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BASIC NUTRITION EDUCATION FOR AFGHAN FAMILIES

Guidance Booklet on Essential Nutrition Messages

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Acknowledgement Malnutrition is one of the main causes of morbidity and mortality in our country. Good nutrition requires improving households’ access to diverse foods, care of mothers and children, and health and sanitation. It is only by working at community level that we can solve these problems in the long-term. We need to help families make the best choices for their health, within the resources they have. We appreciate that these materials have been developed on the basis of formative research and pilot tested, to make sure that they reflects the realities and needs of Afghanistan. The Ministry of Health and Ministry of Agriculture and Animal Husbandry would like to acknowledge the contribution of the many individuals and organizations which made the development of this material possible. The material was prepared by Dr. Roya Mutahar of the MOH Public Nutrition Department and Charlotte Dufour, in consultation with the MOH Information Education Community Department and task force members and the MAAH Extension Department. The material is financially and technically supported by the American Red Cross, Tufts University, UNICEF and Groupe URD. We hope that this material will be useful in your work and thank you for your support in contributing to the health of our nation. Dr. Sayed Mohd Amin Fatimi Minister of Public Health

Ubaidullah Ramin Minister of Agriculture and Animal Husbandry

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HOW CAN YOU PREVENT IT?

WHAT IS MALNUTRITION?

From birth until 6 months, give your baby breastmilk only

CARE FOOD

Continue breastfeeding until 2 years, and at 6 months, give your child

Eat diverse foods, from your own production or

the bazaar

Foods can be preserved to be eaten throughout

the winter

Use iodised salt Pregnant and breastfeeding mothers should eat more for her

and the child to be healthy

HEALTH & SANITATION Take your children to the clinic for vaccination and

when they are sick

Keep the house clean, wash your hands with soap and clean water, and use latrines

Prepare food in clean dishes, protect it from flies and waste, boil water for cooking and drinking

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NUTRITION EDUCATION

GUIDANCE BOOKLET

Good nutrition is essential for health Good nutrition is not only about eating enough good food. It is also about producing, buying, cooking and eating the many different kinds of foods, taking good care of mothers and children, using health services and practicing good hygiene. All families should try to make the best use of available resources to ensure the health and nutrition of all family members. Food and nutrition education can play a vital role in helping poor households to make optimal use of local foods and practice healthy eating patterns. This booklet should be used in relation to the “Nutrition Essentials” poster, which contains key nutrition education messages and should be given to families. The booklet provides basic and simple information on all the main topics that are presented on the poster. This booklet is designed for health educators, community health workers, agricultural extension workers, and personnel working with families in health and food security programmes. “Questions for discussion with families” are suggested as a means of initiating a dialogue with family members. Discussion can help to identify ways for families to put the messages into practice. This material is simple and basic and can be used with other education materials that can provide more detailed information on each of these topics.

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WHAT IS MALNUTRITION AND

WHY IS GOOD NUTRITION IMPORTANT? The body needs food to function properly:

- to have enough energy and strength to carry out daily tasks (for example to walk, work, play.....)

- to grow, in the case of children and babies (including in the mother’s womb)

- to learn and develop mentally - to stay healthy and fight against disease

When the body does not have enough food to function properly or cannot use the food properly because of an illness (immediate causes), the body becomes malnourished. There are different forms of malnutrition:

- wasting: when the body becomes very thin - stunting: when a child does not grow enough, and remains small - micronutrient deficiency diseases: when one or vitamins and minerals

are lacking in the diet, which causes specific disease symptoms Some times, malnutrition cannot be seen. It is “hidden malnutrition”. But it causes:

- weakness, tiredness - vulnerability to disease - poor mental development

Good nutrition is important throughout your life. Healthy adults require good nutrition in infancy and childhood. Mothers need to have good nutrition during pregnancy and when they are breastfeeding so that their babies are healthy. This is shown in the picture below.

Growth Child Failure

Small Adult Women

Low Birth Weight Baby Low adolescent Weight and Height

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CAUSES OF MALNUTRITION

To be well-nourished, you do not only need adequate food, you also need to be healthy. A malnourished person can become ill more easily and an illness can cause malnutrition. For example, when a child is sick, he may lose the food he eats through diarrhoea or by vomiting and s/he may refuse to eat because of the illness. Therefore, inadequate food intake and illness are both immediate causes of malnutrition. This can cause a vicious cycle of malnutrition and disease, which increases the risk of dying.

