nutrition training manual

NUTRITION TRAINING MANUAL

DEVELOPED FOR TEA COMMUNITIES IN UGANDA

NUTRITION TRAINING MANUAL: Developed For Tea Communities in Uganda

Acknowledgements This nutrition training manual has been developed by Uganda Action for Nutrition (UGAN) and the Ethical Tea Partnership (ETP) with the financial support of the Sustainable Trade Initiative (IDH) and Tata Global Beverages (TGB). Authors: Peterson Kato Kikomeko & Ndahura Nicholas Bari: Lecturers at the Department of Human Nutrition & Home Economics, Kyambogo University, Uganda Rukanda Grace and Nangosha Elisha: Researchers at the Uganda Action for Nutrition Editors and technical contributors: Heleen Bulckens, Programme Manager, Ethical Tea Partnership Tina van den Briel, Senior Adviser, Global Alliance for Improved Nutrition

We are especially grateful to the management and workers of Mpanga Growers Tea Factory Ltd and Rwenzori Commodities Ltd for their support to and participation in this project.

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TABLE OF CONTENTS Acknowledgements……………………………………………………………………..2 Document Overview…………………………………………………………………….4 Introduction………………………………………………………………………..……..4 How to use the manual………………………………………………………….……...4

MODULE 1: FOOD&NUTRITION SECURITY Introduction……………………………………………………………………….….…..5 Objectives of the module……………………………………………………….………5 Overview………………………………………………………………………….……...5 Food and nutrition security situation on tea estates in Western Uganda………....6 1.1. Food, nutrition and nutrients……………………………………….….…7 1.2. Balanced diet and child feeding…………..…………………………….14 1.3. Food and nutrition security…………..………………………………….17 Summary module 1…………………………………………………………………….20

MODULE 2: NUTRITION & HEALTH Introduction……………………………………………………………………….….…..22 Objectives of the module……………………………………………………….……....22 Overview………………………………………………………………………….……...22 2.1. Overview of malnutrition………………………………………………….23 2.2. Causes of under-nutrition………………………………………………...23 2.3. Form of under-nutrition…………………………………………………...24 2.4. Wider impact of under-nutrition………………………………………….31 2.5. Family and community prevention of under-nutrition………………….31 2.6. Tips for optimal infant and young child feeding………………………..32 2.7. Nutrition during pregnancy & breastfeeding……………………………35 2.8. Disease prevention & sanitation and hygiene………………………....35 Summary module 2……………………………………………………………………..38

MODULE 3: FOOD SAFETY, STORAGE & PRESERVATION Introduction……………………………………………………………………….….…..40 Objectives of the module……………………………………………………….……....40 Overview………………………………………………………………………….……...40 3.1. The concept of food safety and hygiene…..……………………………41 3.2. Food storage and preservation…………………………………………..45 3.3. Food poisoning…………………………………………………………….48 Summary module 3……………………………………………………………………..50

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Document Overview Introduction This manual has been produced to support Mpanga and Rwenzori employees in providing nutrition training to workers and their families who live in housing provided by the tea estates. Potential users of this manual are: field managers / officers, welfare officers, nurses, doctors, labour line leaders, or anyone else with an interest in this area. The authors have presented the information in an accessible way so that not much background knowledge on nutrition is required before undertaking training delivery. The manual was developed with the clear intention of improving the food and nutrition security – and ultimately the health - of the Mpanga and Rwenzori tea workers and their families. It aims to complement the kitchen garden programme that is being rolled out in the labour lines of Mpanga and Rwenzori, also with the support of ETP, IDH and TGB. In order to establish the current nutritional status of the workers, a nutrition baseline assessment was carried out by UGAN in May 2014. The manual describes the key results of this study and provides information on how the food and nutrition security of the workers can be improved through a more varied diet, the consideration of wider health/food issues such as food hygiene, disease prevention, as well as food storage and food preservation. This is a freely available resource and we would like to encourage other tea producers to use it – in addition to other user groups such as schools, nurses, church groups, etc.

How to use the manual The manual has been divided into 3 modules so as to allow for 3 separate sessions to take place and not overload workers with too much information in one go. The modules cover: Module 1: Food &Nutrition Security Module 2: Nutrition & Health Module 3: Food Safety, Storage & Preservation When workers were interviewed as part of the baseline survey the majority of them made it clear that they would prefer to receive short but frequent training sessions, ideally on the weekend, rather than one long training session over a whole day or two consecutive days. The manual was developed for the trainers, not for distribution amongst the workers. When workers and/or their family members attend the sessions, they should be given the 1-page hand-outs which were developed for each of the modules. These hand-outs give a short summary of what was covered during the sessions. In addition, the poster developed by the ETP and UGAN should be used during the training and can be hung at strategic places around the estates where they are visible to many workers (e.g. on the wall of the dispensaries). 4


MODULE 1: FOOD & NUTRITION SECURITY Introduction We all need food. It allows us to be alive, to grow and be active and in the case of women, it can sustain the growth of a baby. What we eat (our diet) has the power to keep or make us and our children healthy and give us a better life. In the context of tea production, which is very labour-intense, it is important to point out that the diet of the workers will impact not only on their health – and thus their ability to function physically and mentally – but also on their labour productivity. This module covers: the definition of nutrition, the role of nutrients in our body, the food sources of these nutrients, the importance of adequate feeding, the concepts of ‘a balanced diet’ and ‘food and nutrition security.’ The module starts by outlining the current food and nutrition security situation in the tea estates of Rwenzori and Mpanga as was observed during the nutrition baseline study carried out by UGAN in May 2014.

Objectives of the module After having completed this module, participants should be able to:      

Differentiate between food, nutrients and nutrition Understand the classification of food into different food groups Name the nutrients and discuss their importance in the body List the primary food sources for each of the nutrients Understand what constitutes an adequate diet and optimal feeding to children Understand what is food and nutrition security and how it can be achieved

Overview Part 1: Food, Nutrition and Nutrients Part 2: Balanced Diet and Child Feeding Part 3: Food and Nutrition Security

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Food and nutrition security situation on tea estates in Western Uganda In May 2014 UGAN interviewed 125 workers from 3 estates in Western Uganda (as part of the baseline survey) and found that most tea workers and their families did not achieve food and nutrition security. The diets consumed by the workers were not diverse: most households ate only 3 out of 15 food groups. People mostly ate legumes (beans), cereals (maize, rice, millet) and tubers (sweet potatoes, cassava and Irish potatoes). There was very little consumption of other vegetables, fruits, fats and foods of animal origin (such as meat, fish, poultry and milk). The predominant diets were found to be nutritionally inadequate for workers. Different factors were found to influence the foods chosen by the workers, including: income, food prices, types of food available, individual food preferences, cultural background and land availability. The fact that estate policies do not allow estate workers to domesticate birds and animals was also found to have a direct effect on the food and nutrition security of the workers. If they were given the chance to rear fowls and animals then these could act as affordable/cheap sources of animal protein for individual households. With regards to food access; the majority of households purchased their food and very few workers grew (at least some of) their own food. Several factors influenced the purchase of foods, including: respondents’ financial resources, food prices, availability of transport to and from the market, availability of food in the market and distance from the market. Workers who did grow some crops mostly grew tubers/roots, legumes and nuts. Only a small percentage of workers also grew cereals, vegetables and fruits. Factors that were mentioned as affecting crop production included: limited access to land, climate, the time it takes to grow food, soil fertility and lack of confidence in the yield that would be produced. When unable to access adequate food supplies, the majority of workers said that they coped by borrowing food from friends/neighbours. Other coping measures included: getting food on credit, eating less or going hungry and eating any available foods.

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1.1. FOOD, NUTRITION AND NUTRIENTS We often hear the terms food, nutrition and nutrients. Health workers advise us to have a diverse and nutrient-rich diet if we are to be healthy. But what are nutrients and what is nutrition? Food Food is defined as any substance containing nutrients (such as carbohydrates, proteins, and fats) that can be ingested by a living organism and metabolized into energy and body tissue. In essence, food stimulates growth, helps us to stay alive and produces energy. Nutrients Nutrients are the chemical substances found in food. They are extracted from food as it passes through our digestive system and are used by the body to perform its functions. Nutrients contained in food are needed in the right amounts and combinations for the body to function properly. Nutrients are divided into two broad categories: MACRO nutrients and MICRO nutrients.  Macronutrients are required by the body in large amounts; they include carbohydrates, proteins and fat.  Micronutrients are required in relatively smaller amounts by the body; they include vitamins and minerals. The body needs a mixture of both macro and micro nutrients for it to be healthy and function optimally. We access these nutrients through eating food. Nutrition The term ‘nutrition’ broadly covers all processes through which we obtain, prepare and eat food. It further describes what different foods are made of (i.e. nutrients) and the processes through which our bodies make use of the nutrients to enable us to perform daily activities such as work. Apart from focussing on what we should eat, nutrition is also concerned with promoting aspects of personal and environmental hygiene and sanitation, promoting health seeking behaviours and providing care for all household members so that they are healthy. Classification of foodson the basis of the key nutrients they supply Different foods can be grouped into different groups depending on the major nutrients they provide. According to this classification there are:    

Energy giving foods/GO foods Body building foods/GROW foods Protective foods/GLOW foods Water (sits outside of the classification but is mentioned here as it is also essential for the human body to function properly) 7


Most foods provide more than one nutrient. Many energy giving foods are also sources of proteins and micronutrients, while many body building foods also provide energy and micronutrients. ENERGY GIVING FOODSOR GO FOODS

Energy giving foods provide the energy needed by our bodies to:  

Perform activities such as walking, digging, working Maintain normal physiological processes such as breathing and all other processes within our bodies

Energy giving foods are mainly rich in the food nutrients carbohydrates or fats. We obtain carbohydrates through eating plant-based foods. The main examples of carbohydrate containing foods include: millet, Irish potatoes, sweet potatoes, cassava, posho (made from maize or other flour), sorghum, yams, rice, plantain (matooke) and bread. Fats and oils are usually solid, semi-solids or liquid depending on their chemical composition and environmental temperatures. Examples of fats and oils commonly consumed in our diets include liquid oils (sunflower oil, mukwano oil), ghee, suet (fat normally found on kidney and meat of cattle and sheep). Apart from being good sources of energy, fats and oils also add flavour and taste to food. They further insulate the body, cushion vital organs and are essential for the absorption and utilisation of fat-soluble vitamins A, D, E and K. Thus, a very low consumption of fats and oils may lead to a deficiency of these vitamins predisposing our bodies to diseases and/or symptoms associated with a lack of these vitamins. The benefits of vitamins will be discussed later in this session. When a person consumes excessive amounts of energy giving foods and doesn’t utilise this energy through physical activity, this results in surplus energy being converted and stored by the body as excess fat. This puts affected individuals at risk of developing coronary heart disease, high blood pressure and certain types of cancers. The baseline assessment revealed that tea estate workers and their families eat very little fats and oils. If they were to eat more fats and oils, they might have more energy and, in combination with eating foods rich in certain vitamins, their bodies would absorb these vitamins better. 8


BODY BUILDING FOODS OR GROW FOODS Body building foods or GROW foods are those rich in the food nutrients called proteins. They are essential for growth, boosting body immunity against infections and diseases, the formation of all tissues, including muscles, bones, teeth, skin and nails and for wound repair.

