FOREWORD
Adequate nutrition is essential for achieving and preserving health for everyone. Food and
nutrition thus play important roles in care and mitigation of infections including, and
especially, HIV/AIDS.
In recognition of the centrality of adequate nutrition in the fight against HIV/AIDS, the
Department of Public Health has developed the National Nutrition and HIV/AIDS Guidelines for
Service Providers to People Living with HIV/AIDS. The purpose of these guidelines is to enable
service providers to provide high quality nutritional care and support. The guidelines define
what service providers can do to support PLWHA at various contact points and for different
target groups such as children, pregnant and lactating women, and for food-insecure
situations. These guidelines are wide in scope to cater for the different organizations that
currently provide care and support for PLWHA.
We therefore urge each stakeholders to adapt these guidelines to meet the specific needs of
their clients in order to ensure that PLWHA get the very best nutrition care and support. We
encourage you as service providers to use these guidelines to inform your standard of nutrition
care and support for PLWHA, to train new providers in the nutrition care and support of PLWHA
and to develop nutrition and HIV/AIDS guides for PLWHA and their families.
We trust that these guidelines contain information that will enable the users to actively engage
in advocacy, programming, information sharing and on-going research to contribute to the
fight against HIV/AIDS.
Mmatsae Balosang (Mrs)
Director, Department of Public Health
ACKNOWLEDGEMENTS
Developing these guidelines has been a challenging task which was only possible because of
commitment from different stakeholders. The Department of Public Health would like to
express gratitude to members of the Technical Working Team who dedicated their technical
knowledge and time to authoring these guidelines. The team comprised of individuals and
organizations working in the areas of nutrition, dietetics, food security, food science,
medicine, pharmacy, education and HIV/AIDS. We also like to acknowledge contributions from
people living with HIV/AIDS who participated in our sessions. We are grateful to all the
organizations; governmental, non-governmental and developmental partners for their
contribution.
Our gratitude also goes to Dr Maria Nnyepi, the consultant who put a lot of work into finalizing
these guidelines.
Finally, our sincere gratitude goes to WHO-Botswana office for the technical and financial
support rendered to us during this exercise. This project would not have been successfully
completed without their support and guidance.
TABLE OF CONTENTS
FOREWORD
ACKNOWLEDGEMENTS
TABLE OF CONTENTS
TECHNICAL WORKING TEAM MEMBERS
LIST OF ACRONYMS
GLOSSARY LIST
i
iii
v
viii
ix
x
CHAPTER 1
BACKGROUND
1.1 Introduction to HIV and AIDS
1.2 Magnitude of HIV and AIDS problem in Botswana
1.3 Nutritional Status in Botswana
1.4 The Link between HIV/AIDS and Nutrition
1.5 Rationale for the Guidelines
1.6 Target for the Guidelines
1.7 How to use the Guidelines
1.8 Layout of the Guidelines
1
1
1
1
2
2
3
3
4
CHAPTER 2
HEALTHY EATING
2.1 Introduction
2.2 Healthy Eating
2.3 Food Groups and Portions
2.3.1 Cereals, breads, rice and pasta (starchy foods) group.
2.3.2 Vegetables
2.3.3 Fruits
2.3.4 Meat, Poultry, Fish and Alternatives
2.3.5 Milk and Dairy Foods
2.3.6 Fatty and Sugary Foods
2.4 Additional Information
2.4.1 Dietary Fibre
2.4.2 Salt / Sodium
2.4.3 Supplements
2.4.4 Fluids
2.4.5 Alcohol
2.4.6 Physical activity
2.4.7 Healthy body weight
5
5
5
5
7
7
8
9
10
10
10
10
11
11
11
11
12
12
CHAPTER 3
THE RELATIONSHIP BETWEEN NUTRITION AND HIV/AIDS
14
CHAPTER 4
NUTRITIONAL NEEDS AND ASSESSMENT OF PLWHA
4.1 Nutritional Needs
4.1.2 Asymptomatic
17
17
17
(V)
4.1.3
4.1.4
4.2
4.3
4.3.1
4.3.2
4.3.3
4.3.4
4.3.5
Symptomatic
Advanced Stage
Nutrition Screening
Nutrition Assessment
Anthropometric
Biochemical
Clinical
Dietary
Environmental status
18
18
19
21
21
21
22
22
22
CHAPTER 5
NUTRITION CARE FOR CHILDREN WITH HIV/AIDS
23
5.1 Importance of Prevention and Early Intervention on Malnutrition
23
5.1.1 Nutritional Screening
24
5.1.2 Nutritional Assessment
24
5.2 Nutritional Requirements
24
5.2.1 Energy requirements
24
5.2.2 Protein and Micronutrients
24
5.3 Nutritional Support and Care
24
5.3.1 Nutritional care and support for children 0 6 months
24
5.3.2 Nutrition care and support for children 6-24 months
25
5.3.3 Nutritional care and support for children over 2 years
26
5.3.4 Care and Support for Severely Malnourished Children with HIV/AIDS
26
5. 4 Management of Common Nutrition-Related Conditions Intervention for Infants and
children with HIV/AIDS
28
CHAPTER 6
INFANT FEEDING AND PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV/AIDS 29
6.1 Transmission of HIV Infection from Mother to Child
29
6.2 Care and Support of Women, their Partners and Children
29
CHAPTER 7
NUTRITIONAL CARE AND SUPPORT FOR PREGNANT AND LACTATING WOMEN
7.1 Nutritional Requirements
7.1.1 Energy Requirements in Pregnant/lactating HIV Infected Women/Adolescents
7.1.2 Protein Requirements
7.1.3 Micronutrients Requirements
7.2 Nutritional Assessment and Support
31
31
31
32
32
32
CHAPTER 8
PROTECT THE QUALITY AND SAFETY OF YOUR FOOD
8.1 Environmental Hygiene and Sanitation
8.2 Clean and Safe Water
8.3 Personal Hygiene
8.4 Shopping for Food and Eating out
8.5 Hygiene in the Kitchen
8.6 Handling, Cooking and Storage of Food
34
34
35
35
35
36
36
(vi)
CHAPTER 9
NUTRITION AND HIV/AIDS THERAPY
9.1 Anti-Retroviral Drugs (ARVs)
9.1.1 Mode of Action of ARV drugs
9.2 ARV and Non-ARV Drugs Interactions with Food and Their Potential Side Effects
9.2.1 Effects of Food on Drug Efficacy
9.2.2 Drug Effects on Nutrient Absorption, Metabolism, Distribution, and Excretion
9.2.3 Drug Side Effects
9.2.4 Effects of drug side effects on food intake and nutrient absorption
9.2.5 Storage of drugs
9.3 Adverse Effects of Some Food and Drug Combinations
9.4 Recommendations for the Proper Management of Food and Drug- Interactions
9.5 Traditional Remedies and Other Therapies
9.6 Considerations for Special Groups
9.6.1 Pregnant and Lactating Women
9.6.2 Infants and Children
9.7 Counseling on Nutrition and HIV/AIDS Therapy
38
38
39
39
39
40
40
40
41
44
44
45
47
47
47
47
CHAPTER 10
MANAGEMENT OF NUTRITION RELATED COMPLICATIONS in PLWHA
49
CHAPTER 11
NUTRITION EDUCATION AND COUNSELLING
11.1 Nutrition Education
11.2 Nutrition Counselling
11.3 Integrating nutrition into existing programs
52
52
53
55
CHAPTER 12
HIV/AIDS, NUTRITION AND FOOD SECURITY
12.1 How HIV and AIDS affect food security
12.2 Agriculture- related Adjustments of PLWHA and Affected Households
56
56
57
CHAPTER 13
MONITORING AND EVALUATION
61
BIBLIOGRAPHY
ANNEXES
ANNEX 1: Scientific Or English Names Of Some Indigenous Crops/Plants Of Botswana
ANNEX 2: Functions of Nutrients
ANNEX 3: Nutrient Composition of a Sample of Foods
ANNEX 4: Estimated Energy Requirements
63
64
64
65
66
67
(vii)
TECHNICAL WORKING TEAM MEMBERS
1
Mr. M. Basheke
Food and Nutrition Unit, Ministry of Health
2
Ms. M. Chimbombi
Curriculum Development and Evaluation , Ministry of Education
3
Dr. D. Ochola
UNICEF
4
Mr. M. Dibotelo
District Health Team, Kweneng District Council
5
Ms. M. Drage
UNAIDS
6
Ms. J. Gaongalelwe
Curriculum Development and Evaluation, Ministry of Education
7
Ms. B. Gaseitsiwe
Institute of Health Sciences, Gaborone
8
Mr. T. Kache
Department of Clinical services, Ministry of Health
9
Ms. A. Kashani
Food Control Unit, Ministry of Health
10
Ms. L. Koko
AIDS/STD UNICEF
11
Mr. L. Kwape
National Food Technology Research Centre (NFTRC)
12
Ms. T. Ledimo
Dietetics, Mahalapye Primary Hospital
13
Ms. M. Lesiapeto
Dietetics, Princess Marina Hospital
14
Ms. P. Madabe
Food and Nutrition Unit, Ministry of Health
15
Mr. J. Makhanda
Botswana-Baylor Children's Clinical Centre of Excellence
16
Dr. J. Malete
University of Botswana
17
Ms. L. Maribe
World Health Organisation (WHO)
18
Ms. K. Mathafeni
Ministry of Agriculture
19
Ms. S. Mojela
Ministry of Agriculture
20
Ms P. Mogomotsi
Food and Nutrition Unit, Ministry of Health,
21
Ms. K. Mompati
Family Health Division, Ministry of Health
22
Ms. K. Motlhoiwa
Food and Nutrition Unit, Ministry of Health
23
Ms. M. Motshidi
Corps of Health Services, Botswana Defence Force
24
Ms. S. Motswagole
NFTRC
25
Ms. D. Mmualefe
Food and Nutrition Unit, Ministry of Health
26
Ms. N. Mnthali
Curriculum Development and Evaluation, Ministry of Education
27
Ms. O. Ntshebe
Food and Nutrition Unit, Ministry of Health
28
Ms. L. Ntshekisang
Dietetics, Scottish Livingstone Hospital
29
Dr. M. Nnyepi
University of Botswana
30
Mr. A. Okoye
Department of Clinical Services, Ministry of Health
31
Ms. M. Phegelo
Food and Nutrition Unit, Ministry of Health
32
Ms. B. Rakgantswana
Food and Nutrition Unit, Ministry of Health
33
Ms. M. Selwe
Department of Social Services, Ministry of Local Government
34
Ms. J. Sibiya
Food and Nutrition Unit, Ministry of Health
35
Mr. D. Tibe
Food and Agriculture Organization
36
Dr. O. Yarosh
Pediatrics, Princess Marina Hospital
(viii)
LIST OF ACRONYMS
AIDS
Acquired Immune Deficiency Syndrome
ANC
Antenatal Care
ARV
Antiretroviral
BAIS
Botswana AIDS Impact Survey
BMI
Body Mass Index
BOCAIP
Botswana Christian AIDS Intervention Program
BONASO
Botswana Network of AIDS Services Organizations
BONEPWA
Botswana Network of People Living with HIV/AIDS
CBO
Community Based Organization
COCEPWA
Coping Center for People living with Aids
CSO
Central Statistics Office
CWC
Child Welfare Card
FTT
Failure to Thrive
HAART
Highly Active Antiretroviral Therapy
HIES
Household Income and Expenditure Survey
HIV
Human Immunodeficiency virus
IMCI
Integrated Management of Childhood Diseases
IYCF
Infant and Young Child Feeding
MoLG
Ministry of Local Government
NSF
National Strategic Framework on HIV/AIDS
PEM
Protein Energy Malnutrition
PLWHA
People Living with HIV/AIDS
PMTCT
Prevention of Mother-to-child Transmission
RDA
Recommended Dietary Allowance
UNICEF
United Nations Children's Fund
(ix)
GLOSSARY LIST
Asymptomatic: When a person has tested positive but is not showing any symptoms on the infection
Basal Energy Expenditure: Basal Energy Expenditure estimates the minimum amount of energy the
body requires to sustain basic normal functions of the circulatory, respiratory, circulatory
gastrointestinal and renal processes.
Body mass index (BMI): An index used to measure the degree of fatness. It answers the question 'is this
person carrying a healthy weight for their height?' A high BMI means one has excess weight for their
height. The healthy range of body mass index is between 20 and 25. Values below 20 show depletion of
body store.
Food drug interactions: Describes the effect of medications on the nutrients and vice versa on the
body. Some drugs may impair absorption and utilization of some nutrients. Some nutrients may also
impair the utilization of medications by the body
Food security: Having enough food to meet nutritional requirements for the household on a daily basis
Hypoglycemia: low levels of blood glucose
Hyperglycemia: Excessive amount of glucose in the blood
Kwashiorkor: Type of severe malnutrition in children shown by wasting of body (visceral) protein often
characterised by pitting oedema.
Lipodystrophy: Refers to change in fat distribution and/or lipid (fat) metabolism in the body. Such
complications commonly occur as the HIV infection advances.
Marasmus: Type of severe energy malnutrition in children shown by wasting of body fat and muscle.
Nutritional screening: Quick process for identifying possible nutrition problems and factors that my
lead to malnutrition
Nutritional status: How well or how poorly the nutritional requirements of an individual have been
met. Indicators used to determine nutritional status include anthropometric measurements (e.g.
weight), clinical investigations (e.g. blood haemoglobin levels) or clinical signs (e.g. pitting oedema in
the case of kwashiorkor).
Opportunistic infections: Infection by germs that do not normally cause diseases, but will result in
illnesses in people with compromised immune system.
Recommended Dietary Allowance: The amount of nutrients needed to meet the needs of almost all
healthy people. RDAs are set based on the Estimated Average Requirement. When the Estimated
average Requirement cannot be established the Adequate Intakes are used in place of the RDA.
Side effect: Unintended bad (adverse) effects that may result from taking any given treatment/
medications.
Whole grain: Food prepared by using unrefined seeds or grain. For example Ntlatlawane is an example
of a whole grain product because sorghum is milled without removing the husk first.
(x)
CHAPTER 1
BACKGROUND
1.1
Introduction to HIV and AIDS
Human Immunodeficiency Virus (HIV) is a virus that attacks the body's immune system leaving the HIV
infected person vulnerable to infections. What is called Acquired Immune Deficiency Syndrome (AIDS)
is the later stage along a continuum of HIV infection, HIV-related infections and diseases. Without
treatment, HIV will almost always lead to AIDS, which will almost always lead to death.
1.2
Magnitude of HIV and AIDS problem in Botswana
The first cases of HIV were diagnosed in the early 1980s and since then HIV has become a serious health
challenge worldwide. The impact of the pandemic is especially serious in Sub-Saharan Africa which has
just over ten percent of the world's population but more than sixty percent of the people living with HIV
in the world.
The first case of AIDS in Botswana was reported in 1985. Botswana is reported to be one of the most
hard-hit countries in the world today. The 2004 Botswana AIDS Impact Survey (BAIS) II estimates the HIVprevalence in the general population to be 17.1 %, 19.8 % for females and 13.9 % for males. Town
dwellers constitute the highest proportion of the HIV positive population than those living in cities or
rural areas (NACA, 2004).
The HIV/AIDS epidemic has a devastating impact in the Botswana society. The impact is felt at social,
economic, national, community, family and individual levels. There is increased pressure on the health
care systems. The pandemic has had a negative impact on health indicators: Life expectancy has
dropped from 65 years in 1991 to 56 years in 2001 (UNICEF, 2004). There has been a 17% increase in
infant mortality (from 48 to 56 deaths per 1,000 live births) and 21 % increase in the under-five
mortality rate (from 63 to 74 deaths per 1,000 live births) between 1991 and 2001 (UNICEF 2004).
Orphans (age 0-18) constitute 17.7 % of all children (NACA, 2004). According to UNICEF, 120,000
children were estimated to be orphaned by AIDS in Botswana in 2003(UNICEF, 2005).
1.3
Nutritional Status in Botswana
Good nutrition is imperative to good health for everybody, and especially for People Living with
HIV/AIDS (PLWHA). Malnutrition of public health significance exists in Botswana especially in the form
of protein energy malnutrition (PEM), Vitamin A, Iodine and Iron deficiencies. A study conducted in 1994
by the Ministry of Health and UNICEF found that 35 % of the children surveyed had marginal Vitamin A
status (serum retinol<20mg/dl) and of these 2.9% were severely deficient; 38 % of the children and 33%
of the women surveyed were anemic; a total goiter rate was found to be 16%. In 2000, 13 % of children
under the age of five were underweight, 23 % were stunted and 5 % were wasted (CSO, 2001).
Factors contributing to malnutrition are many and include inadequate food intake, diseases, food
insecurity, poor water quality and sanitation, low education and poverty. The poverty rate has been
1
declining though still high, from 47 % in 1993/1994 to 30. 3 % in 2002/2003 (2002/03 HIES, CSO). In
Botswana 23.4 % of the population live on less than one dollar a day, leaving them very vulnerable to
malnutrition. Government has put in place measures to address some of these factors. These measures
include food baskets/ supplementary feeding for the vulnerable groups such as the destitute persons,
the orphans and vulnerable children, home based care patients, children under five years and
medically selected pregnant and lactating women.
1.4
The Link between HIV/AIDS and Nutrition
The relationship between malnutrition and HIV/AIDS can create a vicious cycle in which malnutrition
weakens the immune system and increase susceptibility to infections on one hand while on the other
hand frequent infections and illnesses may impair food intake and nutrient absorption and eventually
lead to the depletion of nutrient stores in the body. Together HIV/AIDS and malnutrition may put PLWHA
at greater risk of morbidity and mortality than their individual effects. The link between HIV/AIDS and
nutrition is developed further in chapter 3.
1.5
Rationale for the Guidelines
These guidelines are designed to equip service providers with necessary nutrition information to
enhance the quality of care and support for PLWHA. They should be viewed in line with Goals number 2
and 4 in the Botswana National Strategic Framework (NSF) for HIV/AIDS. Although the NSF does not
specifically articulate nutrition objectives, outcomes and impact indicators of nutrition care and
support are inseparable from the provision of treatment, care and support (Goal 2) and Psycho social
and economic impact mitigation (Goal number 4). As reflected in the respective impact indicators of
these NSF goals below, nutrition is fundamental to our achievement of the goals.
Goal 2: Provision of Treatment, care and support
Impact indicators:
°2.1 Percent of PLWHA on HAART returning to productive life
°2.2 Percent reduction in HIV beds occupancy rates
Goal 4: Psychosocial and economic Impact Mitigation
Impact indicators:
°4.1 Percent households with orphans receiving care and support
°4.2 Percent absenteeism and sickness in government ministries, parastatals, and private sector
NACA, 2003 NSF.
The guidelines are also in line with the national HIV/AIDS policy which recommends provision of
adequate nutrition information as encapsulated in the following quote;
6.3.6 “Access to information regarding nutrition and nutritional values of foods, particularly locally
available foods, will be provided to all residents of Botswana, especially through support networks
of PLWHA.”
Thus, the national nutrition guidelines are aimed at enabling programmers and service providers to
provide consistent and sound recommendations on the nutritional care and support for the people
2
living with HIV/AIDS. The existence of the guidelines will also contribute to greater awareness of the
importance of nutritional responses to HIV/AIDS.
1.6
Target for the Guidelines
These guidelines are meant to inform service providers in sectors such as health, agriculture, gender
and development, and local government amongst others, who have the primary responsibility of
providing support and care to people living with HIV/AIDS and their affected families. They define
actions that service providers need to undertake in order to provide quality care for and support to
PLWHA at various contact points. Areas at which the guidelines are expected to influence nutrition
service and support include but are not limited to:
1.7
How to use the Guidelines
The guidelines are deliberately wide in scope because they target a wide range of service providers in
the area of HIV/AIDS. Naturally, service providers have to focus more on aspects of the guidelines that
are relevant to the PLWHA who frequent their service delivery areas. For example, providers who
mostly see children will find chapters relating to children more helpful than others. The same is true for
providers in other areas.
