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close this book Community Nutrition Action for Child Survival
close this folder Part I - Community nutrition problems and interventions
close this folder Unit 1 - The nutrition of women and children
View the document Session 1: What is malnutrition?
View the document Session 2: Focus on the nutrition of women and children
View the document Session 2: Focus on women and children
View the document Session 3: Important causes of malnutrition in women and children
View the document Session 4: Community nutrition action for child survival

Unit 1 - The nutrition of women and children


SESSION 1: What is Malnutrition?

SESSION 2: Focus on the Nutrition of Women and Children

SESSION 3: Important Causes of Malnutrition in Women and Children

SESSION 4: Community Nutrition Action for Child Survival

Session 1: What is malnutrition?

Most trainees will have been exposed to basic nutrition principles in their work. This introductory session is intended as a review; however, it may include information new to some trainees. You should develop the session content based on a pre-training assessment of the trainees' knowledge about the nutrition of women and children.


Participants will discuss general nutritional requirements for growth and development. Inadequate diet and illness will be defined as the primary causes of malnutrition in individuals.

Time: 1-3 hours


- Flipchart and marking pens

- Slides and projector or posters showing the symptoms of severe malnutrition

- Handout - "Malnutrition"


1. Read the statement below to the group, or substitute statements about malnutrition in your country. Ask trainees to think about the statement for a few seconds.

"About 17 million of the world's children under five years old died last year; more than 12 million died from diarrhea, pneumonia, and contagious infections. Malnutrition was an underlying cause in all of these deaths. " UNICEF, A Child Survival Revolution, 1983

2. Ask trainees: "What is malnutrition?". Write the answers on the flipchart. Encourage as many answers as possible. The list will often include effects and causes, as well as definitions of malnutrition.

3. Referring to the trainees' answers in 2. above, give the definition of the term "malnutrition" as it will be used throughout the workshop:

Example: "Malnutrition is the physical and mental disability that results when the human body does not get the nutrients it needs to grow and function properly. "

4. Review the basic nutrient requirements for growth and development. Explain the classification of foods according to their primary functions in the body

(use the Basic Three Food Groups or the system of classification used in your country). In groups without nutrition background, conduct an exercise in which trainees practice classifying local foods or pictures of local foods according to their primary functions in the body, e.g., Basic Three Food


5. Ask: " Why do people become malnourished?"

Trainees will give a variety of answers. List their answers on the flipchart; then summarize by saying:

"We can see that there are many reasons people become malnourished. We will be talking about many of the causes of malnutrition during this workshop. In this session, let us begin by talking about the biological causes of malnutrition in the individual. "

6. Explain that the physical causes of malnutrition are:

- inadequate diet

- not eating enough food; not eating enough of certain kinds of food (e.g., foods from each of the three food groups);

- illness.

7. Explain how illness can cause malnutrition by:

- reducing the amount of food eaten;

- reducing the intestine's ability to absorb (use) the food eaten;

- increasing the body's demand for available nutrients.

Describe the body's reaction to specific illnesses (i.e., diarrhea, measles and parasitic infections) and how they affect food intake and use by the body.

8. Draw the cycle of malnutrition-infection to illustrate the following points.

- Malnutrition weakens the body, making it more susceptible to illness, so people who are malnourished get sick more often.

- Illness often reduces nutrient intake at a time when the body needs more nutrients than normal to fight infection.

- Repeated illness complicates and intensifies malnutrition.


9. Ask trainees to brainstorm the signs and symptoms of malnutrition. When they finish, add any additional physical signs and divide the signs into those related to Protein Energy Malnutrition (PEM) and those related to specific vitamin and mineral deficiencies. You may wish to illustrate the signs of severe malnutrition using slides or posters.

Remind trainees that these different types of malnutrition often occur together.

10. Summary

"In this session we have seen that malnutrition is the result of:

- not eating enough food;

- not eating enough of certain kinds of foods;

- illness.

In the next activities, we will be analyzing the nutrition problems of women and young children and identifying community activities that address the immediate causes of malnutrition."

Distribute the Handout - Malnutrition" as a reference.



