body.

The B-vitamins are necessary for converting carbohydrates, fat and protein into energy

and for using them to build and repair the body's tissues. Requirements for B vitamins

vary greatly and it is important to remember that because the different vitamins have

different functions, they are not all needed at the same time as they are used at

different rates for different functions.

B vitamins are classified using numbers, but they also have chemical names. The 8 B

vitamins are:

Thiamine (B1)

Riboflavin (B2)

Niacin (B3)

Pantothenic Acid (B5)

Pyridoxine (B6)

Biotin

Folic Acid

Cobalamin (B12)

B



Thiamine

Thiamine is needed to release energy from carbohydrate. The amount required is

related to the amount of carbohydrate eaten in the diet. It also aids blood formation and

circulation. Good sources of thiamine are whole grains, liver, nuts and seeds.

Deficiency of thiamine causes a disorder of the nervous system called beri-beri.

Characteristics include fatigue, nerve degeneration, poor coordination, oedema,

constipation and irritability. Loss of appetite and difficulty in breathing may also

occur. Deficiency is common in populations where refined white rice is a staple

food.

Riboflavin

Riboflavin is required to release energy from protein, carbohydrate and fats. It is also

important for red blood cell production and growth.

Good sources of vitamin B2 include meat, poultry, fish, dairy products and green

vegetables.

There is no known deficiency disease for vitamin B2. However low intakes result in skin

problems, namely dryness and cracking around the mouth and nose.

Niacin

Niacin has a function in the digestive system, skin and nervous system. It is also

suggested that it has the ability to lower the level of fat in the blood thus aiding

treatment of a condition known as hyperlipidaemia in which blood fat levels are too

high.

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Niacin is made by the body from an amino acid called tryptophan and is found in the

following sources: meat, milk and eggs.

Niacin deficiency results in a disease called pellagra. This is characterized by inflamed

skin, digestive problems and mental difficulties.

Pantothenic Acid

Pantothenic acid works closely with the vitamin Biotin. It is important in the release of

energy from carbohydrates and fatty acids and in the synthesis of hormones.

Pantothenic acid is found in a wide range of foods with meat, whole grains and legumes

being especially rich.

Pyridoxine

Vitamin B6 is needed to release energy from protein. It also is involved in the regulation

of fluid levels in the body and aids red blood cell production.

Vitamin B6 is found in a variety of foods: chicken, fish, liver, eggs, whole-wheat

products, peanuts and walnuts.

Deficiency may occur as a complication of disease and drug effects.

Biotin

Biotin is very similar to Pantothenic acid in its functions and sources. It is needed for the

breakdown and synthesis of carbohydrates, fat and protein. Biotin is found in liver, eggs,

cereals and yeast.

A lack of biotin can cause fatigue, loss of appetite, muscle pain, dry and scaly skin.




Folic Acid (Folate, Folacin)

Folic acid is needed for the formation of red blood cells. It is especially important during

periods of growth such as pregnancy and childhood. It is also important in the

production of DNA, which is essential for the growth and reproduction of normal cells.

Inadequate intake of folic acid during pregnancy can result in birth defects as a result of

cells not being produced properly. Neural tube defects are common in babies where

pregnant mothers have had a diet low in folate.

Low intakes of folic acid can cause diarrhoea, loss of appetite, and weight loss. Other

signs of deficiency include weakness, headaches, and a sore tongue. In children, low

folate levels can slow growth rates and result in complex medical conditions. Anaemia is

a sign of advanced folate deficiency in adults characterized by fatigue and lethargy.

Sources of folic acid include green leafy vegetables, nuts, grains, liver and yeast.

Cobalamin

Vitamin B12 maintains healthy nerve cells and red blood cells. It is also needed to make

DNA.

Deficiency is rare, however it is often seen in individuals who exclude animal produce

from their diet. Deficiency causes a type of anaemia known as megaloblastic anaemia

where the red blood cells become enlarged and damage the nervous system. Typical

signs of deficiency are therefore numbness and tingling of the hands and feet.

Cobalamin is found naturally in animal foods including milk, milk products, eggs, meat

and poultry. Fortified breakfast cereals and canned tuna also contain vitamin B12.



Vitamin C (or ascorbic acid) has many functions. It is necessary in the

formation of collagen (connective tissue) which binds the body’s cells, in immune

responses, wound healing and allergic responses. Vitamin C increases the absorption of

iron in the gut, and due to its properties as an antioxidant it plays a protective role in

the body.

Prolonged vitamin C deficiency can lead to scurvy. The signs of scurvy are bleeding

gums and sore, swollen joints, poor wound healing and damage to bone and body

tissue. In serious cases it can lead to death.

Most fruits, especially citrus and guava, and many vegetables, including fresh potatoes,

are good sources of vitamin C. Eating fresh fruit and vegetables is important for both

adults and children.

Stress and strain on the body, like smoking, increases the amount of cellular by-

products called radicals. Antioxidants counteract the radicals and transform them into

non-damaging products. They can therefore reduce the risk of developing cancer and

heart disease. Other antioxidants are vitamin E, carotenoids and selenium.

Vitamin D is the one vitamin that is made by the body. When the skin is

exposed to sunlight, the ultra violet rays stimulate the production of vitamin D.

This is therefore an important source as vitamin D is found in few food sources.

Vitamin D is particularly important for the use of calcium by the body. It works as a

hormone to control the amount of calcium that is absorbed by the intestines. It is

therefore essential for bone structure, as the more calcium that is absorbed by the body

the stronger the bones and teeth will be.

Vitamin D is found in fish oils, eggs and milk. Lack of vitamin D can lead to rickets, a

disease, which causes soft and deformed bones in young children.

C

C

D



A prolonged lack of vitamin D can result in pain and muscle weakness in adults (a

disease called osteomalacia) and bone degeneration (osteoporosis).

Vitamin E consists of a group of compounds that are called tocopherols and

tocotrienols. Vitamin E is an antioxidant and consequently protects the body against

harmful radicals.

Sources of vitamin E are vegetable oils, nuts and green leafy vegetables.

Vitamin K is made by bacteria in the gut. However, it is also required in the diet

and is found in the following sources;

Cabbage, spinach and green leafy vegetables

Cereals

Soybean

Vitamin K is essential for blood clotting. A lack of vitamin K results in the blood failing to

clot properly, which can be fatal. It is also found to have a role in maintaining strong

bones in the elderly.

How Much of the Vitamins Do We Need?

The body requires different amounts of each vitamin because each of them has a

different function. Many factors influence the amount that each individual needs. It

depends on age, gender, level of activity, state of health. Certain people may have

higher requirements for specific vitamins, for example, those suffering or recovering

from illness, smokers, athletes and pregnant women.

K

E



Calcium

Magnesium

Phosphorous

Sodium

Iron

Potassium

Iodine

Trace Elements

Daily Reference Values (DRV’s) exist to give guidance for daily intakes of each vitamin.

However, these values are estimates and take into account that vitamins and minerals

are consumed over a period of days and weeks rather than each and every day. The

Reference Nutrient Intake (RNI) is given for some vitamins and represents the amount

of each nutrient that the general population requires for good health.

The Availability, Absorption and Loss of Vitamins

The availability of a vitamin for absorption and use in the body is affected by a number

of factors. The amount absorbed by the body can be influenced by other substances

such as minerals and natural chemicals found in foods. For example iron can reduce the

absorption of vitamins A, D and E whereas the absorption of vitamin B12 can be helped

by increased folic acid.

The amount that each individual absorbs will depend on their needs, ability to absorb

nutrients and the amount available in their diet.

Some vitamins are damaged easily by heat, light, preparation and storage. Losses can

occur during food preparation and cooking which in turn can affect the amount of a

vitamin that is consumed and therefore absorbed. For example, when green vegetables

are boiled, vitamin losses occur whereas cooking carrots allows the vitamin A to be

made more available for absorption by the body.

Minerals



Minerals are inorganic substances that are required by the body for a wide range of

functions. They are needed in varying amounts depending on their functions in the

body. Those that are required in smaller quantities are called trace minerals. However,

these minerals are just as important as others despite being needed in smaller amounts.

The best way to ensure that all mineral requirements are met is to eat a varied diet

including a wide range of foods from all food groups.

Calcium

Calcium is a mineral that works with vitamin D to build strong bones and teeth. Ninety

nine percent of calcium is stored in the bones and teeth. The remaining 1% is found in

the blood and soft tissues. This is just as important as it controls muscle contraction and

aids blood clotting.

A lack of calcium can cause growth problems in children. Calcium deficiency may cause

bone abnormalities. Rickets occurs in children who have calcium deficiency. Rickets

affects the structure of growing bone. A lack of calcium stored in the bone results in the

bones becoming soft and weak and unable to bear the weight of the child. Symptoms

include bone pain, delayed teeth formation, curvature of the spine and legs, and poor

muscle strength.

Calcium deficiency in childhood can lead on to osteomalacia in adulthood. As with

rickets, a prolonged calcium deficiency causes the bones to be weak and prone to

fractures. Pain and muscle weakness is experienced.

The density of the bone mass gradually builds up and reaches a peak between the ages

of 30 – 35. After this the bones begin to gradually degrade as less bone is made to

compensate for the bone losses. It is therefore important to ensure an adequate calcium

intake. Severe bone loss results in bone becoming weak and brittle in adulthood, a

condition known as osteoporosis. Osteoporosis results in repeated bone fractures and

general bone pain.