The guidelines can be used:
°
°
°
°
°
°
To develop more detailed and specific operational guidelines
To develop training manuals on the nutritional care of PLWHA
To create messages that advocate good nutrition for all, but particularly for people living
with HIV/AIDS.
To develop guides that simplify information to a level that is understandable to caregivers
and PLWHA.
To provide nutritional and dietary counselling to people living with or affected by
HIV/AIDS.
To monitor and evaluate the integration of nutrition in the care and support of people
living with HIV/AIDS.
These guidelines can be used in conjunction with other reference materials including:
°
°
°
°
°
°
°
°
°
°
National Plan of Action of Nutrition
Draft Policy on Infant and Young Child Feeding (2002).
Guidelines for the PMTCT in Botswana (2005).
Nutrition Guide for People Living with HIV/AIDS (A Handbook for PLWHA).
Revised National Policy on Destitute Persons 2002 (Food Basket program)
CHBC Food Basket Implementation Guidelines (S&CD), MoLG still under construction
Botswana Guidelines on ARVs Treatment
Botswana HIV/AIDS Policy
Guidelines on Management of Severe Malnutrition
Guidelines for the IMCI
3
1.8
Layout of the Guidelines
Each chapter in these guidelines tackles an aspect of nutrition and HIV/AIDS. The Background
information links nutrition and HIV/AIDS. The purpose, rationale and target population for these
guidelines are also articulated in Chapter 1. Chapter 2 introduces and develops the concept of healthy
eating. The information in Chapter 2 is appropriate for most people. The relationship between
nutrition and HIV/AIDS that is introduced in Chapter 1 is developed further in Chapter 3. The focus of
this Chapter is to emphasize the central role that nutrition plays in mitigating HIV infections and in
improving the quality of life of PLWHA. The subsequent chapters discuss the nutritional assessment,
nutritional needs and nutrition care of PLWHA across the different physiologic stages, the management
of common illnesses in PLWHA, and nutrition consideration for people on ARV therapy. Other areas that
are covered in these guidelines include food safety and hygiene, nutrition education and counseling
and the impact of HIV/AIDS in food and nutrition security. The final chapter discusses ways of
monitoring and evaluating the outcomes of these guidelines.
4
CHAPTER 2
HEALTHY EATING
2.1
Introduction
The purpose of this chapter is to introduce the service provider to the basic knowledge of nutrition. The
chapter describes the concept of healthy eating and provides specific guidelines on how to make
healthy food choices and how to select adequate amounts of food from each food group. The
information will enable the service provider to guide the public and PLWHA in preparing meals that will
promote adequate nutrients.
2.2
Healthy Eating
The human body needs food for normal bodily functions. The food provides the body with the necessary
nutrients and energy for growth and development, for replacement and reparation of body tissues, for
resisting and fighting infections and for carrying out normal body functions. Food is also eaten for
social reasons. It is important for everyone to eat healthy for these reasons.
Healthy eating is the practice of making choices about what or how much one eats with the intention of
improving or maintaining good health. Typically, this means following recommendations of "experts"
regarding a nutritionally adequate diet. A nutritionally adequate diet is a diet based on different food
groups: cereals, breads, rice and pasta; fruit; vegetables; milk and dairy products; meat, fish and
alternatives; and limited amounts of foods containing fat or sugar. These foods contain different
nutrients such as carbohydrates, proteins, fat, vitamins and minerals, and water. Food also contains
non nutrient components that are essential to health. Within each of the food groups different foods
provide more of some nutrients than others. No single food can provide all the essential nutrients that
the body needs. Therefore, eating a wide variety of foods from and across all the food groups enables
one to achieve adequate intakes of the nutrients that are important for health and well-being. This is
what constitutes healthy eating.
Following healthy eating principles enables people to eat sufficient amounts and types of food to meet
energy and other nutrients needs for people of different age, sex, physiological state and physical
characteristics. More guidance for individualized guidance on healthy eating can be obtained from
dieticians. Annexes 1-4 provides some of the tools the dietitian can use to offer more specific guidance
for individual clients.
2.3
Food Groups and Portions
Foods are divided into food groups depending on the nutrients they provide. Each food group has a
recommended number of servings/portions that need to be included in the diet each day. Some foods
need to be eaten in large amounts while others should be eaten in small amounts depending on the
nutrients they provide. It is generally recommended that people should strive to eat diets that have the
recommended number of servings from each group on a daily basis. This is important because a healthy
and balanced diet is one that has the right amount of foods from each of the food groups. Table 2.1
shows all the food groups, the recommended number of servings from each group, the examples of
serving portions and the examples of food from each group.
5
Table 2.1: Summary table for the food groups
Food group Recommen Serving size(1 serving)
-ded No.of
servings
per day
Cereals and
potatoes
(starchy
foods)
6 to 11
Vegetables
3 to 5
1 bread slice,
1
1 cup of ready-to-eat
cereal food (e.g.
cornflakes or other
breakfast cereals)
½ cup of cooked cereal
e.g. rice, soft porridge,
samp
1/3 cup stiff papa or stiff
porridge
1 cooked potato or sweet
potato, medium
1 cup of raw leafy
vegetables, ½ cup cooked
vegetable
½ cup raw non leafy
vegetable
¾ cup or medium-sized
glass of vegetable juice
1 cereal bowl of salad
3 heaped tablespoons of
peas
Fruits
1
2
2 to 4
A serving is approximately
1 medium size fruit
½ cup of chopped or
canned fruit
¼ cup dried fruit
¾ cup or medium glass of
fruit juice
A Cup refers to one that can hold 250 ml water
Refer to Annex 2 for the function of nutrients
6
Examples of foods
Rich in
Mabele (sorghum meal),
maize meal, corn on the
cob (mmidi wa
ditlhotlha), rice, maize
rice, bread, cornflakes or
other breakfast cereals,
pasta (e.g.
spaghetti/macaroni),
sweet potatoes,
potatoes, lebelebele
(millet), papa
Energy from
Carbohydrates
, B vitamins:
thiamine
2
(vitamin B1)
and niacin
(vitamin B3)
Morogo wa dinawa (vigna
unguiculata), rotho,
thepe (amaranthus
thunbergii), spinach,
chomolia, cabbage,
butternuts, broccoli,
pumpkins, beetroots,
tomatoes, lettuce,
magapu (watermelons),
marotse/makatane
(melon), makgomane,
etc. Also Fresh, frozen,
dried or canned
vegetables and vegetable
juice are included.
Vitamins,
minerals and
fibre (or
roughage).
Apple, banana, orange,
pear, mango, moretlwa
(grewia flava)
mogorogorwana (monkey
orange), peach, apricots,
guava, morula
(sclerocarya birrea),
moretologa, mmilo (wild
medilar), mmupudu (red
milkwood), passion fruit,
100% fruit juices, pure
fruit juice smoothies,
and Fresh, frozen, dried
or canned fruits.
Vitamins,
minerals and
fibre (or
roughage)
Food group Recommen
-ded No.of
servings
per day
Serving size(1 serving)
Examples of foods
Rich in
Meat, fish
and
alternatives
2 to 3
30g cooked lean meat
(approx. size of palm),
poultry or fish
1 small drumstick
½ cup of cooked dry beans,
or baked beans,
1 egg
1/3 cup nuts
Beef, chicken, fish, pork,
lamb, liver, kidney, eggs,
beans, ditloo, letlhodi
(lentils), peanuts,
manoko (groundnuts),
peanut butter
Proteins, iron,
niacin
(vitamin B3),
thiamine
(vitamin B1)
Milk and
dairy
products
2 to 3
1 cup or 200ml glass of
milk
1 small tub of yoghurt
(150g)
30g/matchbox size of
cheese
Milk, cheese, yoghurt,
madila (sour milk)
Calcium,
vitamin A, D,
E & K,
phosphorus,
proteins
Fatty and
Sugary
foods
Small
amounts
and not
often
1 teaspoon oil/fat
1 teaspoon sugar
Margarine, butter,
animal/vegetable fats or
oil, pie, sugar, biscuits,
cake, chocolates, fizzy
drinks
Energy
2.3.1
Cereal, breads, rice and pasta (starchy foods) group.
This food group, sometimes referred to as 'starchy carbohydrates', should provide most of the food
intake. Aim to include at least one food from this group at each meal. It is recommended to eat 6 to 11
servings per day. A serving is approximately 1 slice of bread, 1/2 cup of cooked cereal, 1 medium sized
potato. The number of servings1 needed depends on the physiological stage (e.g. pregnancy), physical
activity and body size. The lower number of servings from each group provides the right amount of food
energy for sedentary (not physically active) women and older adults. The middle range is appropriate
for children, teenage girls, active women and sedentary men. The upper range meets the needs of
teenage boys, active men and very active women.
In general people should be encouraged to:
2.3.2
o
Base their meals around foods from this group
o
Eat more whole grain or whole-meal breads, pastas and cereals to increase the amount
of fibre in the diet.
o
Use minimal amounts of fat, if any, in preparing foods from this group to reduce the
proportion of fat in the diet.
o
Select more foods from this group because starchy foods are rich in energy.
O
Eat 6-11 servings of starchy foods a day.
Vegetables
Vegetables are rich in micronutrients such as vitamin A, C, folate, magnesium, and potassium. They also
7
provide fiber. Nutrients found in vegetables play major roles in enhancing body processes and
improving the immune function. Vegetables also provide color, flavor and pleasing texture to meals. It
is important that a diet provide a wide variety of vegetables because each family of vegetables is
uniquely rich in some vitamins and minerals and not others. Thus, the provision of a wide variety of
vegetable in the diet over time will ensure that the diet consumed is adequate in most minerals and
vitamins.
Vegetables also provide plant based compounds often referred to as phytochemicals. The
phytochemicals are known to have health promoting properties in the body. Some phytochemicals have
been known to lower the risk of cancer, to lower blood cholesterol, to improve the immune functions
and confer other protective properties to the body. As with vitamins and minerals, different
vegetables provide different phytochemicals.
Both indigenous and non indigenous vegetables are important in the diet and should therefore be
equally provided in the diet. It is recommended that 3-5 servings of vegetables should be included in
the diet each day. Apart from the nutrients they provide, vegetables also provide color and flavor.
Careful selection and preparation of vegetables can make the food more appealing to eat even to those
people with depressed appetites.
Examples of indigenous vegetables include morogo wa dinawa, rotho, leketa, thepe, delele,
lerotse/lekatane, makgomane, magabala and maphutshe. Fresh, frozen, dried and canned vegetables
all count. Refer to table 2.1 for more examples of vegetables.
Nutrients in vegetables can easily be lost if vegetables are over-cooked, cut into small pieces during
food preparation, or exposed to excessive sunlight. Nutrients can be preserved by cooking vegetables
for a very short time (should taste crispy) and re-using liquor that might be left over for other dishes.
Most people should EAT MORE vegetables than they are presently eating.
2.3.3 Fruits
Just like vegetables fruits provide vitamins and minerals. They are rich in Vitamins A, C, potassium,
fiber and phytochemicals. On average most people do not eat enough fruits. It is recommended that 24
portions of fruits be consumed each day. Altogether, 5-9 servings of fruits and vegetables should be
included in the diet each day. As with vegetables, both indigenous and non indigenous fruits are
valuable and should be deliberately included in the diet. In addition, nutrients in fruits can easily be
lost. This can be avoided by using fruits immediately after peeling them and not leaving peeled fruits
exposed to air.
Examples of indigenous fruit include mmupudu, mmilo, moretlwa, morula, moretologa,
mogorogorwana, mmurubele (mulberry). Other fruit are banana, orange, apple, pear, guava fruit, etc.
Fresh, frozen, dried and canned fruit all count. Also, 100% fruit juice and pure fruit juice smoothies
count.
Most people should EAT MORE fruits than they are presently eating: 24 portions a day.
Most people should be encouraged to
o
Choose fruits or chopped vegetables as a snack
o
Add dried or fresh fruits to breakfast cereals
o
Eat fruit or vegetable salads with sandwiches or with pizza
o
Add vegetables to casseroles and stews, and fruits to desserts
o
Eat different fruits and vegetables every day
8
o
Eat 5 9 portions of both fruit and vegetables a day
O
Limit the use of fruits canned in heavy syrup as a way reducing simple sugars
2.3.4 Meat, Poultry, Fish and Alternatives
Meat, fish, poultry, eggs, phane are rich food sources of zinc, iron, copper and B-vitamins. They also
provide high quality protein, whose primary function is to build and repair body tissues. It is
recommended that 2-3 servings of meats, fish or meat alternates be included in the diet each day.
While meats and poultry provide high quality protein and other valuable nutrients, if used without
heeding other dietary guidelines they can be a source of large amounts of fat, saturated fats and
cholesterol. To guard against excessive intake of fat, it is generally recommended that low fat meats be
selected and used more often than meats high in fat. In addition, visible fat in meats should be removed
before the meats are prepared and any excess fat be skimmed off from the gravies once the meats have
been prepared. It is also recommended that the amounts of processed meats such as bacon, salami,
sausages and beef burgers in the diet should be limited to reduce fat and in some cases salt intake.
The fat that is found in meats and poultry is known as saturated fats (or saturates). Saturates are best
kept to a minimum because they increase cholesterol in the blood which in turn increases the risk of
developing heart diseases. Cholesterol found in the body is called “blood cholesterol” while that found
in some foods is “dietary cholesterol”. It should be noted that dietary cholesterol does not have a major
effect on the overall amount of cholesterol in the blood of most people but it is the amount of saturates
eaten which has a big influence on blood cholesterol levels.
Amongst the high protein foods in this group, fish in all of its forms (canned, dried, or fresh) is generally
healthier than other foods. It is lower in fat than some meats and poultry (with skin). In addition,
most of the fat in fish is polyunsaturated oils, which are associated with a lower risk of heart diseases.
Hence, the recommendation is that two portions of fish, especially oily fish such as salmon, mackerel,
herring, sardines, trout, or fresh tuna be included in the diet each week. Some people may benefit from
eating more than this. Oily fish is also rich in omega-3 fatty acids which may help reduce the risk of
developing heart diseases.
Meat Alternatives Meat alternatives generally are foods of plant origin that have comparable amounts
of protein to meats. They are often referred to as phyto protein-rich foods (i.e. protein-rich foods of
plant origin). These include nuts, soya, mycoprotein, textured vegetable protein (TVP), and other
legumes such as ditloo, kidney beans, canned baked beans, and pulses such as lentils (letlhodi). Unlike
meats these foods also provide fiber. Fiber is important in the diet because it lowers blood cholesterol
and blood sugar levels and prevents constipation. They are also less expensive than meats, poultry and
fish. Compared to meats, poultry or fish, meat alternatives are not a rich source of zinc and generally
provide no vitamin B12 (unless fortified), hence vegetarians will especially need to find other sources
for these nutrients. They also have unsaturated oils. Some of the unsaturated oils are necessary in
small quantities for good health. Good sources include olive, sunflower, rape seed, soya and corn oils.
Most people should be encouraged to
o
Choose lean and lower fat meat products
o
Cut visible fat including skin from meat and poultry before cooking and drain away fat
after cooking
o
Choose cooking methods that do not add fat to meats, poultry and fish (boil, stew, grill,
roast or microwave) rather than frying
o
Eat oily fish at least once a week
o
EAT MODERATE AMOUNTS!
o
Limit the use of highly processed meats and meat products
9
2.3.5 Milk and Dairy Foods
Milk and dairy products are good food sources of calcium, riboflavin, vitamin B12 and protein. Milk can
also provide adequate amounts of vitamin A and D if fortified. Calcium-fortified soya milk belongs to
this food group. Calcium-fortified soya milk is considered a milk alternative in the same manner as
there are meat alternatives in the meats, poultry and fish group. The recommended numbers of
servings from this group are 2-4 servings each day. As with meats, milk and other dairy products can
contribute significantly to the amount of saturated fats in the diet. It is best to choose low fat milk and
milk products more frequently than the regular and high fat products, unless there is an established
need for more energy. Some examples of food in this group include cheese, yoghurt and madila (sour
milk). This group does not include butter and cream.
Most people should be encouraged to
o
Choose low fat milk e.g. skimmed milk, ½% 1% and 2% milk more often.
o
Choose low fat yogurts and reduced fat cheeses.
o
Choose frozen yoghurt over ice cream.
o
Limit the use of processed cheese.
o
EAT MODERATE AMOUNTS! (Eating high amount may result in high fat-intake)
2.3.6 Fatty and Sugary Foods
Foods that are high in fat and simple sugars belong to the “Other food group”. These foods provide a lot
of sugar or fat and energy but have few nutrients. When they are used in the diet, it is recommended
that they be used sparingly. Examples of foods that fall this group are given in the following categories:
Sugary Foods: Soft drinks (not diet drinks), sweets, jam, honey (tsina ya dinotshe) and sugar, as well as
foods such as cakes, puddings, biscuits, pastries and ice-cream.
Fatty foods: Margarine, butter, other spreading fats and low fat spreads, cooking oils, oil-based salad
dressings, mayonnaise, cream, fried foods including fried chips, chocolate, crisps, biscuits, pastries,
cake, puddings, ice-cream, rich sauces and gravies are all in this food group because they are high in
fat. Most of these foods are high in sodium (hidden salt). Therefore, most people need to EAT LESS
foods from this food group to reduce salt, sugar and fat intakes from their diet.
Most people should be encouraged to:
2.4
o
Eat small quantities of foods in the “Other food group”
o
Choose low fat or reduced sugar foods where possible.
o
Use spreads and oils sparingly.
o
Choose vegetable oils and fats rather than animal fats.
o
Limit the consumption of sugar-containing foods and beverages.
o
Limit the use of fats/oils in cooking and serving foods.
Additional Information
2.4.1 Dietary Fibre
Dietary fibre is also known as 'roughage'. It can promote a number of positive physiological functions;
helping to prevent constipation, lower blood cholesterol levels and control blood glucose levels (by
reducing glucose uptake after a meal from the gut to the blood, hence managing diabetes). Insoluble
fibre (wholegrain cereals and whole meal bread) can act as bulking (laxative) agents and help prevent
constipation. For fibre to have the best effect on preventing constipation, an increase in fibre intake
10
should be accompanied by an increase in water intake. Soluble forms of fibre (oats, fruit, vegetables
and pulses e.g. beans, lentils, chickpeas) eaten in large amounts can help reduce blood cholesterol
levels and control blood glucose levels.
Because insoluble and soluble fibres are found in different proportions in fibre-containing foods and
have different properties, it is important to eat a variety of fibre-containing foods.
2.4.2 Salt / Sodium
Salt is needed for the body to function properly. However, many of us consume much more than we
need. It is recommended that the average intake of salt should be reduced to 6g/day for adults; and
less for children. Choose foods that are low in salt, and avoid adding salt to foods during cooking and at
the table. Salt is often labeled on foods as sodium. If you use salt it is better to use iodated than non
iodated salt. Iodated salt provide iodine, a micronutrient that prevent development of goiter,
cretinism, mental retardation and other disorders.
2.4.3 Supplements
For most healthy people, a healthy diet as described in this chapter should provide all the vitamins and
minerals the body needs. Certain disease conditions like HIV/AIDS may prompt the need to take
supplements, especially in population where sub-clinical nutrient deficiencies are prevalent. If the
nutrient requirements are not met through a normal healthy diet, a multivitamin and mineral
supplement should be preferred over high doses of single vitamins or minerals supplement. Even then
these supplements should not contain amounts of nutrients higher than 100% of the RDA/AI. High doses
of single nutrient supplements may lead to toxic levels, or may well be unnecessary and expensive.
Supplements should not replace a healthy diet and should not be taken without seeking medical advice.
2.4.4 Fluids
The amount of fluid we need varies from person to person. Factors such as age, climate, diet and
physical activity level all have an influence on fluid requirement. Lack of water can lead to
dehydration, a condition that occurs when you don't have enough water in your body to carry out
normal body functions.