Malnutrition has been identified as one of the world's most serious health problems and a major cause of death in infants and young children. Last year 17 million children under five years of age died throughout the world: 12 million of them died from diseases directly related to malnutrition. (UNICEF, A Child Survival Revolution, 1983)

What is Malnutrition?

Malnutrition is the physical and mental disability that results when the body does not get the nutrients it needs to function and grow. The body gets nutrients from foods. Foods contain different combinations of nutrients, so the body needs different kinds of foods to meet its nutrient requirements. The functions of food in the body can be divided into three categories building and repairing the body's tissues, providing energy and strength, and maintaining or protecting the body from illness.

The Basic Three Food Groups

In order to understand the combinations of foods necessary for growth and health, we often divide the foods according to what they do in the body. A common system for classifying foods is the Basic Three Food Groups. (There are also systems for classifying foods by function and nutrient content that include four, five and six classifications.)

The Basic Three Food Group System divides foods into Body-Building, Energy and Protective categories.

Body-Building Foods (protein) are used by the body for growth and repair of tissue. These foods are very important for everyone, but they are most important for young children who are growing very rapidly and for pregnant and breastfeeding mothers who are nourishing growing babies as well as themselves. The Body-Building Foods include milk, eggs, legumes, fish, meat, poultry, nuts, etc.

Energy Foods (carbohydrates and fats) are those that help us do all of the things we must do every day, i.e., work, walk, play, etc. These are very important foods and they usually make up the bulk of the diet. Energy Foods include cereal grains, roots and tubers, fats and oils, sugars, etc.

Protective Foods (vitamins and minerals) are those that help keep the body free from sickness and functioning properly. These foods include fruits and vegetables, especially dark green and yellow vegetables and fresh fruits.

The body needs some of each of these kinds of food every day to stay healthy. There are also special times when the body needs more food than normal to grow and stay healthy. These include periods of rapid growth, sickness and heavy physical labor.

What Causes Malnutrition?

When the body does not get enough of the foods it needs; when it does not yet the right combinations of food; or, when illness affects the body's ability to use foods properly, a person may become malnourished.

Diets may be deficient in the quantity and the quality of food consumed. This means that the amount of food eaten and/or the nutritional value of the food is below the daily human requirement. The minimum nutrient requirement varies according to the age, size and reproductive status of the individual.

Protein Energy Malnutrition (PEM), one of the most serious nutritional problems, is caused by inadequate intake of body-building and/or energy foods and is usually accompanied by nutritional anemia. Kwashiorkor and marasmus are two types of PEM.

Vitamin and Mineral Deficiencies also cause malnutrition. Anemia (iron), xerophthalmia (vitamin A), rickets (vitamin D) and goiter (iodine) are related to vitamin or mineral deficiencies. Some of these vitamin and mineral deficiencies also occur with protein energy malnutrition.

Illness affects the body's ability to digest and use food, as well as the amount of food eaten. Diarrhea is a good example of an illness that causes malabsorption as well as reduced intake of food. When diarrhea occurs, the intestine is unable to absorb many of the nutrients contained in the food. If the person with diarrhea is feeling unwell, or if there is vomiting, there will also be less food eaten than normal. In some cultures, children with diarrhea may also be taken off food during bouts of diarrhea. Because the body actually requires more nutrients than normal to fight infection, illnesses like diarrhea have a double impact on nutrition status.

What are the Effects of Malnutrition?

Malnutrition causes growth failure, increased risk of infection, physical changes in the body, illness, disability and death. Malnutrition impairs the body's defense systems for fighting infection, meaning that the malnourished become sick more often and suffer more from their illnesses than the well-nourished. This vicious cycle of malnutrition and infection leads to reduced productivity of workers, high drop-out and repeater rates among school children, a greater demand for health and hospital care, high expenditures by the government and waste of human life.






Hair changes

Lack of Body


"Flaky paint" rash

Building and


Swelling (edema)

Energy Foods








Lack of total


"Old man" look

food intake




Skin hanging on bones



Night blindness

Lack of


Bitot's spot

vitamin A






Pale conjunctiva ( eye)

Lack of iron






Pale mouth and tongue


Notched ribs

Lack of


Bowed legs

vitamin D


Enlarged thyroid

Lack of








* These are signs of severe forms of malnutrition. In most cases, people showing these signs have been malnourished for a long time. Although they may not have had visible physical signs of malnutrition, they may have experienced fatigue and sickness. In children, the first sign of malnutrition (PEM) is failure to grow.

