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ANM / Multi-Purpose Health Assistant (Female) · Chapter 4

Hygiene and Nutrition

What to remember

  • Hygiene covers the person, the home, food, water and waste. Safe water, clean hands, safe excreta disposal and clean food stop most diarrhoea, worm and fever diseases.
  • Energy values: carbohydrate 4 kcal/g, protein 4 kcal/g, fat 9 kcal/g. Most nutrition calculations use these three numbers.
  • Each vitamin and mineral has a typical deficiency disease. Matching them is a favourite exam question.

Personal and home hygiene

Personal hygiene means daily care of the body. It includes bathing, washing hair, brushing teeth twice a day, trimming nails, wearing clean clothes and washing hands. Hand washing with soap is the single most useful habit. Wash for at least 20 seconds, before eating, before cooking or feeding a child, after using the toilet, and after cleaning a child's stool.

Other points: use a clean cloth or sanitary pad during menstruation and change it regularly; use footwear to prevent hookworm; keep nails short; keep the eyes clean; avoid sharing towels and combs to prevent skin and eye infections; and take rest, exercise and 7 to 8 hours of sleep.

Housing and ventilation. A healthy home has enough space, light, fresh air and a smokeless stove. Overcrowding spreads tuberculosis and respiratory infection. Smoke from firewood causes chronic cough and eye disease, so cleaner fuel and a chimney help. Good ventilation changes the air and removes smell and moisture.

Water, excreta and waste

Safe water is clear, colourless, odourless, free from germs and chemicals harmful to health. Sources: protected wells, hand pumps, piped supply. Water is made safe on a large scale by sedimentation, filtration (sand filters) and chlorination. At home, methods are boiling (rolling boil for several minutes, the surest method), chlorine tablets, and candle filters. Add a chlorine tablet as directed on the pack and wait 30 minutes. Wells are disinfected with bleaching powder or potassium permanganate during outbreaks. Water is judged safe by checking residual chlorine and absence of coliform bacteria.

Water hardness is caused by calcium and magnesium salts. Fluoride in excess causes dental and skeletal fluorosis; too little leads to dental caries. Excess arsenic and nitrate in water are harmful.

Excreta disposal. Open defaecation spreads cholera, typhoid, hepatitis A, polio and worms. Sanitary latrines include the pit latrine, the pour-flush latrine, the septic tank and the sewerage system. The Swachh Bharat Mission is the national programme for toilets and cleanliness. A latrine should be at least 15 metres away and on lower ground than the well to avoid pollution of the water source.

Waste. Solid waste is household, market and hospital waste. Methods: segregation at source, composting (organic waste becomes manure), landfill and incineration. Bio-medical waste is separated into colour-coded bags: yellow for human and animal anatomical waste, soiled cotton and dressings; red for contaminated plastic such as tubing, syringes without needles and gloves; white or translucent sharps container for needles; blue for glass and metallic implants. Never throw needles in an open dustbin.

Vector control. Remove stagnant water to stop mosquito breeding. Use larvivorous fish (Gambusia), cover water tanks, use nets and screens, and apply insecticide as advised. Keep food covered against flies. Control rats by sealing food stores.

Food hygiene

Foods should be bought fresh, washed, covered, cooked well and eaten soon. Raw and cooked foods are kept apart. Leftovers are refrigerated or reheated well. Milk is boiled or pasteurised. Food handlers must wash hands, keep nails short and not handle food when they have diarrhoea or skin sores. Food adulteration is the addition of harmful or cheap substances. The FSSAI is the national authority for food safety standards. Food poisoning germs include Salmonella, Staphylococcus aureus and Clostridium.

Nutrition: nutrients and energy

Nutrition is the use of food by the body. Nutrients are carbohydrates, proteins, fats, vitamins, minerals, water and fibre.

NutrientMain functionsEnergy per gramSources
CarbohydrateEnergy4 kcalCereals, millets, roots
ProteinGrowth, repair4 kcalPulses, milk, eggs, fish
FatConcentrated energy9 kcalOils, ghee, nuts
Vitamins, mineralsProtection, regulationNoneFruits, vegetables

Worked example. A food has 50 g carbohydrate, 10 g protein and 5 g fat. Energy = 50 × 4 + 10 × 4 + 5 × 9 = 200 + 40 + 45 = 285 kcal.