Every day we lose water through our breath, perspiration, urine and bowel movements. For our bodies
to function properly, we must replenish its water supply by consuming beverages and foods that contain
water or other fluids. Fluids are needed for digestion and absorption of food, regulation of body
temperature and blood circulation, transportation of nutrients and oxygen to cells, and removal of
toxins and other wastes. This "body water" also cushions joints and protects tissues and organs,
including the spinal cord, from shock and damage. Conversely, lack of water can be a cause for many
ailments.
Fluids include water, fruits, fruit juices, drinks (e.g. squash), tea and coffee. The foods we eat also
provide the body with fluids. Some fluids can add significant amounts of energy to the diet. Care should
be taken in selecting healthier options that do not provide empty calories.
The recommended intake is 8 cups/glasses (1.5 to 2 litres) of fluids a day in temperate climates or more
in cases of fever, diarrhea, and physical activity.
2.4.5 Alcohol
Alcoholic beverages add more calories but no value to the nutrient content of the diet. Therefore
nutrition experts recommend limiting alcoholic beverages to no more than 2 units per day for men and 1
unit per day for women. A unit is about 25ml of spirits (standard pub measure), 125ml (small glass) of
wine or half a pint of standard strength lager, beer or cider. Excessive intake of alcohol has deleterious
11
social and health effects. Some of the undesirable health effects of alcohol include increased risk of
liver cirrhosis, fetal alcohol syndrome, alcohol related dementia (side effect of thiamin), impaired
coordination and delayed reaction time. Alcohol also interacts negatively with some medications
including ARVs. The undesirable social effects of excessive alcohol intake include involvement in crime,
violence and risky sexual behavior, automobile accidents, just to mention a few.
Most people who drink should be encouraged to:
°
Eat before taking alcoholic beverages so they will not miss out on essential nutrients.
°
Try non or low alcoholic drinks sometimes.
°
Extend alcoholic drinks with low calorie mixers or water.
°
Drink slowly take smaller sips.
°
Reduce eating crisps and nuts when drinking alcohol as this will add more calories and fat to
your intake.
°
Reduce the intake of salty foods while drinking as doing so will cause them to thirst, and thus
lead to more drinking.
2.4.6 Physical activity
Besides healthy eating, physical activity is of paramount importance in achieving and maintaining
health and wellness. Without exercise, it is difficult to maintain good health even if one makes healthy
food choices. It is recommended that adults should have a minimum of 30 minutes of physical activity
3-5 times a week. This recommendation is in addition to daily household activities. For children a
minimum of 60 minutes of physical activity per day, 3-5 times a week is recommended.
Physical activity or manual work is strongly associated with reduced risks of chronic diseases such as
Heart diseases, obesity and cancer. Physical activity also keeps the bones strong by helping the bones to
be renewed (bone remodeling; thus bone re-absorption and bone formation). The intensity of exercise
is somewhat difficult to standardize because it is very much dependent on the physical fitness of the
person exercising, his/her body weight and age, and the type of activity undertaken. Roughly
moderately intense physical activity can include fast/ brisk walking for at least 30 minutes. In general,
the level of physical activity can be increased by increasing body movements, such as swinging hands
while walking and by increasing the duration of the physical activity.
Examples of physical activity include; walking, jogging climbing or going down stairs instead of using a
lift, parking a car a bit far from your destination (e.g. shopping area) and walking to the shops, cleaning
the house or yard, raking, gardening, washing clothes, gymnastics, aerobics, sporting/playing e.g.
cycling, running, playing soccer, basket ball, tennis, weight-lifting exercises, etc.
2.4.7 Healthy body weight
Body weight is a reflection of energy balance. In order to maintain a healthy body weight it is important
to strike a balance between the energy obtained from food and the energy spent through physical
activity. If the food consumed provides more energy (calories) than the body uses, the excess energy
will be stored in the form of fat deposits and thereby increase the risk of non communicable diseases
such as diabetes, hypertension and cardiovascular diseases.
There are several anthropometric methods that can be used to estimate energy stores. The first and
mostly commonly used method in adults is the Body Mass Index (BMI). This method is used to evaluate
the appropriateness of body weight per given stature. It is calculated as shown in the box below. BMI
values between 20 and 25 are associated with the least risk of morbidity and mortality from nonn
communicable diseases. As BMI increases past 25, the risk of non-communicable diseases and mortality
increases. Refer to the box below to understand the classification criteria for BMI.
12
How to calculate BMI
BMI = body weight (kg)/ (height x height) (m)²
e.g. Man with a weight of 72kg and 1.63m in height
BMI = 72kg / (1.63m x 1.63m) = 27
BMI Classification criteria
< 18.5
Underweight.
18.5 - 24.9
Normal.
25 - 29.9
Overweight
30 - 39.9
Obese
= 40
Extreme Obesity
BMI is the most commonly used method of assessing body fatness because it is relatively simple to
calculate compared to other methods and it is correlated with the risk of non-communicable diseases in
the general population. There are subsets of the population where BMI does poorly in estimating body
fatness. Body builders and other athletes fall into this subset of the population. Due to this limitation,
BMI should not be used to estimate body fatness in this population. Furthermore, other methods of
anthropometric assessment should be used together with BMI from time to time. Other methods that
are commonly used to estimate excess energy stores include skin fold thickness, waist circumference
and waist/ hip ratio. Skin fold thickness assess fat deposits under the skin. These give a good estimate
of total body fat. The use of skin folds thickness is often limited by the high skill level required
compared to estimating body mass index. Hence the method is best used by registered dietitians.
In some countries, BMI-for-age percentiles are used to estimate the risk of fatness in children. In
Botswana, children's growth should be evaluated using growth charts in the children's Child Welfare
Clinic card. The revised graphs can be used to detect children at risk for overweight.
If assessment of body weight reveals excess energy stores, efforts should be put in place to reduce
energy store by a combination of healthy eating as described earlier in the chapter and physical
activity.
Excess energy store can also be reduced by;
o
Choosing more foods that are low in energy such as whole grain cereals, fruit, and
vegetables.
o
Eating less fat. It has twice as many calories as the same weight of starch.
o
Eating less sugar. It has 'empty calories' i.e. calories with no other nutrients.
Walking more often.
o
Doing more activities around the home and garden.
o
Getting involved in some organised sport.
o
Being active throughout your life, not just when you are trying to lose weight.
13
CHAPTER 3
THE RELATIONSHIP BETWEEN NUTRITION AND HIV/AIDS
Good nutritional status is central to health. Dietary energy, protein and other nutrients provide the
body with energy to perform normal body functions and raw materials for building new and repairing
damaged cells and tissues. Like other body systems, the immune system depends on food energy,
protein and other nutrients to actively defend the body from infections. Collectively, different
elements of the immune system are known to act as physical barriers to infectious/foreign substances,
to identify, label, inactivate and even kill infectious organisms. Studies show that changes in the
nutritional status, especially protein energy malnutrition undermines the immune systems' vigilance in
protecting the body against infections. When the immune system is impaired, the body succumbs to
infections. In turn these diseases raise the body's nutrients needs and creates an imbalance between
nutrient intake and needs. If not addressed this imbalance worsens the nutritional status and further
gives way for more opportunistic infections.
The HIV attacks and disables the immune system and creates ample opportunities for other infections.
These other infections are often referred to as secondary or opportunistic infections. The opportunistic
infections together with the primary infections weaken the body immune system further and cause
various illnesses, such as fever, cough, itching, chronic diarrhea, pneumonia, tuberculosis and oral
thrush. The resultant illnesses negatively affect the nutritional status by impairing food intake (e.g.
thrush), promoting loss of nutrients (diarrhea), promoting excessive use of energy (fevers) and
impaired digestion and absorption of nutrients. The nutritional demands that these illnesses put on the
body widen the disparity between nutrient intake and needs, and if unattended promptly these
demands can culminate in malnutrition. Malnutrition can contribute to and result from the progression
of the HIV infection.
Malnutrition and HIV infection have a reciprocal relationship in which malnutrition increases
susceptibility to the HIV infection and the HIV infection creates an environment that precipitates
malnutrition. Together, the HIV infection, malnutrition and opportunistic infections interact in a
manner that leads to further deterioration of health and nutritional status and eventually more rapid
progression to AIDS. This reciprocal relationship is clearly shown in the figure 3.1.
In HIV infected people malnutrition may result from
°
Reduced food intake.
°
Poor absorption of nutrients.
°
Changes in the way the body uses the nutrients.
°
Chronic infections and illnesses.
°
Failure to meet the increased nutrient needs necessitated by fever.
14
Poor Nutrition
resulting in weight loss,
muscle wasting, weakness,
nutrient deficiencies
Increased nutritional
needs,
Reduced food intake
and increased loss of
nutrients
HIV
Impaired immune system
Poor ability to fight HIV
and other infections,
Increased oxidative
stress
Increased vulnerability to
infections e.g. Enteric
Infections, flu, TB hence
Increased HIV replication,
Hastened disease progression
Increased morbidity
Figure 3.1: A vicious cycle depicting the relationship between nutrition and HIV/AIDS
RCQHC/FANTA, 2004
Many people can live with the HIV virus for many years if they maintain good nutrition. However,
this requires timely intervention to break the vicious cycle and improve the immune system, boost
energy and enhance recovery from opportunistic infections. Without intervention the body
gradually becomes weak and eventually succumbs to AIDS. The WHO has classified the progression
of HIV to AIDS into 4 stages as shown in the Table 3.1 below. The first stage occurs early during the
infection and PLWHA show no symptoms. As the infection progresses, more infections become
evident and symptoms become more advanced (stage 4).
Providers are encouraged to
° Ensure that the client understands the relationship between nutrition and
HIV/AIDS.
°
Use the information in chapter 10 to manage nutrition and dietary problems in
PLWHA.
°
Be especially responsive to groups with HIV/AIDS with differing needs. These
include infants and young children, pregnant and lactating women and
severely symptomatic adults
15
Table 3.1 WHO Clinical classification System for HIV
Stage
Symptomatic /
Asymptomatic
Characteristics
1
Asymptomatic
-
Persistent generalized welling of lymph nodes
2
Symptomatic
-
Weight loss, < 10% body weight
Minor mucocutaneous manifestations such as seborrhoeic dermatitis,
prurigo, fungal nail infections, recurrent oral lesions, angular cheilities
Herpes zoster within 5 years
Recurrent upper respiratory tract infections such as sinusitis
3
Symptomatic
-
Bedridden for <50% of the day during the last month
Weight loss > 10% body weight
Unexplained chronic diarrhea >1 month
Oral candidiasis ( thrush)
Oral hairy leukoplakia
Pulmonary tuberculosis
Severe bacterial infections such as pneumonia or pyomyositis
4
Symptomatic
-
Bedridden for <50% of the day during the last month and
HIV wasting syndrome
Candidiasis of the esophagus, trachea, bronchi or lungs
Cryptococcus, extra pulmonary
Cryptosporidiosis with diarrhea for > 1 month
Cytomegalovirus disease of an organ other than the liver, spleen or
lymph nodes
Herpes simplex virus infection, mucocutaneous for> 1 month or visceral
for any duration
HIV dementia (encephalopathy)
Kaposi's sarcoma
Lymphoma
Extrapulmonary tuberculosis
Atypical mycobacteriosis, disseminated or pulmonaryany disseminated
endemic mycosis
Pneumocystis carinni pneumonia
Progressive multifocal leukoencephalopathy
Salmonella septicemia ( non typhoidal)
Toxoplasmosis of the brain
-
16
CHAPTER 4
NUTRITIONAL NEEDS AND ASSESSMENT OF PLWHA
4.1
Nutritional Needs
When people are infected with HIV, their demands for energy and some nutrients may increase as
elaborated in chapter 3. The extent of the increase depends on the severity of the opportunistic
infections and their nutritional status. This chapter provides the nutrition and dietary
recommendations for the care and support of people living with HIV/AIDS. General nutritional
recommendations for the nutritional care of PLWHA are categorized below. However it is
recommended that PLWHA undergo a baseline nutritional assessment to facilitate more targeted
nutrition interventions. More information of how to go about conducting nutritional assessment is
provided in the second half of this chapter.
4.1.2 Asymptomatic
Asymptomatic HIV infected persons require adequate nutrition in order to prevent infections and
maintain normal nutrition status for as long as possible. With a few exceptions, most HIV infected
persons can meet their nutrient requirements by following the healthy eating recommendations as
outlined in chapter 2. However there are some nutrients that are required at higher levels in
asymptomatic HIV infected persons compared to their seronegative counterparts. The specific needs of
nutrients are described below.
Energy: PLWHA who do not display symptoms have elevated basal metabolic rate compared to their
age, sex and physically activity matched HIV negative counterparts. The higher basal metabolic rate
necessitates the provision of 10% more energy. This may be met through a regular balanced diet (a
balanced diet is one that provides a variety of foods in adequate quantities and combinations to supply
essential nutrients on a daily basis as described in detail in chapter 2). Additional servings of energy
giving foods (carbohydrates) can help meet the extra (10%) energy needs. While energy requirements
are higher, it is important that in selecting foods the healthy eating concepts of variety, moderation and
balance are still recognized. The increase in energy intake recommended here should be considered
together with other recommendations about achieving and maintaining a healthy nutritional status
e.g. the importance for most people to achieve and maintain a healthy body weight. Thus it is
important that the added energy should enable PLWHA to maintain their usual body weight but not to
gain weight to levels that could put them at risk for non communicable diseases.
Protein: In the early stages of the infection the amount of protein that is needed is not significantly
different from that of an age, sex, physiologic stage matched person without HIV. Therefore, protein
requirements for an asymptomatic HIV infected person are the same as for the uninfected person.
Micronutrients
Some micronutrients may be needed in higher amounts than others. However it is often difficult to
know which nutrient deficiencies PLWHA may have without tests. For the most part, sub-clinical
nutrient deficiencies can be addressed through the intake of a balanced diet. In a few situations a
micronutrient supplement may be beneficial to PLWHA. However, if supplements are recommended for
17
clients, preference should be given to multiple micronutrient supplements which contain amounts of
nutrients not exceeding 100% of the RDA.
4.1.3 Symptomatic
Protein: Symptomatic HIV positive persons present with several opportunistic infections that affect
their nutritional status. These opportunistic infections increase their nutritional requirements and may
also impair nutrient intake as explained in chapter 3. Therefore the protein needs of symptomatic HIV
infected persons may increase significantly due to opportunistic infections, depletion of stores and
impaired dietary intake. To address this situation, It is generally recommended that protein intake be
increased by 10% in symptomatic HIV infected persons. However, where there is capacity to perform
nutrition assessment, it is best for dietitians to assess and estimate the protein needs because the
needs differ from one individual to another depending on the severity of infections
In less severe situations, protein needs may be met through a regular balanced diet with additional 2 3
servings of protein rich foods.
Energy: HIV infected persons displaying symptoms require between 20-30% more energy to meet the
elevated needs due to infections and changed metabolism. These extra energy needs may also be met
by additional servings across the various food groups. The energy increases remain the same whether or
not the HIV-infected person takes ARV treatment. In some situations such as impaired oral intake
and/or poor food tolerance a modified diet may be more appropriate. In such situations clients should
be referred to a dietitian.
Micronutrients: In symptomatic HIV infected persons the need for some micronutrients are higher.
Examples of some of the micronutrients that may be needed in higher amounts are; Vitamin A, E, Bcomplex, Copper, selenium and Zinc. A client's need for these should be established first by a medical
provider who will also prescribe as he finds appropriate. A dietitian should be consulted for more
information on the dietary sources of specific micronutrients.
4.1.4 Advanced Stage
Protein: Protein requirements for people with advanced HIV infection are 10% higher than the needs of
uninfected people of the same age, sex, weight and height.
Energy: Energy requirements for people with advanced HIV infection are 20-30% higher than their
seronegative counterparts. However, given the numerous medical and nutritional complications in
people with advanced HIV infection, their nutritional needs should be established by an experienced
health professional. Preferably, a team of medical professionals and dietitians should be involved in the
care of people with advanced HIV infection.
Micronutrients: Micronutrient requirements are also higher for the advanced stage as compared to the
asymptomatic stage. While, it has also been established that the requirements for some
micronutrients is higher compared to others, it is still recommended that if supplements are deemed
necessary, they should be provided as multiple micronutrient supplements instead of single nutrients
supplements. In addition, supplement should be provided in amounts not exceeding 100% of the RDA.
NB: Single micronutrient supplements need to be used with caution and proper guidance
18
from medical providers as large doses can be harmful. As such clients should be cautioned
against obtaining and using these without medical advice.
PLWHA should be
-
Counseled to consume a balanced diet.
-
Encouraged to increase their energy intake by 10% if they are asymptomatic or by 20 30% if
they are symptomatic and without co- morbidities. If clients have co-morbidities refer
them to a dietitian.
-
Referred to a dietitian if they fall in the vulnerable population groups (elderly, adolescents,
children, pregnant women etc).
-
Counseled to increase the frequency or number of times they eat per day (i.e. have small,
frequent meals)
-
To enhance their diet by using nutrient-rich foods
-
To increase consumption of fruits and vegetables
-
To increase consumption of foods fortified with the essential nutrients such as vitamin A,
iron, the B vitamins, and vitamins K and E.
-
To use locally available foods to diversify their diets
-
Encouraged to keep exercising regularly
-
Advised to identify and monitor symptoms or conditions that affect their appetite or ability
to eat.
-
Encouraged to check their weight periodically and if possible they should have necessary
laboratory tests.
4.2
Nutrition Screening
Nutrition screening and nutrition assessments are methods used to identify nutritional needs of people.
Nutrition screening is a rapid and economical way of identifying people at risk for poor nutrition. Tools
for nutrition screening can be administered by most service providers because they do not require high
skill level in nutrition. Typically, screening tools are designed to identify people with symptoms that are
suggestive of poor dietary intake, presence of an illnesses or condition that may precipitate
malnutrition. Common examples of people who are likely to be found at risk for poor nutrition include
those with poor appetites, gastrointestinal symptoms that might affect nutrient absorption or oral
symptoms that might interfere with food intake. PLWHA found at high risk for poor nutrition through the
use of nutrition screening tools should be referred to a dietitian for more extensive nutrition
assessment while those with low scores should be assisted using information in the relevant sections of
these guidelines.
Several screening tools are available for use. Some screening tools can be completed by PLWHA
themselves or with the help of the providers. Examples of nutrition screening tools include the Quick
Nutrition Screening and the subjective global assessment tool. The most commonly used screening tool
for PLWHA is the Subjective Global Assessment. This screening tool is preferred because it has been
used successfully before in people with wasting conditions. Amongst criteria found in screening tools,
unintentional weight loss of more than 10% of usual weight within 4-6 months, chronic infections
especially diarrhea and the presence of co-morbidities normally place PLWHA at high risk for poor
19
nutrition. PLWHA found to fit in this category during screening and have a high score in the screening
tool should be referred to a dietitian promptly. Given the importance of regular screening, providers
are encouraged to have a scale and a stadiometer. PLWHA should also be encouraged to own bathroom
scales so that they can monitor their body weights periodically.
Nutrition Screening Tool Based on Subjective Global Assessment
Any weight loss in last 3 months? ( adults)
Score
None
3kg lost [<1 clothes size]
3 6kg lost [1-2 clothes size]
> 6kg lost [>2 clothes size]
0
1
2
3
BMI
> 20
18 -19.9
15 17
< 15
0
1
2
3
Assessment of growth (children)
Growing well(child growth curve continuously moving up)
Growth failure (flat or downward trend of the growth curve)
Weight-for-age below 2 standard deviations
0
4
6
Appetite
Good (most of plate eaten)
Poor (½ plate eaten)
Unable to eat (no food eaten for last 4 meals)
0
2
3
Ability to eat (select all that apply)
No problems
Mild vomiting/diarrhoea
Difficulty swallowing/ chewing e.g. mouth sores
Need help with Feeding
Severe vomiting/ diarrhoea
0
1
2
2
3
Other Problems
None
TB/HIV/AIDS
HIV/AIDS & other infections e.g. TB
0
2
3
Total Score
___________
Scoring :
0-3:
4-5:
Not Currently at risk: Follow Healthy Eating as described in Chapter 2
Some nutrition risk: Follow Health Eating as described in Chapter 2 Use relevant sections of
the National Guideline to address identified nutrition concerns. Reassess after 1 month, is
successive weight loss, score as = 6 and refer to a dietitian
20
=6:
Refer to a dietitian
4
Adapted from the Nutrition Risk Assessment Tool , Directorate of Nutrition, Kwazulu-Natal Health
Department 2004.