Session 2: Focus on the nutrition of women and children


To describe critical events during pregnancy, breastfeeding and weaning that place women and children at high risk of malnutrition. To illustrate the relationship between malnutrition, infection and child spacing.

Time: 1-2 hours


- Newsprint and marking pens or chalkboard and chalk

- Wall chart - "Stages of Fetal and Infant Growth"

- Handout - "Stages of Fetal and Infant Growth"

- Handout - "Focus on Women and Children"


1. Ask trainees: " Who suffers most from malnutrition?" List their answers on the flipchart. Then explain that poor women and children under three years suffer most from malnutrition in both normal and disaster situations because of their special nutritional needs and susceptibility to diseases that can lead to malnutrition.

2. Display the chart - "Stages of Fetal and Infant Growth." Review the characteristics of pregnancy, early infancy and weaning in terms of the nutritional requirements and common illnesses and problems at each stage.

Use the table on the next page to prepare your presentation.




Nutritional Requirements

Common Symptoms


- 350 extra calories per day or about ½ extra plate of food each day*
- green leafy vegetables and meat to prevent anemia
- weight gain of at least 12.5 kg

- anemia
- inadequate weight gain
- low birth weight(<2500 grams)
- premature delivery
- maternal depletion

(0-6 months)

- 550 extra calories per day or about one extra plate of food each day
extra liquids for the breastfeeding mother
breastfeeding should begin immediately after birth (give colostrum)
- breastfeeding should be on demand
- breastfeeding for 4-5 months without supplements

- early introduction of foods other than breast milk leading to diarrhea and decreased production of breast milk
- early termination of
- use of feeding bottles leading to diarrhea and other infections

Weaning/ Breastfeeding
(6 months -2 years)

- begin giving semi- solid food by 6 months
- give 4-6 small meals per day from 6 months to 2 years
- continue breastfeeding
- high energy/mixed diet

- inadequate weight gain
- diarrhea
- measles
- other infections

* Calculation of additional caloric requirements are for a woman weighing 50 kg. Normal daily requirement is 2,000 calories; in pregnancy, calorie requirement increases to 2,350 calories; during the first six months of breastfeeding, it increases to 2,550 calories per day. Calculations for extra plates of food are based on the assumption that women eat three meals per day, under normal circumstances.

During the presentation, encourage trainees' participation in the following ways:

3. Emphasize the importance of a woman's health and nutrition to the health and survival of her child. Ask trainees to tell the group about cases of women they know who have been sick during pregnancy and how this affected the child.

4. Ask trainees: "What happens when an infant is not breastfed during the first year of life? Why do women stop breastfeeding?" Emphasize the role of maternal nutrition in successful breastfeeding. (This topic will be discussed in greater detail in a later session.)

5. Discuss the incidence and the effects of illness, especially diarrhea and measles, during the weaning period. Trainees should understand the need to deal with both illness and feeding habits to improve the nutrition of women and children.

6. Draw the chart below - Effects of Birth Spacing on Child Survival. Ask trainees to brainstorm reasons why large, poorly spaced families are more likely than smaller families to have malnourished children and children who die.

Effects of Birth Spacing on Child Survival

7. To summarize this session, divide trainees into small groups (four-five persons) and ask the groups to agree on one important rule to improve nutrition for each of the topics discussed during this session:

- Pregnancy

- Breastfeeding

- Weaning

- Illness

- Birth Spacing

Each rule should improve some aspect of the nutrition status of women and/or children.

8. When groups finish, ask them to present their rules for improved nutrition. Rules might look like this:

- Eat one extra plate of food every day during pregnancy.

- Begin breastfeeding immediately after birth.

- Do not give foods besides breast milk to infants under four months.

- Breastfeed to prevent diarrhea.

- Allow at least three years between the births of your children.

9. Close the session and bridge to the next:

"In this session, we reviewed the reasons for increased risk of malnutrition during pregnancy, early infancy and wearing. As managers, we are concerned with using our limited resources to produce the best results possible. In order to do that, we must decide who needs our help the most and who will benefit the most from it. In nutrition and health care, we emphasize the needs of mothers and children and strategies for working with them because they are the ones who suffer the most from malnutrition."