Bodybuilding foods come from two major sources: 1. Animal-based foods and related products: fish, meat, poultry, eggs, milk and yoghurt. 2. Plant-based foods and related products: mainly beans (incl soy beans) and peas Animal-based foods provide a richer source of proteins that are more easily utilised by the body than those supplied by plant-based foods. We can increase household intake of animal-based proteins by domesticating certain animals and birds. The birds (hens, ducks) can be eaten but also lay eggs, which are a rich source of proteins. Animals like rabbits are also relatively easy to rear: they do not require much space to be kept, are not too demanding in as far as feeding is concerned and have high multiplication rates. The quality of proteins from plant-based foods can be improved by eating a combination of different such foods, e.g. rice and beans. The proteins missing in beans are present in rice so when these are eaten in combination one can also obtain a good supply of proteins for the body. It is therefore important to eat a mixture of plant-based foods in our diets and even more so if access to animal-based foods is limited. We have different protein requirements at different ages: children require more protein-rich foods than adults because they are growing. Pregnant women should also eat plenty of protein-rich foods because they need to feed themselves as well as their growing baby. The same is true for lactating / breastfeeding mothers whose bodies need to be able to produce breast milk. 9


Examples of locally available plant-based foods rich in proteins:

Ground nuts

Simsim (Sesame) seeds

Soy (soya)

Beans

Examples of locally available animal-based foods rich in proteins:  Meat, fish, eggs, milk and milk products including yoghurt and fermented milk  Others include edible insects such as grasshoppers (nsenene) and white ants (enswa)

Chicken

Eggs

Beef

White ants

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Fish

Grasshoppers


PROTECTIVE FOODS OR GLOW FOODS

Protective or GLOW foods include vegetables and fruits. These foods are rich in vitamins and minerals which are required by the body for physiological functions such as the strengthening of the immune/defence system and to prevent conditions such as anaemia (resulting from iron deficiency), night blindness (resulting from Vitamin A deficiency), goitre (resulting from iodine deficiency) and rickets (resulting from a lack of Vitamin D and calcium). Some vitamins and minerals are also essential for the production of energy by the body and maintaining water balance in the body. Vegetables Vegetables are a rich source of several vitamins and minerals. In addition, vegetables add taste, flavour and colour to our meals. Common vegetables include: amaranthus (dodo), spinach, kale (sukumawiki), pumpkin leaves, cowpea leaves, carrots, cassava leaves, green pepper, nnakati, malakwang,eboo.

Amaranthus (ddodo)

Spinach

Cabbage

Carrots

Fruits A variety of fruits are grown and are accessible in the markets of Western Uganda, including avocados, mangoes, pawpaws, pumpkin, passion fruit, pineapple, jackfruit, oranges, lemons and other citrus fruits. The deep yellow or orange coloured fruits are richer in vitamins, particularly vitamin A.

Pineapple

Passion fruit

Orange

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Mango


Table 1: Examples of vitamins and minerals, their functions and food sources Nutrient Function Vitamin A Strengthens our immunity which helps us fight off infections Improves vision in dim light Keeps the skin and the linings of some parts of the body, such as the nose, healthy Vitamin D Helps the body absorb calcium Keeps bones and teeth healthy Vitamin E Helps maintain cell structure by protecting cell membranes Vitamin K

Helps with blood clotting

B-group Vitamins

Help the body release energy from food Keep the skin, eyes and the nervous system healthy Helps with wound healing Strengthens our immunity which helps us fight off infections Helps form healthy red blood cells Helps reduce the risk of central nervous system defects such as spina bifida in unborn babies Helps make red blood cells, which carry oxygen around the body

Vitamin C

Folic acid

Iron

Calcium

Iodine

Helps build strong bones and teeth Helps muscles and nerves function normally Helps to ensure blood clots normally Helps to regulate the thyroid gland (in the neck) which controls the development of the body, including the brain, and regulates physiological processes (or metabolism).

Food sources Dark green leafy vegetables such as spinach, broccoli and carrots. But also: pumpkin, liver, fish, kidney and dairy produce such as yoghurt, eggs, fortified margarine Sun light, fish liver oils, milk, fortified margarine, eggs, liver Soya, groundnuts, fortified margarine or oil, wholegrain cereals, eggs, peanut butter, tomatoes Vegetables such as spinach, lettuce, cauliflower, and cabbage, broccoli, fish, liver, meat, eggs Millet, sorghum, beans, peas, eggs, liver, meat, milk, fresh fruit, green leafy vegetables, wholegrain cereals Citrus fruits such as oranges, lemons and tangerines, red and green peppers, tomatoes, broccoli, potatoes Leafy green vegetables such as spinach, broccoli, and lettuce, liver, beans, peas, fruits such as oranges, bananas, avocados and melons Liver, meat, offal, beans, millet, sorghum, ground nuts, eggs, most dark green leafy vegetables such as amaranthus and parsley Milk, cheese and other dairy foods, green leafy vegetables, such as cabbage and okra Iodized salt, sea food

Vegetables and fruits are a major source of vitamins and minerals which are required by our brain, eyes, muscles, bones, blood, glands, to perform all the functions for which they are designed

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Key vitamins and minerals for children and pregnant/breastfeeding women:

   

Iron: Iron deficiency is a major cause of anaemia and impairs the child’s/baby’s cognitive and physical development Iodine: Iodine deficiency is the greatest single cause of mental retardation and brain damage Vitamin A: Vitamin A deficiency causes early childhood blindness and increases the severity of infections and anaemia, in both children and pregnant/breastfeeding women. Zinc: Zinc deficiency affects children’s health and physical growth; it is also essential for mothers during pregnancy.

WATER Water is essential for the human body to function properly. As the body cannot store water, it requires fresh supplies of safe, clean water every day. The amount a person needs to drink depends on a variety of factors such as environmental temperature and activity level. E.g. if you work hard in hot weather you may need to drink more. All drinks such as tea, coffee, fruit juice count towards the recommended daily total of at least 8 cups a day (for an adult). The body requires water for many reasons:     

To transport nutrients around the body To make blood, saliva, tears and sweat To enable body processes such as digestion To keep the mouth and lungs moist, and to keep the skin moist and cool To produce breast milk, which is also a source of water for breastfeeding children

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1.2. BALANCED DIET AND CHILD FEEDING In part 1, we looked at ‘what’ our bodies need to be healthy. Here we will look at ‘how much’ we need of each of the foods – this is being referred to as ‘adequate nutrition’. A diet that is able to provide all the recommended (adequate) amounts of nutrients in the right amounts and quality for the body to perform all its physical and physiological activities depending on one’s age, sex and physical activity level is called a ‘balanced diet’. This implies that all the main food types (carbohydrates, fats, proteins, vitamins, minerals, and water) are eaten in correct proportions throughout the daily life of an individual. Balanced diets benefit individuals, families, communities and the nation at large. It is especially important for the following categories of people to have a balanced diet: Pregnant women  Their food intake will need to support themselves as well as their growing foetus  Pregnant women will therefore need more nutrients than non-pregnant women  The foetus/baby (inside the woman’s womb) needs a wide variety of nutrients in order to grow well and be physically and mentally healthy, e.g. folic acid and iron Breastfeeding/lactating women  Lactating mothers need enough nutrients so that they have enough energy to go about their daily lives as well as produce breast milk  Maternal nutrition has only a minor effect on the composition and quantity of breast milk produced. Unless a mother is severely malnourished, her milk will be fine  Mothers whose diets are poor deplete their own energy levels, and may become anaemic, but their bodies will continue to produce the milk their baby needs by pulling from the mother’s energy stores (at her expense but not her baby’s expense) Babies (up to 6 months)  They need to be breastfed. Breast milk contains all the nutrients a baby needs Children  They are growing and developing (physically and mentally) and therefore have extra nutritional needs to be able to do so  They are meant to gain body weight and height. If children are under-nourished they risk ‘wasting’ or being ‘stunted’  The first 1,000 days in a child’s life (starts at conception and until 2 years of age) are crucial. Any damage to their growth (physically and mentally) in these 1,000 days through a lack of nutrients is irreversible  A child with an adequate diet has a stronger immune system (than an undernourished child) and this helps him/her fight off illnesses People with chronic (long-term) illnesses (e.g. HIV/AIDS)  They will better respond to treatment  Adequate nutrition will affect the immune system and help them fight off other diseases The key to a balanced diet is to consume a variety of foods in their right amounts 14


Generally speaking, in order to maintain/attain a balanced diet, we should eat:     

Starchy foods, such as millet, rice, potatoes, cassava, matooke. Starchy foods should make up around one third of everything we eat Fruits and vegetables. They are a vital source of vitamins and minerals. We should try to eat a variety of fruit and vegetables each day, ideally 5 portions in total (e.g. 3 types of vegetables and 2 fruits) Meat, fish, eggs, beans, nuts and seeds. These foods are all good sources of protein, vitamins and minerals Milk and dairy foods: Milk and dairy foods such as fortified yoghurt are good sources of protein, vitamins A, D, and B group vitamins and the mineral calcium Moderate amount of food high in fat and/or sugar. Fats and sugar are both sources of energy for the body. In addition, fats help transport fat soluble vitamins. Health recommendations stipulate a modest intake of fat and sugar. An excess of these foods can lead to being overweight or obese as well as the development of other diseases like diabetes and heart disease. Given the high energy requirements for estate tea workers, restrictions on fat and sugar intake are likely to be unnecessary.