4.3
Nutrition Assessment
Nutritional assessment involves the use of anthropometry, dietary, clinical observations and
biochemical methods to determine the current nutritional status of individuals. The major purpose of
nutritional assessment is to determine the severity of nutritional impairment and its probable causes.
The focus in nutrition assessment is to use the information obtained from dietary and anthropometric,
clinical, biochemical, and other methods to recommend interventions that will yield positive changes
in the nutrition status of PLWHA. As opposed to nutrition screening, nutritional assessment requires
adequate training in nutrition. Thus it is recommended that all PLWHA who require nutritional
assessment should be referred to a dietitian.
ABCDE Assessment of:
A - Anthropometric
B - Biochemical
C - Clinical
D - Dietary
E - Environmental status
4.3.1 Anthropometric
In conducting anthropometric assessments, dietitians measure and analyze the adequacy of body
height, weight, hip and waist circumferences and skin folds. The readings obtained are directly
compared to known reference standards or computed to indices of nutrition significance such as body
mass index. Anthropometric assessments provide information about the body composition (% leanness
or adiposity or distribution of adipose tissue in the body) and allow providers to evaluate functional
status of PLWHA. The tools used in assessing anthropometrics can be as economical and simple as
weighing scales, height boards and non-stretchable tapes or be more technologically advanced
equipment such as bioelectric impedance analysis, dual X-ray absorptiometry, cross-sectional
computed tomography, and magnetic resonance imaging. While it is important to compare the
measurements obtained from PLWHA with the reference standards, the importance of tracking changes
in the client's own measurements over time is paramount. Hence it is important to keep records well
and to encourage PLWHA to know their usual body weights, body mass index and others indices.
4.3.2 Biochemical
Dietitians use observations from the laboratory examination of blood, blood products, urine and other
body samples to identify metabolites and body proteins of nutrition significance and markers of
infection. Biochemical analysis can provide information about minerals and vitamins status and protein
store by using biomarkers. It is advantageous in that it can provide information about sub-clinical levels
of malnutrition and prompt early provision of interventions before severe deterioration of nutritional
status occurs. Examples of biochemical indicators of nutritional significance include but are not limited
to blood counts, CD4 cell count, enzymes, levels of hemoglobin, glucose, albumin, prealbumin, iron,
blood lipids.
21
4.3.3 Clinical
The key in clinical assessment is to identity physical manifestation of nutrient deficiencies or excesses.
This requires a lot of skill and experience. Careful examination of eyes, hands, fingers, hair, mouth,
gums and skin, tummy and body shape can provide valuable information for nutrition assessment.
4.3.4 Dietary
Dietary assessment evaluates the adequacy of the food and the nutrients consumed. This involves
assessment of eating patterns, frequency of meals and the factors influencing the choice of food
procured. The underlining objective is to establish the client's ability to consume enough amounts and
variety of food to meet his/her needs. A variety of methods are available for use. Some of these are
food records, dietary history, 24-hr recalls and food frequency. The choice of the method should match
the characteristic of the clients. It is best to use a combination of methods that will adequately reflect
the clients' usual intake, current intake, dietary preferences and practices, food intolerances and any
dietary changes that may undermine dietary intake. Dietary assessment should also capture
information regarding the use of food supplements or substances used as such.
4.3.5 Environmental status
The physical, psycho-social and economic environment in which PLWA live may also influence their
nutritional status. These environments may negatively affect food security, balance and variety in
diet, frequency of meals and methods of food preparation. For example, PLWHA who are temporarily
debilitated by illnesses may find it difficult to purchase, prepare, and eat food, while poverty, lack of
refrigeration or lack of appropriate cooking facilities, may restrict the choice of food. Some PLWHA
may also find it difficult to access social safety net programs or fail to collect their food supply if
already enrolled in safety net programs. The amount of food consumed at each sitting may also be
restricted by factors such substance / alcohol abuse, depression or senile dementia. All these factors
have a bearing on the overall nutritional status of PLWHA and should receive prompt attention as do the
ABCDs of nutritional assessment.
Proper utilization of nutritional assessments methods enables providers to
°
Establish the correct nutritional status of PLWHA
°
Confirm the adequacy of recommended interventions and prompt providers to review
the interventions.
°
Confirm the absence of illnesses that aggravate nutritional wastage and provide
treatment for illnesses that reduce food intake.
°
To adjust meals and meal plans for other chronic illnesses associated with HIV.
°
To facilitate provision of therapeutic nutritional care and support PLWHA
22
CHAPTER 5
NUTRITION CARE FOR CHILDREN WITH HIV/AIDS
Children born to mothers infected with HIV are often born with weight and height below average.
Although those uninfected catch-up those infected do not. An earlier and more pronounced deficit in
height-for-age is noted, especially by the 15th month of age. Unlike adults, children with HIV have added
challenges because of the extra energy required to sustain growth and development. Pediatric HIV
disease often leads to multiple nutritional deficiencies; such as, macronutrients (protein, or energy) or
micronutrient (minerals and vitamins) deficiencies or both. These can lead to wasting (decrease in
weight-for-height), underweight (decrease in weight-for-age), or stunting (decrease in length or
height for age). Initially, malnutrition leads to weight loss or poor weight gain and if prolonged (chronic)
deficit in linear growth develop.
Malnutrition in children with HIV/AIDS leads to compromised immune function, delayed growth and
development and possible treatment failures. However there is evidence that show that once children
are put on treatment their growth rate also improves. This is true even for children who had growth
retardation. In fact for most of these children with a few exceptions who experienced severe
deprivation early in life, recovery is complete.
IMPORTANT DEFINITIONS
Growth Failure : Failure to gain weight in three consecutive months.
Underweight : Low weight compared to children of same age and sex (technically: weight-forage below two standard deviations (at -2 z-scores) of the mean of the reference
population
Wasting
: Low weight for height/length : weight-for-height/length below two standard
deviations (at -2 z-scores) of mean of the reference population
Stunting
: Low length/ height compared to children of same for age and sex. (technically:
height-for-age below 2 standard deviations of the( at -2 z-score)of the mean of
reference population
5.1
Importance of Prevention and Early Intervention on Malnutrition
Prevention of malnutrition is facilitated by routine nutrition screening (and where necessary
nutritional assessment) of all children infected with HIV. Nutrition screening enables providers to
identify factors that are often associated with malnutrition. Once the concerns are identified they
should be followed up with appropriate management promptly. The reason management must be
prompt is because failure to do so will not only increase the likelihood of malnutrition but the resulting
malnutrition can make the child more vulnerable to opportunistic infections. For example, if during
nutrition screening it becomes evident that the child has fever, the fever must be managed quickly
because 1) fever increases nutritional requirements 2) fever reduces the desire to eat and 3) the higher
nutrition requirements and the poor dietary intake in children with fever will put the child at an even
higher risk of malnutrition than their individual effects. In addition poor nutrition delays the physical,
cognitive, physiological and social development of children. It is therefore important that providers
must make all efforts to prevent malnutrition and where risk factors for malnutrition are identified
they should be addressed promptly.
23
5.1.1 Nutritional Screening
It is recommended that all children with HIV infection be screened for risk of malnutrition within 3
months of diagnosis and every 1-6 months thereafter, relative to age, problems and nutritional status.
The nutrition screening tool provided in section 4.2 Nutrition Screening) can be used to facilitate this
process.
Nutrition screening may be performed by the consulting health care professional or a
professional from another more appropriate practice area/ agency through a referral. In both
situations, however, it is important that the needs of the caregiver/ family unit are considered. Where
possible health facility visits must be kept to a minimum as these have social and financial implications
on the caregiver/ family unit. All efforts must be taken to support the caregiver or family unit by
arranging appointments in a manner that lightens their schedules and financial burdens. For example,
appointments can be arranged such that caregivers can come for multiple services within the same day.
5.1.2 Nutritional Assessment
Nutritional assessment is to be carried out by a dietitian. Any of the nutrition assessment methods
described in Chapter 4 can be used. What is crucial is that the child's measurements be compared to a
suitable reference standard for age and gender.
5.2
Nutritional Requirements
Nutritional requirements for children are best estimated by the dietitian because the recommended
dietary allowances (RDA) for children infected with HIV are not well established. The increase in basal
energy expenditure (BEE) associated with HIV infection observed in adults is not well understood in
children. However, since the energy needs of asymptomatic adults are reported to increase by about
10% due to increased basal energy expenditure, it is probable that the same is true for children.
Although the evidence is still inconclusive the energy needs for HIV infected children are set at 10%
above that of their HIV negative counterparts. Refer to the table below for the recommended energy
needs of children infected by HIV. These recommendations were provided by the WHO technical
Working Team on children (2003)
5.2.1 Energy requirements
Asymptomatic
Symptomatic without wt loss
Symptomatic with weight loss
5.2.2
An increase of 10% above RDA
An increase of 20-30% above RDA
An increase of 50 100 % above RDA
Protein and Micronutrients
Protein and micronutrient requirements for HIV infected children are similar to those of uninfected
children. Therefore, protein and micronutrients RDA for healthy children apply for infected children as
well. However, there is some consensus that some increase is warranted especially in symptomatic
children in the same manner as the nutrients requirement for malnourished children are higher.
5.3
Nutritional Support and Care
5.3.1 Nutritional care and support for children 0 6 months
Nutrition care is discussed in detail in chapter 6 and in the PMTCT guidelines and the Infant and young
child feeding policy draft document. Briefly, HIV infected children between 0-6 months can be on
exclusive breastfeeding or receive replacement formula feeding. The choice of the feeding method is
24
made by the mother following counseling by a health professional. Which ever method mothers select
they are strongly discouraged from mixed feeding as doing so will encourage the transmission of HIV
through breastmilk. Please refer to chapter 6 for more details.
5.3.2 Nutrition care and support for children 6-24 months
I.
Support mothers/caretakers to provide children infected with HIV with nutritious diet
and to address factors that result in decreased food intake.
In addition to either exclusive breastfeeding or formula feeding children 6-24 should be progressively
introduced to complementary foods. Therefore providers should counsel mothers/caretakers on
feeding recommendations as provided on the child welfare card (CWC) or IMCI. Recommendations for
feeding well and sick children should be shared with the mother. Providers should also encourage
mothers to provide children with adequate amounts of and a variety of foods to meet the high needs
associated with growth and development. This can de done by teaching parents how to increase the
energy and nutrient density of foods, supporting caregivers in developing appropriate child rearing
practices, and in using available child survival services. Specific ways of achieving these are outlined
under the respective sub headings below; In addition to all these it is important that providers
continually increase their knowledge and skill level in the care and support of children.
To get additional energy and nutrients,
°
Encourage mothers to offer children adequate amount of food, feed more often, offer
nutrient dense snacks like; eggs, yogurt between meals
°
Promote foods and fluids that are rich in energy and nutrients
°
Advise on use of foods fortified with micronutrients e.g. foods issued at the clinics for
the under fives (e.g., Tsabana and Enriched Maize Meal)
°
Discuss food fortification like addition of oil, sour milk, margarine, peanut butter to
porridge (for more examples see CWC card).
°
Encourage frequent eating of fruits and vegetables
°
Encourage continued adequate milk intake
°
Give more nutritious foods if the child wants to eat
°
Educate mother of non-nutritious foods (fresh chips, fizzy drinks, etc) and encourage
them to restrict their intake.
To support the mother/caretaker to:
°
Provide nutritious food according to the weight and age of the child, and increase the
food portions, as the child grows older.
°
Feed the child frequently (five to six times per day) and provide nutritious snacks in
between meals
°
Make sure the child's food is freshly prepared.
To Support mothers/caretakers to use essential child survival services.
°
Ensure that each child has a Child Welfare Card.
°
Assess children for complete and up-to-date immunization. Immunize or refer children
whose immunization is not up-to-date.
°
Assess whether children are receiving vitamin A supplementation. If it has not been done
in the last 6 months, provide the service.
25
°
°
°
°
°
°
°
°
°
°
°
°
Ensure that all immunizations and vitamin A supplementation have been recorded on the
CWC
Counsel mothers/caretakers about the importance of taking their children for monthly
growth promotion and monitoring.
Children brought for growth monitoring should be weighed accurately; children should
be weighed without shoes, diapers and clothing.
The weights should be plotted accurately against the ages on the Child Welfare Card.
Mothers or caregivers whose children have growth failure should be advised accordingly.
Nutrition counseling should be given to all mothers/caretaker irrespective of the growth
status/pattern of the child.
Mothers should be counseled on proper care and use of the CWC.
The child's diet should be reviewed at every contact to ensure appropriate feeding.
Help mothers to practice active responsive feeding
Assess and promote good hygiene and proper food and water safety and handling (as
detailed in Chapter 8.)
Encourage mothers to seek healthcare and support if the child is either not growing well,
loosing weight, has eating problems, has sores/ulcers in its mouth, or gets opportunistic
and other infections, such as malaria/fever, diarrhoea and respiratory infections.
Promote continued adequate dietary care and support during and after illness.
Create awareness about psychological and socio-economic support that households with
HIV/AIDS infected children can access in their locality
5.3.3 Nutritional care and support for children over 2 years
In addition to providing nutrition care and support guidelines for children 6 24 months, mothers of
children 2 years and older must be advised to provide children with a balanced diet that is based on the
principles of a healthy diet as detailed in Chapter 2. However the portions of the food provided must be
smaller than adult portions to match those recommended for children. In general serving portions for
children are about ½ of adult sizes. As the child grows the amount of food given should be increased
gradually.
5.3.4 Care and Support for Severely Malnourished Children with HIV/AIDS
Severely malnourished children with HIV/AIDS are about five times more likely to die than uninfected
children. Such children rarely respond to conventional nutritional rehabilitation and take much longer
to recover. Providers are strongly encouraged to refer children with acute and severe malnutrition
to the hospital where they can receive care from a team of medical doctors and dietitians. All
children with weight for height less than 70% or below -3 standard deviations with or without oedema
are considered to have acute and severe malnutrition.
The Management of severely malnourished children with HIV involves achieving high energy and high
nutrient intakes to realize complete recovery. However, the high energy and nutrient dense diet
should be progressed as tolerated and with extreme caution. Given the seriousness of severe
malnutrition in all children let alone those infected with HIV, providers should encourage caregivers to
request healthcare promptly when children are not growing well. To this end, regular attendance of
Growth Monitoring should be encouraged. In addition to all these, providers must familiarize
themselves with the signs and symptoms of severe malnutrition. Refer to the Tables 5.1 for the
26
suggested nutrition interventions for children with common nutrition related conditions.
Providers must;
Be aware of signs of severe malnutrition:
°
Look out for visible severe wasting, especially of the trunk and buttocks.
°
Look out for oedema (swelling) of both feet.
°
Look for anaemia, pallor of the palms and mucus membranes.
°
If possible weigh the child and record on the child welfare card.
°
Look for possible signs of parent's negligence; caregivers can play a major role in putting
their children as risk for malnutrition.
If the child has severe malnutrition and is being transferred to the nearest hospital check for
and attend to complications that might lead to death:
°
If the child has a very low body temperature (below 35 degrees centigrade), keep the
child warm.
°
If the child is dehydrated or has diarrhoea, give resomal or diluted oral rehydration
°
solution as is described in the Acute and Severe Malnutrition guidelines to replace lost
fluids.
°
If the child has hypoglycemia (characterized by drowsiness and stupor), give a glucose
solution (use intravenous fluids in moderation) as per guidance provided in the Acute
and Severe Malnutrition (ASM) guidelines.
°
Provide broad-spectrum antibiotics to all children with severe malnutrition.
°
Hospitalized children should be provided with F75 if it is available within two hours of
admission to start with and progress as outlined in the ASM guidelines
Counsel the mothers/caretakers on the need for referral and urgently refer children with
severe malnutrition to the hospital or an appropriate nutritional rehabilitation institution.
°
When in a hospital or a Nutritional Rehabilitation Centre, severely malnourished children
should be managed according to the Botswana guidelines for management of severe
malnutrition.
°
Severely malnourished children with HIV/AIDS who are not on ARVs should be referred to
providers of anti-retroviral therapy services.
°
Severely malnourished infants are at higher risk of serious illnesses and mortality than
older children.
For children who had been hospitalized, upon discharge caregivers must be encouraged
°
To feed the child frequently with energy and nutrient-dense food.
°
To involve the child in play and stimulation in order to foster the child's development.
°
To take the child for regular follow-up to ensure the child completes immunization
receives 6-monthly vitamin A and undergoes monthly growth monitoring.
°
To see a social worker, if providers suspect the child severe malnutrition was related to
problems that might require the intervention of a social workers, such as parents who
27
neglect children, have mental health problems, or are poor.
5. 4 Management of Common Nutrition-Related Conditions Intervention for Infants and children
with HIV/AIDS
Please refer to Table 5.1 for the management of the common nutrition related conditions in infants
and children with HIV/AIDS. These suggestions were provided because they were shown to work.
However, children who show no improvement despite careful implementation of the recommended
interventions should be referred to a dietitian for a thorough nutrition assessment as there may be
other underlying conditions.
Table 5.1: Suggested Nutritional Intervention for Infants and Children with HIV/AIDS
6
SYMPTOMS
INTERVENTION
Normal/mild symptoms; fever,
infection
· Well balanced diet, nutrient dense with snacks
· In the case of fever encourage fluids
Poor weight gain/growth, poor
appetite
· High calorie, high protein, nutrient dense diet.
· Nutritional supplementation under close dietetic monitoring
Diarrhoea6 /mal-absorption
· Give oral rehydration solution and feed soft foods as soon as food
can be tolerated. Ideally, children should be fed within 4 hours
of re-hydration.
· Encourage fluids for dehydration
· Avoid concentrated formulas
· Avoid excessive fruit juices and foods with sorbitol
· Restrict lactose if necessary till diarrhoea resolves
· Avoid intake of insoluble fiber; soluble fiber maybe helpful
· Avoid high fat foods if steatorrhoea is suspected
Nausea, vomiting
·
·
·
·
·
·
Eat cold foods and beverages
Eat dry foods, such as crackers or toast
Small frequent meals
Low fat, bland, non spicy foods
Avoid strong smelling foods
Avoid carbonated drinks
Oral/oesophageal/gastric
discomfort and pain
·
·
·
·
·
·
·
Smooth, soft foods
Cold, non-spicy foods
Cut food into small pieces
Milkshakes, ice creams
Drink through straw
Small, frequent meals
To aid swallowing, use mild sauces and gravies on foods
Developmental delay
· Feeding/swallowing evaluation by trained individuals
· Texture modifications or feeding by parent or caretaker
For more detailed classification of diarrhoea and recommend feeding consult the IMCI guidelines, page 11.
28
CHAPTER 6
INFANT FEEDING AND PREVENTION OF MOTHER TO CHILD
TRANSMISSION OF HIV/AIDS
6.1
Transmission of HIV Infection from Mother to Child
Infants can acquire HIV infection through mother-to-child transmission (MTCT), blood
transfusion or infected blood products, and/or use of contaminated instruments. In MTCT,
infants can acquire HIV infection before, during or after delivery. Transmission of HIV from an
infected mother to her infant can occur during pregnancy or delivery. The additional risk of
transmission from breast milk is about 15% for babies who are breastfed for up to 6 months and
about 20% for babies' breastfed in their second year of life. Women who are infected during
breastfeeding have a much higher risk (29%) of transmitting the virus through breast milk.
Given these risk, feeding recommendations that reduce the rate of MTCT have been provided.
See table 8.1 for recommendations of women of different HIV status. All women should be
educated fully about the available infant feeding options and their risks and benefits. It is only
when women are empowered through education and skill acquisition that they can be in a
better position to select feeding options that will work well for them and their infants.