Distribute the Handout - "Focus on Women and Children" as a reference.

Stages of fetal and infant growth




Nutritional Requirements

Common Symptoms


- 350 extra calories per day or about ½ extra plate of food each day*
- green leafy vegetables and meat to prevent anemia
- weight gain of at least 12.5 kg

- anemia
- inadequate weight gain
- low birth weight(<2500 grams)
- premature delivery
- maternal depletion

(0-6 months)

- 550 extra calories per day or about one extra plate of food each day
extra liquids for the breastfeeding mother
breastfeeding should begin immediately after birth (give colostrum)
- breastfeeding should be on demand
- breastfeeding for 4-5 months without supplements

- early introduction of foods other than breast milk leading to diarrhea and decreased production of breast milk
- early termination of
- use of feeding bottles leading to diarrhea and other infections

Weaning/ Breastfeeding
(6 months -2 years)

- begin giving semi- solid food by 6 months
- give 4-6 small meals per day from 6 months to 2 years
- continue breastfeeding
- high energy/mixed diet

- inadequate weight gain
- diarrhea
- measles
- other infections

* Calculation of additional caloric requirements are for a woman weighing 50 kg. Normal daily requirement is 2,000 calories; in pregnancy, calorie requirement increases to 2,350 calories; during the first six months of breastfeeding, it increases to 2,550 calories per day. Calculations for extra plates of food are based on the assumption that women eat three meals per day, under normal circumstances.

Session 2: Focus on women and children

Women and young children are more likely than most other groups to become malnourished because of the events in their lives that increase their nutritional requirements. The body demands extra food during periods of growth, physical work and illness. Women and young children often experience two or three of these conditions at the same time. In many communities, their needs for extra foods are not met.

The period of greatest nutritional demand on women and children begins at conception and continues through the fetal and infant periods until about three years of age. The periods that demand greatest food intake and the problems associated with them are:


Pregnancy increases a woman's need for food. She is eating for two people, herself and the baby growing inside of her. If she does not eat the foods she needs, her baby may be born weak and sickly, and her own body and health may suffer. Even under optimal conditions after birth, infants who have been retarded in growth during fetal life sometimes continue to grow slowly for many years. They may also show a tendency towards poorer intellectual performance, compared with infants who grew normally before birth.

Mothers from poor sectors of society frequently have only an inadequate diet available and have very limited opportunities for proper antenatal care, including the prevention and treatment of anemia, malaria and other infections. This largely explains why lower birth weights are found in these groups. Poor diet may be caused by low income, inadequate food production, lack of knowledge about nutrition or food taboos imposed during pregnancy. Also, a woman's activity rarely decreases during pregnancy. Many women continue to till the soil, carry wood and water, and take part in other strenuous jobs until delivery.

To insure the best fetal growth and give every child a good start in life, it is important to prevent and treat infectious diseases and high blood pressure during pregnancy, and to make the mother and father understand the importance of a good and sufficient diet during pregnancy. In addition, both parents should understand the need to slow the mother's work pace, and so allow her to have sufficient rest before delivery.


Research has confirmed the universal superiority of mother's milk both nutritionally and from an anti-infective point of view. Breastfeeding is also valued for child-spacing and emotional bonding between mother and baby.

Breastfeeding should begin as soon after birth as possible. Colostrum, the first milk produced by the breasts after birth, provides important protection against infection as well as nutrients for the growing infant. To insure adequate breast milk production and growth of the infant, Breastfeeding should be "on demand. " Breast milk alone is sufficient for an infant from birth through four to six months of age. Breastfeeding should continue as long as possible (2-3 years) to provide continued protection from illness and important nutrients for growth and development.

Good maternal nutrition is important during the Breastfeeding period. Additional food and liquids should be consumed as in pregnancy. If the Breastfeeding woman's diet is inadequate, she may become weak. The quality of breast milk also depends on the adequate nutrition of the mother and, of course, the quality of breast milk affects the growth of the infant.

The declining pattern of Breastfeeding is one of the world's most serious nutrition problems. It has been estimated that some 10 million cases of infant marasmic diarrhea occur in developing countries each year, many as a result of early termination of Breastfeeding and introduction of feeding bottles and breast milk substitutes.