The above diagram shows how the condition affects bone, causing a thinning of the

bone tissue. This causes fractures to occur more easily. Bone degradation may also

results in poor spinal support (see picture on page 25).



Calcium absorption depends on vitamin D and so the two nutrients are dependent on

each other. This explains why calcium and vitamin D deficiency show similar signs.

Rich sources of calcium are dairy produce, together with pulses, nuts, dried fruit and

green vegetables. Many foods are also fortified with calcium. Calcium availability,

however, can be affected by substances in other foods that bind to the calcium and

prevent absorption. Wholegrain cereals and pulses contain a (natural) substance called

phytate and some green leafy vegetables contain another called oxalate that decrease

the absorption of calcium.

Iron

Iron is a major part of red blood cells and is necessary to keep all of the body's cells

working properly. Iron is needed for the substance in red blood cells called

haemoglobin, which is needed to transport oxygen around the body. A lack of iron leads

to iron deficiency anaemia. Iron deficiency anaemia is the most widespread nutritional

problem in the world. It can be very serious in children and women of childbearing age,

especially during pregnancy. It is also common in teenage girls and in those who have

suffered severe blood losses such as through injury or menstruation. Iron deficiency

anaemia causes tiredness, irritability, low attention span, learning difficulties, poor

growth and development, and increased illness and maternal mortality, especially at

delivery.

There are two types of iron available from the diet:

1. Haem iron which is found in meat, fish, poultry and liver. It is absorbed easily

by the body.

2. Non-haem iron found in dark green leafy vegetables, dried fruits and whole

grains. This form of iron, however, is not absorbed as easily by

the body, and its absorption is affected by other foods.

Substances as phytates and tannins restrict the absorption of non-

haem iron. Phytates are found in cereals and pulses and tannins



are found in tea and coffee. It is therefore recommended that tea

and coffee are not consumed at meal times as they can inhibit

absorption by up to 40%. Vitamin C however increases the

absorption of non-haem iron and if consumed together with iron

rich foods iron absorption will be significantly increased.

Phosphorous

Phosphorous is a component of bones and teeth and is present in all animal and plant

cells. It is also involved in enzymes and is needed for the metabolism of energy from

glucose.

Phosphorous has an important role in maintaining healthy bones and teeth as 80% of

phosphorous is stored as calcium salts in the skeleton. Phosphorous therefore works

closely with calcium and vitamin D. It is essential that all three nutrients are available in

adequate amounts to work together to ensure healthy bones and teeth.

Good sources of phosphorous tend to be those rich in protein and include milk, meat,

nuts, whole-grains and green vegetables. Pumpkin and sunflower seeds are very rich

sources.

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Iodine

The primary function of iodine is to make thyroid hormones. Thyroid hormones are

made in the thyroid gland and are essential for controlling metabolism and therefore

proper growth and development. A lack of iodine in the diet results in lethargy and

mental retardation.

The characteristic sign of iodine deficiency is a swollen thyroid gland in the neck, known

as goiter.

Iodine deficient mothers can bear children who are severely iodine deficient, and the

infant suffers from mental disability known as cretinism. This condition causes mental

retardation and dwarfism.

Iodine is restricted to only a few sources. Seafood is a rich source of iodine as is iodized

salt. Foods such as vegetables grown in iodine rich soil may contain iodine but not in

significant amounts. In the Maldives tuna fish contain iodine but levels are reduced

significantly after prolonged periods of cooking. Reef fish is a far better source of iodine.



Potassium

Potassium is found in all body fluids and has many functions;

It is needed for normal muscle tone and function

Keeps heartbeat regular

Needed for a healthy nervous system

Maintains normal blood pressure

Regulates the transfer of nutrients to cells

Potassium is found in almost all foods but rich sources include dairy products (except

cheese), green leafy vegetables, apricots, fish, bananas, and brown rice. Raw foods are

a better source of potassium as losses occur during processing.

A lack of potassium in the diet causes fatigue, muscle weakness and cramping, and

rapid heartbeat.

Sodium

Sodium, together with potassium, helps regulate the water content of the body. Like

potassium, sodium is present in all body fluids and is essential for hydration as it

controls the amount of water in cells. In contrast, potassium functions to carry waste

products out of the cells.

Potassium takes

waste products out of

the cell

Sodium takes water

into the cell

BODY CELL



It is therefore important that the balance of potassium and sodium in the body remains

constant and equal. If imbalanced, waste products can accumulate inside the cells and

healthy nutrients and water remain outside the cells.

In addition, sodium is required to regulate nerve impulses and muscle contractions.

Although sodium chloride (salt) is found in few foods naturally, all processed refined

foods contain added salt ensuring that deficiencies are rare. Salt is also used in cooking

and added as table salt supplying adequate amounts from the diet. In hot climates, it is

necessary to ensure that sodium levels do not deplete as sodium is lost through sweat

and can destroy the potassium/sodium balance in the body. Care must be taken

however, not to consume excess sodium as salt, as this can result in high blood

pressure (hypertension) and further complications.

Magnesium

Magnesium is needed for muscle contraction, nerve impulses, bone mineralization and

energy metabolism. It is present in all body cells. It also forms part of enzymes involved

in energy transfer from fats, proteins and glucose.

It is also important in regulating the amount of calcium in the blood.

Magnesium deficiency is rare, and is usually a result of a clinical condition rather than a

deficient diet. However symptoms include muscular weakness, confusion, tremors and

difficulty in swallowing.

Magnesium is present in dark green leafy vegetables, nuts, seeds, soybeans and wheat-

germ.



Trace Elements

Trace elements is the term used to describe minerals that are essential for good health

but are needed in very small quantities. Trace elements include zinc, fluoride, selenium,

copper, and chromium. See Appendix for information on these nutrients.

Fortification and Supplements

Many foods are fortified with vitamins and minerals due to the losses that occur in

processing and the rise in concern over adequate dietary intake of nutrients. Foods that

have had vitamins and minerals added to them are called fortified foods. An example of

a fortified food is iodised salt. Iodine is frequently added to salt to produce iodised salt

for use in cooking. Cereals and dairy products are also commonly fortified with vitamins

and minerals to enhance their nutritional content.

Additional mineral supplementation in the diet is unnecessary provided the individual

eats a varied and balanced diet. However, in developing countries where food variety

and shortages exist it is sometimes necessary to have a supplement in the diet. The

sick, pregnant and young who have higher nutrient requirements should ensure that

they eat foods rich in vitamins and minerals before resorting to additional tablet

supplementation. It is important that supplementation is prescribed by a doctor only, as

excess vitamin and mineral stores can cause toxicity and illness.

The amount of a particular vitamin or mineral that an individual absorbs will vary

depending on their needs and body stores. Together with other influencing factors such

as age, gender and health these factors require serious consideration before

supplementation is advised.

Water

Our bodies are over 70% water. Water is a major part of all body fluids; blood, digestive

juices, urine, tears, saliva and sweat. It is therefore involved in all body functions;



circulation, digestion, absorption, getting rid of waste substances, cell production and

metabolism, and chemical reactions. It is essential for the body.

The amount of water that we need depends on many different factors such as age, job,

climate, activity levels and diet. It is essential however that an adequate intake is

maintained to replace the water lost from the body. Excessive loss of water can cause

dehydration. Hot weather, physical activity and sickness (such as diarrhoea, vomiting

and fever) can all cause increase fluid losses, which need to be replenished through

drinking clean water.

Nutrition Requirements

All nutrients have different roles and functions in the body, some of which are needed in

larger amounts than others. The nutritional requirements for nutrients vary among all

individuals and depend on a number of different factors:

Age

Gender

Level of physical activity

State of health

Environment

Due to individual needs being different, different types and amounts of foods are

needed for a balanced diet. For example a balanced diet for an athletic man will not be

the same as that of a young child.

Nutritional requirements are based on values known as Dietary Reference Values

(DRVs). These are estimates for different groups of people and should not be viewed as

goals for individuals. DRVs include three different estimates:



Estimated Average Requirement (EAR)

This is an estimate of the average requirement for energy or a nutrient for a group of

people.

Reference Nutrient Intake (RNI)

The RNI is the amount of a nutrient that is enough to ensure that the needs of the

group (97.5%) are being met.

Lower Reference Nutrient Intake (LRNI)

The amount of a nutrient that is enough for only the small number of people that have

low requirements (2.5%). This is the minimum requirement for a nutrient.

This can be shown on a graph.

The graph shows how the

majority of people consume

average requirements.

The daily diet should be made up of all nutrients to achieve a healthy balanced diet.

Energy should be derived from all nutrients of the daily calorific intake;

Fat should provide 30-35% of calories

Protein should provide 15%

Carbohydrate should provide 55%

The Balance of Good Health is a symbolic representation of the proportions and types of

foods that should be consumed in order to achieve a balanced diet.



This is not a requirement for every meal however, but a guide for daily and weekly

intakes. This is also shown using the food pyramid (see Appendix v)

It is based on eating a selection of foods from the five food groups (see Appendix vi).

The Balance of Good Health

As the diagram shows, bread, cereals and potatoes and fruit and vegetables should

make up the main part of the diet, with sugar and fatty foods being only eaten in small

amounts.