As shown in the pyramid below, it is important to eat a variety of foods. As a general rule, we should consume less of the foods that are in the tip of the pyramid and more of the foods that are lower down. For a healthy diet, a minimum of 5 food groups have to be eaten every day.

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Table 2 : Common myths and facts about a balanced diet / adequate nutrition Myths

Fact

Adequate nutrition means eating chicken, fish and meat. This is expensive and therefore unaffordable.

Adequate nutrition is eating all the three main food types (energy giving foods, body building foods and protective foods) in correct proportions. Your diet does not have to be expensive for it to be healthy. Plant-based protein sources such as beans, peas, and groundnuts are fairly affordable and can be grown in the backyard. Silver fish (mukene) is rich in proteins and relatively cheap. Beef and chicken are not the only sources of protein.

Fruits are eaten by children and poor people only

Household domestication of chickens, rabbits or goats can enable a family to afford animal-based proteins. Fruits and vegetables should be eaten by all, irrespective of age, sex and income category. They are a good source of vitamins and minerals which are essential for our bodies to perform their functions.

One day sample menu for an adult (3000 kcal) The number of meals (a meal is a selection of foods prepared and served in a single serving as breakfast, lunch, or supper) an individual should eat in a day varies with age, sex, physiological status, and physical activity level. Children eat smaller food portions because their stomachs are smaller and so require more frequent feeding compared to adults. While adults can do with three meals a day, children below five years need five meals a day because of their increased nutrient requirements for growth and development. Table 3: One day sample menu for an adult Breakfast Maize meal porridge with milk and sugar (1 cup/250ml) 2 slices of bread Yellow banana Tea (1 cup)

Lunch Bean/peas/fish/meat stew (2 handfuls) with a teaspoon of ghee Millet bread and cassava / matooke / sweet potatoes/ yams / Irish potatoes / rice / maize (2/4 of the plate) Amaranthus (dodo) / cassava leaves / cabbage / spinach / avocado(1 handful / 90g) A slice of mango/banana / pawpaw / jack fruit Boiled water (1 glass)

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Supper Groundnut/bean/peas/fish/mea t stew (2 handfuls) Matooke and sweet potatoes / yams / Irish potatoes / rice / maize (1/4 of the plate) Cabbage / cassava leaves / cabbage / spinach / avocado(1 handful / 90g) Fresh (passion) juice (1 glass)


1.3. FOOD AND NUTRITION SECURITY At the start of the module we defined the terms ‘food’ and ‘nutrition’ and further highlighted how these relate to our health. This session adds the term ‘security’ to food and nutrition and explains the inter-relationship and difference between food security and nutrition security. We also observed in the introduction that tea estate workers were not food and nutrient secure as they did not eat adequately (only 3 out of 15 food groups). What is food security? When food security is achieved this means that: “Each person has (physical and economic) access at all times to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life.” In other words, to be ‘food secure’ at individual, household, village, or community level, food should be: Available: refers to the physical presence of food, be it from own production or from the market or shops Accessible: refers to households and all individuals within those households having sufficient resources such as money, labour, time and knowledge to obtain appropriate foods for a nutritious diet Utilizable: Individuals should be able to eat and absorb in their bodies the available and accessible food. There should be no diseases or ailments like diarrhoea, malaria, worm infestation that limit individuals from benefiting from the eaten food Sustainable: Individuals should feel confident that they will have enough food to feed their family tomorrow, the next week, month and year. Food should therefore be available, accessible and utilizable at all times What is nutrition security? Sustainable access to food does not necessarily mean that all household or community members will be healthy. There are other factors in addition to food security that help ensure the achievement of individual, household and community health: 



There is a need to provide adequate care for the young, the sick, the elderly, the physically handicapped and all other household members. Care can mean ensuring that all individuals have eaten according to their needs, that those who are sick are treated, and that women are supported to exclusively breastfeed their children for the first 6 months There is also the need to adequately prevent and control diseases so that foods eaten can be used by our bodies. This necessitates having measures in place which prevent, control and treat any diseases. Such measures can include: maintaining environmental hygiene and sanitation, taking children for immunisation, attending antenatal clinics by pregnant mothers, seeking medical treatment for any infections, deworming children and all other household members.

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From the above, we observe that three conditions must be fulfilled if all individuals are to be healthy: food security, adequate care and adequate prevention and control of diseases. It is only when these conditions are fulfilled that a household or community can be nutrient secure. Nutrient security is more than food security. Individuals, households and communities can only attain good health and nutrition if the three conditions of nutrient security; food security, adequate care, and adequate prevention and control of diseases are achieved.

How can food and nutrition security be improved on the tea estates? In order to achieve food and nutrition security among tea estate workers, the underlying factors holding individuals back from accessing and utilising food, providing care for household members and seeking treatment for all ailments would need to be addressed. The challenges will need to be addressed at different levels; at household level as well as at estate management level. Actions that can be taken by the workers / households:  Development of household and community gardens so that a wide variety of fruits and vegetables can be grown. The following nutritious foods can be grown: beans, peas, ground nuts and various kinds of green leafy vegetables such as amaranthus (dodo), spinach, kale (sukuma wiki), cabbages, as well as red/orange/yellow coloured vegetables such as chilli peppers (habanero), carrots, tomatoes. Fruit trees can be planted and yield lemons, oranges, mangoes, avocadoes, pineapples, passion fruit, etc.  Constructing food stores such as granaries to preserve surplus food and provide food in times of scarcity  Household domestication of birds and animals (rabbits, cows, goats, chicken, ducks, etc.) can provide milk, ghee, meat and increase household income through selling some of the products  Preserving and basic processing of food, through methods such as solar drying or fermentation which can improve the nutrient content of some foods and increase the availability of seasonal foods (e.g. mangoes, tomatoes, cabbage)  Practicing exclusive breastfeeding for children below 6 months and giving those 6-24 months nutrient-rich foods 4-5 times a day, in addition to breast feeding Actions that can be taken by the estate management:  Allowing workers to grow food in the labour lines and possibly, on other idle land on the estate (e.g. on some estates in India, workers are allowed to grow rice)  Using idle estate land for growing fruit trees, e.g. citrus fruits (rich in Vitamin C), avocadoes or mangoes and distributing this among the workers  Allowing workers to construct food stores and/or develop communal food storage facilities  Allowing the workers to keep livestock in a way that is manageable for the estate (it works in other countries like India where estate workers have cows and chickens). It would enable relatively cheap access to animal-based proteins  Better equipped health facilities and more health-focused campaigns / sensitisation among the workers, e.g. on breast feeding and child feeding  Arranging transport to local markets 18


  

Buying food products in bulk and selling it on to the workers who will then benefit from economies of scale (e.g. cooking oil, rice, fruits, …) Providing nutrition, cooking and food preservation lessons Promoting economic activities through which households can obtain extra income that can then be used to purchase food

How to ensure adequate care for all household members  Effectively using the available resources to ensure that food is available to all household members  Attending to all household members who are sick  Nurturing the physical and social development of children (e.g. allowing children to play and socialise)  Promoting general family happiness where all members can freely interact and eat food as a family (i.e. controlling violence in a household and/or community) How to prevent and control diseases  Promoting individual, household and community hygiene  Ensuring that all children are immunised according to recommended health schedules  Effective treatment of infections, e.g. diarrhoea, malaria, worm infestations, etc.  Improving health seeking behaviours such as women seeking antenatal care during pregnancy, women giving birth at health facilities, individuals going for regular medical checkups and seeking early treatment for illnesses

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SUMMARY MODULE 1: FOOD&NUTRITION SECURITY We need a BALANCED DIET to stay healthy. Children also need it to grow well, both physically and mentally. Eating a diverse diet means eating many different foods each day so that we consume lots of different nutrients. These nutrients keep us healthy in different ways: e.g. iron helps the body make red bloods cells (which carry around oxygen and therefore give us energy), vitamin C helps fight off illnesses and protein is the body's primary building block for muscles, bones, skin and hair. Most foods provide more than one nutrient. We need to eat all of the following in the right amounts: TYPES OF NUTRIENTS

FOODS THAT CONTAIN THESE NUTRIENTS

BENEFITS OF THESE NUTRIENTS

PROTEINS

Animal-based: fish, meat (includes poultry), eggs, milk, yoghurt, grasshoppers (nsenene) and white ants (enswa)

BUILD AND REPAIR OUR BODIES

Plant-based: beans (include soy beans) peas, nuts, seeds

CARBOHYDRATES

Millet, Irish potatoes, sweet potatoes, cassava, posho, sorghum, yams, rice, plantain (matooke) and bread

GIVE US ENERGY

FATS

Sunflower oil, Mukwano oil ghee, suet

GIVE US ENERGY

VITAMINS &

FRUITS: mango, orange, pineapple, avocado

PROTECT AGAINST ILLNESS

MINERALS

VEGETABLES: amaranthus (dodo), spinach, kale (sukumawiki), pumpkin leaves, cowpea leaves, carrots, cassava leaves, green pepper, nnakati, malakwang,eboo, green beans, tomato, sweet potato

HELP PRODUCE ENERGY

CLEAN WATER and other drinks

HYDRATION

MAINTAIN WATER BALANCE

Nutritious diets do not have to be expensive; key is to consume a variety of locally available/grown food on a daily basis.