From six months to two years of age, Breastfeeding should continue, but a growing child also needs to eat other foods in sufficient quantities to meet his body's requirements. This is called the weaning period when new foods are gradually added to the infant's diet. It is a critical period in the life of the child, because new foods and exposure to contaminated foods, water and utensils mean that weaning age children are more likely to become sick from diarrhea and other infections. This is also a period of rapid physical and mental development. If children are not given sufficient amounts of food and a diet rich in body-building, energy and protective foods during these critical years, they will stop growing. They may become sick more often than well-nourished children, and some will die. Those who live, but have been severely malnourished during this period, may never reach their physical and mental potential during life.

Infection and Malnutrition

One of the greatest dangers of the weaning period is the change from sterile breast milk to animal milk, semi-solid and solid foods, which are often acquired, stored and fed in unsanitary conditions. The weaning process is associated with the highest rate of infection, particularly of the gastrointestinal tract, that the child will experience in its entire lifetime. Infections, in turn, prepare the way for malnutrition and increase the negative effects of an inadequate diet.

Diarrhea is the most common infection of the weaning period; it is also the disease that kills more children in the world today than any other. A malnourished child will get diarrhea an average of four times as often and is also more likely to die from a diarrhea! infection than a well-nourished child.

Measles, tuberculosis, malaria, whooping cough and parasitic infections also have very detrimental effects on young children during infancy and weaning. These illnesses are both made more serious by malnutrition and can contribute to malnutrition. Immunization and improved nutrition are the keys to preventing measles, tuberculosis, whooping cough and other serious childhood illnesses that can cause and make malnutrition worse.

Child Spacing and Malnutrition

The amount of time between births is very important for the health of women and children, as is the total number of births in a woman's lifetime. Infants are more likely to survive if at least three years are allowed between births. This gives a woman's body the chance to rest after pregnancy and breastfeeding, before beginning this demanding cycle again. Adequate spacing between births helps to avoid depletion of the woman's body and deprivation of the growing fetus.

Spacing also reduces the total number of births and increases each child's share of family resources, especially food. Children from smaller families with several years allowed between births are generally better nourished, better educated and more productive than those from large, poorly spaced families.

Session 3: Important causes of malnutrition in women and children

In Sessions 1 and 2, we discussed the biological causes of malnutrition and the special nutritional risks of women and young children. We know that a few simple practices (i.e. improved feeding, immunization, treatment of diarrhea and child spacing) could improve nutrition and save many lives. However, it is not always easy to spread and gain acceptance for these practices. Malnutrition is the result of complex socio-economic causes within the family and the community. Before we can promote improved nutrition practices, we must understand more about how and why people do things the way they do at present.


To explore the social, economic and cultural causes of malnutrition in women and young children.

Time: 2 1/2 hours


- Flipchart and marking pens

- Handout _ "A Story About Malnutrition"

- Handout - "Causes of Malnutrition in My Region"

- Trainer's Reference "Socio-Cultural Causes of Malnutrition"


1. Distribute the Handout - "A Story About Malnutrition." Read the "Story About Malnutrition" slowly, asking trainees to follow along as you read.

2. Ask trainees to re-read the story; then, ask them to list on a sheet of paper as many causes of malnutrition in the story as they can.

3. Now, ask trainees to state one cause at a time. List the mentioned causes on the flipchart. List each cause only once. Continue asking participants for causes until no new causes are given.

Expect the following causes of malnutrition:

- Family has rocky/infertile land

- Family is large - five births/four living children

- Elizabeth fed only starchy energy foods

- Mother believes eggs are bad for children

- Mother only takes children to health center when they are very sick

- Health care is far away from the village

- Mother does not know that lack of food is a reason for Elizabeth's sickness

- Belief that "evil eye" causes malnutrition

- Mother and grandmother have little time to care for young children

- Births have been spaced less than three years apart

- Drought sometimes destroys crops

- Frequent diarrhea

Explain that there are many interrelated reasons why women and children become malnourished.

Note: If the causes given by trainees are too general or vague, ask, "Why is that a problem?" until the answer given refers to a specific action, belief or condition causing the malnutrition.