It is also important to remember that nutritional requirements increase when the body is

not functioning properly or is under stress or strain. It is therefore important that

nutritional intakes increase during sickness and during recovery.

Certain groups of people may have higher requirements for a specific nutrient such as a

vitamin or mineral if suffering from a medical condition. For example, an elderly woman

suffering from osteoporosis may require a higher calcium intake than a healthy woman

of the same age.

Children also require more energy per kilogram of body weight and nutrients than adults

as it is necessary to meet the nutritional demands made by phases of growth and

development.

The graphs below highlight how nutritional requirements vary.



Healthy Meals

A balanced diet must consist of balanced meals. A balanced meal consists of different

foods that provide a variety of nutrients. Different types of food should be combined to

give a balanced meal.

Ingredients for a balanced meal:

1. Staple

This provides the most calories, together with protein and

some minerals and vitamins. Staples are starchy foods and

cooked cereals such as bread, pasta, potato, rice, and

roshi.

2. Meat, fish, or legumes

These provide calories, protein, fibre and some vitamins

and minerals. Iron is supplied from this group. Legumes

include dhal, beans and nuts.



3. Vegetables and/or fruit

These provide vitamins and minerals such as vitamin A, C,

folic acid, and iron.

4. Fat rich foods

Vegetable oils, margarine, coconut, milk and cheese supply

fat. Children need more fat than adults.

Children require less food than adults and should be given small regular meals rather

than a few big meals because of smaller stomachs. The diagrams below show balanced

meals for children and adults.

Adult Child

Snacks may also be eaten as part of a balanced diet but care should be taken to ensure

that these do not interrupt the pattern of regular meals and that they are nutritious and

not high in saturated fat and sugar.



Good value snacks include:

Pieces of cooked cassava, potato, or breadfruit

sandwich

Milk, cheese or egg

Fruits such as mangos, bananas, oranges and apples

Bad value snacks are:

High sugar foods such as sweets, chocolate, biscuits

Foods that are high in fat and give few nutrients such as crisps,

ice-cream and fried short eats

Sugary drinks such as sweet tea, coffee and fizzy drinks

Nutrition Requirements at Different Ages

Infants, 0 – 6 months

Breast milk provides all the energy and nutrients a baby needs

for growth and development. It also contains antibodies,

hormones, enzymes, growth factors and other substances

needed for a healthy development. A healthy baby does not

need any food or drink other than breast milk for the first six

months of its life. The composition of breast milk changes over time, in accordance with

the changing needs of the growing baby.

Babies are born with appetite control which matches their bodies' needs. However,

babies have different feeding patterns. Some babies need to feed 12-15 times while

others 6-8 times during 24 hours. Putting the baby to the breast whenever it shows

signs of hunger during the day and night is the key to establishing good milk supply and

good growth.



Young Children, 7 months - 2 years

While breast milk is the basic food of the baby, it is not enough

to meet the increased nutritional needs as the baby grows older.

By six months babies should be introduced to other foods to

supplement the energy, protein, vitamins and minerals provided

by breast milk.

This process of introducing new foods into the baby’s diet is

called complementary feeding. This will also accustom the baby to varieties in food

flavours and textures and establish good food patterns from an early age.

Breast milk should continue to be the main ingredient of the diet, but different types of

complementary foods should be introduced gradually. Foods for babies require special

preparation to make sure that they are soft, clean and easy to digest. Food can be

softened by cooking and then pureed, mashed or chopped.

To meet all of the baby’s nutritional needs it will be necessary to add foods high in

energy and other nutrients (oil, fruit, vegetables, legumes, animal products) to the

family’s staple food. Once the baby is accustomed to liquid and soft foods, and as the

teeth appear, semi-solid and then solid foods can gradually be introduced to the diet.

Preparing safe and nutritious complementary foods can take time and effort. Many

parents need practical advice and assistance to help them provide their babies with the

foods they need. Introducing the baby to family food instead of ready-made packets is

preferred as the baby will be introduced to different tastes and textures and she/he will

be used to the tastes of the food she/he will eat when older. One of the most common

first foods for babies is rice based porridge.



10BChildren, 3 – 12 years

The food and nutrition of a young child is important, as this is the time when food

preferences and habits will be established. It is also an important period in life as it is

when a child grows and develops. Young children are often the most at risk of being

malnourished. They have very high energy and nutrient needs for their body size in

comparison to adults. Proper care and feeding is essential for their normal growth,

development and activity.

Energy requirements increase dramatically as a child grows rapidly and becomes more

active. Foods must therefore be high in energy but also rich in nutrients. A good supply

of protein, calcium, iron, vitamin A and D are also of primary importance. Childhood is

the most important time for the development of bones and teeth. Milk is therefore an

important part of the diet.

Iron is important during this phase of life. A lack of iron can cause poor weight gain,

poor development and frequent infections. Meat, liver and eggs are rich sources of iron,

and can be given to children. Iron should therefore be consumed from alternative

sources such as green vegetables and pulses. Iron absorption can be increased by

consuming vitamin C, for example, having orange juice at meal times.

It is necessary to ensure that a child’s diet is not too high in fibre as this will restrict the

absorption of other nutrients and will fill the child up so that fewer nutrient rich foods

are consumed. It is important also that the sugar and salt content is controlled.

Consumption of foods high in sugar such as drinks with added sugar can result in dental

problems. Also consumption of high caffeine foods such as coca cola and black tea

reduces iron absorption and should be avoided as much as possible.

Children cannot eat the same amount of food in one meal as adults. Active children also

spend a lot of energy and should sustain energy requirements by eating small meals and

snacks spread over the day. Children should be encouraged to exercise and stay active

in order to become healthy adults and avoid obesity.



Sick children must be encouraged to eat and drink, even if they have little appetite.

They should be offered softer textured foods. Lots of fluids, like milk, fruit juice, soups

and clean water, are especially important when a child has diarrhoea. Children

recovering from fevers and sickness should also be given plenty of energy and nutrient-

rich foods to eat as well as liquids such as juices.

The focus should be on developing healthy eating habits of children at this age. Children

can eat many of the same foods as their parents. The importance of a healthy balanced

diet should be reinforced by guiding food choices and feeding patterns and highlighting

the importance of avoiding foods that are high in fat and sugar, in favour of nutrient rich

fruit and vegetables.

11BAdolescents, 13 – 18 years

Adolescence is a period of rapid growth and development and thus, adolescents have

very high energy and nutrient needs. They need adequate intakes of vitamins and

minerals, especially iron, calcium, vitamins A, C and D. In addition, adequate amounts of

energy and protein are needed to sustain growth and development. Teenagers usually

satisfy this increased need by snacking in between meals. Teenagers should therefore

be encouraged to choose healthy snacks in order to avoid excess weight gain, which can

lead to obesity.

Special attention should be given to adolescent girls who begin menstruation and need

to be well nourished both for their immediate development and the future stresses of

childbearing. Anaemia and calcium deficiency are common problems so foods rich in

calcium and iron should be encouraged.



Further concerns for teenage girls are focused around the issues of slimming and eating

disorders. Teenage girls are likely to adopt low energy diets and habits such as smoking

in an effort to control weight. This can lead to nutrient deficiencies and problems in later

life. Adolescent girls who become pregnant are at particular risk and must have

additional nutrients for their baby’s growth as well as for their own.

Adulthood

It is important during adulthood to maintain a healthy diet that

provides adequate vitamins and minerals. Diets should be

balanced, and saturated fat, salt and sugar intakes monitored so

as not to increase the risk of becoming obese, developing heart

disease, and diabetes.

Food is the body’s fuel and consequently the more active people are the more food is

needed whereas less active people will need less food. Having a proper body weight is

important to good nutrition and can also affect the happiness and enjoyment of life.

Being underweight can lead to malnutrition.

Malnutrition often results in lack of energy, reduced ability to work and other nutritional

problems. Being very overweight (obese) is also a form of malnutrition and can lead to

serious health problems including cardio-vascular disease, diabetes and hypertension.

Overweight people often find it harder to do physical work, exercise and stay fit.

Whilst it is common that the body weight will fluctuate to a certain extent, it is advisable

to avoid extreme weight loss or weight gain. Diets that promise rapid weight loss

normally only make you loose water and as soon as you start eating normally again, the

weight gets back to what it was before you started the diet.



If you want to gain weight If you want to loose weight

Eat more of your regular foods

Eat less energy-dense foods,

especially ones high in fat

Eat more frequent meals and

snacks

Eat more foods rich in fibre, e.g.

fruit, vegetables and whole grain

products

Eat a greater variety of food

Eat regular meals; constantly going

hungry is not the answer

Make sure you are eating enough

protein and energy

Drink water before eating; it will

“fill up” your stomach so you eat

less

Increase the energy content of

your food by adding fats, oils and

sugar

Increase exercise level; be more

active in everyday life and more

vigorous exercise sessions can be

gradually introduced

Keep fairly active as exercise helps

stimulate appetite and is important

for good health

Avoid or minimise stressful

situations as worry and stress can

cause weight loss



Pregnant and Breastfeeding Mothers

Women need to eat enough before, during and after pregnancy to

deal with the extra strain that pregnancy puts on the body. When a

woman is pregnant or breastfeeding, she must meet the baby’s

nutritional needs as well as her own.

If the mother’s diet does not satisfy the needs of her body, the baby

will draw on, and reduce, the mother’s own stores of nutrients. This puts the mother at

increased risk of illness and can affect the baby’s development.