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It is especially important for the following categories of people to have a balanced diet:  Pregnant and breastfeeding/lactating women  Babies (up to 6 months)  Children  People with chronic (long-term) illnesses (e.g. HIV/AIDS) Key vitamins and minerals for children and pregnant/breastfeeding women:  Iron: Helps make red blood cells, which carry oxygen around the body. Iron deficiency is a major cause of anaemia and impairs a child’s cognitive and physical development  Iodine: Helps to regulate the thyroid gland (in the neck) which controls the development of the body, including the brain, and regulates physiological processes (or metabolism). Iodine deficiency is the greatest single cause of mental retardation and brain damage  Vitamin A: Strengthens our immunity which helps us fight off infections. Improves vision in dim light. Keeps the skin and the linings of some parts of the body healthy. Vitamin A deficiency causes early childhood blindness and increases the severity of infections and anaemia, in both children and pregnant/breastfeeding women  Zinc: Supports the immune system, promotes healthy growth during childhood, and heals wounds. Zinc deficiency affects children’s health and physical growth. The food pyramid: All of these types of food should be eaten but the foods at the bottom should be eaten most and those at the top more sparingly.For a healthy diet, a minimum of 5 food groups need to be eaten every day.

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MODULE 2: NUTRITION & HEALTH Introduction When workers were interviewed as part of the baseline survey, they were only able to describe a limited number of signs and symptoms of malnutrition. This poses a risk to the timely identification of malnutrition in the community setting. To address this, this module explains the different forms of malnutrition, how it can be identified and what the main nutrient deficiencies are - which gives us an insight into the prevention of malnutrition. This module therefore explores the link between nutrition and health for the most vulnerable groups in society: (young) children, pregnant women, and the sick. It explains how to care for young children and what the special nutritional needs are of pregnant women. The final section looks at how optimal nutrition and attention to sanitation and hygiene can help prevent diseases. The baseline survey revealed that there is clearly scope to prevent diseases better in the tea estates covered by the study. For example, around 40% of those interviewed did not boil water before consuming it with most of them believing that un-boiled water is clean. At the same time, it was found that 19% respondents had a household member who had suffered from diarrhoea in the month preceding the survey. In order to control worm infestation, 88% of the respondents routinely had their children de-wormed. In addition, 81% of respondents had a household member suffering from malaria.

Objectives of the module After having completed this module, participants should be able to: 1. Describe the causes and dangers of under-nutrition 2. Describe how to care for under-nourished children 3. Explain how to prevent under-nutrition and diseases 4. Pass on recommended infant and young child feeding practices 5. Support the community to implement hygiene and sanitation practices

Overview 1. 2. 3. 4. 5. 6. 7. 8.

Overview of malnutrition Causes of under-nutrition Forms of under-nutrition Wider impact of under-nutrition Family and community prevention of under-nutrition Tips for optimal infant and young child feeding Nutrition during pregnancy & breastfeeding Disease prevention & sanitation and hygiene

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2.1. OVERVIEW OF MALNUTRITION The term ‘malnutrition’ refers to two conditions: under-nutrition or over-nutrition. Overnutrition is a condition that results from eating food in excess of body requirements. In such circumstances, individuals tend to become overweight or obese. Under-nutrition results from not eating enough to supply the body with all the required food nutrients. In this situation, affected individuals lose weight, frequently fall sick and become deficient of some macroand micronutrients. In children, physical growth and mental development can be severely affected. Here the main focus will be on under-nutrition given that it is the bigger challenge in our communities.

2.2. CAUSES OF UNDER-NUTRITION Many factors can cause under-nutrition as summarized below. Most of these relate to eating diets low in nutrients, severe and repeated infections, not feeding children as recommended, poor household and environmental hygiene, failure to treat household members on time and failure to care and attend to all household members. Some of these factors are in turn related to low understanding of how we should feed, poverty, and the lack of food at household level (household food insecurity).

MALNOURISHED CHILD

Inadequate diet

Household food insecurity

Frequent illness

Inadequate maternal and childcare

Poor access to health care and healthy environment

Culture, education, awareness

Livelihoods

Policies

Financing Policy and leadership commitment to improved nutrition 23


2.3. FORMS OF UNDER-NUTRITION Under-nutrition manifests itself in 4 different forms:  Acute under-nutrition or thinness  Underweight  Stunting  Micronutrient deficiencies 1. Acute under-nutrition Acute under-nutrition is a condition characterized by weight loss, wasting, and in very severe cases the swelling of both feet with fluids (bilateral pitting edema). It is called acute because its causes may be sudden and individuals develop related signs within a few days. In most cases the child is already under-nourished/underweight and if it then suddenly gets sick with fever and diarrhoea, the condition may become ‘acute.’ Health workers further differentiate between two forms of severe acute malnutrition: marasmus (non-edematous malnutrition) and kwashiorkor (edematous malnutrition). The relationship between under-nutrition and external factors can be seen in the following figure:

Poor hygiene and sanitation

Inadequate knowledge

Low food production

Sickness Gender/Status

UNDERNUTRITION

Absent parents

Lack of variety of foods

Cultural and social practices

Poverty

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NUTRITION TRAINING MANUAL: Developed For Tea Communities in Uganda Figure 2.1: Common Causes of Malnutrition in Communities

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Box 2: Kwashiorkor/oedematous malnutrition Kwashiorkor normally happens in children between 6 months and 3 years. This condition is usually seen in children who have stopped breast feeding and are mainly fed on energy-giving foods with minimal protein content.

Common Signs and Symptoms of Kwashiorkor - Swelling (pitting oedema) of feet, hands and face - Thin/ reddish hair which can be pulled out easily - The child’s muscles are weak and wasted, especially in the upper arms, thighs and the neck - Child has no interest in their surroundings - Skin loses colour and becomes lighter, peels off and develops sores - Children develop pot bellies

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2. Underweight An individual is underweight when he/she has low weight compared to the average weight of healthy individuals of the same age and sex. It may develop slowly or suddenly depending on the cause of malnutrition. Underweight children can be identified easily if their age is known. Parents/carers who are worried about their child’s weight or growth are advised to visit a health centre on a monthly basis so that health workers can monitor the child’s weight.

3. Stunting Stunting is a form of under-nutrition where a person is too short for his/her age compared to other healthy individuals of the same age and sex (< -2 standard deviations below the growth reference). It may be as a result of long term inadequate food intake, frequent illnesses, inappropriate feeding practices and/or poor absorption of nutrients in the body. This condition reflects growth failure and is irreversible if not addressed within the first two years of the child’s life. In some communities more than half of the children may be stunted. This makes it difficult for people to recognize this as a problem. However, the consequences of stunting are very serious: they affect the child’s mental and physical development, will lead to poorer results in school and a lower income-earning capacity later on in life.

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4. Micronutrient deficiencies As covered in module 1, vitamins and minerals, also known as micronutrients, are a critical component of good nutrition. In particular, folate (vitamin B9), iodine, iron, vitamin A, zinc, and other B vitamins including thiamine (vitamin B1), riboflavin (vitamin B2), niacin (B3), cobalamin (vitamin B12) and pyridoxine (vitamin B6) are important for healthy and productive populations. Without them, babies may be born with birth defects (because of their mothers’ deficiencies), children can develop blindness and an inability to learn properly, among other long-term disabilities. Each year, more than one million children under five die from vitamin A and zinc deficiencies around the world. Vitamin and mineral deficiencies affect up to two billion people. Prolonged failure by individuals to eat foods rich in vitamins and minerals may lead to the development of vitamin and mineral deficiency disorders. Manifestations of vitamin and mineral deficiencies take long to develop and individuals may not realize that they are affected. By the time signs are seen, the conditions are in advanced stages; for this reason, vitamin and mineral deficiencies are also referred to as hidden or silent hunger. In order to combat some of these deficiencies, children are given vitamin A supplements, women are given iron/folic acid supplements when pregnant and people are advised to use iodized salt in food preparation. Micronutrient deficiencies that constitute a public health concern in Uganda: a) Vitamin A deficiency The body’s immune system needs vitamin A in small amounts to help fight infections. Vitamin A is also important for proper growth and reproduction. Insufficient vitamin A impairs vision. Vitamin A deficiency is the leading cause of blindness in children. Globally, an estimated 250,000 to 500,000 vitamin A-deficient children become blind every year. Half of these children die within a year of becoming blind. Vitamin A deficiency also causes night blindness and increases the risk of child deaths, especially from diarrhoea and measles, as well as maternal deaths. In Western Uganda, 44 of every 100 children between 6 months and 5 years are not adequately fed on foods rich in Vitamin A.1 Consequently, 30% of these children suffer from Vitamin A deficiencies.2 b) Iron deficiency Iron is a mineral that, combined with a protein in our blood, carries oxygen throughout our body. It is absolutely critical to growth and development and ultimately to survival, and our bodies store it in several places. Women need more iron than men. During pregnancy, the growing baby also requires iron that is taken from the mother’s blood and iron stores. In its more severe stages, iron deficiency causes anaemia. Anaemia is defined as a low blood haemoglobin concentration. Apart from a deficiency of iron in the diet, anaemia may also result from other causes, such as severe blood loss, other micronutrient deficiencies or 1

UBOS and ICF International Inc. 2012. Uganda Demographic and Health Survey 2011. Kampala, Uganda: UBOS and Calverton, Maryland: ICF International Inc. 2

UBOS and ICF International Inc. 2012. Uganda Demographic and Health Survey 2011: Vitamin A Addendum. Kampala, Uganda: UBOS and Calverton, Maryland: ICF International Inc.