7
While all breastfeeding mothers should be taught proper positioning and attachment to
prevent the development of cracked nipples and other breast conditions, this counsel is
particularly important in HIV infected women. Cracked nipples, mastitis and breast abscesses
increase the risk of HIV transmission through breast milk. Health workers should demonstrate
proper positioning and attachment to prevent the development of cracked nipples and counsel
mothers on how to prevent and manage other types of breast problems. Further, if
breastfeeding HIV positive mothers develop any of these conditions, infant-feeding options
should be revisited.
6.2
Care and Support of Women, their Partners and Children
Prevention of MTCT starts with well informed and empowered women and their partners.
Therefore, women and their partners should be encouraged to know their HIV status and
together commit to zero HIV transmission. Women and their partners who are already
infected should be supported and helped to access HAART and IPT Prophylaxis as early as
possible and accompany each other to all HIV related services. Further, women and
children identified as HIV-positive during MCH care should be fully integrated into all
routine services. For those couples who have not conceived as yet and have the desire to
raise a family, there is need to also educate them about the risks associated with
pregnancy and alternative ways of becoming parents.
7
Use the Botswana IYCF training materials
29
Table 6.1 Specific feeding recommendations
Client situation
Feeding recommended in first 6
months
Feeding recommended beyond 6
months
Exclusive breastfeeding with no
added foods or liquids.
Breastfeeding and complementary
foods until 2 years and beyond.
HIV-positive women
Exclusive formula feeding with a
cup. No added foods or liquids and
no breast milk
Formula for at least 1 year while
providing complementary foods
HIV- positive women
who are unable or
unwilling to use infant
formula
Exclusive breastfeeding with no
added foods or liquids
Abrupt cessation of breastfeeding
by 6 months with transition to
formula or other milk and
complementary foods.
Women of unknown
9
HIV status (these
women should
continue to receive
encouragement to
know their HIV status)
Exclusive breastfeeding with no
added foods or liquids.
Breastfeeding and complementary
foods until 2 years and beyond
In addition to the above feeding
options, caregivers should be
encouraged to include 2-3 serving
of milk (cow, goat, or soy milk) into
the child's diet every day.
HIV-negative women
8
8
HIV negative mothers should be encouraged to continue with safer sex because the risk of MTCT can increase dramatically if the mother
contracts HIV while lactating.
9
If a woman of unknown status takes a test for HIV; the recommendation on the safe infant 1feeding method should be tailored to her
HIV status as recommended above. For more details, please refer to PMTCT National Guidelines
30
CHAPTER 7
NUTRITIONAL CARE AND SUPPORT FOR PREGNANT AND LACTATING
WOMEN
Good maternal nutrition before and during pregnancy and in lactation is vital for the survival
and well being of the developing infant. During pregnancy and lactation, the needs for energy,
protein and various micronutrients are increased to meet the demands for enough gestational
weight gain, growth and development of the fetus, and milk production.
In addition to the above burden, HIV infection puts an extra demand on the body. HIV also
causes excess nutrient loss and mal-absorption, further increasing the nutritional needs of HIV
infected pregnant or lactating woman, increasing their risk of developing malnutrition and
mortality. The nutritional status of an HIV infected woman before, during and after pregnancy
influence her own health and the risk of transmitting HIV to her infant. In order to maintain
good health as well as for optimum pregnancy outcome, the HIV infected pregnant or lactating
woman needs additional food to meet the extra energy demands.
7.1
Nutritional Requirements
7.1.1 Energy Requirements in Pregnant/lactating HIV Infected Women/Adolescents
Energy requirements vary according to the stage of the disease. Table 1 illustrates the
changes in the recommended energy intakes for pregnant/lactating women based on the
stage of the disease. The amount of the increase in energy is the same for HIV-infected
persons who are taking ARVs. The level of additional energy intake for the HIV-infected
pregnant/lactating woman depends on the presence and severity of symptoms. Thus, the
energy needs for a pregnant symptomatic woman, would be equal to the energy need of a
non infected woman of about the same age, weight and stature plus an additional 20% (for
HIV infection) plus 285 Kcal/day for pregnancy. Using the same table, the energy needs for
an asymptomatic lactating mother would be equivalent to the energy needs of a non
infected woman of the same age and physical status plus an additional 10% ( for HIV
infection) plus 500 kcal/day for lactation.
Table 7.1 Estimated Changes in the Daily Energy Needs
Stage In
Disease
T h e Nutritional Needs For Pregnant Nutritional Needs For Lactating
Women/Adolescent
Woman/Adolescent
Asymptomatic
Early symptomatic
symptomatic
Additional
energy due to
HIV (kcal)
Additional
energy due to
pregnancy (kcal)
Additional
energy due to
HIV(kcal)
10%
20%
30%
+ 285
+ 285
+ 285
10%
20%
30 %
10
10
Additional
energy for
Lactation(kcal)
+500
+ 500
+ 500
Energy can be measured using kilocalories or Kilojoules. To convert kilocalories into kilojoules multiply
kilocalories by 4.2
31
7.1.2 Protein Requirements
The protein requirements of an HIV infected woman is the same as that of a non infected woman of the
same age, physiologic stage and physical characteristics. However, HIV infected pregnant/lactating
adolescents and adults may need additional protein over the level recommended for healthy non-HIV
infected pregnant/lactating adolescents and adult women. This is likely if they are symptomatic.
°
°
°
Daily recommended protein intake is 1 g/kg body weight in healthy non pregnant women.
Non-HIV infected healthy pregnant and lactating women require an additional 6g/day and
16 g/day respectively.
Additional protein is reduced to 12 g/day for lactating mothers after the 6th month and to 11
g/day after the 12th month
The protein should contain the entire range of essential amino acids. This requires consumption of a
large variety of plant proteins or a mixture of plant and animal food sources.
7.1.3 Micronutrients Requirements
Adequate intake of vitamins and minerals is crucial in the care and support of pregnant adolescents
and adults. Pregnant adolescents and adults should consume diets that ensure micronutrient
intakes at RDA levels. In addition, HIV infected pregnant women should be given iron, folate, and
vitamin A supplement as is standard antenatal care for all pregnant women in Botswana.
Pregnant HIV positive women who are not gaining weight for 2 to 3 month (especially in the
second and third trimester) or have a BMI less than 18.5, and women who are practicing
exclusive breastfeeding in the first 6 months after delivery and have a BMI of less than 18.5
should be provided with the vulnerable group ration for pregnant / lactating mothers.
7.2
Nutritional Assessment and Support
In addition to the recommendations for all PLWHA provided in the preceding chapters service providers
should:
7.2.1 Support pregnant adolescents and adults to monitor their nutritional status.
Providers should:
°
°
°
°
°
Ensure that every pregnant adolescent / woman has an antenatal card to record weight
changes during pregnancy.
Educate HIV infected mothers about the importance monitoring their nutritional status.
(e.g. keeping a record of their body weight ): This will enable mothers to
Know whether they are gaining adequate weight (as in pregnancy) or are losing weight at a
rate that is detrimental to their health.
Be able to plan appropriately so that they may address their dietary needs.
Ensure that nutrition interventions are individualized for every woman.
7.2.2 Women gaining less than one kilogram per month in the second and third trimester should be
referred to a health facility immediately where they can receive more care.
32
At this referral providers should:
°
°
Discuss with the pregnant adolescent/woman to identify the probable causes of
insufficient gestational weight gain and work with her to determine the best course of
action to promote weight gain.
Screen for signs and symptoms of anemia and where necessary provide appropriate care.
7.2.3 Support pregnant adolescents and adults to consume enough food to meet their energy and
nutrient needs.
Providers should:
°
°
°
°
°
°
°
°
Establish whether the woman's intake is adequate and if not providers should identify and
address factors that limit dietary intake and help the mother address them.
Encourage pregnant and lactating adolescents and adults to consume foods rich in
micronutrients and go to ANC services for guidance on micronutrient supplementation.
Ensure that lactating adolescents and adults get vitamin A supplementation at delivery or
at least within the first eight weeks of delivery.
Supplement Iron, folic acid and Vitamin A according to the national guidelines.
Ensure that mothers use iodized salt.
Encourage pregnant and lactating adolescents and adults to get enough rest, particularly in
the third trimester of pregnancy.
Encourage mothers to continue with usual/ moderate physical activity to preserve lean
body mass.
Advise women on the dietary management and appropriate interventions of diarrhea,
nausea, vomiting, malabsorption, loss of appetite, and oral thrush as these conditions may
prevent weight gain, as well as have a negative impact on nutritional status
7.2.4 Support pregnant and lactating mothers to prevent illnesses that may affect their nutritional
status or their ability to eat.
Providers should counsel caregivers to:
°
°
°
°
°
°
Seek early treatment for infections such as fever, malaria, TB and diarrhea to minimize
their impact on the mother's nutritional status.
Promptly get treatment for malaria, including presumptive treatment and prevention by
using insecticide treated mosquito nets.
Advice mothers to avoid alcohol, smoking and recreational drugs (elicit).
Support women to practice food safety and hygiene, in order to avoid food borne illnesses.
Refer mothers to reproductive health services where they can get family planning support
as well as STD and HIV re-exposure counseling.
Advise mother to continue with safer sex practices
33
CHAPTER 8
PROTECT THE QUALITY AND SAFETY OF YOUR FOOD
Food can be contaminated with harmful bacteria and viruses (germs) that cause food poisoning. These
germs are difficult to detect from just the appearance, taste or smell of food, but they can cause illness
ranging from mild to very severe and even life threatening. The human body ordinarily is well equipped
to deal with these germs, but individuals with weakened immune systems, such as those with HIV/AIDS
can be at far greater risk of contracting food-borne illnesses. Once contracted, food-borne illnesses can
further weaken the immune system and hasten the progression of HIV infection and be fatal for persons
with AIDS.
Since most food borne illnesses result from improper handling of food, HIV infected persons can help
themselves by following basic food safety guidelines. Applying these guidelines when buying, preparing
and storing food, as well as following good environmental hygiene and sanitation recommendations,
can allow them to eat defensively while choosing a nutritious diet.
8.1
Environmental Hygiene and Sanitation
Dirty surroundings attract insect vectors such as flies, cockroaches and rodents. All these spread
diarrhoeal diseases, which lead to loss of water and nutrients in the body. The most common vectors
are:
° Flies- These sit on unprotected food feed on it and leave their excreta on it. They carry germs
on their bodies and legs, thus contaminating food, which may cause diarrhoeal diseases.
° Cockroaches- These also feed on food that is not covered, mostly during the night. They can
also contaminate food with harmful organisms.
° Rodents- These may discharge germs and contaminate the places they visit. Most of these
vectors live in filthy places, garbage dumps, excrement, decomposed matter, sewers and
drainage pipes.
To ensure good health, it is important to get rid of these vectors in the home. Where possible, homes
should be fumigated to control vectors.
The health provider should emphasize the following:
° The general surroundings should be kept clean all the time. Leftovers and rubbish should be
safely thrown in the garbage for collection. Dirty areas where there is indiscriminate disposal
of feacal matter lead to the spread of diarrhoeal diseases that would lessen absorption of
nutrients in the HIV/AIDS patient and worsen their condition
° Where there are no flush toilets, it is advisable to use good well-constructed, clean, ventilated
latrines that should also have a cover or lid for the hole. For flush toilets, ensure that these are
regularly cleaned and disinfected if possible.
° Hand washing facilities should be provided within the latrine with soap and a towel, wherever
possible.
° Wash clothes, bedding and surfaces that might have been contaminated with fecal matter
with hot water and soap.
° Animals should be kept away from food and water sources as they may contaminate it.
34
8.2
Clean and Safe Water
Use safe clean water from protected sources such as treated piped water supplies, boreholes and
protected wells. If the water is not from a protected source, it should be boiled before consumption.
When collecting and storing water in the home, use clean containers with a lid to prevent
contamination because when people drink contaminated water they get sick. Water containers in the
home can easily become contaminated by dirty cups and hands that have not been washed. Always use
clean container to scoop water from the water storage container.
8.3
Personal Hygiene
° Always wash hands with clean water and soap before, during and after preparing food or
eating, after visiting the toilet and changing diapers.
° Dry hands on a clean cloth or towel. The cloth or towel should be washed and replaced
regularly. If possible, it is advisable to use a disposable towel.
° Cover all cuts or infections on hands with secure bandage to prevent contamination of food
during preparation and handling.
° Nails should always be kept short and clean.
° Always cover your mouth when coughing or sneezing.
° Personal hygiene should always be observed when breastfeeding.
8.4 Shopping for Food and Eating out
Prevention of food borne illness starts with your trip to the supermarket.
When buying food:
° Start by picking up packaged and canned foods.
° Read labels and check the ingredients list, expiry date or best before date.
° Check canned foods to see whether they are damaged such as dented cans, bulging lids or
leaking cans which are sticky on the outside. All damaged cans should be returned.
° Select frozen foods and perishables such as meat, poultry or fish last. Always put these
products in separate plastic bags so that drippings don't contaminate other foods!
After shopping, place fresh foods in the refrigerator and the frozen ones in the freezer, as soon as
possible. If there is no refrigerator, buy perishable foods in small quantities that can be used
immediately.
When eating out:
° Avoid places where cleanliness is questionable.
° Always order food well done.
° Foods such as steak, hamburger or other piece of meat should not have pink colour or
blood in the center.
° Fish should be flaky, not rubbery, when you cut it,
° Eggs should be fried on both sides until well done.
° Seafood should not be eaten raw or even when lightly steamed.
35
8.5
Hygiene in the Kitchen
°
°
°
°
°
°
°
°
8.6
Keep all food preparation surfaces clean.
Use clean dishes and utensils to store, prepare, serve and eat food.
Cover food to prevent both flies and dust from contaminating the food.
Keep garbage in a covered bin (and empty it regularly) so it will not cause offensive smells and
attract flies, which can contaminate food with germs.
Kitchen utensils should not be stored on the ground where they can be contaminated with
disease causing organisms. Instead they should be placed on a raised platform, where there is
sunlight and enough air circulation.
Cleanliness is vital to food safety. Refrigerators should be defrosted and cleaned thoroughly
and regularly.
Dish towels should be washed and boiled often to kill germs
The use of dish towels to wipe hands after washing them should be discouraged because dish
towels can spread germs
Handling, Cooking and Storage of Food
° Wash vegetables and fruit with clean water. If it is not possible to wash fruits and vegetables
properly, remove the skin before eating to avoid contamination. Cut-off the bruised parts of
fruits and vegetables to remove any moulds and bacteria growing there.
° Throw away foods that have gone bad or well past the “sell-by” or expiration date.
° Wash utensils and surfaces touched by animal products with hot water and soap before
preparing other foods such as raw salads.
° Wooden boards should not be used for cutting animal products. Plastic cutting boards are
better.
° Keep meat and fish separate from other foods.
° Food from dented or bulging cans should not be consumed; once a can has been opened, the
food should be removed from the original can and kept in a clean non-metallic container.
Use clean cups and spoons to feed infants.
When cooking food:
°
°
°
°
Cook food on a high heat to kill most germs and eat it as soon as possible after cooking.
Do not overcook vegetables as vitamins and minerals will be lost.
Cook meat and fish well, until there are no red juices.
Boil eggs until hard and avoid using cracked eggs; do not eat soft-boiled eggs, raw eggs or any
food containing raw eggs.
For proper food storage:
° Store cooked and fresh food in a cool place or refrigerator where available, because germs
multiply more quickly in warm food.
° Store raw and cooked foods separately; use containers to avoid contact between them.
° Do not store foods for long periods in the refrigerator.
° Where there is no refrigerator, fresh products such as meat, chicken or fish should be
36
°
°
°
°
°
°
°
°
°
purchased in the amounts for immediate consumption.
Fruits and vegetables should be checked regularly for ripeness and decaying pieces removed
to prevent further spoilage.
Avoid storing leftovers in particular stews, gravies, salads unless they can be kept in a
refrigerator or a cool place.
Do not store leftovers in the refrigerator for more than one or two days. Reheat leftovers to
steaming point before they are served for consumption.
Where there is no refrigerator, leftovers should be used the same day after thorough heating at
high temperature.
Never store leftovers of infant foods.
Cooked food should be stored above raw meat in the refrigerator to ensure that foods are
protected from raw meat drippings.
Cover and store food in containers away from insects, rodents and other animals.
Frozen foods should never be thawed and then re-frozen. Meat should be packed into daily
portions before freezing and thawed at refrigerator temperature and not at room
temperature.
Keep freshly cooked food hot before serving. Keep cold foods such as salads cold before
serving.
37
CHAPTER 9
NUTRITION AND HIV/AIDS THERAPY
PLWHA may take various types of medications to reduce the effects of HIV on the body, to treat
opportunistic infections, and other common ailments such as colds, malaria, and/or intestinal
parasites. Some also use herbal remedies and take micronutrient supplements. Though there is no
cure yet for HIV/AIDS, antiretroviral (ARV's) drugs are being used to manage HIV by lowering the
viral load and thus reducing morbidity and mortality.
Effective medical treatment can slow the progression of HIV, reduce opportunistic infections, and
ease symptoms, but food can interact with drugs and affect the drugs' efficacy. Drugs can also
interact with foods and nutrients and negatively affect nutritional status. The side effects of both
traditional and modern medications can affect both food intake and nutrient absorption and
thereby the client's adherence to medications. Additionally, drugs and food can interact to cause
adverse effects. Ultimately, if not addressed, drug and food interactions can result in deterioration
of health and nutritional status.
The purpose of this chapter is to provide information on Anti-retroviral drugs (ARVs), their
interactions with food, and potential side effects, traditional remedies and other therapies as well
as counseling on nutrition and HIV/AIDS therapy.
9.1
Anti-Retroviral Drugs (ARVs)
ARVs significantly reduce the replication of HIV in the body and slow the progression of the disease.
They are classified into three different groups namely; Reverse transcriptase inhibitors, Protease
inhibitors (PIs) and Fusion inhibitors (refer to table 9.1).
Table 9.1: Classes, Types and Examples of ARVs
Class
Type
Examples of Drugs
Reverse Transcriptase
inhibitor
Non-nucleoside reverse
transcriptase inhibitor (NNRTI)
*Efavirenz (EFV)
Delavirdine (DLV), *Nevirapine (NVP)
Nucleoside reverse transcriptase
inhibitor (NRTI)
*Abacavir (ABC)
*Didanosine (ddl), Emtricitabine (FTC)
*Lamivudine (3TC), *Stavudine (d4T)
Zalcitabine (DDC), *Zidovudine (ZDV)
Nucleotide reverse transcriptase
inhibitor (NtRTI)
*Tenofovir (TDF)
Protease inhibitor
Protease inhibitor (PI)
Atazanavir (ATV), Amprenavir (APV)
Fosamprenavir (f-APV)
*Indinavir (IDV)
*Lopinavir/Ritonavir (LPV/r)
*Nelfinavir (NFV), *Saquinavir (SQV)
Fusion inhibitor
Fusion inhibitor (FI)
Enfuvirtide (T-20)
* Drugs marked in asterix are those currently available in Botswana.
38
9.1.1 Mode of Action of ARV drugs
Each type of ARV is active at different stages of the virus' replication. Three or more ARVs are generally
combined to enhance their efficacy in suppressing this replication. This is referred to as Highly Active
Antiretroviral Therapy (HAART). For example, the action of the antiretroviral Zidovudine is enhanced if
used in combination with Lamivudine and Efavirenz or Nevirapine. Thus a person who is on treatment
for HIV/AIDS will have to take a combination of ARVs rather than one or two.
Fusion inhibitors are a new type of ARV that prevents HIV from binding to the surface of the T-cell and
infecting the T-cell. HIV-positive people who have become resistant to PIs, NRTIs, and NNRTIs are likely
to benefit from the fusion inhibitors because they are a different type of ARV.
9.2
ARV and Non-ARV Drugs Interactions with Food and Their Potential Side Effects
Modern and traditional medications can interact with food in four major ways as illustrated in Figure
9.1. Proper dietary management interventions can help manage some of these negative effects and can
also help PLWHA maintain adequate food intake and compensate for affected nutrients.