Protein is made of amino acids. Essential amino acids cannot be made by the body and must come from food. Pulses and cereals together give better protein than either alone. Fats supply essential fatty acids and carry vitamins A, D, E and K. Fibre prevents constipation.

Balanced diet has the right amounts of all nutrients from cereals, pulses, vegetables, fruits, milk and a little fat. Needs are higher in pregnancy, lactation, childhood and adolescence. Food groups: energy-giving (cereals, oils, sugar), body-building (pulses, milk, egg, meat, fish) and protective (vegetables, fruits).

Vitamins and minerals

NutrientDeficiency disease or signGood sources
Vitamin ANight blindness, xerophthalmia, Bitot's spotsGreen leafy vegetables, carrot, papaya, liver
Vitamin B1 (thiamine)BeriberiWhole grains, pulses
Vitamin B2 (riboflavin)Cheilosis, angular stomatitisMilk, eggs
Niacin (B3)PellagraCereals, meat
Vitamin B12Pernicious anaemiaAnimal foods
Folic acidMegaloblastic anaemia, neural tube defect in the babyGreen leaves, pulses
Vitamin CScurvyAmla, guava, citrus
Vitamin DRickets in children, osteomalacia in adultsSunlight, fish oil, egg
Vitamin KBleedingGreen leaves
IronAnaemiaGreen leaves, jaggery, meat
IodineGoitre, cretinismIodised salt
CalciumPoor bones and teethMilk, ragi
Fluoride (excess)FluorosisWater

Vitamins A, D, E and K are fat-soluble. B-complex and C are water-soluble. Iron absorption improves with vitamin C. Anaemia is defined by low haemoglobin; in a pregnant woman haemoglobin below 11 g/dL is anaemia. Iron and folic acid tablets are given to adolescents, pregnant and lactating women. Using iodised salt prevents goitre.

Protein-energy malnutrition and assessment

Kwashiorkor is mainly protein lack: oedema, swollen face, thin hair, skin changes, fatty liver, the child is irritable. Marasmus is lack of energy and protein: severe wasting, "old man" face, no oedema, hungry and alert. Marasmic kwashiorkor shows features of both.

Body Mass Index (BMI) = weight in kg ÷ (height in metres)². Standard WHO cut-offs: below 18.5 underweight, 18.5 to 24.9 normal, 25 to 29.9 overweight, 30 and above obese. Worked example: weight 60 kg, height 1.5 m gives 60 ÷ 2.25 = 26.7, which is overweight.

Child growth is followed on a growth chart; mid-upper arm circumference (MUAC) below 11.5 cm in a child of 6 to 59 months indicates severe acute malnutrition, and 11.5 to 12.5 cm is moderate. Weight and age are plotted for growth monitoring.

Rehydration. Oral rehydration solution (ORS) is for diarrhoea. Mix one packet in one litre of clean water, give small sips, and add zinc for children for 14 days (as per the national guideline). Continue breast feeding.

Nutrition programmes

ICDS (Integrated Child Development Services, 1975) works through anganwadi centres. It gives supplementary nutrition, immunisation, health check-up, referral, pre-school education and health education. The Mid-Day Meal (renamed PM POSHAN in 2021) and the national anaemia control programme (now Anaemia Mukt Bharat) address school children. Poshan Abhiyaan (national nutrition mission) targets stunting, underweight and anaemia. Vitamin A, iron and folic acid, and iodised salt programmes run through the health system. Anganwadi workers and ANMs work together at village level.

Health education in hygiene and nutrition

Health education turns knowledge into habit. A worker teaches through home visits, group talks, demonstrations and posters. Good topics are hand washing steps, cooking and storing food safely, making ORS, feeding of infants and young children, use of iodised salt, and care of pregnant and nursing mothers. Demonstration works best: let the mother prepare the ORS or a mixed porridge herself. Use local foods such as ragi, jowar, jaggery, groundnut, green leaves, eggs and fruits that are cheap and available. Encourage kitchen gardens and the use of clean water for cooking. Link the family to the anganwadi centre for supplementary food and to the sub-centre for iron and folic acid tablets.