For example:

- "People are poor" is a very general cause of malnutrition. It does not describe a situation that one could hope to change in a short period of time. "Ignorance" is another general reason that does not give us enough information.

- Two specific causes might be:

"Body-building foods (eggs, legumes) are produced in the village, but people sell them and use the money to buy rice, a less expensive staple food."

"Families do not know that their children's illnesses are caused by lack of food."

4. Invite a resource specialist to discuss the common causes of malnutrition in your country. Make sure the causes mentioned in the Handout - "Socio-Cultural Causes of Malnutrition" - are discussed.

5. Distribute the Handout - "Causes of Malnutrition in My Region. " Ask trainees to answer the questions on the handout about the causes of malnutrition in their own regions. Facilitators should assist participants during this exercise.

6. Hold a question and answer summary of this activity in which the resource specialist responds to questions from trainees about the causes of malnutrition in their regions.

7. Summary

"Before we can introduce changes in nutrition practices in the community, we must understand how people perceive nutrition problems and the constraints they have to accepting new practices. Constraints are forces against change. If we understand the constraints to improved nutrition, we will be better able to develop educational messages and activities that community members can understand and accept."



This story is told by (Maria), a 30-year-old woman from the village of (__). (Maria) is married to (John) and they have four small children. Last year (Maria's) fifth child died only a week after it was born. Now, (Elizabeth), the three year old, is sick with fever and a cough. Maria is very worried.


When my husband and I first came to (village) to live with his family, we had only one child, our oldest son (Peter). Now, (Peter) is nine years old, and he and his younger brother, who is seven, are studying in the village school. The two youngest children, (Jane) and (Elizabeth), are still very small. (Jane) is five and (Elizabeth) will soon be three.

Life has been difficult for us here in (village). Our land is rocky, and there are years when the rains come late and our crops fail. This year, my husband has been lucky to get work on a plantation about 40 km from (village). The money he earns on the plantation is little but with it we will buy rice this winter and seeds for next year's planting. While my husband is away, my mother-in-law and I must manage the house and the farming.

Today, I am very worried about my youngest daughter (Elizabeth). Poor little (Elizabeth), she has always been so thin and small. Now, she is coughing and coughing and she feels so hot. It seems as if God does not want her to stay with us for very long.

Last month, I took (Elizabeth) to the health center because she had very bad diarrhea. The health center is far and we must walk most of the way. I only take the children there when they are very sick and our own cures do not make them well.

At the health center, the nurse gave me some packets for the diarrhea. She also told me that (Elizabeth) needed to eat more food and that I should give her eggs and milk or meat every day. The nurse was very nice, but what she told me did not make any sense. Where am I to get these special foods for (Elizabeth)? The only time my family eats meat is at feast time when a goat is slaughtered. The milk the old cow gives is very little and if I do not sell it, who will pay the school fees for my sons?

I have a few chickens, but I am afraid to give their eggs to (Elizabeth). Is it not true that eggs are very strong food for such a small child? They will certainly make her stomach hot and cause more diarrhea.

I do not understand why (Elizabeth) needs such special foods. The other children are thin but they are not sick like (Elizabeth). They eat the same foods we have always eaten, (rice and soup) in the morning and the evening.

My mother-in-law says that (Elizabeth) has been bewitched. I am beginning to believe that what she says is true. Next week, I will arrange a cure for (Elizabeth) with (Don Miguel). (Don Miguel) is our village healer; he is very wise and will know what to do to make (Elizabeth) healthy.

To the Trainer:

Adapt or rewrite this story based on the most common causes of malnutrition in your country or region.

Discussion Starter:

List as many possible causes of malnutrition in this story as you can.



List all of the factors (beliefs, practices, social and economic conditions, etc.) that you feel are causes of malnutrition in women and children in your area. Be specific!



Factors affecting food availability and use within the family will determine how we go about introducing new ideas and practices to improve nutrition.

1. Traditional Beliefs and Food Habits

Every culture in the world has beliefs about food and certain practices that affect the foods people eat. Some of these beliefs and practices help people to stay healthy; others can be harmful.