Figure 9.1: Types of Interactions between Medications and Food
1
FOOD
2
3
4
Affects
MEDICATION ABSORPTION, METABOLISM
DISTRIBUTION, EXCRETION
Affects
NUTRIENT ABSORPTION, METABOLISM,
DISTRIBUTION, EXCRETION
MEDICATION
MEDICATIONS'
SIDE EFFECT
Affects
FOOD INTAKE & NUTRIENT ABSORPTION
MEDICATION +
CERTAIN FOODS
Creates
UNHEALTHY SIDE EFFECTS
Source: Castleman et al forthcoming
9.2.1 Effects of Food on Drug Efficacy
Food intake or meals can enhance or inhibit the absorption, metabolism, distribution, and excretion of
medications. This type of interaction varies from one drug to another and requires appropriate dietary
responses to improve the client's adherence and optimize the medication's efficacy.
Dietary management to improve the efficacy of a medication includes taking the medication with food,
on an empty stomach, or with or without certain types of foods (Table 9.2). Examples of the ways food
intake affects drug efficacy are:
°
Food enhances the absorption or metabolism of some ARVs and inhibits the absorption or
metabolism of others. For example, a high-fat meal increases the bioavailability of the
nucleotide analogue Tenofovir (Pronsky, Meyer, and Fields-Gardner 2001). A high-calorie,
high-fat, high-protein meal decreases absorption of the protease inhibitor Indinavir and
reduces the absorption of the nucleoside reverse transcriptase inhibitor Zidovudine. It is
therefore recommended not to take Zidovudine with high-fat meals e.g. fried foods, foods
high in animal fat (saturated fats).
°
Food reduces the absorption of Isoniazid and Rifampin, medications commonly used to treat
tuberculosis. Therefore, Isoniazid and Rifampin have to be taken 1 hour before or 2 hours
after meals.
° Food reduces the rate of absorption of aspirin (acetylsalicylic acid), used to treat fever and
pain that are common in people living with HIV/AIDS. Aspirin is best taken 2 hours after meals
with a full glass of water (notwithstanding its gastric erosive properties).
39
As the effect of food on the efficacy of a drug is food and drug specific, the counsellor should help the
client draw up a food and drug timetable. This timetable should take into account both the food and
drug interactions of each drug to be taken and the client's eating habits to ensure the greatest efficacy
of the treatment.
9.2.2 Drug Effects on Nutrient Absorption, Metabolism, Distribution, and Excretion
Certain medications affect nutrient absorption, metabolism, and excretion hence could have negative
effects on nutritional status. Dietary management may require either increasing food intake, taking a
nutrient supplement to compensate for the nutrient affected, or reducing the nutrient intake if the
metabolite produced can negatively affect health.
Drugs that may require increased food or nutrient intake: The medication Isoniazid, commonly taken
to treat tuberculosis, inhibits the metabolism of vitamin B6. The antibiotic and anti-tuberculosis
medication Rifampin may increase vitamin D metabolism. Supplementation of these vitamins is
therefore recommended as necessary.
Drugs that may require reduced food or nutrient intake: Studies have reported lipid abnormalities,
such as increased level of triglycerides, cholesterol, and fat mal-distribution in people who have taken
protease inhibitors or non-nucleoside reverse transcriptase inhibitors. The protease inhibitors
Saquinavir and Ritonavir may cause an elevation in cholesterol and triglycerides levels, which may
increase the risk of cardiovascular diseases (Pronsky, Meyer, and Fields-Gardner 2001). Most of the
protease inhibitors may cause changes in lipid levels that require both dietary and medical responses.
Lipid abnormalities include hypertriglyceridemia, hypercholesterolemia, and lipodystrophy syndrome:
° For hypertriglyceridemia, it is important to maintain a healthy weight, eat a variety of foods,
reduce the intake of refined sugar and excessive carbohydrates, increase intake of fibre,
avoid alcoholic beverages, exercise daily, and take medication to lower triglycerides.
°
For hypercholesterolemia, it is important to maintain a healthy weight, eat a diet low in fat
and limited saturated fat, increase intake of fruits and vegetables, avoid food rich in
cholesterol, avoid alcohol and smoking, exercise daily, and take medication to lower the
cholesterol (Pronsky, Meyer, and Fields-Gardner, 2001)
°
The effective management of fat mal-distribution or lipodystrophy syndrome has not yet been
established. Diet and exercise, use of medications, and change in the ARV regimen can help.
Some antiretroviral drugs may affect glucose metabolism and cause insulin resistance. Insulin
resistance is associated with increased risk of diabetes (Gelato 2003). For diabetes, specific
carbohydrate controlled diet, reduced intake of refined sugar and saturated fat, exercise, and antidiabetic medications are recommended.
Progressive lactic acidosis is a complication of NRTI therapy (Carr 2003). The signs of severe lactic
acidemia include fatigue, weight loss, abdominal pain, dyspnea, liver dysfunction, and cardiac
dysrhythmias. In case of any of these symptoms, the client should be referred for further management.
9.2.3
Drug Side Effects
The side effects of drugs on food intake and the effects of drugs on nutrient absorption, metabolism,
distribution and excretion may have the most negative impact on the nutritional status of PLWHA. The
side effects of drugs and the effects of the disease are often difficult to distinguish. For example,
headaches, malaise, fever, and gastrointestinal symptoms may be side effects of drugs but can also be
associated with HIV and AIDS.
9.2.4 Effects of drug side effects on food intake and nutrient absorption
40
Modern and traditional medications may cause side effects that affect food intake and nutrient
absorption. Side effects may include changes in taste, loss of appetite, nausea, bloating and heartburn,
constipation, vomiting and diarrhea that affect food intake and nutrient absorption. Changes in taste,
loss of appetite, nausea, bloating and heartburn, and constipation may lead to reduced food intake,
whereas vomiting and diarrhea can cause poor nutrient absorption. Reduced food intake and poor
nutrient absorption can lead to the weight loss and wasting associated with faster progression of HIV to
AIDS.
Table 9.2 lists the purposes, recommendation/ advice, and potential side effects of some of the widely
taken medications treating HIV/AIDS, opportunistic infections and other conditions. This list is not
comprehensive, health workers and other service providers are encouraged to update the list as
medications become available or their use is discontinued.
9.2.5: Storage of drugs.
Some medications are sensitive to storage temperature. D4T liquid is very unstable at room
temperature so it must be kept refrigerated at all times. Some medications, for example Kaletra's
capsule do not need to be refrigerated, but must be kept in a cool place in the house. In general
however, day time temperatures in Botswana can be too hot even for those medications which do
not normally require refrigeration. Therefore PLWHA on ARV must be properly educated on the safer
places to store their medications. In general most medications will keep well in a cupboard in the
house. Preference should be in a cupboard or table that is shaded from direct sunlight at any time
of the day. Storing medications on window sill must be discouraged because the temperature there
can be very high.
Table 9.2: Recommendations/Advice for Taking ARVs and Other Medications
Medication
Purpose
Recommendation/ advice
Potential side effects
Abacavir (ABC)
Antiretroviral
Can be taken without regard to food
Nausea, vomiting, fever, allergic
reaction, anorexia, abdominal
pain, diarrhoea, anaemia, rash,
hypotension, pancreatitis,
dyspnoea, weakness and
insomnia, cough, and headache
Didanosine (ddI)
Antiretroviral
With water only, 1hour before or
2hours after eating.
Avoid alcohol. Do not take with
juice. Do not take with antacid
containing aluminium or
magnesium.
Anorexia, diarrhoea, nausea,
vomiting, pain, headache,
weakness, insomnia, rash, dry
mouth, loss of taste,
constipation, stomatitis,
anaemia, fever, dizziness, and
pancreatitis.
Efavirenz (EFV)
Antiretroviral
Can be taken without regard to food. Elevated blood cholesterol
levels, elevated triglycerides
Take at bedtime. Avoid alcohol.
levels, nightmares, rash,
dizziness, anorexia, nausea,
vomiting, diarrhoea, dyspepsia,
abdominal pain, flatulence
Indinavir (IDV)
Antiretroviral
1 hour before or 2 hours after meal.
Drink at least 1,500ml of fluid daily.
Do not drink grapefruit juice as it
may lower the level of medicine in
the blood.
Avoid St. John's wort.
Lamivudine
(3TC)
Antiretroviral
Can be taken without regard to food. Nausea, vomiting, headache,
dizziness, diarrhea, abdominal
Avoid alcohol.
pain, nasal symptoms, cough,
fatigue, pancreatitis, anaemia,
insomnia, muscle pain, and rash
41
Nausea, abdominal pain,
headache, kidney stones, taste
changes, vomiting, regurgitation,
diarrhea, insomnia, ascites,
weakness, and dizziness. May
increase the risk of lipodystrophy.
Medication
Purpose
Recommendation/ advice
Potential side effects
Indinavir (IDV)
Antiretroviral
1 hour before or 2 hours after meal.
Drink at least 1,500ml of fluid daily.
Do not drink grapefruit juice as it
may lower the level of medicine in
the blood.
Avoid St. John's wort.
Nausea, abdominal pain,
headache, kidney stones, taste
changes, vomiting, regurgitation,
diarrhea, insomnia, ascites,
weakness, and dizziness. May
increase the risk of lipodystrophy.
Lamivudine
(3TC)
Antiretroviral
Can be taken without regard to food. Nausea, vomiting, headache,
Avoid alcohol.
dizziness, diarrhea, abdominal
pain, nasal symptoms, cough,
fatigue, pancreatitis, anaemia,
insomnia, muscle pain, and rash
Lopinavir
Antiretroviral
Can be taken without regard to food. Abdominal pain, diarrhea,
headaches, headache, weakness,
Avoid St John's
nausea. May increase the risk of
lipodystrophy and or diabetes.
Nelfinavir
Antiretroviral
With meal or light snack. Do not take Diarrhea, flatulence, nausea,
with citrus juices or apple sauce. abdominal pain, and rash. May
increase the risk of
Avoid St John's wort.
lipodystrophy.
Nevirapine (NVP)
Antiretroviral
Can be taken without regard to food. Nausea, vomiting, rash, fever,
headache, skin reactions,
Avoid St John's wort.
fatigue, stomatitis, abdominal
pain, drowsiness, paresthesia.
High hepatotoxicity.
Ritonavir
Antiretroviral
With meals if possible. Avoid St
John's wort.
Nausea, vomiting, diarrhea,
hepatitis, jaundice, weakness,
anorexia, abdominal pain, fever,
diabetes, headache, dizziness.
May increase the risk of
lipodystrophy
Saquinavir
Antiretroviral
With a meal or a light snack; take
within 2 hours of a fat containing
meal and high calcium meal. Do
not take with grape juice due to
acidity.
Mouth ulceration, taste changes,
nausea, vomiting, abdominal
pain, diarrhea, constipation,
flatulence, weakness rash, and
headache. May increase the risk
of lipodystrophy.
Avoid garlic supplements and St
John's wort.
Stavudine (d4t)
Stavudine (d4t)
Can be taken without regard to
food.
Must be stored in a refrigerator.
Nausea, vomiting, diarrhoea,
peripheral neuropathy, chills and
fever, anorexia, stomatitis,
diarrhoea, anaemia, headaches,
r a s h , b o n e m a r r o w, a n d
pancreatitis.
May increase the risk
l i p o d y s t r o p h y. L i m i t t h e
consumption of alcohol.
Tenofovir (TDF)
Antiretroviral
With food
Abdominal pain, headache,
fatigue, and dizzinessAbdominal
pain, headache, fatigue, and
dizziness
42
Medication
Purpose
Recommendation/ advice
Potential side effects
Zidovudine/lami Antiretroviral
vudine/ Abacavir Combination
(AZT/3TC/ABC)
On empty stomach if possible; if
not, with low-fat meals
Nausea, vomiting, abdominal
pain, diarrhea, anorexia, fever,
bone marrow suppression,
anaemia, and hyperlactacemia.
Zidovudine (AZT) Antiretroviral
With low fat meal. Avoid alcohol.
Anorexia, anaemia, nausea,
vomiting, bone marrow
suppression, headache, fatigue,
constipation, fever dizziness,
dyspnea, insomnia, muscle pain,
and rash.
Chloroquine
Treatment of
Malaria
With food
Stomach pain, loss of appetite,
nausea, vomiting. Not
recommended for breastfeeding
women taking high doses for
rheumatic diseases.
Fluconazole
Treatment of
Candida
With food
Nausea, vomiting, diarrhea. Can
be used during breastfeeding
Isoniazid
Treatment of
Tuberculosis
1hour before or 2 hours after meals. Anorexia and diarrhea.
May cause possible reactions with
foods such as bananas, beer,
avocados, liver, smoked pickled fish,
yeast and yogurt.
May interfere with vitamin B6
metabolism, especially in adults
and thus require vitamin B6
supplementation. Avoid alcohol
Infrequent occurrence
diarrhea, vomiting, nausea
of
Nystatin
Treatment of
Thrush
With food
Quinine
Treatment of
Malaria
With food
Rifampin
Treatment of
Tuberculosis
On an empty stomach 1hour before
or 2 hours after meals. Avoid
alcohol.
Bright orange urine, Nausea,
vomiting, diarrhea and loss of
appetite.
Sulfadoxine and
Pyrimethamine
(Fansidar)
Treatment of
Malaria
With food and continuous drinking
of clean boiled and cooled water
Nausea, vomiting, taste loss, and
diarrhea.
Not recommended if folate
deficient. Not recommended for
women breastfeeding.
Sulfonamides:
Sulfamethoxazol
e,
Cotrimoxazole
(Bactrim®,
Septra®)
Antibiotic for
treatment of
pneumonia
and
Toxoplasmosis
With food and continuous drinking
of clean boiled
and cooled water (at least 8
standard
glasses per day)
43
Nausea, vomiting, and abdominal
pain
Appropriate dietary responses
Appropriate dietary responses may help maintain food intake and compensate for nutrient losses. Dietrelated side effects need to be managed immediately to help continue proper eating habits and
maintain weight. Examples of appropriate dietary responses include the addition of flavour enhancers
such as salt, sugar, spices, vinegar, or lemon to help stimulate the taste buds, increase taste acuity, and
mask unpleasant flavours as a result of taste changes from medication.
Energy and nutrient dense foods such as fortified maize, rice, and carrots as well as drinking plenty of
fluids may help replace nutrient losses and prevent dehydration during fever or diarrhoea. Since drug
side effects such as changes in taste, loss of appetite, nausea, constipation, vomiting, diarrhoea,
bloating and heartburn are similar to HIV/AIDS-related symptoms, the dietary management is the same.
Refer to chapter 10 for practical suggestions of how to manage these conditions.
Some ARVs have been associated with increased risk of bone disorders such as osteoporosis, osteopenia,
and osteomalacia (Tebas et al 2000) and may require medical and dietary responses. A balanced diet
with high calcium foods such as milk, yogurt, cheese, or calcium and vitamin D supplements may be
required, along with a medical response. This is especially important for populations already at risk of
calcium deficiencies, children because they are still growing and pregnant and lactating women whose
calcium needs are increased.
Proper nutritional management of the side effects of medications will help improve the client's
adherence to the treatment. If not properly managed, diet-related side effects of medications often
lead to interruption of treatment or poor adherence to treatment. The health worker or counsellor
should refer the client to specialized professionals such as dietitians, social workers and doctors as
necessary for individualized care.
9.3
Adverse Effects of Some Food and Drug Combinations
Combinations of specific medications and food can cause unhealthy side effects. Such food should not
be taken at the same time as these medications. The consumption of alcohol can cause inflammation of
the pancreas while taking the ARV Didanosine and should be avoided. Alcohol is a liver enzyme inducer
hence any drug that is metabolized by the liver is quickly eliminated when taken together with alcohol.
It should also be avoided while taking the anti-tuberculosis medication Isoniazid, as this combination
may increase the risk of inflammation of the liver.
Nutrition and other health professionals strongly discourage the use of alcohol because of
its adverse effects on nutrients, disease conditions, adherence to treatment regimens and
metabolism of some medications
Drug-drug Interactions
People living with HIV/AIDS often take several modern and traditional therapies simultaneously. This
combination may affect the drug efficacy and the patient's nutritional status. Such interactions need to
be managed appropriately to ensure that side effects do not affect food intake, nutrient absorption and
metabolism and to ensure optimal efficacy of all medications.
The antifungal agents Fluconazole (Diflucan®) and Ketoconazole (Nizoral®) may inhibit the metabolism
of protease inhibitors and contribute to increased toxicity of these drugs.
9.4
Recommendations for the Proper Management of Food and Drug- Interactions
Antiretroviral therapy is becoming simpler, with fewer doses and fewer pills. Given the rapid evolution
in antiretroviral therapy and the effects of food and drug interactions on drug efficacy and nutritional
status, health providers and counsellors should know about and keep up to date with possible
44
interactions and their management. Different drugs have different food interactions, therefore
recommendations should be drug specific.
The following recommendations to guide the health worker or counsellor in addressing food and drug
interactions for the people living with HIV/AIDS should be supplemented by other related national
guidelines:
° Understand the specific interactions of each drug used and counsel accordingly.
° If several drugs are taken, refer to the food and drug interactions of each.
° Pay close attention to the client's diet and drug regimen and manage interactions that will
affect nutritional status. The nutrition implications of some drug combinations differ from the
implications of an individual drug. For example, food reduces the absorption of the protease
inhibitor Indinavir, but when Indinavir is taken in combination with Ritonavir or Delavirdine,
studies have shown that food has no effect on its absorption, and it can be taken with or
without food.
° Involve the client in finding solutions for side effects and food-drug interactions.
° Give special consideration to traditional medicines. While some side effects of traditional
medicines may be known, many of their food and drug interactions are not known. Help the
client who is taking traditional medicines alone or with other drugs to identify their side
effects and food and drug interactions and use the foods available to mitigate their impact on
nutritional status.
° Be attentive to the side effects and nutritional implications of ARVs for malnourished patients.
These effects have been studied primarily on well-nourished populations and are not well
documented among malnourished people. Act promptly to alleviate their negative impact on
the health and nutritional status.
° Food insecurity may constrain people living with HIV/AIDS from meeting optimal food and
nutrition responses. Seek alternative responses that are feasible given the circumstances.
° Refer complicated cases to specialists e.g. doctor, dietitian, social worker.
° Providers should inform PLWHA that they should not stop their ARVs without consulting their
doctors. If PLWHA find the side effects of their medications to be unbearable they should
consult their doctors because there may be alternative drugs that can be prescribed for them.
9.5
Traditional Remedies and Other Therapies
The use of traditional therapies such as herbs, teas, and infusions (extracts) to treat several symptoms
or diseases is a common practice. People living with HIV/AIDS often use traditional therapies to relieve
symptoms and increase their sense of hope, empowerment, and control over their health problems.
These traditional therapies vary from one place to another. Since traditional medications may have side
effects and interact with certain foods or other drugs, it is important to address their side effects as
well as their negative effects on nutrient absorption, metabolism, distribution and excretion. Studies
have shown that the blood concentration of the protease inhibitors e.g. Saquinavir decrease by as much
as 50 percent if taken together with a garlic supplement. Garlic is usually taken as a traditional therapy
to strengthen the immune system. Saquinavir should therefore not be taken with a garlic supplement
(Piscitelli et al 2002).
Very little information on the interactions between antiretroviral medication and traditional
medication and herbs is available. It seems prudent to recommend that patients on HAART should not
use traditional medicine and herbs if the effects of these are not known. Timely management of
traditional therapy and food interactions will help prevent weight loss, wasting, and malnutrition.
Examples of some herbal products used in Botswana are garlic, green tea, African potato, moducare,
Immune boosters, St John`s wort, Tim Jan (wonder juice), Prosit, Stametta, Uzifozonke, Masututsa,
Ginseng Vital Tea, Devil`s Claw, Royal jelly, Cod Liver Oil, Promune, Herbal Green, Herbal Tonics,
Brewers yeast, Nerve Tonics, Aloe Vera, Gingko Biloba, Echinacea and many other herbs or supplements
45
that are presently marketed in Botswana. Some of the drug-herb interactions are listed in Table 9.3.