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heavy intestinal worm infestation. Iron deficiency also impairs brain development and increases maternal and child mortality. Globally, more than 130,000 women and children die each year because of iron deficiency anaemia. In Uganda, it is estimated that 50% of children under 5 years and 24.2% of women of reproductive age are anaemic. In Western Uganda, 39 of every 100 children are believed to be anaemic. c) Iodine deficiency Eighteen million children per year are born with impaired mental abilities around the world because of iodine deficiency. Nearly two billion individuals have insufficient iodine in their diets, including one third of all school age children. Populations with chronic iodine deficiency showed a reduction in their intelligent quotient (IQ) of 12.5 to 13.5 points. Iodine is a mineral essential for human development and growth. Our bodies need iodine to produce the hormones that regulate the thyroid gland. The most commonly known sign of iodine deficiency is goitre, the swelling of the thyroid gland in the neck. Iodine deficiency primarily affects the developing brain. If a pregnant mother is severely iodine deficient, this may lead to cretinism in her baby, the most serious form of mental retardation and associated physical disabilities. d) Zinc deficiency The human body relies on zinc to perform many functions including healing of wounds, growth and repair of tissue, proper clotting of blood, correct thyroid function, metabolism of proteins, carbohydrates, fats and alcohol, foetal development and sperm production. The symptoms of severe deficiency include retarded growth, diarrhoea, mental disturbances and recurrent infections. Zinc supplementation trials conducted over the last few decades in children from developing countries have indicated improved growth rates and reductions in incidences of diarrhoea, pneumonia and various infectious diseases. e) Vitamin B12 deficiency Deficiency of Vitamin B12 (cobalamin) causes neurological deterioration, a specific form of anaemia, and possible impaired immune function among other health consequences. In infants and young children it can severely delay their development. f)

Other Vitamin B deficiencies: thiamine (B1), riboflavin (B2) and niacin (B3), pyridoxine (B6) and cobalamin (B12)

Vitamin B deficiencies are highly prevalent in many developing countries, especially where diets are low in animal products, fruits and vegetables, and where cereals are highly milled prior to consumption. Pregnant and lactating women, infants and children are most at risk of vitamin B deficiencies. Severe thiamine deficiency can result in potentially fatal heart failure or peripheral neuropathy. Early symptoms of riboflavin deficiency can include weakness, fatigue, mouth pain, burning eyes and itching. More advanced deficiency can cause brain dysfunction. Niacin (B3) deficiency can result in pellagra, which causes skin rashes. Other symptoms include vomiting, diarrhoea, depression, fatigue and loss of memory. Symptoms of severe vitamin B6 deficiency include neurological disorders (i.e. epileptic convulsions), skin changes and possibly anaemia. 29


g) Folate deficiency Folate (vitamin B9) plays a key role in cell multiplication and tissue growth. Deficiency of folate during pregnancy increases the risk of giving birth to infants with neural tube defects and possibly other birth defects. Spina bifida and anencephaly, the two most common neural tube defects, occur when the neural tube does not close properly, exposing the baby’s brain or spinal cord to amniotic fluid. Neural tube defects affect an estimated 300,000 or more new-borns each year globally. Folate deficiency can also lead to impaired cognitive function in adults. It tends to be more prevalent in populations that consume a lot of cereals (low in folate) and few leafy greens and fruits (high in folate).

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2.4. WIDER IMPACT OF UNDER-NUTRITION The consequences of under-nutrition are not only felt by the affected individuals; other household members and the community are equally affected when many individuals in a particular community are under-nourished. Individual consequences

Family and community consequences

Physical abnormalities/impairments

- Cost associated with the treatment of under-nourished persons

Impaired brain development

- Poor family and community development

Frequent illnesses

- Loss of labour productivity which affects engagement in economic activities and income potential

Death

- Loss of family members and loss of income

Children are unable to grow into productive adults

2.5. FAMILY AND COMMUNITY PREVENTION OF UNDERNUTRITION It is always important that adequate measures are undertaken for all household members to stay healthy. Prevention should be the key for optimal health outcomes and is cheaper than treatment.         

All household members should eat adequately with a focus on everyone eating a diverse diet (covering all food groups) All household members should receive timely treatment for all diseases, e.g. diarrhoea and malaria Maintain individual, family and community hygiene and sanitation Babies should be exclusively breastfed for the first 6 months of their life, and given other nutrient-rich foods in addition to continued breastfeeding from 6 months onwards The growth of children should be monitored till they are 2 years of age Children should get their vaccinations in time Children should get a Vitamin A supplement two times per year Pregnant women should attend ante-natal services and comply with prescribed iron/folic acid medication If parents are HIV positive, their children can be tested at 10 weeks of age so that they can know if they are infected with HIV and they can begin to receive treatment and care

A child with any signs of malnutrition (most typically, loss of weight or swelling of the body) should be taken to a health facility immediately for a medical examination. Also children showing any of the following signs should be seen by a doctor urgently: 31


    

High fever (possible risk of malaria) Refusal to feed and being very weak Chest infection (cough and difficulty breathing) Diarrhoea (more than 3 loose stools a day for two days or more and/or blood in the stool, sunken eyes) Vomiting (cannot keep anything down)

2.6. TIPS FOR OPTIMAL INFANT AND YOUNG CHILD FEEDING Children under 6 months of age Breastfeeding is crucial from birth to when children are 6 months old. They should be exclusively breastfed and do not need any other foods or liquids with the exception of medications prescribed by health personnel. How to practice exclusive breastfeeding:  As soon as the baby is born, have the midwife put the naked baby between the mother’s breasts, cover her lightly and keep the baby there for at least one hour. Let the baby start sucking.  The child should be initiated to breastfeeding within one hour after birth  During these first days, feed the baby often (every 11/2 to 2 hours) for short feeding times. Frequent feeding will help the milk to flow sufficiently  Breastfeed for a longer time at each feed as the child grows older  Let the baby empty one breast at a time. This will ensure that the baby gets the most nutritious and satisfying milk. If still hungry, offer the baby the other breast

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   

Ensure correct positioning and attachment of the baby to the breast as this helps to ensure that the baby sucks well, the mother produces a good supply of breast milk and it prevents the mother from developing sore and cracked nipples Breastfeeding the baby often, at least 10 times, day and night, as this helps to produce lots of breast milk to ensure that the baby grows healthy Water or pre-lacteals (sugar water or liquids/fluids) are NOT necessary and should not be given to children under 6 months The mother should ensure that she eats a diverse diet (containing a variety of foods), maintains personal hygiene and seeks medical attention whenever feeling unwell

Benefits of exclusive breastfeeding  Breast milk is the only food that is well balanced; there is no other food as good as breast milk for a baby  Breast milk is inexpensive, always available and does not need any preparation  Breast milk is sterile/clean. It is therefore completely safe for the baby to drink  It provides the baby with immunity thus preventing the child from frequent illnesses, such as diarrhoea and respiratory infections  Breastfeeding initiates bonding between the mother and her child

For a child between 6–24 months old  Introduce nutrient rich foods and also continue breastfeeding  Foods should initially be made soft and easy to eat by the child  It is advisable to introduce one food at a time while monitoring for any likely intolerances to particular foods  As the child grows to 12 months, gradually introduce the child to the household diet  Give children small but frequent feeds  Always ensure that children are fed patiently; they should not be forced to eat  Children should be encouraged to eat more at every meal, and given an extra meal each day (or extra snacks in between meals)  Give fluids to drink preferably fruit juices, clean water, yoghurt, milk. However, limit fluid intake before meals as this limits the quantity of food children can eat Home feeding of a sick child During illness (malaria, diarrhoea, pneumonia or other) the parent/carer must ensure that they continue feeding the child and increase fluids as follows: 33


Less than 6 months  Breastfeed more during illness. This will help the baby fight the illness, recover more quickly and not lose weight. Breastfeeding also provides comfort to a sick baby  If the baby refuses to breastfeed, continue to encourage your baby until he or she takes the breast again  Give only breast milk and prescribed medicines to the baby  If the baby has been very ill, you may need support to re-establish exclusive breastfeeding  If the baby is too weak to suckle, either express breast milk and feed by cup or hand express milk directly into the baby’s mouth. This will also help the mother to keep up her milk supply and prevent breast swelling More than 6 months  Increase the frequency of breastfeeding and offer additional food to the child to maintain his or her strength and prevent weight loss  Feed the child foods that he or she likes in small quantities throughout the day  Take time to patiently encourage the sick child to eat as his or her appetite may be decreased because of the illness  Offer the child simple foods like porridge and fruits, even if he or she does not express interest in eating  Avoid spicy or fatty foods  Do not use bottles, teats or spouted cups, since these are difficult to clean During recovery  When a baby is recovering from an illness, he/she will need to be breastfed and eat more than usual  If the child is over 6 months, give him or her one additional meal of solid food each day during the next two weeks after he/she has recovered. This will help your child regain the weight lost during the illness  Take enough time to actively encourage your child to eat this extra food and breastfeed more frequently until his or her appetite has returned  It is very important that the child gets the vitamin A supplement twice in the year to help the body recover faster 34


2.7. NUTRITION DURING PREGNANCY & BREAST FEEDING Adequate feeding is important for all women of reproductive age but especially when they are pregnant. Pregnant women should:  Eat one extra meal a day during pregnancy in addition to regular meals, and two extra meals during breastfeeding  Eat plenty of fruits and vegetables with every meal  Drink enough liquids every day (8 glasses)  Avoid taking tea or coffee with meals because they interfere with iron absorption and may therefore contribute to anaemia. It is better to drink tea or coffee an hour before or after a meal  Throughout your pregnancy and for at least 3 months after your baby is born you need iron and folic acid to prevent anaemia. It is better to take iron tablets with meals to increase absorption and avoid potential side effects, particularly nausea  Always use iodised salt to prevent poor brain development, poor physical growth and goiter. Iodised salt also protects against abortions, miscarriages and stillbirths  Get a vitamin A capsule from the nearest health facility and take immediately after delivery or within 8 weeks to help build your baby’s immune system through your breast milk  Take de-worming tablets as prescribed to treat worms and to prevent anaemia  Do not use alcohol, narcotics or tobacco products. They can damage the unborn baby  Sleep under an insecticide-treated mosquito net to prevent malaria. Take antimalaria medication as prescribed by a health worker  Attend antenatal care at least four times during pregnancy and always follow your health worker’s recommendations Special note for the adolescent mother: Before the age of 18 your body is still growing. You need extra care, more food and more rest than an older pregnant or breastfeeding mother to enable your body to grow fully and ensure that it produces enough milk for your baby.