The additional needs can generally be met by eating a wide variety of foods including

fresh fruits and vegetables.

Pregnant women should be encouraged to have regular medical checks to ensure that

they are keeping themselves and the developing baby well nourished. In some cases

vitamin and mineral supplements might also be recommended, but these should be

taken only as advised by a doctor. During pregnancy the requirement for iron is

particularly high and supplements are often needed. Folic acid is another common

supplement.

The Elderly

As people begin to feel the effects of old age, illness and loss of taste and thirst

sensation can reduce appetite. Further, loss of teeth can make chewing difficult and a

variety of stomach and intestinal disorders can lead to digestive problems.

Disabilities and infirmities, coupled with poverty, loneliness and depression can make

acquiring and preparing food difficult. All older people should therefore pay attention to

their nutritional needs.



Even though most people need less energy as they get older, the elderly need adequate

amount of protein, carbohydrates, fat, vitamins, minerals and dietary fibre. Women

should have an adequate calcium intake throughout life to reduce bone loss.

Consumption of high energy foods may be particularly important if appetite falls and

overall food intake is limited. Maintaining adequate fluid intake is also important.

Clinical Nutrition

Malnutrition is a clinical diagnosis which includes several overlapping syndromes. They

are due to inadequate supply, relative to demand, of energy or essential nutrients.

Malnutrition is more common and obvious in young children than in adults, as they

require extra food for growth. They also have little control over the supplies of food

offered to them and have far smaller stores for coping with the setback of food shortage

and infection.

Protein Energy Malnutrition

First recognized in the 20th century, the full impact of protein energy malnutrition (PEM)

has been revealed only in recent decades. Infants and young children are most

susceptible to PEM’s characteristic growth impairment because of their high energy and

protein needs and their vulnerability to infection. The term protein-energy malnutrition

has replaced a group of related disorders that include marasmus, kwashiorkor, and

intermediate states of marasmus-kwashiorkor.

There are several indicators to detect PEM:

Low weight-for-height or wasting is a measure of acute malnutrition caused by a

sudden change in the diet e.g. during a serious disease.

Low height-for-age or stunting is a measure of chronic malnutrition or consistent

under-nourishment over a longer period.

Low weight-for-age or underweight is an overall measure of malnutrition.



• Protein-energy malnutrition (PEM) affects every fourth child world-wide: 150

million (26.7%) are underweight while 182 million (32.5%) are stunted

• Geographically, more than 70% of PEM children live in Asia, 26% in Africa and 4%

in Latin America and the Caribbean. Their plight may well have begun even before

birth with a malnourished mother

Varying degrees of PEM require varying treatment methods. Ideally, each child should

be examined to exclude the possibility of underlying disease, such as bacterial or viral

infections. The management of a malnourished child often also requires an improvement

in the child’s environment – family’s income, knowledge of child care and stimulating

play as well as improvements in hygiene, diet and feeding practice are all important.

These measures should be linked to a systematic community involvement in health

promotion aimed at enhancing exclusive breastfeeding, improving hygiene, increasing

rates of immunisation and organising systems for child health care, with regular weight

monitoring and help parents with family planning.

Serious cases of PEM need hospital treatment where first the child’s acute problems are

diagnosed and treated including antibiotic therapy, maintenance feeds and supplements.

The second stage ‘high-quality’ feeds are offered in increasing amounts to permit rapid

catch-up growth. In the last stage, the child is weaned to home feeds.

Obesity

Obesity has been identified as one of the most important public health problems of our

time. No single disease accounts for all the excess mortality among obese people, but

cardiovascular disease is the main cause of increased mortality. The mortality from

coronary heart disease, congestive heart failure, stroke and hypertension all increase

with age, but within any age group the mortality among obese individuals is greater

than among lean ones. Obesity is an important risk factor for gallstone formation.



Obese men have an increased risk of cancers of the colon, rectum and prostate,

whereas in women the increased risk involves the breast, ovary, endometrium and

cervix. Other penalties of obesity include osteoarthritis of the weight-bearing joints

(especially back, hips and knees) and social discrimination. All of these penalties

decrease with weight loss, with the exception of the risk of gallstone formation.

One way to measure desirable range of weight for height for adults is to calculate the

Body Mass Index (BMI). The index is calculated by dividing the individual’s weight (in

kg) by the square of his or her height (in metres). Thus a person who weighs 55 kg and

who is 1.60 m tall would have a BMI of U55/(1.60 x 1.60) = 21.5U, which is in the

desirable range.

Body Mass Index kg/(m2)

>40 obese, class III

35-40 obese, class II

30-35 obese, class I

25-30 overweight

18.5-25 normal/desirable

16.5-18.5 moderately underweight

<16.5 severely underweight

The best strategy to treat obesity depends on the ability, inclination and degrees of

obesity of the subject. Some factors which influence appropriate advice are:

1. Age and BMI of person.

2. Person’s target weight and expected benefits from weight loss.

3. Previous attempts at weight loss.

4. Domestic circumstances.

5. Other diseases and medication.

Appropriate rate of weight loss also depends on the age and grade of obesity. For the

first month of dieting the rate of weight loss is more rapid due to loss of water. The



optimum rate of weight loss is 0.5-1.0 kg per week which corresponds to an average

energy deficit of 500-1000 kcal (2-4 MJ) per day.

The disadvantage of losing more are that there may be excessive loss of lean tissue, it

becomes difficult to provide the essential nutrients in such a restricted diet, it is

unnecessary unpleasant, and that there will have to be large adjustments when the

target weight is achieved to find a suitable weight-maintenance diet.

Diabetes

There are several types of diabetes, all characterised by a failure to maintain the

concentration of blood glucose within the normal range.

Type I diabetes mellitus or insulin dependent diabetes mellitus (IDDM) presents with

acute symptoms induced by a high blood glucose. The classic symptoms of IDDM are

thirst and weight loss. The patient becomes dehydrated because of water loss as water

is excreted with glucose by the kidneys.

The patient may appear very ill, dehydrated and unconscious with a sweet breath of

acetone being excreted via the lungs. Rehydration, electrolyte replacement and insulin

therapy is required. In such patients’ education with regard to insulin therapy, diet and

modification of lifestyle are the major considerations.

Type II diabetes or non insulin dependent diabetes mellitus (NIDDM) is characterised by

the development of progressive insulin resistance. About 2-3% of the population has

type II diabetes, but the rate is increasing as adults become more overweight and live

longer. The risk of developing diabetes in adults with a body mass index (BMI) >30 is

five times that of adults with a BMI <25. The cause of type II diabetes is unclear, but

involves both an impaired secretion of insulin by the liver and the development of tissue

resistance to insulin. Frequent urination and thirst are early symptoms of diabetes.



Blindness and kidney failure are particular problems in the long-term management of

type I diabetes whereas cardiovascular disease including coronary heart disease and a

severe form of atherosclerosis are seen in both types.

Dietary Management of Type I Diabetes

Education is the cornerstone of modern diabetic management. People with diabetes

need to be taught the practical skills of insulin administration and blood testing and have

the knowledge to deal with different day-to-day situations and activities. Normal weight

individuals have to receive daily injections of insulin, but the amount required depends

on several factors.

Dietary Management of Type II Diabetes

The education and management of people with NIDDM depends on their individual

needs. The aim is to relieve the symptoms of diabetes and to minimise its impact on

diseases caused by diabetes. First, dietary methods are used to reduce weight and the

intake of quickly absorbed carbohydrates. If dietary measures fail to control blood

glucose levels, drug therapy is prescribed in addition to diet.

Diseases of the Heart and Circulation

Diseases of the circulatory system account for a great number of total morbidity and

mortality in adults throughout the world. The basic pathology underlying coronary heart

disease is the plaque, which is a build-up of fatty deposits within the wall of an artery

that narrows the artery thus reducing blood flow. Two major clinical conditions are

associated with these processes: angina pectoris is characterised by pain and discomfort

in the chest which is brought on by exertion or stress, and which may also radiate down

the left arm and to the neck.

It results from a reduction or temporary block to the blood flow through the coronary

artery to the heart. The pain usually passes with rest and seldom lasts for more than 15



minutes. A coronary thrombosis or heart infarction results from prolonged total

obstruction of the artery, which causes infarction or death of some of the heart muscle

and is associated with prolonged and usually excruciating central chest pain.

There is no single cause of coronary heart disease but a number of risk factors including

lifestyle, behaviour, physical and chemical characteristics influence the likelihood of

developing coronary heart disease. High cholesterol and triglycerides levels,

hypertension, type II diabetes, obesity and low birth weight may increase the risk of

coronary heart disease.

Nutritional recommendations for high-risk populations include reduction in saturated

fatty acids found in butter, margarine, full-fat milk, cheese and red meat. Further,

increase in fibre, fruits and vegetables intake.

Iodine Deficiency Disorders

The importance of iodine arises from the fact that it is a constituent of the thyroid

hormones which are essential for normal growth and physical and mental development

in humans and animals.

The most familiar iodine deficiency is goitre – swelling of the thyroid gland in the neck.

However, the understanding of iodine deficiency now concerns all effects of deficiency

on growth and development and is denoted iodine deficiency disorders (IDD). Severe

iodine deficiency leads to severe retardation of growth and maturation of almost all

organ systems. Body weight does not increase and there is retardation of bone growth.