To prevent this vicious cycle from occurring, it is necessary to address all the underlying causes of malnutrition, which are presented in the picture below. They include:

- poor household food security: families do not have access to sufficient and diverse foods

- poor caring and feeding practices: families are not able to take good care of mothers and children, because they do not have the knowledge or resources

- poor health and sanitation: hygiene practices are poor, and families do not have access to health services

Poor household

Poor caring and feeding

Poor health & sanitation

Inadequate f d i k

Disease

Malnutrition

Causes of malnutrition

DISEASE MALNUTRITION

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Food security is when households have physical, social and economic access to sufficient, safe and nutritious foods that meets their dietary needs and preferences for an active and healthy life. Households can have access to food through:

- Food production. This means they should have sufficient land and/or animals to produce enough foods

- Purchase in the bazaar. This requires that food be available in the market, and that families should have sufficient income to buy appropriate foods.

Adequate food security entails that families have access to enough diverse foods. Many Afghan families have access to sufficient quantities of wheat, for example, but this is not enough to be healthy. They also need to have access to other foods, such as meat, fish, poultry, milk/cheese, eggs, fruits and vegetables, beans and nuts. Poor food security can be due to a lack of productive resources (such as land, animals) and to a lack of income. But it can also be due to a lack of knowledge, when families do not know about the importance of eating different foods and how they can access them. An important aspect of food security is having access to enough different foods throughout the year. In many areas of Afghanistan, access to food is good during the summer, but much more difficult during the winter months, when stocks of diverse foods are low, when access to markets is difficult because of the snow, or when food prices are high. To have an active and healthy life, it is necessary to:

1. to eat diverse foods 2. to eat diverse foods every day all year round, even during the winter 3. to eat foods that contain increased amounts of special nutrients, such as

iodised salt

FOOD

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1. EATING DIVERSE FOODS In Afghanistan, many households eat mostly bread and tea. But this is not enough to be healthy. Food is composed of elements called “nutrients”. There are two types of nutrients:

- macronutrients (“big nutrients”): carbohydrates, protein and fat

- micronutrients (“small nutrients”): vitamins and minerals

Both macronutrients and micronutrients are essential for health and they play different roles in the body. Different nutrients are contained in different foods. This is why it is important to eat as many different foods as possible every day. Families should try to eat foods from each of the food groups presented in the table below. FOOD GROUP Examples of foods Cereals wheat, rice, maize Roots / tubers Potatoes, turnips, radishes Legumes / pulses /nuts Lentils, chick peas, red beans and nuts Vegetables and fruits spinach, leech, carrots, “seech”, tomatoes, onions,

cabbage, cauliflower, aubergine, etc. oranges, limes, rhubarb, apples, apricots, melon, peaches, pears, etc.

Animal foods Meat, fish, poultry, eggs, milk, cheese, krut Fats Oil, ghee, butter Sugar Sugar, honey

Key messages • Every day, you should eat foods from each of the following groups:

- Cereals, such as wheat, rice and maize - Pulses, beans or peas, and nuts (or animal foods, such as milk, meat if possible) - Vegetables and fruit, spinach, carrots, bonjon, oranges, apples - Fat, such as oil and ghee

• If you can, try growing vegetables and fruits in a kitchen gardens • Fruits and vegetables can lose their vitamins if they are cooked too long. It is better to

cook vegetables in a pressure cooker or to fry them, rather than boil them.

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Questions for discussion with families

• Are any foods produced by the household? Which ones? Can they grow more diverse fruits and vegetables?

• Which foods are available on the market? Can households buy them? • Are there customs and beliefs that restrict the consumption of certain

foods? • What can be done to increase households’ consumption of diverse foods?

2. EATING DIVERSE FOODS DURING THE WINTER Having access to fruits, vegetables and milk is easier in the summer, when these foods are produced. But eating a diverse diet is important throughout the year, especially during the winter when the body needs sufficient nutrients to fight against cold and disease. There are ways of processing and preserving foods to keep them for winter months. For example:

- Drying fruits and vegetables: apricots, peaches, tomatoes, berries (“tut”), walnuts, almonds

- Burying vegetables in the ground, in a well isolated hole: potatoes, carrots, turnip…

- Making fruit jams and juices: apples, apricots, apples - Making cheese and yoghurts from milk Key messages • Eat diverse foods throughout the winter • You can preserve foods that are available in the summer by:

- Drying fruits - Burying vegetables in the ground - Making fruit jams and juices - Making cheese and yoghurt

• When processing and storing foods, make sure they are protected from contamination by germs

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Questions for discussion with families