2.8. DISEASE PREVENTION & SANITATION AND HYGIENE 1. Disease prevention through nutrition Good nutrition is important to prevent or reduce the duration and impact of many childhood diseases as well as chronic illnesses which may arise at a later age, like diabetes and cancer, and to manage diseases like HIV/AIDS and tuberculosis (TB). It ensures your body’s defence system stays strong and therefore reduces the chance of falling ill. Eating plenty of protective foods (fruit and vegetables) will help fight off diseases. Ideally, fruits and vegetables are eaten every day. Green leaves (like: dodo, nakati, bugga, malakwang, boo, pumpkin leaves, cassava leaves, sukama wiki, spinach) provide nutrients which help boost the body’s defence system. In circumstances when people are already ill, they do not feel like eating as they might have side effects from their treatment, infections in the mouth or lost their appetite. They could be encouraged to eat liquids like soups several times a day.

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On the other hand, there are certain foods that we should try to limit consumption of in order to prevent disease: Salt: too much salt can cause high blood pressure. 1-3 grams of salt (just few grains) each day is enough for a child and an adult Sugar: can cause diabetes (high sugar in the blood) and is bad for your teeth and mouth because it can cause thrush and holes in the teeth. 2 tea spoons of sugar or honey each day is enough to meet the daily need for sweetness Fried food and processed, pre-packed food: like oily or fatty foods like chips and deep fried meat or chicken. This can lead to the accumulation of fat in the blood vessels making them thin. This process affects proper blood flow in the body especially blood moving to and from the heart. This can lead to heart related diseases like hypertension (high blood pressure). Unhealthy snacks: like sugary sweets, cakes, buns, chocolate and sweets, which cause holes in the teeth as well as spoil a child’s appetite. Instead of these, give a child fruits (fresh or dried), bread, ground nuts, Gizelli (boiled maize and beans) or Kacumbali (cut tomato and onion salad) Sodas: which are very bad for small children as they damage their teeth and they develop the desire for sweet foods early in life Caffeine: (found in coffee and in smaller doses in tea) when taken too often it can stop the heart from pumping enough blood. Individuals especially children should not take more than 1-3 cups of coffee a day as it is a drug and can affect their ability to sleep well. Pregnant women should take it in moderation as well to protect their unborn baby. Tea should not be taken up to 1 hour after a meal as it can prevent micronutrients (iron) from being absorbed. Alcohol: it is dangerous for the body when taken in large amounts every day. It can stop body organs from working properly (mainly the liver) and should therefore never be given to children and pregnant women 2. Disease prevention through hygiene and sanitation Also personal and environmental hygiene practices are crucial to prevent and control diseases. The focus in this section is on hygienic food preparation. Once children are not breastfed anymore they lack the immunity protection provided by breast milk. In addition, from 6 months, children require complementary feeds which puts them at risk of diseases through unsafe food preparation. Key to clean and safe food preparation: clean hands, clean utensils, safe water and food, and safe food storage. Clean your hands  After using the toilet  After cleaning baby’s bottom  Before preparing food  Before feeding children or eating yourself 36


Wash hands thoroughly with soap/ash and plenty of water. Wash also between the fingers and under your nails. Dry hands in the air or use a clean cloth. Clean your utensils  Clean surface (table, mat or cloth)  Wash utensils immediately after use  Keep clean utensils covered  Use clean utensils, especially for young children. Open, smooth surfaced spoons are easier to clean  Baby’s cup should be washed & scrubbed in hot soapy water, and dip the cup in boiling water before use if feasible

Safe water and milk - Boil/treat water for drinking and baby’s feeds - Boiling means water surface is bubbling vigorously - Keep water in clean covered container. Ideally, a container where cups cannot be dipped - Boil milk before use - Milk and water can be boiled together

Safe storage  Keep foods in tightly covered containers  Store dry foods if possible (e.g. milk powder, sugar)  Use milk within one day if not refrigerated  Use prepared feeds within one hour  Keep rubbish bins covered and remove the rubbish regularly  Keep food preparation areas in good condition (repair wall cracks or holes)  Use baits or insecticides to kill pests (taking care not to contaminate food)  Keep domestic animals and insects away from food preparation areas  Do not store baby’s milk in pottery (unless it has a lid); it allows evaporation of water from the surface Module 3 will talk about food safety and food hygiene in more depth.

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SUMMARY MODULE 2: NUTRITION & HEALTH Definition of under-nutrition Under-nutrition results from not eating enough to supply the body with all the required food nutrients. Affected individuals lose weight, become deficient of macro- and micronutrients and therefore frequently fall sick. Causes of under-nutrition  Lack of dietary diversity  Eating foods low in nutrients  Failure to feed children as recommended  Poor household and environmental hygiene  Failure to treat household members on time  Failure to care and attend to all household members

Family and community prevention of undernutrition Prevention should be the key as it is cheaper than treatment. All household members should:  Eat adequately with a focus on everyone eating a diverse diet  Receive timely treatment for all diseases  Maintain individual, family and community hygiene and sanitation Growth of children should be monitored till they are 2 years of age and take vitamin supplements Children should get their vaccinations in time HIV positive parents should seek additional services

Forms of under-nutrition Acute under-nutrition or thinness: characterized by weight loss, wasting, and in very severe cases the swelling of both feet with fluids Underweight: Individuals have low weight compared to the average weight of healthy individuals of the same age and sex Stunting: Individuals have less height compared to the average height of healthy individuals of the same age and sex. It is irreversible Micronutrient deficiencies: Individuals are deficient of vitamins and minerals. These deficiencies take long to be detected until signs are visible. By then, much damage has already been caused Impact of under-nutrition  Physical abnormalities/impairments  Impaired brain development  Frequent illnesses  Death  Faltered growth in children  Increased costs associated with the treatment  Poor family and community development  Loss of labour productivity, income and family members

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Tips for optimal infant and young child feeding • Initiate breast feeding in the first hour of life • Exclusively breast feed children up to 6 months of age and continue breast feeding until they are 2 alongside their other meals Maternal health • Eat more during pregnancy and breast feeding • Eat plenty of fruits and vegetables • Drink enough water (8 glasses) • Avoid taking tea or coffee • Take iron and folic acid tablets throughout pregnancy • Take vitamin A capsule within 8 weeks of giving birth to help build the baby’s immune system through your breast milk • Use iodized salt • Take de-worming tablets to treat worms and to prevent anaemia • Do not use substances like alcohol, narcotics or tobacco • Sleep under an insecticide-treated mosquito net to prevent malaria • Take anti-malarial drugs as prescribed by a health worker


Sanitation and hygiene to prevent diseases Clean your hands  After using the toilet  After cleaning baby’s bottom  Before preparing food  Before feeding children or eating yourself Wash hands thoroughly with soap/ash and plenty of water. Wash also between the fingers and under your nails. Dry hands in the air or use a clean cloth. Clean your utensils and crockery (plates/bowls)  Before and after feeding your baby and food preparation generally

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MODULE 3: FOOD SAFETY, STORAGE & PRESERVATION Introduction Ensuring food safety and hygiene is important at individual, household and community level. It ensures that foods are safe for human consumption and that individuals do not develop any food-borne illnesses. This module equips participants with an understanding of key food safety and food hygiene issues and how these can be maintained within households and communities. The module explores different areas with regards to food safety including: food spoilage, food storage and food poisoning. An assessment of the food handling, safety, storage and hygiene practices by workers in Rwenzori and Mpanga tea estates revealed that:  





Household ownership of food storage facilities varied with only 63% of households reportedly storing food Households that stored food made use of cupboards, containers, baskets, sacks and open floors to store food. Those that did not own food storage facilities mentioned the lack of storage space, consumption of all food prepared and the lack of money to buy food storage facilities as being limiting factors to food storage. Respondents identified the following food hygiene practices: proper covering of food (68% of respondents), cooking of food (22% of respondents), use of clean utensils in food preparation (5% of respondents), warming of leftover food before consumption (4% of respondents) and keeping cooked and raw foods separately (1% of the respondents) Main challenges in ensuring food safety included the lack of adequate food storage facilities and poor storage methods that result in the destruction of stored food by pests, including cockroaches and rats

Objectives of the module By the end of this module, participants should be able to demonstrate good practices with respect to food safety and hygiene, including through food storage and preservation techniques. They will also learn how to prevent food poisoning.

Overview 1. The concept of food safety and hygiene 2. Food storage and preservation 3. Food poisoning

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3.1. The concept of food safety and hygiene Once food has been harvested, gathered or slaughtered, enzymes and bacteria become active in this food which cause it to deteriorate in texture and composition until it eventually becomes unfit for consumption. This deterioration is known as decay and leads to eventual food spoilage. Food safety and hygiene entail undertaking a series of measures to avoid spoilage and contamination of food.

At the core of maintaining food safety is the need for proper food handling (including cooking), storage and preservation as these greatly influence how long a food can stay fit for consumption.