The brain is especially susceptible to damage during the foetal and early postnatal

period.

Marine fish and shellfish are the best sources of iodine in nature. Eggs, milk and meat

also contain iodine whereas plant foods are likely to have reduced iodine content in



iodine deficient soils. Cooking reduces the iodine content of foods with over half of the

iodine escaping during boiling.

Iodisation of salt has been the most common way of correcting IDD and it has proven to

be successful in many countries. However, there is still the problem of distribution and

the iodine content will fall if the salt is left uncovered or exposed to heat. Iodised oil

either by injection or orally is also being used in areas where IDD is considered a major

public health problem.

Iron Deficiency – Anaemia

Iron deficiency is the most common nutritional deficiency in the world today. The World

Health Organization estimates that as many as 4-5 billion, 66-80% of the world’s

population, may be iron deficient. About 2 billion people are anaemic, mainly due to iron

deficiency, and in developing countries, frequently exacerbated by malaria and worm

infestations. Symptoms of iron deficiency are lack of energy, tiring easily, shortness of

breath, palpitations, headache, weakness, dizziness and irritability. Other symptoms are

sore mouth and tongue, sensation of a lump in the throat with difficulty of swallowing,

nails breaking easily and eating of materials such as ice, clay, paper, dirt etc. occurs

particularly in children.

The most common indicator for iron deficiency is haemoglobin below the level that is

normal in that individual and, in time, below 13 g/dl in men and 12 g/dl in women.

Other indicators are the size of red cells, mean corpuscular haemoglobin, serum iron

level and serum ferritin level. A firm diagnosis of iron deficiency requires a blood count

testing for the indicators mentioned above.

To establish that iron deficiency is due to nutritional deficiency requires an assessment

of the subject’s diet and the exclusion of blood loss. Foods rich in iron are meat and

meat products, cereals, vegetables, beans and fruits.



Treatment of iron deficiency is usually done by oral iron salts, like ferrous sulphate.

Dietary treatment is desirable but economic, traditional or religious situations may make

this difficult.

Anaemia with small red blood cells also occurs in thalassaemia syndromes and in the

anaemia of chronic disorders. These are different from iron-deficiency anaemia.

Thalassaemia is a heterogeneous group of disorders of haemoglobin synthesis.

Eating Disorders

Eating disorders are a complex combination of physical and psychological aspects of

shape and weight and are usually divided into anorexia nervosa and bulimia nervosa.

Anorexia Nervosa

Anorexia nervosa is a state in which the sufferer, usually female, refuses to eat enough

to maintain normal body weight for height. Usually she claims to want to lose weight to

be slimmer; sometimes she says that she does not feel hungry or that it is

uncomfortable to eat. The current definition of anorexia nervosa has four criteria:

1. Refusal to maintain body weight over a minimal normal weight for age and

height

2. An intense fear of gaining weight or becoming fat, even though underweight

3. A disturbance in the way one’s body weight, size or shape is experienced

4. In females, absence of at least three consecutive menstrual cycles when

otherwise expected to occur

All anorexics refuse food and count calories and many eat as little as 200-300 calories

per day. They may also take strenuous exercise and take an immense interest in

cookery and cooking for other people, although they will avoid eating the food they cook

themselves.



The disorder takes a physical toll on sufferers in that they may have dry skin, excessive

growth of dry brittle hair over the nape of the neck, cheeks, forearms and thighs. They

often have cold hands and feet. They can develop cardiac abnormalities and suffer from

constipation. Long-term absence of menstruation may lead to premature bone loss and

place sufferers at risk of osteoporosis later in life.

Bulimia Nervosa

Bulimia nervosa patients have powerful urges to overeat, which they alternate with

periods of starving themselves. Like anorexics, they have a ‘morbid fear’ of fatness and

some develop the habit of vomiting or purging in order to control their weight. There are

five main criteria:

1. Recurrent episodes of binge eating

2. Experience of lack of control over the binges

3. Attempts to prevent weight gain by the regular use of self-induced vomiting,

laxatives, diuretics, or strict dieting or fasting, or by vigorous exercise

4. A minimum average of two binge-eating episodes per week for at least 3 months

5. Persistent concern over body shape and weight

Typically, bulimics start the day by eating nothing or very little, then possibly are ‘good’

at lunchtime with a yoghurt or fruit, after which eating may escalate to include several

meals or several items of food, typically high in calories, fat and carbohydrates. Bulimics

usually eat in private, hiding the problem from other people. Often they do not eat

normal meals, and have difficulty in experiencing hunger or knowing when they have

reached ‘fullness’ at the end of a meal. After an eating binge they will experience

extreme guilt and desolation. Days of binge-eating may alternate with several days of

strict dieting or starving.

Like anorexia nervosa, bulimia nervosa can take its toll physically on the health of the

sufferer. Some experience amenorrhoea, oedema and possible kidney dysfunctions. The

vomiting results in symptoms of muscle weakness, constipation and headache.



Palpitations, abdominal pains, easy fatigue, sore throat and swollen salivary glands are

other symptoms. The disorder leads to a predisposition to cardiac arrhythmias. Many

bulimics have dental problems.

Treatment of eating disorders normally includes hospitalisation, drug treatments and

psychological treatment. Given that it is extremely difficult to persuade a determined

anorexic to put on weight in hospital, many programmes have adopted a behaviour

modification approach with close follow up by a psychological consultation. Family

therapy and attitude change are also common in treatment programmes of sufferers of

eating disorders.

Food Safety

Five keys to safer food:

Keep clean

Wash your hands before handling food and often during food preparation

Wash your hands after going to the toilet

Wash and sanitise all surfaces and equipment used for food preparation

Protect kitchen areas and food from insects, pests and other animals

Why?

While most micro-organisms do not cause disease, dangerous micro-organisms are

widely found in soil, water, animals and people. These micro-organisms are carried

on hands, wiping cloths and utensils, especially cutting boards and the slightest

contact can transfer them to food and cause food borne diseases.

Separate raw and cooked

Separate raw meat, poultry and seafood from other foods

Use separate equipment and utensils such as knives and cutting boards for

handling raw foods

Store food in containers to avoid contact between raw and prepared foods



Why?

Raw food, especially meat, poultry and seafood, and their juices, can contain

dangerous micro-organisms which may be transferred onto other foods during food

preparation and storage.

Cook thoroughly

Cook food thoroughly, especially meat, poultry, eggs and seafood

Bring foods like soups and stews to boiling to make sure that they have reached

70°C. For meat and poultry, make sure that juices are clear, not pink. Ideally,

use a thermometer.

Reheat cooked food thoroughly

Why?

Proper cooking kills almost all dangerous micro-organisms. Studies have shown that

cooking food to a temperature of 70°C can help ensure it is safe for consumption.

Foods that require special attention include minced meats, rolled roasts, large joints

of meat and whole poultry.

Keep food at safe temperatures

Do not leave cooked food at room temperature for more than 2 hours

Refrigerate promptly all cooked and perishable food (preferably below 5°C)

Keep cooked food piping hot (more than 60°C) prior to serving

Do not store food too long even in the refrigerator

Do not thaw frozen food at room temperature. Thaw the food in the refrigerator

Do not re-freeze food once it is thawed.

Why?

Micro-organisms can multiply very quickly if food is stored at room temperature. By

holding at temperatures below 5°C or above 60°C, the growth of micro-organisms is

slowed down or stopped. Some dangerous micro-organisms still grow below 5°C.

Use safe water and raw materials



Use safe water or treat it to make it safe

Select fresh and wholesome foods

Choose foods processed for safety, such as pasteurised milk

Wash fruits and vegetables, especially if eaten raw

Do not use food beyond its expiry date

Why?

Raw materials, including water and ice, may be contaminated with dangerous micro-

organisms and chemicals. Toxic chemicals may be formed in damaged and mouldy

foods. Care in selection of raw materials and simple measures such as washing and

peeling may reduce the risk.

PART 3 USING YOUR KNOWLEDGE

This part of the guide is designed to help you use the knowledge you have gained from

the previous section, in order to communicate and educate others about health and

nutrition.

It contains ideas for activities to do with different groups of children and ways in which

you can hold workshops and sessions to educate people about health and nutrition.

The previous section provides you with all the information and knowledge you require to

successfully teach others about health and nutrition, and as an individual who works

within the field of health or education for children you have the responsibility to pass on

what you know to your colleagues, peers, family and friends.

Use your knowledge and help make a difference!

Activity Ideas for Children

14BGrades 1-3



Healthy foods

Healthy food collages using rice, pasta, beans

Give each child in the class a different type of

food packaging, then with the help of the

students split them into two groups – food that is

good for us and food that is bad for us. Why is it

good or bad? Discuss reasons with the group

Food necklaces. Have a selection of healthy food

shapes cut out of paper or card, with a hole

through the middle. Give each child a piece of

string and allow them to make their own healthy

necklace.

Painting with vegetables. Use potatoes, carrots

and any vegetable or fruit that can be used to

print. Cut out shapes, dip them in paint and use

them to create pictures.

Our favourite foods. Ask each member of the

class what their favourite food is and plot the

results on a display graph for the children to see.

What is the most popular food in the class?

What is the healthiest food? How many children

prefer the healthy food?

Class Activities

Fruit tree. Have a large tree shape cut out from

paper displayed on the wall. Next to the tree



have a number of apple shapes cut out in paper.