• Are foods available in the area that can be preserved for the winter? • How are fruits, vegetables, nuts and animal products preserved in the

area? Can more be preserved, and how? • Are preserved foods stored in a safe place that is protected from

contamination? 3. PREVENTING IODINE DEFICIENCY Iodine is a micronutrient which is very important for children to grow properly and to develop into healthy intelligent adults Iodine deficiency is very common in Afghanistan. It leads to:

- goitre - mental deficiency - spontaneous abortions - cretinism

If a pregnant mother does not have sufficient iodine, her body may not be able to keep the baby, or her baby can be born with mental slowness. Iodine deficiency diseases can be very easily prevented by eating iodised salt every day. When iodised salt is cooked too long, the iodine content is reduced. It is better to put the salt at the end of the meal preparation to make sure it preserves all its iodine.

Key messages: • Buy iodised salt, instead of rock salt or “normal salt” • Use iodised salt for all your cooking • Put the salt in the food at the end of the meal preparation

Questions for discussion with families

• Are families aware of the consequences of iodine deficiency? Do they know that it can be prevented?

• Is iodised salt available in the bazaar? • Are households buying iodised salt? If not, why?

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Caring practices describe the ways in which family members are cared for, in particular infants and young children. This includes how children are fed, how often, who takes care of them, for how long each day, and how they are treated when they are sick. The well-being of mothers is also an important aspect of care, since mothers need to be healthy to take good care of the family. Sometimes, poor care is due to lack of knowledge and it will be important that family members have an opportunity to learn about how to give appropriate care. Sometimes, a mother has the knowledge but she does not have the time and resources to put into practice. For example, when a mother has many small children and there are no other adults in the household, she has little time to care for each child. Caring practices will also depend on the type of support and advice that mothers receive from their families, neighbours and health services. Being able to care properly for children requires knowledge, time, resources and support. Information on caring practices should also be shared with mothers-in-law, husbands, relatives and neighbours as they have a strong influence on how a mother is able to care for the children. Also, they can help mothers in taking care of the children. All caring practices are important for good health and nutrition. But the following three things are particularly important for good maternal and child nutrition:

- exclusive breastfeeding up to 6 months of life - appropriate complementary feeding for children 6-24 months - good maternal nutrition

CARE

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1. EXCLUSIVE BREASTFEEDING OF CHILDREN UNDER 6 MONTHS Breastmilk is the only food that a baby should eat, until the age of 6 months because: • Breast-milk contains all the essential nutrients

and fluids for the health and growth of the infant.

• Breast-milk is always clean. Other milks easily

become contaminated. • Breast-milk protects the infant from disease and death. Collustrum

(fella), the first (yellow and thick) milk contains many elements that protect the child, and is very rich in essential nutrients.

• Breast-milk is available all the time and requires no preparation: The

more an infant suckles, the more milk is available. • Breast-milk is free • Breast-milk contributes to a special relationship between mother and

infant • Mothers who practice exclusive breastfeeding do not become pregnant

so soon. Virtually all women are able to breastfeed- but sometimes they may need some encouragement from the family and healthworkers to support her confidence.

Key messages: • Start breastfeeding within 1 hour following birth. • Do not give other foods (e.g. ghee, tea, sugared water, etc.) before

starting to breastfeed • Give the first milk (yellow and thick), called “collostrum” (fella) • Breastfeed the child often: the more he suckles, the more milk is

produced • Do not give the baby bottles or pacifiers: they are dirty and make the

child sick • Give the baby only breastmilk until he is 6 months old • Continue breastfeeding until the baby is 2 years old

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Questions for discussion with families • Are foods, such as tea, butter sugared water, etc. given at birth? Why? • Do mothers give collostrum or discard it? Why? • How often do mothers breastfeed, and until what age? • Do they give foods other than breastmilk before 6 months? Which ones? • What are some of the mothers’ concerns about their ability to breastfeed? 2. COMPLEMENTARY FOODS FOR CHILDREN 6-24 MONTHS After 6 months, breastmilk is no longer sufficient to meet a child’s needs. Growing infants need to eat diverse foods, to make sure they are get all the nutrients (energy, protein, vitamins, minerals…) that they need. When the foods given to infants are too ‘weak’ or over-diluted with water: the child’s stomach fills up too quickly and s/he is not hungry anymore, but the child has not eaten enough nutrients to be healthy and grow. Young children should be given foods that contain enough energy-giving foods (carbohydrates and fat), protein and micronutrients. Foods for children between 6-12 months should be soft and easy to swallow (e.g. mashed foods, soups), but should not contain too much water. For example, soups can be made using milk. Foods and fluids given to a child should be protected from germs to prevent the child from becoming sick. (see the page on food hygiene, below).