Food is considered safe for human consumption when it is free from substances like contaminants, toxins and micro-organisms that can cause undesirable reactions in the body when such foods are eaten. To ensure that food is safe for consumption, it should be:  Protected from contamination by harmful bacteria, poison and other foreign bodies  Prevented from having any bacteria present multiplying to an extent which would result in the illness of consumers or the early spoilage of the food  For some foods: thoroughly cooked to destroy any harmful bacteria present  Discarded when spoilt and/or contaminated The benefits of proper food safety and hygiene are:  More efficient utilization of food consumed by the body contributing to improved health and nutrition outcomes  Prevention of food-borne illnesses (and sometimes death)  Less food wastage Causes of food spoilage Contamination of food stuffs can occur through different ways, including: inappropriate food handling at different stages throughout the food chain; poor hygienic conditions of the places where food is placed, prepared and/or stored; intentional or non-intentional mixing of food with other foods or non-food substances that are unhygienic (also known as food adulteration) and general poor environmental hygiene. Food can also be contaminated when put together with other foods that have already undergone spoilage. It is normal for food to spoil when no measures are undertaken to prevent its spoilage. Naturally, foods spoil over time due to the presence of either naturally occurring enzymes in particular foods or due to other external organisms or factors. Fruits and vegetables spoil over time because of the presence of naturally occurring enzymes that cause ripening and eventually, decay. Food spoilage may also be caused by micro-organisms such as moulds (commonly seen on bread), or yeasts and bacteria. These cause the food to break down, rot or go sour. The food may then discolour, smell bad or become sticky and slimy. Chemical hazards like pesticides and toxic metals may also lead to food contamination and spoilage. Like other living things, micro-organisms such as bacteria, need food, warmth, moisture and time to grow and multiply. The ideal temperature for most bacteria is 30-45°C. Bacteria thrive best in damp conditions and in moist foods. When the correct conditions for growth are present, bacteria can double in number every 10 to 20 minutes, so that in about six hours 1 million could be produced from just one bacterium! As they increase in number, micro-organisms feed on nutrients present in a food leading to chemical and physical 41


changes in the natural composition of the food and eventually food spoilage. Boiling kills most bacteria and cold temperatures slow down their growth. Freezing does not kill bacteria, it only inactivates the enzymes (they stay dormant until they defrost). Identifying spoilt food Food that is spoilt can be identified in different ways:  Off odours: Foods tend to develop undesirable off-flavours and/or odours as they spoil  Discolouration: Food undergoing spoilage normally changes in colour  Slime / Stickiness: Gravy or soups sometimes become thick and slippery to touch  Unusual taste: Food that is undergoing spoilage often changes in taste  The production of gas: Some foods - especially when stored in sealed containers develop some gases which will be noticeable when opening the container  Mould growth: Other foods, e.g. bread develop fungi like growth which is easy to see with the naked eye Foods at high risk of food spoilage Some foods are prone to faster spoilage by micro-organisms than others. Foods that spoil fast are usually referred to as “high risk foods.” Most often these are ready to eat foods or rich protein foods and require refrigerated storage. Examples of these foods are:  (Cooked) meat, including poultry  (Cooked) meat products including gravy, stews  Milk and milk products  Eggs and products made from raw eggs  (Cooked) Fish Food cross-contamination Previously safe food can spoil when it gets contaminated by bacteria from another food in a process known as cross- contamination. For example, it may occur when raw and cooked meat are cut on the same board or when fruits and vegetables are cut on a board previously used for cutting meat on but which was not cleaned. The main carriers of bacteria and causes of cross-contamination are:  Humans  Rubbish  Pets and other animals  Food, e.g. raw meat or poultry In order to avoid cross-contamination:  Do not let raw meat drip onto other food and keep raw meat separate from other food  Never use the same chopping board for raw meat and ready-to-eat food without washing the board (and knife) thoroughly in between  Maintain personal and environmental hygiene at all times. For example, always wash hands, chopping boards and utensils before starting food preparation All individuals carry bacteria in their intestines, nose, mouth and on their hands. These micro-organisms can easily be passed on to food when individuals do not maintain good hygienic practices, such as washing hands before cooking and after using the latrine. General tips for preventing food contamination and spoilage: Food hygiene  Keep raw and cooked meats separate to avoid cross- contamination 42


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It is useful to have a separate chopping board for raw meat. Do not put ready to eat food, such as bread, salad or fruit on a worktop or chopping board that has been touched by raw meat, unless it has been washed thoroughly first Cook eggs, meat, fish and poultry thoroughly to kill bacteria Thaw frozen meat and poultry thoroughly before cooking Cool and cover leftovers Preheat leftovers until piping hot to ensure that all bacteria are destroyed Wash fruits and raw vegetables before eating Prior to consumption, rinse fresh fruits and vegetables to remove possible pesticide residues, soil, and/or bacteria

Personal hygiene  Wash hands thoroughly with soap and water and dry them at each of these times: before starting to prepare food; after touching raw meat, including poultry; after touching raw eggs; after going to the toilet; after touching the bin and after touching pets or other animals  Cover or tie back hair and wear a clean apron/cloth whenever you are going to prepare food  Avoid touching face or hair while preparing food  Keep fingernails clean and short  Do not cough or sneeze over food  Avoid wearing rings, earrings or watches when preparing food  Cuts and wounds should be covered with a waterproof dressing  A person who has been ill, especially with food poisoning, should not work with food or be in the food preparation area Kitchen hygiene Cleaning the kitchen and all areas, surfaces and utensils used for food preparation is important to keep food safe and prevent bacteria from spreading. Avoiding the build-up of refuse also leads to better hygienic conditions in a kitchen. One must ensure that the area and utensils that have been used for food preparation are cleaned before doing anything else. ‘Clean as you go’: This provides a clean environment for other food preparations. The following should be noted:  Ideally, the kitchen should have adequate lighting and ventilation  Ensure having adequate supply of water and cleaning materials  Always wash worktops/chopping tables and utensils before food preparation begins  Regularly disinfect and change kitchen cloths as these are an ideal breeding ground for bacteria  Use separate cloths for kitchen (dishes) and bathroom (hands and body)  Keep kitchen bin covered, empty daily and disinfect once a week  Disinfect worktops regularly  Keep pets and all domesticated birds and animals out of the kitchen at all timesincluding night  Sweep kitchen floor daily and wash and disinfect regularly  Wipe up any spoilt foods straight away  Sanitize worktops/chopping tables and utensils thoroughly (with detergent) after they have been touched by raw meat, including poultry or raw eggs  Always ensure using clean utensils for serving food as this prevents the spread of bacteria 43


Disinfecting and sanitization of kitchen and kitchen equipment Disinfection refers to the use of antimicrobial agents-referred to as disinfectants to destroy micro-organisms that live on different objects including kitchen utensils, working tops and floors. Sanitization on the other hand refers to the cleaning of something by disinfecting or sterilization. The most commonly available home disinfectant or sanitizer is JIK. JIK is sold inexpensively in a number of local shops in most trading centres. To use JIK for disinfecting and or sanitization, follow the following diluting instructions: Add 1 cup (250ml) of JIK to 1L of water. Wash the affected areas and rinse after 1 minute, or, Add ¼ cup (62.5ml) of JIK to 5 litres of water. Wash the necessary areas and rinse after 30 seconds Environmental hygiene The environment in which we live has a big impact on the safety and hygiene of the food that we eat. For this reason, proper environmental hygiene should be maintained in our households, in the markets from where we buy household food, in homestead gardens where vegetables are grown and in all public and private areas and water sources. Sanitizers are we substances that simultaneously clean and disinfect At household/community level should ensure:  Proper refuse disposal in designated places are antimicrobial agents that areurinating applied to non-living objects  We Disinfectants use clean pit latrines/toilets (defecating and should happen in to destroy microorganisms that are living on the objects. designated places only)  We have sufficient supplies of water, soap and other disinfectants chemical that kills germs: a chemical that destroys or inhibits the growth of microorganisms that cause disease  Water places are kept clean and not used by animals  To keep public places clean at all times Failure to maintain environmental hygiene Microsoft® Encarta® 2009. © 1993-2008 Microsoft Corporation. All rights reserved. may lead to waste being washed into our sources of water and food. It also leads to rapid multiplication of flies that further spread germs and bacteria.

Cooking Tips  All foods that are not eaten raw should be properly cooked (includes boiling, frying, roasting)  Especially meat (beef, pork, chicken) should be well cooked as eating undercooked meat can lead to worms  Meat that is properly cooked does not have any pink parts. If meat has pink parts, one should continue cooking as this meat is still undercooked  To check a whole chicken or other thick piece of meat, pierce the thickest part of the leg with a clean knife until the juices run out. The juices should not have any pink or red in them  Leftover food should always be kept in clean covered containers and kept in cool temperatures. This food should be reheated (until piping hot) before eating. However, leftovers should not be reheated more than once and should be used within 1 – 2 days of cooking

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3.2. Food storage and preservation Storing food the right way can be a great help in ensuring a household’s food security. This section discusses the importance of food storage and the different ways in which households can rightly store different types of foods. Food storage broadly refers to the different means through which food can be kept for longer periods without the food spoiling. The shelf life of a food is the length of time a food remains safe and fit for human consumption. It is essential to store food properly to ensure the following:  Food remains in good condition for as long as possible  Food is protected from flies, dust and other organisms that can spoil and/or contaminate food  Food is protected from organisms like insects and rats that eat and spoil food. For instance, proper storage of grains protects it from rats and aphids which eat and spoil maize  Reduction in post-harvest food losses General guidelines for food storage Foods should be stored differently on the basis of how fast they will spoil or develop offflavours. Foods can be categorised into 3 groups: 1. Perishable (e.g. milk, meat, raw fish) 2. Semi-perishable (e.g. vegetables and grains) 3. Non-perishable foods (tinned or dried food) Perishable foods: e.g. eggs, milk, cream, fresh meat. These have the shortest shelf life and must be used within a few days. These should be stored in a clean cool place. In the absence of refrigerators, such foods can be placed in clean containers, saucepans or pots. The containers can then be placed in a basin of cold water covered with a clean piece of cloth. In all circumstances, milk and meat should be consumed within 2 days. Semi-perishable foods: e.g. bread, cakes, fresh fruit and vegetables. Breads and cakes should be stored in a bread bin or tin. Fruit and vegetables may be stored in a rack or basket. When put in storage, care should always be taken to remove and discard the particular foods that start showing signs of spoilage so as to avoid cross-contamination. Non-perishable foods: e.g. dry, bottled and tinned foods can be stored in a cupboard on their own or in airtight containers Further food categories and their storage methods The recommended storage conditions for foods often vary; the variations even differ for the same foods depending on the freshness or dryness of the particular food. Storage of cereals, bread, flour, and rice  Bread needs to be stored in its original package at room temperature. It should be used within 5 to 7 days or else it will grow moulds (a sign of spoilage)  Cereals - depending on the quantities and level of dryness - may be stored at room temperature in tightly closed containers to keep out moisture and insects. Properly dried cereals packaged in sacs can be stacked on racks in a dedicated food store. Due attention should be taken to keep out rodents (rats) that normally feed on stored grain 45


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Raw rice can be stored in closed containers at room temperature and used within one year. Once cooked, rice should be eaten immediately in the absence of refrigeration

Storing fresh vegetables  Proper storage of fresh vegetables helps to maintain their quality and retain nutrient value. Most fresh vegetables need to be stored under low temperatures in areas which are neither humid nor damp. If available, fresh vegetables can be stored in a clay pot fridge.