Each time a child eats an apple, banana, mango

or other fruit allow the child to write their name

on a shape and pin/tac the shape to the tree. At

the end of the week see who has eaten the most

fruit and award them a prize.

Fishing game. Using food shapes made out of

card/paper. Attach paperclips to the shapes and

place them on the floor. Give each child a fishing

rod made out of sticks with string on the end. At

the end of each piece of string attach a magnet.

The aim of the game is to fish for food. Time the

game for a few minutes. The children must then

separate the foods they have caught into good

and bad foods. The child with the most good

foods wins!

Healthy party. Hold a class healthy party. Each

child must bring something that is healthy to eat

to share with class members. Talk about why

each food is healthy and enjoy the fun!

Growing grass. Each child requires one foot of an

old pair of tights, marker pens, grass seed, sand,

water and a pot. First place the grass seed in the

tight and then fill with sand to make a round

head shape. Using markers give the head a face.

Stand the head in a pot and water well. Water

daily and watch the hair grow. Talk to the



children about growing plants. What could they

grow that they can eat?

Nutrition Olympics. An outdoor athletic event that

reinforces eating five fruits and vegetables a day.

Children complete five activities each with a

different fruit or vegetable at the centre of the

activity.

1. Coconut bowling (children bowl with coconuts)

2. Papaya weight lifting (two papayas at the end of a

stick/branch form the weights)

3. Mango relay (relay with mango instead of baton)

4. Apple throw (throw apple up and catch as many times as

possible)

5. Potato sack race (stand inside sack and jump the race)

Finally the last event is the Food Pyramid

challenge where children have to assemble the

food pyramid in the shortest time possible from

the packets and food displayed on the table.



Grades 4-6

Games

Unscramble words game

Word search

Crosswords



What am I? Game involving children in pairs. One child has a piece of paper with

the name of a healthy food put on their backs. The child has to guess what they

are by asking their partner a series of questions. For example:

Q. Do I grow on a tree? A. Yes

Q. Do I grow in Maldives? A. Yes

Q. Am I green in colour? A. No

Q. Am I round? A. No

Q. Am I orange? A. Yes

Q. Am I a mango? A. Yes

Bingo. Have sheets with foods listed on them. Call out random foods from the

sheets. The first person to have five healthy foods is the winner. Bingo!

Fun Stuff!

Poem writing. Write a poem about your favourite healthy food. Why is it healthy

and good for you?

Food Pyramids. Create your own food pyramid using foods (i.e. rice, pasta,

beans) and packaging from food.

Create a class cookbook. Each child brings in their favourite recipe from home.

On each page of the book for each recipe include what is healthy and what is

unhealthy about that dish.

Eating diary. Complete an eating diary for one/two days. Compare the diaries

with friends. Create a chart with three categories: Good food I ate, bad food I

ate, foods I avoided. Graph the results and compare what they have eaten as a

class with the food pyramid. How healthy are they? How can they be healthier?

What changes do they need to make to their diets?



15BGrades 7+

Health and Nutrition

Collect magazine articles about health and nutrition. Group the class and give

each group a different article. Is it correct in what it claims? Discuss the article as

a group and report back to the class. Is the information correct? What messages

does it portray? Who is it aimed at? Is it successful? As an extension activity

children can design and create their own magazine/paper articles.

Make posters about health and nutrition.

Exploring the long term negative health aspects of some foods. Give each group

a different unhealthy food. Ask them to discuss and come up with a number of

problems that can result from long term consumption. Create and perform a

short play/drama based on these problems and their consequences. Focus on

diet related diseases such as stroke, heart disease, diabetes, and osteoporosis.

One week exercise plan. Plan an exercise regime for one week. Discuss the

benefits of exercise. How do you feel after exercise? Do you notice any

difference as the week progresses?

The Body

Body Picture. Have a life sized picture of the body on the wall. What do we need

for different functions? Have the names of vitamins and minerals written on

pieces of card. Stick them where they are needed, for example, vitamin A at the

eyes and on the skin.



Group Tasks

Group children. Give them a scenario. Someone is ill and suffering from a diet

related disease. Give the children the full details of this person, i.e. their name,

age, date of birth, occupation, family, habits (smoker/exercise etc). The task for

the group is to construct a diet and exercise plan for the patient. What must they

eat more of and why? How will this help? An extension exercise is to perform a

short role play/drama to display their knowledge on the subject. How can the

patients help themselves?

Timeline Challenge. Construct a timeline which shows the relationship between

the health issues of adults and the eating habits of children

Eat Smart Hotaas! The children are the new recruited task force to improve the

health and nutritional status of locals in their area. Their guidelines are to design

and develop signs for local tea shops/restaurants and shops that are healthy in

terms of nutrition, food safety and hygiene.

Children must create a checklist of points and then visit local teashops and have

a forum to decide which tea shops/restaurants will be awarded the award. This

could also be conducted in school canteens. Children must think about what

makes a teashop healthier than another? Is it clean and hygienic? Why? How?

For those that do not receive the award, design and distribute a leaflet

explaining how they can be made healthier, more nutritious and more aware of

food safety.



Ideas for Schools

Select one day a week to be a fizz free day where no fizzy drinks are allowed to

be brought to or consumed in schools.

Fizz free schools. Promote the consumption of healthy drinking by only selling

juice, un-carbonated soft drinks, milk and water.

Start breakfast clubs in schools. Encourage children to bring breakfast with them

to school and allow a ‘breakfast break’ during the morning at approximately 8

o’clock to allow children to have breakfast before their lessons continue. Children

are required to bring to school roshi, mashuni, or sandwiches for breakfast

together with water, milk or juice to drink.

Parents Day. Parents are invited to come to school with children without

breakfast and experience a day in the lives of their children. The aim being to

make parents/guardians aware of a day in school and how children cope with the

school day on an empty stomach, what they eat, and how this affects their

health and academic ability.

How to Plan and Hold a Workshop

Follow these simple guidelines to plan an effective workshop:

Know your target audience

Have an understanding of the level of the group’s knowledge. It is unrealistic to hold a detailed workshop for young children who do not have a strong knowledge of the subject

Set realistic aims and objectives

Set targets and expected outcomes

Plan your workshop in detail



Ensure your workshop has a structure

Try to use a variety of methods, for example, interactive activities as well as lectures

Always start by introducing yourself and the topic

Have an icebreaker at the start to help the group relax and get to know each other

Use ideas from workshops that you have attended

Always spend time at the end of the workshop evaluating the success with the group

Use the feedback to write a report on the workshop giving details of what activities were successful and those, which were not.

Use this report for future reference

APPENDICES

i. Daily energy and nutrient needs

ii. Nutrients

iii. Vitamins

iv. Minerals

v. Food pyramid

vi. The five food groups

vii. 8 Guidelines to a healthy diet

viii. Workshop plan

ix. Simple meal plan – for use in workshops

x. Case studies – for use in workshops

xi. Website wonders

xii. Cartoon characters – aids to health promotion





Nutrients Sources Carbohydrates Rice, maize, wheat and

other cereals

Root crops Legumes Roshi, bread and rolls

Fruits and vegetables Soft drinks, drinks with

much sugar like jelly juice, cakes and chocolates

All types, but brown varieties are better than white as they are whole-grain and therefore more nutritious

Potatoes, yam and cassava Such as peas and beans All types but brown,

wholegrain varieties are healthier as they contain more fibre

Contain fibre and natural sugar providing long term energy

Supply immediate short-term energy release but no other nutrients

Fats Oils

Meat and meat products Butter, margarine Milk products Fish

Nuts

Seeds Soya beans Popadoms Chocolate, crisps

Sunflower, vegetable and olive oil

Chicken, beef, and mutton Milk, cheese and yoghurt Oily fish such as fresh

tuna, swordfish, baitfish, sardines, mackerel

All types, particularly coconut Especially sesame seeds and

groundnuts

Protein Fish Meat Dhal curries

Beans Eggs Dairy

All types All types Chick peas have a higher

protein content but lentils are also good

Milk, cheese, yogurt



Simple Sugars (monosaccharides) (disaccharides)

Starch Dietary Fibre

Glucose Sucrose Glycogen Cellulose

Fructose Lactose Pectin

Galactose Maltose Hemicellulose


73

Table 1: Fat soluble vitamins

Vitamin Main functions Sources Deficiency Excess

A Essential for vision especially in dim light. Needed for healthy skin and growth.

As retinol in milk, fortified margarine, butter, cheese, egg yolk, liver and fatty fish. As carotenes in milk, carrots, tomatoes, dark green vegetables.

Reduced night vision; loss of sight through gradual damage to the eyes. Lowered resistance to infection.

Vitamin A is stored in the liver and when an excess is consumed toxicity can occur.

D Promotes calcium and phosphate absorption from food and is essential for bones and teeth.

Sunshine, fortified margarine, oily fish, egg yolk, fortified breakfast cereals.

Failure of bones to grow and calcify leading to rickets in children and osteomalacia in adults.

Vitamin D can be toxic.

E Protects cell membranes.

Vegetable oils, nuts, vegetables and cereals.

Deficiency may occur in premature infants or due to malabsorption.

Not known.

K Essential for blood clotting.

Made by bacteria in the gut. Dark green leafy vegetables, e.g. cabbage and spinach.

Deficiency leads to an increased clotting time.