Exam traps

  • Fat gives 9 kcal per gram; carbohydrate and protein give 4.
  • Kwashiorkor has oedema; marasmus has none.
  • Night blindness is vitamin A, not vitamin D.
  • Rickets is in children; osteomalacia is in adults.
  • Beriberi is B1; pellagra is niacin; scurvy is vitamin C.
  • Vitamin C helps iron absorption.
  • Fat-soluble vitamins are A, D, E, K.
  • Yellow bag in bio-medical waste is anatomical waste and soiled dressings; sharps go in a white puncture-proof container.
  • ORS packet goes in one litre of water.
  • BMI uses height in metres squared, not centimetres.

One-liners

  • 1. Hand washing with soap is the cheapest way to prevent diarrhoea.
  • 2. Boiling is the surest home method to make water safe.
  • 3. Iodine deficiency causes goitre.
  • 4. Iron deficiency is the commonest cause of anaemia.
  • 5. Vitamin D can be made by skin in sunlight.
  • 6. Marasmus is severe wasting without oedema.
  • 7. BMI = weight (kg) ÷ height² (m²).
  • 8. ICDS delivers services through anganwadi centres.
  • 9. FSSAI is the food safety authority.
  • 10. Gambusia fish eat mosquito larvae.
  • 11. Vitamin B12 deficiency causes pernicious anaemia.
  • 12. Folic acid before and in early pregnancy prevents neural tube defects.

Practice questions

  1. How much energy does 1 gram of fat give?

    1. 2 kcal
    2. 9 kcal
    3. 4 kcal
    4. 7 kcal
    Answer

    B. 9 kcal

    Fat gives 9 kcal per gram; carbohydrate and protein 4.

  2. Deficiency of vitamin A causes

    1. Scurvy
    2. Night blindness
    3. Beriberi
    4. Rickets
    Answer

    B. Night blindness

    Vitamin A is needed for dim-light vision.

  3. Deficiency of vitamin C causes

    1. Beriberi
    2. Pellagra
    3. Osteomalacia
    4. Scurvy
    Answer

    D. Scurvy

    Scurvy shows bleeding gums and poor wound healing.

  4. Beriberi is due to lack of

    1. Thiamine (B1)
    2. Riboflavin (B2)
    3. Vitamin B12
    4. Niacin
    Answer

    A. Thiamine (B1)

    Thiamine deficiency causes beriberi.

  5. Pellagra is due to lack of

    1. Vitamin C
    2. Niacin
    3. Thiamine
    4. Folic acid
    Answer

    B. Niacin

    Pellagra: dermatitis, diarrhoea, dementia.

  6. Rickets in children is due to lack of

    1. Vitamin K
    2. Vitamin E
    3. Vitamin A
    4. Vitamin D
    Answer

    D. Vitamin D

    Vitamin D is needed for bone mineralisation.

  7. Goitre is prevented by use of

    1. Iodised salt
    2. Fluoride water
    3. Iron tablets
    4. Vitamin A drops
    Answer

    A. Iodised salt

    Iodine is needed to make thyroid hormone.

  8. Severe wasting with no oedema in a child is

    1. Kwashiorkor
    2. Marasmus
    3. Rickets
    4. Scurvy
    Answer

    B. Marasmus

    Marasmus is energy deficiency with wasting.

  9. Oedema, swollen face and thin hair in a child indicate

    1. Night blindness
    2. Marasmus
    3. Xerophthalmia
    4. Kwashiorkor
    Answer

    D. Kwashiorkor

    Kwashiorkor is mainly protein deficiency and shows oedema.

  10. Which vitamin group is fat-soluble?

    1. B and C
    2. B12 and C
    3. A, D, E and K
    4. C and D only
    Answer

    C. A, D, E and K

    B-complex and C are water-soluble.

  11. The surest home method to make water safe is

    1. Adding salt
    2. Boiling
    3. Straining through cloth
    4. Letting it stand overnight
    Answer

    B. Boiling

    A rolling boil kills germs.

  12. Calculate energy: 20 g carbohydrate, 5 g protein, 10 g fat.

    1. 250 kcal
    2. 130 kcal
    3. 85 kcal
    4. 190 kcal
    Answer

    D. 190 kcal

    20×4 + 5×4 + 10×9 = 80 + 20 + 90 = 190 kcal.