The metabolism of traditional medicines is not fully known. Furthermore each plant may contain
multiple chemicals with varying pharmacological action. Drug-drug interactions of these chemicals are
not known nor are their toxicity or side effects. Moreover since their doses are not standardized it is
difficult to make clear what is safe for an adult or child of a certain weight, height, nutritional status
etc. Therefore patients are advised to be cautious in taking traditional medicines and other therapies.
There is need to encourage and strengthen communication between health workers, traditional
practitioners and patients.
Other practices such as induction of vomiting, diarrhoea or colon cleansing should be discouraged.
These may aggravate already existing conditions such as fluid and electrolyte imbalance and food
retention and absorption which would negatively affect the nutritional status of the patient. These
practices also adversely affect the efficacy and effectiveness of ARVs and other oral drugs used in
the management of HIV/AIDS.
Table 9.3: Possible Drug-herb Interactions
HERB
POSSIBLE INTERACTION WITH DRUGS
St. John's Wort
Reduces the efficacy of most ARV drugs; Indinavir, Lopinavir, Nelfinavir,
Nevirapine, Ritonavir, and Saquinavir.
Saint Johns Wort may cause excessive stimulation and sometimes
dizziness, agitation and confusion when taken with antidepressants.
White Willow
It exhibits similar reactions as aspirin (aspirin is derived from white
willow). Long term use may lead to gastrointestinal irritation and
stomach ulcers.
Hawthorn
Should not be taken with Digoxin; the medication prescribed for some
heart ailments. The combination can excessively lower the heart rate,
causing blood to pool, bringing on possible heart failure
Ginseng
Goldenseal
Feverfew
Garlic combined with diabetes medication can cause a dangerous
decrease in blood sugars.
Garlic decreases blood concentrations of the ARV Saquinavir if taken
together.
For patients taking medication to control diabetes or kidney disease,
this herb can cause dangerous electrolyte imbalance.
Should never be taken with Imitrex or other migraine medications. It
can result in dangerously elevated heart rate and blood pressure
Guarana
Increases stimulant effect of caffeine and other central nervous
system stimulants. It may cause insomnia, trembling, anxiety,
palpitations, urinary frequency, and hyperactivity.
Kava
Should not be taken together with substances that also act on the
central nervous system, such as alcohol, barbiturates, anti
depressants, and antipsychotic drugs.
St. John’s Wort
Reduces the efficacy of most ARV drugs; Indinavir, Lopinavir, Nelfinar,
Nevirapine, Ritonavir and Saquinavir.
St. John’s Wort may cause excessive stimulation and sometimes
dizziness, agitation and confusion when taken with antidepressants.
White Willow
It exhibits similar reactions as aspirin (aspirin is derived from white
willow). Long term use may lead to gastrointestinal irritation and
stomach ulcers.
46
9.6
Considerations for Special Groups
9.6.1 Pregnant and Lactating Women
Pregnant women living with HIV/AIDS are treated with ARVs such as Nevirapine or Zidovudine or both
during pregnancy or at the onset of labour to reduce mother-to-child transmission of HIV. It is critical to
ensure that food and drug interactions during pregnancy do not result in reduced food intake and
limited weight gain for the pregnant mother. These may further weaken the mother and also contribute
to low birth weight for the baby. The health worker or counsellor should be aware of the possible
negative effects of the drugs and drug interactions on the foetus and counsel accordingly.
The goal of nutritional management of food and drug interactions during pregnancy and lactation aims
to ensure good health and nutrition for the mother by maintaining or improving food intake through the
consumption of a variety of foods. This will ensure adequate weight gain. Indicators of good nutrition
include type of foods consumed, frequency of meals and quantity of food, weight gain, and the absence
of micronutrient deficiencies.
9.6.2 Infants and Children
Children living with HIV/AIDS are at a greater risk of malnutrition.
include:
The causes of malnutrition
° Inadequate nutrient intake as a result of anorexia, nausea, oral or oesophageal lesions or
generalized malaise and weakness
° Increased nutrient and energy requirements during hyper-metabolic periods induced by fever
and secondary infections
° Protein, calorie, fluid and micronutrient losses with vomiting, diarrhea and mal-absorption.
Given the high risk of malnutrition for infants, children and young people living with HIV/AIDS, those
taking ARVs and other drugs need to be monitored closely to manage the side effects of the drug and the
food and drug interaction. Side effects of medications and food and drug interactions are similar to
those experienced by adults living with HIV/AIDS. The health worker or counsellor should work closely
with parents or caregivers to ensure that children do not reduce their food intake, and that they eat a
variety of foods, gain weight, and continue to grow.
9.7
Counseling on Nutrition and HIV/AIDS Therapy
The management of HIV and other related conditions necessitates that the patient be well informed in
order to make better decisions about their nutrition and their therapeutic status. Therefore it is the
duty of healthcare providers to equip them with the necessary information. The following points should
be considered during counselling of the patient:
° On every contact, emphasize to the PLWHA the need to adhere to instructions on use of
medications including taking all the medicine and/or completion of the full course.
° Inform PLWHA of the side-effects likely to be experienced in the course of ARV and other
medicines and how to manage them.
° Inform PLWHA on foods likely to interfere with ARVs and other medications that the client may
be using.
° Counsel PLWHA to avoid beverages such as alcohol.
° Assist PLWHA to adjust the consumption of certain foods and/or supplements to compensate
for drug effects on specific nutrient utilization. Devise meal plans and drugs timetable to
minimize the side effects of the medication.
° Caution PLWHA about herbs that may be sold under the pretext of being a cure for HIV infection
or opportunistic infections.
47
° For PLWHA living in areas where malaria is prevalent, clients should be advised to use
insecticide treated nets and to promptly seek treatment for suspected malarial illness.
° Record any side effects and action taken regarding these side effects and refer all abnormal
reactions to a health facility.
All health care providers attending to PLWHA should receive regular updates on possible sideeffects of drugs clients may be taking and on drug-food or nutrient interactions and best
management practices.
In conclusion, careful consideration and management of drug and food interactions is required in
HIV/AIDS therapy to ensure drug efficacy and client adherence and avoid negative effects on
nutritional status. The dietary management of drug and food interactions in HIV/AIDS therapy will help
minimize the side effects of medications and maintain food intake, minimize the effect of medications
on nutrient absorption and metabolism, ensure efficacious treatment, and improve client adherence.
Since very little information on the interaction between antiretroviral medication and traditional
medication and herbs is available, it is not advisable for patients on HAART to use traditional
medication and herbs.
Successful management of the client's drug and food interactions requires that the counsellor
understand the specific food-drug interactions. This should be used to motivate the client to use
available foods to improve their eating habits and address side effects.
The health care provider should always consult current national guidelines and refer complicated cases
to specialists in different areas of practice.
48
CHAPTER 10
MANAGEMENT OF NUTRITION RELATED COMPLICATIONS in PLWHA
The nutrition related complications observed in people with HIV/AIDS may occur as a result of the
severity of illness, new infections, side effects of drugs or consumption of contaminated food.
In this chapter several suggestions are presented for the management of the following nutrition related
complications/symptoms. Some of these suggestions include lifestyle and behavior modifications for
managing;
°
Diarrhea
°
Lack of appetite
°
Nausea and vomiting
°
Sore mouth or when eating is painful
°
Other digestive problems
°
Changes in the taste of foods
°
Skin problems
°
Colds, coughs and influenza
°
Fever
Others (severe conditions like metabolic aberrations that require a referral to a Dietitian).
PLWHA who present with these conditions should be given nutrition education on how best to promote
adequate dietary intake and minimize the negative effect of these conditions on their nutritional
status. Since people react to foods differently, nutrition must education focus on encouraging people
to select foods that work for them. Once the conditions have improved, normal mixed diets can be
resumed as tolerated.
However, PLWHA who have several of these conditions at the same time will require the services of a
dietitian. Such people need to be referred so that they can receive adequate care for their multiple
conditions thereby decrease the likelihood that the combination of these nutrition related conditions
may promote further deterioration of nutritional status and health.
While there is much known about the management of nutrition-relation conditions in PLWHA, more
is being discovered everyday. It is therefore recommended that providers should continually
update their knowledge base and skill level in this area. This can be done through regular reading
of nutrition and HIV/AIDS references and attendance at workshops and seminars where HIV/AIDS
care and support issues are being discussed. Similarly, providers should encourage PLWHA to
familiarize themselves about their conditions. HIV/AIDS networks such as BONEPWA, BONASO,
BOCAIP, COCEPWA, and Support Groups, are examples of places where PLWHA can be exposed to
more information about care and support issues
Table 10.1: Practical Suggestions on How to Manage Common Nutrition Related
Complications in PLWHA
HERB
Recommended management strategy
Fever and loss of appetite
High-energy high-protein liquids and fruit juice(100% juice).
Provide small portions of soft preferred foods with a pleasing aroma
and texture throughout the day.
Provide nutritious snacks whenever possible.
Give non-sugary liquids often.
49
HERB
Recommended management strategy
Sore mouth and throat
imit citrus fruits, tomatoes, and spicy food.
Limit very sweet foods.
Provide high-energy, high-protein liquids with a straw e.g. milk
shakes, drinking yogurt
Offer foods at room temperature or cooler.
Offer thick, smooth foods such as pudding, porridge, mashed
potatoes, mashed carrot or other non-acidic vegetables and fruits.
Nausea and vomiting
Eat small snacks throughout the day and avoid large meals.
Eat bread, crackers, toast and other plain dry foods.
Avoid foods that have a strong aroma.
Drink diluted fruit juices, other liquids and soup.
Eat simple boiled foods, such as porridge, potatoes, and beans.
Loose bowels
Eat bananas, mashed fruits, porridge and soft rice,
Eat smaller meals often.
Eliminate milk momentarily. Use fermented dairy products such as
yogurt with live culture and madila slowly, (smaller amounts to
start with and progress as tolerated)
Decrease high-fat foods
Momentarily remove foods high in insoluble fibre (roughage) from
your diet
Drink liquids often.
Fat mal-absorption
Eliminate oils, butter, margarine, and foods that contain or were
prepared with them.
Eat only lean meats.
Eat fruit and vegetables and other low-fat foods.
Severe diarrhea
Drink liquids frequently.
Drink oral rehydration solution.
Drink diluted fruit juices.
Eat bananas, mashed fruits, soft rice and porridge.
Fatigue, lethargy
Have someone pre-cook foods to avoid energy and time spent in
preparation.
Eat fresh fruits or foods that require minimal or no cooking.
Eat snack foods throughout the day.
Drink high-energy, high-protein liquids.
Set aside time a day for eating and resting.
50
HERB
Recommended management strategy
Weight loss
Eat more frequently (small frequent meals)
Select energy dense foods
Use locally available food to increase energy intake
Re asses access to foods and refer
Changes in body shape
Encourage exercise such as Walking and if fitness levels allow
aerobics, jogging, using staircases, hiking, skipping and weight
lifting exercises in your daily routine
Refer to medical provider for re-assessment
Frequent illnesses
Follow food and water safety recommendations ( see chapter 8)
Seek prompt treatment of opportunistic infections
Refer for re-assessment, may qualify for ARVs
Woods (1999)
51
CHAPTER 11
NUTRITION EDUCATION AND COUNSELLING
11.1 Nutrition Education
Nutrition education should assist PLWHA to make healthy dietary choices. As it has been captured in the
previous chapters, adequate nutrition supports normal body functions and processes that enable
people to lead healthy lifestyles. Adequate nutrition is influenced by daily food choices that people
make. Many of these choices are informed by religious and cultural beliefs. In addition, rapid dietary
changes that are brought about, in part, by globalization have resulted in a rapid shift from healthy
traditional and indigenous foods to highly processed foods. Yet these highly refined foods have a long
term negative effect on the health and nutrition of individuals and population groups. The emergence
of dietary transitions that are typical of countries with transitioning market economies can become
particularly challenging for PLWHA. PLWHA are bombarded with a plethora of fast foods, highly refined
food items, and food supplements, many of which carry unsubstantiated health claims.
Nutrition education is a set of learning experiences designed to facilitate the voluntary adoption of
eating and other nutrition-related behaviours that are conducive to health and well-being.
“Where the world is changing very slowly, you don't need much information. But when change
is rapid, then there is a premium on information to guide the process of change.”
- Lester Brown.
Nutrition education is especially important for PLWHA because of the nutrition-related demands that
the virus puts on the body. Nutrition education must therefore be integrated into the care and support
provided to PLWHA. The goal of nutrition education must be to help PLWHA understand the need to
maintain an adequate diet and how to manage common health problems that may negatively affect
their nutritional status. Many people do not have the necessary knowledge to ensure that they have
adequate nutrition. Thus, every one can benefit from nutrition education which is seen as sharing
information and giving relevant advice.
Nutrition education messages should take into account the different stages in the life cycle; early
childhood, adolescent and adult stages. For children, parents should encourage a positive interest in
food and eating including;
°
Serving attractive foods with colour
°
Serving small and frequent servings at a time
°
Allowing some freedom to choose
°
Allowing children to eat the amount of food they can handle. Children should not be forced
to eat more food than they can eat.
°
Building healthy eating habits very early in children's lives
While it is important to educate children about good nutrition, parents should be made aware that they
are responsible for teaching their children bad dietary habits. For the most part children eat what
parents eat. If parents have unhealthy dietary practices, children grow up thinking that these bad
habits are acceptable. For the most part, parents send subtle bad messages about nutrition to children
by buying them junk food often and even packing junk food for them while they go to school.
There are difficult challenges that are posed by the adventurous adolescent stage. Some of these are
characterised by trials of new foods and dietary practices, peer pressure, and influence of advertising.
Depending on the early childhood experiences, adolescents can be rebellious in their rejection of
52
certain foods. For example if they were forced to eat green vegetables they may grow up resenting
vegetables and by the time they reach adulthood stage some of these undesirable dietary practices
may have hardened. Changing dietary is possible when;
°
The basis for the present habits and beliefs that support them are known
°
There is a clear goal to accomplish, especially for health reasons (e.g. control of diabetes,
°
HIV/AIDS, or heart conditions); this could be a compelling motive to change.
°
There is fear of disability or death.
°
Customary diet is used as the basis to build on in making diet adequate
°
Behaviour is still at developmental stage and superficially rooted in culture
Nutrition education should focus on the following;
°
Healthy and balanced nutrition
°
How adequate nutrition can be achieved
°
Relationship between nutrition and HIV/AIDS
°
Nutrition requirements for PLWHA
°
Healthy lifestyles for PLWHA
°
Food and water safety
°
Hygiene
°
Dietary management of HIV/AIDS relation complications
°
Nutritional issues associated with modern and traditional settings
°
Nutrition on living positively in the 21 century
st
The content for the above topics can be found in the different chapters of this manual. With regard to
bullet number 9, PLWHA must be encouraged to select adequate diets and safe foods even when eating
in restaurants or other food outlets, social gatherings or preparing packed meals. With regard to points
6 and 7, PLWHA must be encouraged not to consume food purchased from food outlets if it appears, or is
even suspected not to have been prepared according to the Food and Water Safety Standards (Chapter
8).
11.2 Nutrition Counselling
“Counselling is a process of dialogue and mutual interaction that is aimed at facilitating problem
solving, understanding, motivation and decision-making. It empowers individuals, families or specific
groups to think and systematically analyse their own situations with regard to a specific issue.
Counselling also helps them make informed choices and commitment to take actions appropriate to
their own situations” TFNC, 2003.
Nutrition counselling helps children and adults living with HIV/AIDS to address their dietary
requirements. It includes assisting them to address their feelings and reactions to their HIV status.
Nutrition counselling also enables PLWHA to respond positively to their nutritional requirements. Good
nutrition counselling should result in positive changes in eating habits and help improve their quality of
life. Where children are involved, counsellors are encouraged to employ a family model because
compliance is better when the whole family observes healthful lifestyles than when it is only one
member of the family who attempts to do so.
An effective counsellor should be able to empathize with clients. In addition, the counsellor should be
able to view the client without being judgemental. Counselling as a process requires confidentiality,
53
warmth, understanding, and respect for the client. In counselling PLWHA, the counsellor needs to be
knowledgeable in HIV and AIDS issues, and be observant of how the client reacts to the HIV infection.
In providing nutrition counselling, the counsellor should work with the client in examining their
nutritional options and making the best choices. In so doing, the clients are more likely to own the
options taken.
In preparation for nutrition counselling, clients can be advised to keep a record of their diet, food
inventory and any other resources that will assist both the counsellor and the client to address the
identified dietary concerns. Tools such as the form below can help PLWHA or caregivers to monitor the
food intake. The form is to be filled every day for a week prior to the next appointment, noting the
amount of food consumed and the time the food is eaten. This form needs to be taken to the PLWHA's
next appointment with a counsellor. Under the comment section PLWHA can provide any information
that will help the provider assess the food intake. Comments can be about any factors that might
influence food intake such as factors that make food intake different from one day to another.
Table 11.1 Food Record Table
Meal
Breakfast Morning
Snack
Afternoon
Snack
Lunch
Supper
Bedtime
Snack
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Comments
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
54
11.3 Integrating nutrition into existing programs
There are several centres where HIV and AIDS services are provided. Nutrition education and
counselling programs should be integrated into these existing services as much as possible and where
appropriate. It should be noted that nutrition is an integral part of care and support for PLWHA. In most
instances provision of nutrition service has been left to the health workers at facility level, leading to
an overload on this sector. There is therefore, a need for all sectors that provide HIV/AIDS services to
include nutrition education and counseling within their care and support package. The National
Nutrition and HIV & AIDS guidelines should be used to assist service providers at various contact points
to address the nutritional needs of PLWHA by:
° Creating awareness among different community programs and government sectors of need for
nutritional education and counseling
°
Using community based approaches as much as possible
°
Educating the recipients and family members of the purpose of the food rations (e.g. food
basket).
°
Monitoring the usage of the food rations provided by government and other service providers
°
Promoting the inclusion of nutritional education and counseling for PLWHA in other programs,
especially community based food and nutrition projects such as backyard vegetable gardens,
small livestock rearing, poultry rearing and income-generating activities.
The contact points that can address nutritional needs of PLWHA and the general public are shown in the
diagram below.
Figure: 11.1. Nutritional Care and Support Contact Points
Nutritional Care and Support
Social gatherings
· Kgotla meetings
· Ceremonies
· Rituals
Voluntary
Counseling Testing
Care Centres
e.g. OVCs, Day Care Centres,
hospices,
e.g. Tebelopelo VCTC
Work place
Health facilities
· Government
· Parastatal
· Private Sector
Nutritional
Care and
Support
Households
· Referral Hospital
· Primary hospital
· Clinics
· Health post
· Mobile Stops
· Private Practitioners
· Traditional Healers
·Families
Counselling Centres
Organisations
· NGOs
· CBOs
?VDCs, PTAs, VHTs, HBC
· Religious Organisations
· Workers’ Unions
· HIV & AIDS Networks e.g. BONEPWA,
BOCAIP, COCEPWA etc.
Institutions
· Schools
· Education Centres
· Colleges/UB
· Rehabilitation Centres
55
CHAPTER 12
HIV/AIDS, NUTRITION AND FOOD SECURITY
“When you ask people with HIV and AIDS in rural communities in the developing world what
their highest priority is, very often their answer is food. Not care, not drugs for medical
treatment, not relief from stigma, but food”
(Piot and Pinstrup-Andersen, 2002; p11).
This chapter deals with coping strategies which could be used as a guide to meet the nutritional
needs of PLWHAs in food insecure situations. Food insecurity exists whenever the availability of
nutritionally adequate and safe foods or the ability to acquire foods in socially acceptable ways is
limited or uncertain.
To be food secure, all people must be having social, physical and economic access to safe, nutritious,
adequate and culturally acceptable food at all times. Household food security is characterized by four
components, namely availability, accessibility, utilization and sustainability. To achieve these,
households must not only have the ability to produce, purchase or store food but, must also have
adequate knowledge on food groups and their nutritive value, food preparation and balancing of meals.