Constructing a clay pot fridge This is made of a clay pot, a basin of water and a clean cloth. Place the pot in the basin of water. Put the vegetables inside it and cover the pot with a clean wet cloth. Place one corner of the cloth in the basin of water so that water is continuously sucked into the cloth as it dries out.

Figure 1: Demonstrating a clay pot fridge

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Root vegetables (potatoes, sweet potatoes, onions, etc.), squashes and eggplant can be stored in a cool, well-ventilated place between layers of grass Onions should be left to dry thoroughly under the sun to avoid rotting in storage and when well dried can be kept for about 3 months Tomatoes continue to ripen after harvesting and should be stored at room temperature

Storing fresh fruits  All fresh fruits generally need to be stored in a cool area, preferably in a clay pot fridge  Fruits have a tendency to either be contaminated by other foods and or to absorb odours from other foods. They therefore need to be kept separately Storing milk and milk products  Milk is a highly perishable food and yet very nutritious. To prolong its shelf life, milk should never be left at room temperature for a long time as it spoils quickly 46


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Care must be taken to keep milk in clean covered containers that should be left to stand in a cool place. Unrefrigerated milk should be used within a day

Storing meat and fish  Meat (including poultry), fish, eggs and milk are the best sources of proteins in the human diet. Given their high protein and moisture content, these products are highly perishable. It is for this reason that these products will spoil faster than others however well prepared and stored. One big contributor to the faster spoilage of fresh cuts of meat is the fact that these usually contain spoilage bacteria on the surface that can grow quickly, producing slime and causing spoilage after a few days. Meat should be prepared and eaten within 24 hours of purchase/slaughter.  Ground and thinly cut pieces of meat are more susceptible to spoilage given the larger surface area for bacterial action. Meat and meat products should be used within a few days. If the meat cannot be used within a day, it is advisable to dry, smoke or salt it before storing it  Like meat, fresh fish should be eaten immediately. Never store fish in water as this leads to loss of nutrients from the fish. In order to store fish for longer, it should be smoked. Storing Root Tubers (Cassava, Sweet Potatoes)  Most root tubers may not be stored well for long after harvest, however root tubers keep longer than other vegetables, fruits, meat, milk, etc.  When tubers will not be prepared within a few days, care should be taken to avoid bruising them. It is advisable to harvest cassava before it becomes fibrous, with part of the aerial stem still attached. This helps preserve the tubers in good condition.  Cassava tubers can also be piled into heaps and watered daily to keep them fresh or coated with a paste of mud to preserve their freshness. They can keep for about 4-7 days.  Unbruised sweet potatoes can be kept in a cool, dry place for up to 4-7 days. Care should be taken to remove any sprouting buds.  In times of bumper harvests, tubers cannot be kept for long; it is advisable that these are peeled and sliced in small pieces and then sun dried on canvas or cleaned floors. Once well dried, the sliced dry tubers can be kept in sacks and stored for up to 3-4 months without spoiling. Food preservation refers to the different techniques that are applied to food to prevent it from spoiling. The science behind food preservation involves either:  The destruction of micro-organisms responsible for causing food spoilage  Reducing/eliminating the water (moisture) content from food  Altering the temperature and other conditions that favour the growth of food microorganisms, and thereby retarding microbial growth and replication (thus delaying food spoilage). Simple household food preservation techniques Drying A number of foods (fruits, vegetables, tubers-cassava, and potatoes) which cannot be stored for long in their fresh state without spoiling can be preserved by drying. Before drying, there should be enough sunshine and foods should be sliced in small pieces for them to dry faster. Dried fruits can be eaten in their dry state (e.g. dried jackfruit), vegetables and potatoes need to be cooked by boiling in water while dried cassava can be ground into flour and used later. 47


Smoking Smoking meat and fish is a highly recommended method for prolonging their storage life. The fish is first cooked over a high fire and then smoke-dried in one to five days (and nights) over a low fire. Fresh-dried fish keeps for up to a week, while hard-dried fish (keeping fish in salt for several weeks) keeps for several months. Salting Salting is a simple food preservation method that can be used to prolong the shelf life of food for a few days. When added to foods, salt takes out moisture and retards microbial growth and replication. Boiling Boiling of foods kills food microbes. Perishable foods can be boiled, cooled and kept in clean containers and then used within a day.

3.3. Food poisoning Food that has not been stored or prepared well has a high chance of containing a lot of micro-organisms. Depending on the level of micro-organisms, this food becomes unsafe for human consumption. When individuals consume spoilt or contaminated food, they develop food-borne illnesses; a condition usually referred to as food poisoning. Food poisoning is an acute illness, which usually occurs within 1 to 36 hours of eating contaminated or poisonous food. Symptoms of food-borne illnesses normally last from 1 to 7 days and may include one or more of the following:  Abdominal pain  Diarrhoea  Vomiting  Fever  Dizziness We can avoid most food-borne illnesses through observing strict hygiene and sanitary measures in preparing and storing food, serving food soon after preparation, and only eating pre-heated (very hot) leftover foods. Who is at risk of food poisoning? Anyone is prone to developing food poisoning if he/she eats contaminated food. Groups with an increased risk include:  Young children  Pregnant women  Elderly people  Individuals with autoimmune disorders, liver disease or decreased stomach acidity  Alcoholics – because of possible liver damage/disease  People weakened by malnutrition and illness, including chronic diseases  Individuals eating meals within institutionalised settings who share utensils and where the risk of unhygienic food handling practices is increased What to do when food poisoning arises? When symptoms of food poisoning manifest themselves for less than 24 hours (such as short episodes of vomiting and small amounts of diarrhoea) then this can usually be cared 48


for at home. If it persists for longer, then medical attention should be sought. The following is recommended:    

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Do not eat solid food while nauseous or vomiting but drink plenty of fluids and cereal gruels/porridges Sip small, frequent sips of clear liquids, including water to stay hydrated Avoid alcoholic and caffeinated drinks If available, Oral Rehydration Solution can be used. Mix one sachet of ORS powder into one litre of boiled or treated water in a clean container and stir well until it fully dissolves into a solution. Where this is not available it can be made from 1 litre of clean boiled/treated water, 6 level table spoonful of sugar, half level tablespoon of salt, and stir until sugar and salt dissolve and give to the person experiencing vomiting or diarrhoea. After successfully tolerating fluids, eating should begin slowly from the moment nausea and vomiting have stopped. One is encouraged to start by eating cereals

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SUMMARY MODULE 3: Food Safety, Storage & Preservation Food spoils. It is in our power however to prolong the shelf life of food through correct handling, storage and preservation. Once food has spoilt it should be thrown away as it can make us sick. HOW TO HANDLE FOOD?

HOW TO STORE FOOD?

Cook with clean hands, utensils and cooking area

Keep perishable foods COOL, e.g. in ‘clay pot fridge’ and use within a few days or less

Meat, eggs, fish contain a lot of bacteria. Cook these foods thoroughly to kill the bacteria Avoid these foods from contaminating other food, for example by washing your chopping board before cutting vegetables

Remove fruits/vegetables that show signs of spoilage as they will spoil the other fruits/veg they are mixed with Keep dry foods in closed containers HOW TO PRESERVE FOOD?

Throw away spoilt food = food that has changed in colour, is mouldy/gaseous, smells badly and/or has changed in taste

Drying ( e.g cassava, sweet potatoes, leafy vegetables)

Wash fruits and raw vegetables before eating Smoking (e.g. meat and fish) Salting (e.g meat and fish) Boiling (all foods with exception of fruits)

Food Poisoning When we consume spoilt food, we can develop food poisoning. Symptoms normally last from 1 to 7 days and may include abdominal pain, diarrhoea, vomiting, fever, dizziness. We can avoid it through observing strict hygiene and sanitary measures in preparing and storing food, eating food soon after preparation, and only eating pre-heated (very hot) leftover foods. What to do when food poisoning arises? When symptoms of food poisoning manifest themselves for less than 24 hours (such as short episodes of vomiting and small amounts of diarrhoea) then this can usually be cared for at home. If it persists for longer, medical attention should be sought. The following is recommended:  Do not eat solid food while nauseous or vomiting but drink plenty of fluids and cereal gruels/porridges  Sip small, frequent sips of clear liquids, including water to stay hydrated  Avoid alcoholic and caffeinated drinks  If available, use Oral Rehydration Solution. Mix one sachet of ORS powder into one litre of boiled or treated water in a clean container and stir well until it fully dissolves into a solution. Where this is not available it can be made from 1 litre of clean boiled/treated water, 6 level table spoonful of sugar, half level tablespoon of salt, and stir until sugar and salt dissolve and give to the sick person  After successfully tolerating fluids, eating should begin slowly from the moment nausea and vomiting have stopped. We should start by eating cereals

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