  13. A food contains 40 g carbohydrate, 10 g protein and 10 g fat. What is the energy?

    1. 290 kcal
    2. 220 kcal
    3. 380 kcal
    4. 190 kcal
    Answer

    A. 290 kcal

    40×4 + 10×4 + 10×9 = 160 + 40 + 90 = 290 kcal.

  14. A woman weighs 60 kg and is 1.5 m tall. Her BMI is nearest to

    1. 26.7
    2. 30.5
    3. 40
    4. 22.5
    Answer

    A. 26.7

    60 ÷ (1.5×1.5) = 60 ÷ 2.25 = 26.7.

  15. A man weighs 72 kg and is 1.6 m tall. What is his BMI?

    1. 32.0
    2. 45
    3. 28.1
    4. 24.8
    Answer

    C. 28.1

    72 ÷ 2.56 = 28.1.

  16. A person weighs 50 kg and is 2 m tall. What is the BMI?

    1. 10
    2. 25
    3. 100
    4. 12.5
    Answer

    D. 12.5

    50 ÷ 4 = 12.5, which is underweight.

  17. A child eats a diet of 2000 kcal of which 60% is from carbohydrate. How many grams of carbohydrate is that?

    1. 1200 g
    2. 300 g
    3. 120 g
    4. 500 g
    Answer

    B. 300 g

    60% of 2000 = 1200 kcal; 1200 ÷ 4 = 300 g.

  18. How much energy comes from 25 g of fat alone?

    1. 250 kcal
    2. 225 kcal
    3. 100 kcal
    4. 175 kcal
    Answer

    B. 225 kcal

    25 × 9 = 225 kcal.

  19. How much haemoglobin level defines anaemia in a pregnant woman?

    1. Below 8 g/dL
    2. Below 15 g/dL
    3. Below 11 g/dL
    4. Below 5 g/dL
    Answer

    C. Below 11 g/dL

    Below 11 g/dL in pregnancy is anaemia.

  20. Which food helps most in absorbing iron from plant foods?

    1. Tea
    2. Milk
    3. Fat
    4. Vitamin C rich food
    Answer

    D. Vitamin C rich food

    Vitamin C improves non-haem iron absorption.

  21. In bio-medical waste, needles and sharps are placed in a

    1. White puncture-proof container
    2. Red bag
    3. Yellow bag
    4. Black bag
    Answer

    A. White puncture-proof container

    Sharps go in a white translucent puncture-proof container.

  22. Soiled cotton and dressings in bio-medical waste go in the

    1. Black bag
    2. Blue box
    3. White container
    4. Yellow bag
    Answer

    D. Yellow bag

    Yellow category covers anatomical waste and soiled dressings.

  23. Which method of waste disposal turns organic waste into manure?

    1. Incineration
    2. Landfill only
    3. Dumping in a drain
    4. Composting
    Answer

    D. Composting

    Composting breaks down organic waste into compost.

  24. How much water is used to dissolve one ORS packet?

    1. Half a litre
    2. One litre of clean water
    3. Five litres
    4. One glass
    Answer

    B. One litre of clean water

    Standard ORS packet goes in one litre.

  25. Larvivorous fish used to control mosquito breeding is

    1. Catla
    2. Rohu
    3. Gambusia
    4. Hilsa
    Answer

    C. Gambusia

    Gambusia eats mosquito larvae.

  26. Which statement about iron is correct?

    1. It is a fat-soluble vitamin
    2. It prevents goitre
    3. Deficiency is the commonest cause of anaemia
    4. It is found only in milk
    Answer

    C. Deficiency is the commonest cause of anaemia

    Iron deficiency is the leading cause of anaemia.

  27. Which deficiency in early pregnancy increases the risk of neural tube defect in the baby?

    1. Folic acid
    2. Iodine
    3. Vitamin K
    4. Vitamin C
    Answer

    A. Folic acid

    Folic acid is advised before and in early pregnancy.

  28. ICDS services are delivered through

    1. Sub-centres only
    2. District hospitals
    3. Private clinics
    4. Anganwadi centres
    Answer

    D. Anganwadi centres

    Anganwadi centres are the ICDS service points.