A belief or practice promotes good nutrition if it encourages people to eat a food which is good for them. For example, in many countries it is common for women when pregnant and after birth to follow food taboos that encourage them to drink additional liquids and eat body-building foods like chicken or meat. In Africa, one traditional practice involved abstinence from sexual intercourse until a child could walk to his father carrying a plate of food (two-three years). This allowed the child to benefit from his mother's attention and, most importantly, from breastfeeding. It was also an effective method of family planning. It is important to remember that even if a belief seems to be unscientific, if it means extra food for someone who needs it, then the belief and practice should be encouraged.

Beliefs or practices which block foods from women and children are harmful and should be discouraged through education and example. These include any beliefs or practices that restrict foods or liquids from:

- pregnant and breastfeeding women;

- anyone with diarrhea, especially a young child;

- weaning-age children;

- anyone who is sick.

Some specific examples include:

- Trying not to eat during pregnancy so that the baby will be small and the delivery easy

- Not giving colostrum to newborn infants

- Withholding specific foods from children because they are believed to result in an illness like worms or a change in character

- Withholding food and water during diarrhea

- Feeding men and boys first or feeding them the largest portions

It is interesting to note that most food restrictions apply to those who need food the most - women, young children and people who are sick. These are the groups who most often become malnourished.

Beliefs about the causes of malnutrition in children also affect how families treat malnourished children and whether or not they will accept advice from outsiders. Most cultures have beliefs about what causes severe forms of malnutrition, and they often have a special name for the disease. Some groups believe that malnutrition comes from "the evil eye"; others believe an unfaithful husband or wife has caused it; still others believe that malnourished children have been contaminated by pregnant women or another malnourished child.

A thorough understanding of local food habits and beliefs is the key to working successfully with any community on nutrition problems. Remember:

- A belief or practice is considered helpful and should be supported if it encourages giving extra food and liquid, even if it is not based on scientific fact.

- Harmful beliefs and practices are those that restrict foods from the vulnerable groups.

- It is always best to encourage positive traditional beliefs and practices while trying to change harmful practices through education and example.

2. Food Supply

In rural areas, the amount and quality of a family's land, its income and its equipment affect the foods available for child feeding. The knowledge of farmers also affects the variety of foods they grow and their harvests. Environmental factors (i.e., rainfall, insects, etc.) have an effect on food supply, as does the demand for certain types of cash crops in the marketplace. In many areas, the switch from subsistence crops to cash crops has had a very negative effect on the amount and the kinds of food available in rural areas. A regular "hungry season" each year before the harvest can also be a serious problem. In urban and increasingly in rural areas, cash income is an important factor in a family's ability to buy food for child feeding that it does not produce.

3. Early Termination of Breastfeeding, Use of Feeding Bottles

This has become a problem in developing and developed countries in recent years. Urban areas, as well as some rural areas, are increasingly bombarded with advertising promoting the use of feeding bottles and infant formulas. Middle- and upper- class women who have tended to accept this advertising are poor role models for their rural and less advantaged "sisters." The lack of financial resources needed to purchase breast milk substitutes, the lack of clean water in most areas and poor environmental hygiene combine to make bottle feeding a deadly practice. All mothers should be encouraged and helped to breastfeed their infants; those who cannot breastfeed should be taught hygienic practices and the use of cup and spoon for feeding their small children.

4. Time Available for Child Care and Feeding

This is one of the factors that is often overlooked when thinking of child health and nutrition. In most societies, the mother is the individual responsible for the care and feeding of the family's young children. She is often responsible for a variety of other tasks at home, in the fields and in the marketplace as well.

We know that young children must eat more frequently during the day than older children and adults (four-five meals per day). If family meals are normally prepared only twice each day, it may be difficult for a mother who is working in the fields, gathering firewood and food for the animals or fetching water to feed her young children as many times each day as she should. To save time she may feed the baby foods that are of the same consistency as those of the adults, or the baby may be given to an older sister who is sharing a bowl with the rest of the children while trying to feed herself and the baby.

5. Women's Health

It is estimated that about half of non-pregnant and two-thirds of pregnant women in the developing world suffer from iron-deficiency anemia (WHO 1979). Anemia affects a woman's ability to care for herself and her young children because it makes her feel tired and weak. Anemia during pregnancy and breastfeeding can have serious effects on unborn or breastfeeding infants. Other common conditions that affect a woman's ability to care for herself and her young children include malaria, gastro-intestinal disorders and parasitic infections. The availability of health care services can be critical not only to the health of women but also to the health and nutrition of their children.