Not known.



Table 2: Water soluble vitamins

Vitamin Main Functions Sources Deficiency Excess

Ascorbic acid (vitamin C)

Involved in the production of connective tissue and bone. Aids wound healing and iron absorption.

Fresh fruits especially citrus fruits and green vegetables. Also found in potatoes.

Scurvy. Poor wound healing and bleeding gums.

May lead to kidney stones.

Thiamine Involved in the release of energy from carbohydrate. It is important for the brain and nerves, which use glucose for their energy needs.

Cereals, nuts and pulses are rich sources. Green vegetables, and fruits and fortified cereals contain thiamine.

Deficiency leads to beriberi. The body excretes excess thiamine.

Riboflavin Involved in energy release, especially from fat and protein.

Rich sources are liver, milk, cheese, yogurt, eggs, green vegetables and yeast extract, and fortified cereals.

Deficiency includes changes to the mucous membrane and skin around the mouth and nose.

The body excretes excess riboflavin.

Niacin Involved in the Rich sources include liver, Deficiency leads to pellagra. High doses cause dilation of



release of energy.

beef, mutton and fish. Most breakfast cereals are fortified.

arteries and reduction of blood lipids. Excess can cause kidney damage.

B12 Necessary for the proper formation of blood cells and nerve fibres.

Rich sources are offal and meat. Eggs and milk also contain B12. Almost no plant foods contain B12. Fortified breakfast cereals are a useful source.

Deficiency leads to pernicious anaemia.

No toxic effects known.

Folate Involved in the formation of blood cells. Reduces the risk of birth defects in babies.

Liver, (and orange juice, dark green vegetables) are rich sources.

Deficiency leads to megaloblastic anaemia.

No known toxic effects.

Source: HUwww.nutrition.org.ukUH

http://www.nutrition.org.uk/


76

Table 1: Major Minerals

Mineral Main Function Main Sources Deficiency Excess

Calcium Formation and maintenance of bones and teeth.

Blood clotting and nerve functions.

Milk, cheese, yogurt and canned fish are rich sources. Also dark green leafy vegetables.

Bone weakening- rickets and osteomalacia. Linked to vitamin D deficiency.

Not known in adults.

Sodium Regulation of body water content. Nerve functions.

Salt - either added to foods during processing or at home in cooking or at the table.

Fatigue, nausea, cramps. Thirst is experienced.

Excess sodium has been linked to high blood pressure.

Potassium Functioning of cells. Part of body fluids.

All foods except sugars, fats and oils.

Weakness, mental confusion and, if extreme, heart failure.

Excess is dangerous.

Magnesium Involved in energy transfer in the cell, in enzyme activity and muscle functioning.

Widespread but wholegrain cereals, nuts and spinach are good sources.

Depression, irritability, fits, tiredness and, if extreme, heart attack.

Excess magnesium is not absorbed.

Phosphorus An essential component of all cells and present in bones and teeth.

Milk, cheese, meat, fish and eggs are good sources.

Dietary deficiency unknown.

Not known in adults.



Table 2: Trace Minerals

Mineral Main Function Main Sources Deficiency Excess

Iron Formation of haemoglobin in red blood cells.

Red meat and offal are rich sources. Cereals, bread, and vegetables contain some iron. Breakfast cereals may be fortified.

Iron deficiency anaemia. Excessive absorption may be due to a rare genetic disorder.

Zinc Essential for growth, and sexual maturation. Involved in enzyme activity and taste.

Milk, cheese, meat, eggs and fish, wholegrain cereals and pulses.

Dietary deficiency is rare; may cause delayed puberty and retarded growth.

Interferes with copper metabolism.

Iodine Formation of thyroid hormones.

Milk, seafood, seaweed. Iodised foods such as salt.

Goitre and cretinism. Excess iodine is not absorbed.

Fluoride Increases the resistance of teeth to decay.

Fluoridated water, tea, fish and toothpaste.

Tooth decay more likely. Fluorosis.

Copper Forms part of many enzymes and needed for iron to function.

Green vegetables, fish and liver

Rare Not known

Chromium Involved in the action of insulin, controlling glucose levels of the blood

Found in a variety of foods Not known Not known



Selenium As an antioxidant it protects cell membranes.

Cereals, meat, fish, offal, cheese and eggs.

Keshan disease (a type of heart disease).

Excess selenium is toxic.

Source: HUwww.nutrition.org.ukUH



79

The Food Pyramid



1BThe Five Food Groups

Bread, cereals and

potatoes Fruit and

vegetables Milk and dairy

foods Meat, fish and alternatives

Foods containing fat and/or sugar

What’s included

Breakfast cereals, pasta, rice, oats, noodles, maize, millet and cornmeal.

Fresh, frozen and canned fruit and vegetables and dried fruit. A glass of fruit juice can also contribute.

Beans and pulses can be eaten as part of this group.

Milk, cheese, yogurt.

This group does not include butter, eggs and cream.

Meat, poultry, fish, eggs, nuts, beans and pulses.

Meat includes meat products such as beef burgers. These are all relatively high fat choices. Beans, such as canned baked beans, and pulses are in this group.

Fish includes reef and tuna fish, frozen and canned fish such as tuna.

Foods containing fat: margarine, butter, other spreading fats and low fat spreads, cooking oils, mayonnaise, cream, chocolate, crisps, chips, biscuits, pastries, cake, puddings, ice-cream, rich sauces and gravies.

Foods containing sugar: Soft drinks, sweets, jam and sugar as well as foods such as cake, puddings, biscuits, pastries and ice-cream.

Main nutrients

Carbohydrate (starch)

Fibre

Some calcium and iron

B vitamins

Vitamin C

Carotenes

Folic Acid

Fibre and some carbohydrate

Calcium

Protein

Vitamin B12

Vitamins A and D

Iron

Protein

B Vitamins, especially B12

Zinc

Magnesium

Fat, including some essential fatty acids. Carbohydrate (sugar). Some products also provide other nutrients e.g. fat soluble vitamins and some contain salt.

Recommendations Eat lots Eat lots

Eat or drink moderate amounts and choose low fat versions whenever you can.

Eat moderate amounts and choose low fat versions whenever you can.

Eat foods containing fat sparingly and look out for the low fat alternatives.

Foods containing sugar should not be eaten too often, as they can contribute to tooth decay.

Source: www.nutrition.org.uk



U8 GUIDELINES TO A HEALTHY DIET

Enjoy your food Eat a variety of different

foods Eat plenty of foods rich in

starch and fibre Eat plenty of fruit and

vegetables Don’t eat too many foods

that contain a lot of fat Don’t have sugary foods

and drinks too often Eat the right amount to be

a healthy weight Exercise regularly

Taken from: HUwww.food.gov.ukUH

http://www.food.gov.uk/


82

2BWORKSHOP PLAN

3BActivity

Length of session Specific tasks Your role Target

Introduction 15 minutes Introduce yourself

to the group

Introduce the topic

Explain the plan of

the day i.e. what

you will do, how it will work etc

Explain the aims

of the day

To ensure that all

members

understand the aims and

objectives of the day and what they

will be doing To introduce

yourself

Ice breaker 15 minutes Introduce and

oversee an activity that integrates all

members of the group

To introduce all

members of the group to each

other To relax those

attending

To create a relaxed

pleasant atmosphere

Morning session

Introducing Nutrition

To educate the

group about health

and nutrition



Nutrition Basics 30 minutes Using the food pyramid as

a guide, split the group into 5 groups each representing

a different food group. Ask

the group to discuss what nutrients that food group

contains. Circulate around the groups and give advice

where necessary. Get the groups to report back to

the rest of the group.

To give an

overview of basic

nutrition

To establish a level

of knowledge

among the group that is sufficient to

use to educate

others

A Healthy Diet 30 minutes A healthy diet should contain all food groups in

the proportions

demonstrated in the food pyramid. Split the group

into 2 groups and give each a case study, stating the

diet of an individual. The groups must assess the

diets and make suggestions

as to how the diet could be improved. What is healthy

about the diet? What needs improvements? What may

the consequences be if

unhealthy habits are continued? What are the

individuals needs?

To explain a

balanced diet, and clarify how it

varies between

individuals

Balanced Meals 30 minutes Show using plate

presentations how different

groups of people need different proportions of

foods. Explain the reasons for differences.

To establish what

healthy meals are,

how they differ for

different people



Lifestyles 30 minutes Relate nutrition to lifestyle.

Smoking, activity levels, and state of health all affect

nutrition and requirements.

Explain nutrition in

relation to

lifestyles and how different factors

affect each other

Afternoon session Educating Others

To show how

working together can make small yet

significant changes to the lives of

others and their

health. To emphasis how

simple activities

can be used to educate using key

ideas.

To come up with

innovative ideas for tackling

nutrition and health issues

To encourage

members to have the confidence to

plan and conduct

simple workshops and education

based sessions using their

knowledge

Young children 30 minutes Choose an activity from the guide and allow the group

to play the game/do the activity. Spend 5 minutes

after the activity assessing

how useful it was. How is it best used? What situation

would it be most relevant to? What did they learn

from the activity?

Adolescence 30 minutes Brainstorm activity. Split the group into 2 groups and

ask each group to come up with issues that are of

concern with teenagers.

Ask them to think back to there own experiences.

After discussing issues that are of concern during

adolescence, ask each group to come up with 3

ways in which these issues

could be tackled with the children.