  29. Which agency lays down national food safety standards?

    1. ICMR
    2. NITI Aayog
    3. BIS only
    4. FSSAI
    Answer

    D. FSSAI

    Food Safety and Standards Authority of India.

  30. A mid-upper arm circumference below 11.5 cm in a child aged 6 to 59 months suggests

    1. Normal nutrition
    2. Severe acute malnutrition
    3. Overweight
    4. Anaemia only
    Answer

    B. Severe acute malnutrition

    MUAC below 11.5 cm is the SAM cut-off.

  31. Statements: 1. Carbohydrate gives 4 kcal per gram. 2. Protein gives 9 kcal per gram. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    Protein gives 4 kcal per gram; fat gives 9.

  32. Statements: 1. Kwashiorkor shows oedema. 2. Marasmus shows severe wasting. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are correct.

  33. Statements: 1. Hand washing with soap prevents diarrhoea. 2. It should be done after cleaning a child's stool. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are recommended practice.

  34. Statements: 1. Rickets occurs in children. 2. Osteomalacia occurs in adults. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are vitamin D deficiency diseases at different ages.

  35. Statements: 1. Vitamin A is water-soluble. 2. Vitamin C is fat-soluble. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    D. Neither 1 nor 2

    A is fat-soluble and C is water-soluble.

  36. Statements: 1. Excess fluoride in water causes fluorosis. 2. Excess fluoride prevents all dental disease. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    Excess fluoride harms teeth and bones.

  37. Statements: 1. Raw and cooked foods should be stored apart. 2. Food handlers with diarrhoea should not handle food. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are food hygiene rules.

  38. Statements: 1. BMI uses height in metres. 2. A BMI of 22 is normal by standard WHO cut-offs. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Normal is 18.5 to 24.9.

  39. Match the nutrient with the deficiency: 1. Vitamin B12, 2. Iodine, 3. Iron. Which set is correct?

    1. 1 goitre, 2 pernicious anaemia, 3 anaemia
    2. 1 pernicious anaemia, 2 goitre, 3 anaemia
    3. 1 pernicious anaemia, 2 anaemia, 3 goitre
    4. 1 anaemia, 2 goitre, 3 pernicious anaemia
    Answer

    B. 1 pernicious anaemia, 2 goitre, 3 anaemia

    B12 gives pernicious anaemia, iodine gives goitre, iron gives anaemia.

  40. Match the bag with the waste: 1. Yellow, 2. Red, 3. White container. Which set is correct?

    1. 1 soiled dressings, 2 contaminated plastics, 3 sharps
    2. 1 soiled dressings, 2 sharps, 3 contaminated plastics
    3. 1 sharps, 2 soiled dressings, 3 contaminated plastics
    4. 1 contaminated plastics, 2 sharps, 3 soiled dressings
    Answer

    A. 1 soiled dressings, 2 contaminated plastics, 3 sharps

    Yellow: anatomical and soiled; red: plastics; white: sharps.

  41. Match the vitamin with its source: 1. Vitamin A, 2. Vitamin C, 3. Vitamin D. Which set is correct?

    1. 1 carrot, 2 sunlight, 3 guava
    2. 1 carrot and papaya, 2 amla and guava, 3 sunlight
    3. 1 amla, 2 sunlight, 3 papaya
    4. 1 sunlight, 2 carrot, 3 amla
    Answer

    B. 1 carrot and papaya, 2 amla and guava, 3 sunlight

    Standard sources of each vitamin.

  42. Statements: 1. Poshan Abhiyaan targets stunting and anaemia. 2. ICDS began as a nutrition and child-care programme. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are correct.

  43. Statements: 1. A pit latrine should be placed at least 15 metres from a well. 2. It should be on higher ground than the well. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    It should be on lower ground to avoid pollution of the well.

  44. Statements: 1. Iron and folic acid tablets are given to pregnant women. 2. Zinc is added in the treatment of diarrhoea in children. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are standard programme measures.

  45. Which mineral deficiency is the most common cause of nutritional anaemia in India?

    1. Calcium
    2. Iron
    3. Iodine
    4. Zinc
    Answer

    B. Iron

    Iron deficiency is the commonest nutritional anaemia.

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