6. Women's Status and Education

Attitudes toward women's roles in the family and in society affect all aspects of their lives, including diet, work, education and access to health care. Increasing women's education and income can have very positive effects on their decision-making roles in the family and on the nutrition and health of their children.

7. Large Families, Poorly Spaced Births

All of the problems of food availability and time for child care are worsened when there are many children to feed and care for. In addition, a woman who has had many pregnancies (more than five) has a good chance of being sick herself, with little energy to meet the demands of her family.

Traditional beliefs play an important role in determining family size and spacing of births. Attitudes toward male and female roles, the value of male children and children as security in old age are important. Competition between wives in polygamous situations also affects family size.

8. Accessibility of Health Information and Services

Preventive and curative health care facilities are often located at a distance from the rural village, implying a long walk and/or transport costs. Women may have little time to participate in the activities of the health center even when activities and health workers are located at a reasonable distance. Health information may not be available to families for the same reasons given above or because ethnic and class barriers make it difficult for them to seek and understand such information.

Session 4: Community nutrition action for child survival


To introduce six community-appropriate nutrition and health interventions that can reduce malnutrition and improve child survival through growth monitoring, promotion of breastfeeding, improved weaning practices, oral rehydration therapy, immunization and family planning.

Time: 1/2 hour


- Handout - "Community Nutrition Action for Child Survival "

- Trainer's Reference - "Estimates of Child Survival through Intervention"

- Newsprint and marking pens

Note: This session can be used as an introduction to the following units in Part I of this module.


1. Introduction: In the previous sessions we discussed the many causes and effects of malnutrition in women and children. What can be done to improve nutrition and thus, the survival and quality of life for women and young children? There are probably as many ways to improve nutrition as there are causes of malnutrition. Some interventions are more expensive and more time consuming than others. Some require highly trained "experts." Many, however, can be carried out by community members and families if they are given only a little training and support.

What are these community nutrition interventions?

2. Distribute the Handout - "Community Nutrition Action for Child Survival." Review each of the six interventions with the trainees. These interventions and the roles that community members can play in their introduction will be covered in detail in the following units.

3. Use the UNICEF estimates of child lives that could be saved each year to demonstrate the dramatic effect that these simple interventions could have on child survival.






No. of Deaths
Per Year

Lives that
Could Be Saved

Community Interventions

Low birth weight

3 million

1 million

- Growth monitoring
- Maternal nutrition
- Breastfeeding
- Improved weaning
- Family planning

Immunizable diseases

3.3-5 million

3-4.5 million

- Immunization


5 million

2.5-3.5 million

- Oral rehydration therapy


13 million

9 million



Adapted from UNICEF. "A Child Survival and Development Revolution. "

Assignment Children. Geneva, 1983, p. 51.



American Public Health Association. Mothers and Children. Quarterly Newsletter, various editions.

Cameron, M. and Hofvander, Y. Manual on Feeding Infants and Young Children. Oxford University Press, 1983.

Center for Population and Family Health. Family Planning: Its Impact on the Health of Women and Children. Columbia University, 1981.

Hamilton S., Popkin, B. and Spicer, D. Women and Nutrition In Third World Countries. Praeger, New York, 1984.

Jelliffe, D.B. Child Nutrition in Developing Countries. U.S. Agency for International Development, Washington, D.C., 1969.

United Nations International Children’s Emergency Fund. "A Child Survival and Development Revolution." Assignment Children. Geneva, 1983.

World Council of Churches. Contact. "The Nutrition of Mothers and Children" 50. Christian Medical Commission, April 1979.

World Federation of Public Health Associations. Improving Maternal Health in Developing Countries. Washington, D.C., 1984.

___ . Maternal Nutrition. Washington, D.C., 1983.

___. Oral Rehydration Therapy. Washington, D.C., 1983.

World Health Organization. Guidelines for Training Community Health Workers in Nutrition. WHO Offset Publication No. 59. Geneva, 1981.

___. Towards a Better Future, Maternal Child Health. Geneva, 1980.