Adults 30 minutes Opinions and habits are

hard to change in adults. However, focus on

educating them and

offering alternatives to what they already do. Ask

each member to write down a recipe that they use

regularly. Then work in pairs. Swap recipes and

make recommendations on

how that can be improved and made more nutritious.

To let the group

establish and

understand how habits can be

changed by simple

changes.

Planning and conducting

workshops

30 minutes Split the group into smaller

groups and give each group an age range and a topic.

The groups must then come up with a simple 20

minute session, complete with aims and objectives

and expected outcomes.

Share ideas with the other groups, discussing good

and bad points about each one.

To encourage the

group to assess

ways in which they can easily educate

others

Final Activity 30 minutes Ask the members to get

into small groups and discuss what they have

learnt and achieved from attending the day.

In what ways can they use

their knowledge?

To allow members

of the group to

assess what they have learnt and

achieved.

To prepare to

conclude the

session



Conclusion 15 minutes Discussion with the group,

recapping on what has been learnt during the day.

Assess the day’s activities, what was enjoyed and

successful? What requires improvement?

To finalise the

topics covered

during the day To tackle any

questions and

queries

To ensure all

members leave on

a positive note To recap on the

days activities,

what has been learnt

Assess the day in

terms of its

strengths and weaknesses

To cover any

questions that the group may have

**This plan is based on a session for school health assistants/teachers.


87

Simple Meal Plan

4BUMealU UChangesU UGeneral Advice

Breakfast Try to eat food low in fat and

high in carbohydrates

Cereals with milk

Toast

Yogurt and fruit

Boiled egg and toast/bread

Mashuni, roshi, black tea Drink milk, juice or water instead of tea

Fish curry, roshi, black tea Drink milk, juice or water instead of tea

Omelette and bread, black tea Drink milk juice or milk tea instead of black tea

Add ingredients such as tomato, and cheese to omelettes to make them more nutritious

Tea Choose short eats which are

not fried

Go for a portion of fruit

instead Crackers

Sandwich

Short eats, black tea Try fruit instead of short eats

Lunch Add vegetables to curry to

increase the nutrition content Have fruit as a desert

Curry and rice, black tea Drink water or juice with meal

Noodles Add chicken, tuna and vegetables to noodles

Tea Choose short eats which are

not fried Go for a portion of fruit

instead

Crackers

Sandwich

Short eats, black tea Try fruit instead of short eats

Dinner Try having additional

vegetable dishes i.e. boiled

carrots, potato, cabbage Try new meals such as dhal

curries, salads, pasta and

potato and vegetable dishes.

Curry and rice, black tea Drink water or juice instead of black tea

Make salads from leaves to add vitamins and minerals

Noodles Add chicken, tuna and vegetables to noodles


88

5BCase Study 1

Hassan Yasir is 10 years old. He was born with a birth weight of 2.3 kg. He was

breastfed until the age of 4 months exclusively and then weaned quickly onto

foods such as crackers and fruits. His mother stopped breastfeeding Hassan at

the age of 6 months, after which water and juice became typical daily fluids.

A typical day’s meal for Hassan is:

Breakfast A cup of Milo

Interval Coke and biscuits

Lunch Rice and Rihaakuru

Afternoon Tea Black tea and short-eats

Dinner Curry and rice

What improvements can be made to Hassan’s diet?

What food groups are included in his daily diet?

What may the consequences be if Hassan’s eating habits do not change?



6BCase Study 2 Aminath Ali is a busy working woman. She is 27 years old. She is married with

one child aged 7 months who she is breastfeeding at least twice a day. Aminath

works between 7.30 am and 2.30 pm every day and sometimes at the weekends

also. She also goes running twice a week. Aminath prepares meals for her

family.

A typical days meals for Aminath are:

Breakfast Not eaten

Tea Black sweet tea and shorteats

Lunch Curry and rice, water

Afternoon Tea Black sweet tea and shorteats

Dinner Noodles, water

What improvements can be made to Aminath’s diet?

What food groups are included in her daily diet?

What may the consequences be if Aminath’s eating habits do not change?



7BWebsite Wonders

Check out the following websites for help, advice and information:

HUwww.nutritionexplorations.orgU

HUwww.wiredforhealth.gov.ukU

HUwww.nutrition.org.ukU

HUwww.navigator.tufts.edu/UH

HUwww.kidfood.orgU

HUwww.healthyfridge.orgU

HUwww.dole5aday.comU

HUwww.ific.orgU

HUwww.kidshealth.orgU

HUwww.nlm.nih.gov/medlineplusU

HUwww.education-world.comU

HUwww.betterhealth.vic.gov.auU

HUwww.anyvitamins.comU

HUwww.milk.co.ukU

HUwww.breakfastforlearning.ca/english/resourcesU

HUwww.breakfast-club.co.ukU

HUwww.welltown.gov.ukU

HUwww.galaxy-h.gov.ukU

HUwww.lifebytes.gov.ukU

HUwww.mindbodysoul.gov.ukU

http://www.nutritionexplorations.org/

http://www.wiredforhealth.gov.uk/


http://www.navigator.tufts.edu/

http://www.kidfood.org/

http://www.healthyfridge.org/

http://www.dole5aday.com/

http://www.ific.org/

http://www.kidshealth.org/

http://www.nlm.nih.gov/medlineplus

http://www.education-world.com/

http://www.betterhealth.vic.gov.au/

http://www.anyvitamins.com/

http://www.milk.co.uk/

http://www.breakfastforlearning.ca/english/resources

http://www.breakfast-club.co.uk/

http://www.welltown.gov.uk/

http://www.galaxy-h.gov.uk/

http://www.lifebytes.gov.uk/

http://www.mindbodysoul.gov.uk/



Ideas behind the ‘Eat Right’ Family

The basic ideas lying behind the development of food based characters is to develop a

group of cartoon characters that can then be facilitated to be used for a wide range of

health and nutrition promotion activities.

The concept of a family was decided on as the family forms an important part of

Maldivian life and culture and to involve all members of a family means that people of all

ages will be able to relate to the characters.

Therefore the ‘Eat Right’ family can be used to target people of all ages, from young

children to the elderly. In this way, it is also able to tackle the lifecycle nutrition

components.

The food types on which the characters are based were chosen with relation to foods

that are commonly eaten by the Maldivians as well as trying to incorporate different

food groups. The names were similarly chosen as names with which Maldivians are

familiar with, and are easily recognisable.

By using a family based idea, many different groups can be targeted:

Mas Men of all ages including teenage boys, how to eat healthily etc,

and aspects of sport and exercise nutrition could be implemented.

Roshi Women’s health matters, importance of nutrition for themselves

as well as their children. Nutrition during pregnancy and

breastfeeding.

Falho Elderly nutrition and the importance of caring for an aging body.

Subjects surrounding lifelong nutrition. Children may also be

taught about the effects they have on their future health.



Ambu Teenagers and older children will benefit from advice on healthy

eating habits and nutrition. Aspects of eating disorders and dieting

could also be approached.

Dhonkeyo Childhood nutrition, breastfeeding, introducing complementary

food and nutrition during growth phases. The importance of

different nutrients and why they are of importance in the diets of

children, Parents may also be targeted through this.



The father, head of the house. He keeps his family healthy by making sure

that they eat fish everyday to provide essential vitamins and minerals which

help them grow and keep them strong.



Mohammed’s wife is Rasheeda Roshi. She is busy with her family feeding

them all and taking good care of them. Together she and Mohammed make

the perfect team! Roshi is part of a meal that tastes great with fish.



The oldest member of the family, the Grandmother. Her name is Fathmath

Falho. As an old lady, Fathmath knows how important it is to eat the right

foods and stay healthy so she makes sure that her grandchildren eat papaya

as often as they can to give them plenty of vitamin C to fight infections, and

vitamin A for good eyesight and healthy skin.



Dhiyana’s older sister is called Aisha Ambu and enjoys looking after her baby

sister. When old enough to eat solids, Aisha is looking forward to feeding

mango to baby Dhiyana.

Aisha has grown up healthy and strong following a healthy lifestyle of

exercise and good food. Her parents, Mohammed and Rasheeda have always



made sure that she has eaten fruit and vegetables everyday, and only had

snack foods as a treat on special occasions.

The baby of the family is Dhiyana Dhonkeyo. She is only a few months old

but already full of life as she has been fed properly on breast milk. With

Mohammed, Rasheeda and Fathmath looking after her, she is sure to grow up

fit and healthy with a well balanced diet.



REFERENCES

Burgess, A., Maina, G., Harris, O. and Harris, S., (2000), How To Grow A Balanced Diet: A Guidebook for Community Workers, VSO Books, The Chameleon Press, UK Food Safety (poster), WHO, 2003 Multiple Indicator Cluster Survey, (2001), Ministry of Health, Male’, Republic of Maldives National Nutrition Strategic Plan 2002 – 2006, (2003), Department of Public Health, Male’, Republic of Maldives Seres, Nina (2000), Nutrition throughout the Life Cycle, 4th Report on the World Nutrition Situation, UN ACC Sub-Committee on Nutrition, Jan 2000 The Health Master Plan 1996 – 2005, (1998), Ministry of Health, Male’, Republic of Maldives HUwww.food.gov.ukU HUwww.nutrition.org.ukUH

http://www.food.gov.uk/


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