Key Messages: • After 6 months, gradually introduce a diversity of foods in the child’s diet

(fruits, vegetables, meat, milk, oil, eggs) in addition to breastmilk • Between 6 and 8 months, give the child soft, mashed foods (without using

too much water) 2 to 3 times a day • Between 9 and 12 months, give the child soft foods 3 to 4 times a day, in

addition to breastmilk and snacks • Between 12 and 24 months, the child can share family foods, but should

be fed 4 to 5 times a day, in addition to breastmilk and snacks.

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• When the child is sick, feed him small quantities more often and give him more fluids. After the illness, the child should be fed more than usual.

• Use clean foods, and clean cooking utensils when preparing the food and feeding the child

• Always wash your hands before feeding the child • Boil any water that you give the child • Continue breastfeeding until 24 months

Questions for discussion with families • At what age are complementary foods introduced in a child’s diet? • What foods are given and how are they prepared? • How often does a young child eat? • Until what age do mothers continue breastfeeding? 3. GOOD MATERNAL NUTRITION A pregnant and/or lactating mother needs to eat more than when she is not pregnant, because she needs to have enough nutrients for herself and for the child. A mother who does not eat enough will give birth to small baby, who is more likely to become sick and die. She also has a greater risk of dying when giving birth. A pregnant mother needs a lot of iron and folic acid, to make her blood and that of her baby strong. Iron and folic can come from foods (red meat, liver, green vegetables, banana, orange, melon, peanuts). A pregnant mother should obtain iron/folic acid tablets from the clinic and take them every day. She should reduce her workload and be allowed to take some extra rest. When a mother has too many children close together, she is not able to replenish her nutrient stores and to become strong again. This can make the mother and the next baby weak and at risk of disease or death.

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Key messages: • During pregnancy and lactation, a mother must eat more energy and

protein-rich foods, such as bean, legumes, meat, oils, nuts, cereals, milk, eggs.

• A pregnant mother should regularly go to the clinic or health post for ante-natal care, to check she is gaining sufficient weight, and to receive iron and folic acid supplements

• After delivery, a mother should go to the clinic for a check-up and to receive vitamin A supplements

• Adolescent girls should eat sufficient food, to prepare their body for pregnancy. Pregnancy before the age of 18 increases the health risks for the mother and baby.

• Even mothers who are not pregnant should eat well, because they need energy to take good care of their family

• There should be at least two years between each pregnancy, to allow the mother to become strong again and replenish her nutrient stores for the next baby.

Questions for discussion with families

- Do some mothers report feeling weak and tired during and after pregnancy?

- What do pregnant and lactating mothers eat and in what quantities? - Is it the same as before pregnancy? How can the quantity and types of

foods eaten be increased? - Is there a clinic in the area that can provide antenatal care? Can the

mother go? If not, why not and how can she solve that problem? - Do mothers know about iron/folic acid supplements during pregnancy,

and vitamin A supplements for after delivery?

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Diseases, such as diarrhoea, measles, and ARI are common in Afghanistan, and are main causes of malnutrition. Many children become malnourished when they have diarrhoea: they lose appetite, and all the nutrients they are able to eat are lost, or families don’t give the sick child food, in hopes that if there is nothing inside, nothing will come out. Diseases can be spread due to poor sanitation in the home and neighbourhood. Environmental and personal hygiene are very important to preventing malnutrition due to disease. Access to and use of health services, such as clinics and health posts, is very important for staying healthy and preventing malnutrition. Sometimes, health services can be present, but families do not use them. This can be due to a lack of knowledge on the importance of vaccination and on the possibility to treat disease. Even if a child eats well, he can become malnourished simply because of disease. This is why good nutrition requires:

- good home and body hygiene, to prevent diarrhoea and ARI - good food hygiene, to prevent food poisoning, vomiting and diarrhoea - going to the health centre, for vaccination against the main diseases

HEALTH AND SANITATION

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1. GOOD HOME AND BODY HYGIENE Germs are carried in dirt and faeces. If a house is not kept clean, and if you do not wash yourself and your clothes properly, there is a risk that you will be exposed to germs and become sick with diarrhoea. When washing something (body, clothes, house), it is important to always use clean water and soap. Washing without soap does not kill germs. Main source of contamination include:

- faeces (human and animal) - dirty water, especially water in contact with

faeces (for example, if the latrine waste runs near a river)

- animals (they carry germs in their coats and attract flies)

During the winter, families tend to live together in single rooms, to keep warm. However, there is a risk that if one person is sick with respiratory infection, she will transmit her disease to other family members. Try to ventilate the room regularly to renew the air.

Key messages • Keep the house clean by sweeping the floor, dusting surfaces with a damp clean cloth,

washing sheets, blankets and towels with clean water and detergent • Wash your hands carefully with soap often (between fingers, under fingernails): - after going to the latrine, cleaning a baby’s bottom, contact with animals - before preparing food, eating and feeding a child • Clip your nails regularly. • Use a latrine, and make sure the waste cannot get into the water supply. If defecation

is done in the open, cover faeces with earth or sand. • When animals live in the house, make sure they live in a separate area from the

family, and avoid contact with them. • Keep the house well ventilated throughout the year

Questions for discussion with families

Have any children been sick from diarrhoea in the house? When? Is the house kept clean? Are there animals living among household

members? How often, and when, do household members wash their hands? Their body?

Their clothes? Do household members use a latrine? Is it clean? Are many people living in the same house? Are the rooms well ventilated

during the winter?

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2. FOOD HYGIENE Dirty food can also cause disease. It must therefore be prepared and stored carefully. There are different sources of contamination of food:

- an unclean kitchen - kitchen waste - dirty cooking utensils (pans, plates, etc.) - flies - dirty water used for cooking - soiled foods (smelly foods that take on a strange colour) - dirty clothes and hands of the person preparing the food

Sometimes you can see when foods are soiled, because they smell bad and have a strange colour. These should not be eaten and should not touch other foods. Some foods such as milk, fish, cooked meat, cooked rice and other cereals can spoil quickly.

Key messages • Clean the kitchen every day with clean water and detergent • Keep pans, dishes and cooking utensils clean by washing them with clean

water and soap. Dry them on a rack. • Do not eat uncooked foods with soil on them. Keep them separate from

cooked and unsoiled foods • Wash your hands before preparing food, and wear clean clothes • After handling uncooked food, wash hands well before handling cooked

foods • Meat and fish need to be cooked through the centre to kill germs.

Vegetables and fruits should be washed with clean water. • Cooked foods should not be kept at warm temperatures for more than two

hours before eating • Store food in a clean, dry and cool place • Cover food to protect it from flies • Keep waste in a covered container and away from food • Boil water that is used for drinking and cooking for at least 20 minutes • Store boiled water in a covered container. Use a clean long handled

dipper or pour water out, to avoid dipping your hands into the water.

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Questions for discussion with families

• How are cooking utensils kept clean? • Do family members wash their hands with soap and water before

handling foods? • How can foods and drinks be covered? • Where can the food be stored safely in the home? • Is water boiled before drinking and cooking? How is boiled water stored?

3. USE OF HEALTH SERVICES AND VACCINATION Vaccination is essential to protect children and mothers from diseases that can increase the risk of malnutrition, such as measles and tuberculosis. After a child is born, a mother should take her baby to the clinic, to receive vaccination against the main diseases: Tuberculosis (BCG vaccine), diphtheria, tetanus and pertusis (DTP vaccine), polio (polio vaccine - drop), measles (measles vaccine). For some diseases, the child should be vaccinated several times. If the mother does not return to complete all the vaccinations, the child will not get the protection of the vaccination. The clinic or health worker will guide the family on the correct number and timing of vaccinations. Pregnant mothers should also go to the clinic to be vaccinated against tetanus, starting in the first antenatal care visit. They should return to the clinic regularly to make sure the baby is growing properly, to receive iron and folic acid tablets, and to prevent complications with the pregnancy. When children are sick, they need to be taken to the health centre. Delaying to do so can lead to complications which make it more difficult to treat the child.

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Key messages • Vaccine protects the human body from the childhood illnesses. Children

who are not vaccinated can become sick and, in the case of polio, disabled.

• Bring your child to the clinic for vaccination right after birth, and complete all the vaccines before the first year.

• if your child was not vaccinated as a baby, take it to the clinic for vaccination as soon as possible

• Return to the clinic as indicated by the nurse or doctor to complete all the vaccinations

• When you are pregnant, go to the clinic for ante-natal care, to receive the Tetanus Toxoid vaccination and iron/folic acid tablets

• Take your child to the health centre when it is sick, to make sure she or he gets appropriate treatment

Questions for discussion with families

- Where is the nearest health centre to receive vaccination and seek care? - Do mothers take their children there? Why or why not? - Have all the vaccinations for mothers and children been completed?

Why? - How can families ensure that every body is vaccinated appropriately?