Nutrition security implies that food security is a necessary but not sufficient precondition for ensuring
satisfactory consumption and nutrition of the individual (Mugabe et al.,1998). At the aggregate level a
household can be food secure while individual members are nutrition and food insecure. Intrahousehold food distribution should take into account the different nutritional needs of individual
members of the household. In addition, for an individual to be nutrition secure there should be
adequate nutrient intake and efficient utilization by the human body.
12.1
How HIV and AIDS affect food security
HIV and AIDS are a threat to human health and to the social and economic aspects of life. HIV/AIDS has a
devastating effect on nutrition and food security. HIV/AIDS increases the risk of food insecurity through
its impact on productive labour, earnings and savings. Most often, individuals cut back on food intake
by reducing portion size or skipping meals, diverting any earnings and savings to meet health care and
funeral costs. This leads to poverty, increased vulnerability to risky behavior such as sex for food and
money, child labour, crime and drug abuse, etc. Labour of healthy family members is often shifted
from normal food production activities to caring for sick household members. HIV and AIDS thus affect
household food security.
A majority of households with PLWHA are chronically food insecure. They may be unable to follow food
and nutrition recommendations due to their inability to access food required through the market or
own production.
56
Key Concepts:
°
Availability: Food availability addresses the issue of adequacy, variety and consistency in
supply of nutritious foods to households.
°
Accessibility: Food accessibility deals with the means to obtain adequate quantities and
varieties of foods for every family member.
°
Utilization: Utilization is about ensuring that every household member is able to properly use
the food resources to meet their daily energy and nutrients requirements.
°
Sustainability: Sustainability in food security is when households are food secure and family
members are able to meet their food entitlements all the times.
HIV and AIDS affect household food security and nutrition through multiple routes. The impact is
clearly felt through diminished income, reduced well-being, increased vulnerability and high food
insecurity and malnutrition, especially in the rural areas. In situations where adults are terminally
ill or have passed away, children are often left to make decisions on the running of households. In
most cases, they have limited decision making experience, limited access to resources, less
knowledge and physical strength required to run and maintain the households' livelihoods (IFPRI,
2002).
There is often a shift from labour intensive to non-labour intensive farming activities (to
compensate for lost labour through HIV and AIDS) without considering the nutritive value of the
substitute produce. Affected farming households tend to switch to maize crop because it requires
less work particularly in terms of fighting pests like birds that feed on crops and has a better market
value. Yet, this switch is more of a Devil's Trade-off. Maize is both a heavy feeder and it depletes
the soil. Maize is also less drought resistant than sorghum or millet. Generally maize has fewer
amino acids than millet and sorghum, and does not provide an adequate nutritional substitute which
is crucial for HIV infected people (Yamano and Jayne, 2004).
Culturally, women are charged with responsibility and are expected to have knowledge on food
preparation, how much and what needs to be consumed in the household. However, with the advent
of HIV and AIDS, these roles have shifted to caring for the sick (by women) leading to compromised
household nutrition as under aged children may be required to take the responsibility of doing
household chores like cleaning and food preparation.
The combined effects of all the above, result in declined family welfare, reduced productive
capacity of households, depleted savings and increased demand for care and support for the sick and
orphans, leading to food insecurity and malnutrition.
12.2
Agriculture- related Adjustments of PLWHA and Affected Households
Given the effects of HIV and AIDS as discussed in the previous section, PLWHA and affected households
have been found to adjust in the following ways:
°
°
°
°
Non-adherence to nutrition recommendations e.g. Reduction of food intake or skip meals.
Migration of adults in search of work, this leads to the fragmentation of affected households.
Adoption of risky behavior such commercial sex to raise cash for food.
Witdrawal of children from school to care for sick family members and/or their
57
younger siblings.
° Sale of key assets like livestock to meet medical and nutrition costs.
° Shift to less labour intensive farming systems (e.g. small stock, maize, tubers, melons, sweet
reed).
° Reduction in area cultivated and leaving more land fallow.
Mechanisms to improve food security and nutritional intake for PLWHA and affected families should be
designed and implemented at household, community and national levels. These may include, diet
diversification, increased production of nutritious, low cost and non labour intensive crop products,
involvement in small income generating activities, keeping animals both as a source of food and
income.
Adequate food and nutrition security have a buffering role to play in mitigating the impact of HIV and
AIDS at individual, community and national levels. Therefore, more attention must be paid to and
special focus redirected to food security and nutrition considerations in the disease prevention, care
and support.
As a service provider you should be aware of strategies available to strengthen food access and
availability among households affected by HIV/AIDS. The following are strategies that PLWHA can use to
cope in a food insecure situation:
At Household Level:
° Involvement in income generating activities such as small stock (goats, sheep, pigs, rabbits,
etc.), poultry (chickens, doves, ducks, etc) and bee keeping.
° Involvement in food production e.g. back yard gardening for consumption as well as for income
generation
° Using money economically and wisely, for example, by purchasing cheaper but nutritious foods
and other seasonally or locally available foods.
°
Encourage utilization of veld and indigenous products e.g. motopi, mmupudu, moretologa,
mogwana, moretlwa, mosata, maboa, morula, dikgeru/dicheru, mogorogorwana,
makgomane, makatane, lerotse, etc.
° Only sell assets such as livestock to generate extra income as a last resort.
° Improving food preparation and practices to minimize nutrients loss and enhance nutrient bioavailability (refer to chapter 8 Food Safety).
° Encourage and strengthen food storage for future use.
58
° Practicing proper food handling including food storage, processing and preservation to
minimize post harvest losses.
° Ensuring food safety by adhering to practices of safety and hygiene (refer to chapter 8).
If food insecurity still exists, utilize available government and other organizational programmes e.g.
food basket, community based support programmes, etc.
At Community Level:
° Create or promote awareness amongst community members on HIV and AIDS so that PLWHA and
their households are neither stigmatized nor discriminated, hence threatened in terms of
household food security.
° Ensure that food and nutrition security for households is mainstreamed in all community
activities and programmes.
° Mobilize the needed resources (material, financial, human and time) for carrying out
interventions aimed at improving food and nutrition security for households with PLWHA.
° Promote coordination of technical support rendered by extension staff to households with
PLWHA for improved household food security
° Ensure that relevant policies, guidelines, legislations and actions aimed at improving
household food security for PLWHA are adhered to; and
° Solicit support from the councils and community leadership for the implementation of planned
activities for food security of households with PLWHA.
° Engage Village Development Committees and Village Health Committees to identify food
insecure households for assessment and assistance by appropriate institutions like
Department of Social and Community Development.
At National Level:
° Strengthen overall coordination of all household food security programmes as well as
facilitation of community-led development programmes and link them with other health
programmes
59
° Emphasize and support small scale food production
° Facilitate and monitor vulnerability assessment
° Facilitate and promote growth monitoring and promotion
° Review or formulate relevant policies, guidelines, legislation and actions aimed at improving
household food and nutrition security for PLWHA.
° Strengthen policies that ensure diversification of livelihoods
In order for the service provider to give better advice and guidance, they must work in collaboration
with the following:
°
Agriculture and other local extension workers
°
District Health Teams
°
District Multi-sectoral AIDS Committees
°
Voluntary Counseling and Testing Centers
°
Village Development Committees
°
Village Health Committees
°
Community leaders (e.g Dikgosi, Councilors, Religious leaders etc)
°
PLWHA groups
°
Community based organizations
60
CHAPTER 13
MONITORING AND EVALUATION
Monitoring and Evaluation is very essential to maintain a systematic assessment, analysis and
documentation of the progress in the implementation of major activities related to nutritional care and
support. In this regard, it is important to monitor the implementation of the guidelines and review
them in relation to local experiences. This will help to provide information on how well the guidelines
are contributing to the health of the PLWHA and their families. Generally monitoring is performed in the
form of inventories in order to track input and out put variables and the extent differs among programs,
with some being more advanced than others.
Monitoring focuses on the processes of implementation while evaluation entails an assessment of the
impact on the health and nutritional situation of PLWHA. Some of the key elements of program
monitoring are;
°
Setting target dates of implementation.
°
Task accomplishment to meet the set targets.
°
Advocacy i.e. selling the guidelines to management of different organizations to attract the
necessary support.
°
Resource mobilization.
Evaluation entails outcome assessment with the following key features;
°
Conducting a baseline study against which future changes can be compared.
Setting milestones.
°
Defining outputs to be reached.
°
Conducting periodic reviews.
°
Carrying out a final evaluation to determine whether a project can be scaled up or replicated
elsewhere.
Monitoring and evaluation will focus mostly on the following key elements:°
Are the guidelines helping in the delivery of nutritional care and support of PLWHA?
°
Which elements are working well, which ones are not and what are the gaps?
°
Are the guidelines contributing to the improvements of the nutritional status and quality of life
of the PLWHA?
61
°
Are there any dietary changes among the PLWHA?
Monitoring and evaluating the implementation of the guidelines and reviewing them should
involve the following interventions:
°
Monitoring the number of people trained and the number of copies of the guidelines
distributed during a given time.
°
Continuous support and follow up of the health workers and other stakeholders who have been
trained on the use of the guidelines in order to assess their usefulness, problems experienced
and lessons learnt
°
Follow up with the key stakeholders involved in the implementation of the guidelines in order
to assess the practicality of the use of the guidelines within their agencies.
°
Interviewing the PLWHA who received nutritional care and support to assess the extent to
which they have been able to follow the guidelines and suggest modifications.
Implementation Strategies
°
Assessing the types of nutritional support activities such as counseling, food intake and food
security given to the PLWHA and their families.
°
Having periodic meetings with the stakeholders to get comments on the guidelines, identify
gaps and to facilitate the review.
°
Ministry of Health (FNU) should monitor the availability, accessibility and use of the national
nutrition guidelines to the stakeholders in the various sectors.
Follow-up and assessment of the use made of the manual, problems experienced and lessons
learned by relevant field staff.
°
Inviting comments from self-help groups on the guidelines.
62
BIBLIOGRAPHY
CSO ( 2001). Multiple Indicator Survey 2000. CSO, Gaborone
International Food Policy Research Institute (IFPRI) (2002). AIDS: The new challenge to
Food Security. IFPRI 2001/2002 Annual Report, Washington D.C.: IFPRI.
Mugabe M., Holboe-Ottesen, G., Gobotswang, K. (1998). From Food Security to
Nutrition Security. Lentswe La Lesedi: Gaborone.
National Aids Coordinating Agency (2003]. Botswana National Strategic Framework for HIV/AIDS
2003-2009. Gaborone, Botswana.
National Aids Coordinating Agency, CSO, Development partners (2005). Botswana Aids Impact
Surveillance II (2004).
Piot, P. and Pinstrup-Andersen, P. (2002). AIDS: The new challenge to Food Security.
In, IFPRI, 2001/2002 Annual Report, Washington D.C.: IFPRI.
Pronsky, Meyer, and Fields-Gardner (2001).
nd
RCQHC/FANTA (2004). HIV/AIDS: A guide for nutrition care and support. 2 Edition. Food and Nutrition
Technical Assistance Project. Academy for Educational Development. Washington D.C.
UNICEF (2005). The state of the word children.
US Department of Health and Human Services, HIV/AIDS Bureau (2002). Health care and HIV:
Nutritional guide for providers and clients.
Yamano, T. and Jayne, T.S. Measuring the Impacts of Working-Age Adult Mortality on Small-Scale Farm
Households in Kenya. World Development, Vol. 32(1), pp.91-119, 2004.
63
ANNEXES
ANNEX 1:
Scientific Or English Names Of Some Indigenous Crops/Plants Of Botswana
Trees and Shrubs
Herbaceous plants/legumes
Melons / tubers
Moringa (Moringa olifera)
Lengana (Artemisia affra)
Tswii (Nymphaea spp.)
Morula (Sclerocrya birrea)
Mosukudu (Lippia scaberrima)
Lerotse cooking melons
Morojwa (Azanza garckeana)
Mosukujane (Lippia javanica)
Magabala
Mogorogorwane (Strychnos
cocculoides)
Morama (Tylosema esculenta)
Morama (Tylosema esculenta) Rothwe (Cleome gynandra)
Mmupudu (Mimusops
zeyheri)
Delele -Jute Mellow(Corchorus)
Mongongo (Schinziophyton
rautaneni
Letlhodi/Ditlhodi
Moretlwa, motsotsojane:
(Grewia spp)
Motlopi (Boscia albirunca)
Moretologa (Xemenia caffra)
Motsintsila bird plum
(Berchemia
Scientific names are in italics, English names are underlined
64
ANNEX 2: Functions of Nutrients
Nutrients
Function of Nutrients
Food Sources
Calcium
°Promotes bone and teeth health
°Plays a role in muscle contraction and
Milk, yogurt, canned fish if bones
are eaten, dark green leafy
vegetables
relaxation and nerve function,
°Involved regulation of blood pressure and
blood clotting
°Promote immune function
Folacin, folic
acid or folate
Fluoride
Iodine
°Plays a role in development of nervous
system
°Helps in the formation of red blood cells
Green leafy vegetables, fortified
break-fast-cereals,
Legumes, liver
°Strengthens bone and teeth
°Prevents tooth decay
Fluoridated water,
°Plays a role in the health of thyroid gland and
the formation of thyroid hormones
°Regulate growth, development and metabolic
processes through in role in formation of
thyroid hormones
Iron
Vitamin A
Vitamin C
°Plays a role in transporting ( hemoglobin)
Iodized salt, food crops planted
in soils rich in iodine, dairy
products or cattle feeding on
iodine rich grass of feeds
oxygen through the body and release of oxygen
for use in muscle (myoglobin)
°Plays a role in the use of energy by body cells
Red meats(beef, mutton, goat
meet, game meat) Liver, poultry
dried legumes( dried beans,
dried peas)
°Antioxidant; maintains the integrity of skin
and cell membranes
°Plays a role in vision and adaptation of light
°Plays a role in bone and tooth growth
°Plays a role in immune function
Yellow fruits and vegetables e.g.
carrots, pawpaw, mango,
peaches, pumpkins) liver, eggs
and dark green vegetables e.g.
spinach, broccoli
°Antioxidant, helps body resist infections
°Helps promote wound healing
°Maintains collagen and thus important if blood
Citrus fruits (oranges, lemons,
limes), watermelons, cabbage,
green peppers, Tomatoes,
spinach, lettuce, strawberries,
broccoli and other fruits and
vegetables
vessels and bone health
°Promotes absorption of Fe
Vitamin D
°Improves bone health through its role in
calcium and phosphorus absorption
Selenium
°Antioxidant, found in enzymes that reduce beef, food crops planted in soils
oxidant stress in the body.
rich in selenium
°Regulates thyroid hormones
Zinc
Food in most protein rich foods,
°Important in immune health
°Plays a role in cell growth, formation of proteins red meats, whole grains
in the body, and healing of wounds
°Improves use of sugar by body tissues through is
role in insulin action
° Promotes normal growth and normal
development
65
Fortified milk, Body makes is own
Vitamin D when some sunlight
exposure, liver, egg yolk
ANNEX 3: Nutrient Composition of a Sample of Foods
Food group
( serving size)
Carbohydrates
Grams
Protein
Grams
Fat
Grams
Energy
Kilocalories (kCal)
Grains/ Cereals
15
3
1
80
5
3
0
25
15
0
0
60
12
8
0-3
90
5
120
8
150
½ cup soft porridge( sorghum / maize
meal) or 1/3 cup stiff porridge, ½ cup
rice,
1 slice of pre-sliced bread
Vegetables
½ cup cooked leafy vegetable, ½
chopped/ or cooked non leafy
vegetable, e.g. carrots
1 cup leafy uncooked vegetable e.g.
lettuce, ¾ c vegetable juice (100%)
Fruits
1 small-medium fruit
1/2c chopped or canned fruit
Dairy
1 cup Skim, ½ to 1% fat milk
1 cup Low fat 9 (2%fat), low fat or 2/3
cup fat free yoghut); 30 gm low fat
cheese
1 cup Full fat milk
Proteins
0
7
5
75
0
0
5
45
30 gram low-fat meat( about a deck of
cards; ½ cup dried cooked beans, 1 egg
(boiled), small drumstick of chicken with
skin removed
Other (Fat/oil)
1 teaspoon of oil, butter, regular
margarine , 1 tablespoon mayonnaise,
regular salad dressing , 1/8 slice of
° Refers to the average nutrient composition for foods within a group. Some food items may have a little
more while others may have a little less than the figures provided.
° Please consult a dietician for nutrient composition of combination foods or food prepared in marinates,
added oils etc such as samp and beans/nuts, sorghum and beans, pizza's etc because the amount of their
components is often varies from one person's recipe to another.
° The amount of fat estimated for cereals assumes that no fat/oil was added to during preparation. If fat,
oil, butter, margarine or any other type of fat or oil is added, increase the amount of fat and energy
accordingly using the information in the other category. Note also that whole grains will have slightly more
fat, protein and energy than refined grain products because the germ is milled together with the grain.
° If salad dressings are used or oil is added during preparation, estimate the fat and energy the added fat/oil
has added to the food using the information in the other food group
fruits canned in juice, if heavy syrup is used reduce the serving size to 1/3 cup
Fruited and sweetened yoghurt have more calories, use information provided in the food label
66
ANNEX 4: Estimated Energy Requirements
Estimated energy requirements for healthy non HIV infected populations by age, sex and
physical activity level
Male
Activity /
Age
2-3
Female
Sedentary
Moderate
Active
Activity/
Age
Sedentary
Moderate
Active
1000
1000-1400
1000
2-3
1000
1000-1200
1000-1400
1200 - 1400 1400-1600
1400-1800
4-8
1200 - 1400 1400-1600
1600-2000
4-8
9-13
1600 - 2000 1800-2200
2000-2600
9-13
1400-1600
1600-2000
1800-2200
14-18
2600
2400-2800
2800-3200
14-18
2000
2000
2400
19-20
2400
2800
3000
19-20
2000
2200
2400
21-25
2400
2800
3000
21-25
1800
2200
3000
26-30
2400
2600
3000
26-30
1800
2000
2400
31-35
2400
2600
3000
31-35
1800
2000
2200
36-40
2400
2600
2800
36-40
1800
2000
2200
41-45
2200
2600
2800
41-45
1800
2000
2200
46-50
2200
2400
2800
46-50
1800
2000
2200
51-55
2200
2400
2800
51-55
1600
1800
2200
56-60
2200
2400
2600
56-60
1600
1800
2200
61-65
2200
2400
2600
61-65
1600
1800
2000
66-70
2200
2200
2600
66-70
1600
1800
2000
71-75
2200
2200
2600
71-75
1600
1800
2000
76 and up
2000
2200
2400
76and up
1600
1800
2000
Source: UDSA: http://www.mypyramid.gov/professionals/pdf_calorie_levels.html
accessed 08/12/2006
67
Annex 5: National Nutrition and HIV/Aids Guidelines Evaluation Questionnaire
Please complete the questionnaire after 12 months following introduction of the guidelines to
you organization. The evaluation questionnaire should be faxed to 390 2092 or posted to Food
and Nutrition Unit, P/Bag 00269, Gaborone.
1.
Name of your organization ______________________________________
2.
Is your organization a
2.1 Government health facility
2.2 Private health facility
2.3 Private business
2.4 Training institution
2.5 Organization of PLWHA ( e.g. COCEPWA)
2.6 Hospice
2.7 Other ( please specify)_________________________
3
Which group of PLWHA do you provide service to the most?
3.1 Children
3.2 Adolescents
3.3 Adults
3.4 All PLWHA who come to our programs/organization
4
How many years have you been a service provider for PLWHA?________________
5
How many years has your organization been providing care and support to
PLWHA?____________
6
Do you provide nutrition care to PLWHA?
Yes
No
7
Which of these services does your organization provide?
7.1 Nutrition education
7.2 Food supplies
7.3 Ready prepared meals
7.4 Personal hygiene supplies
7.5 Medical care
7.6 Referral services to other organizations for PLWHA
7.7 Counselling services
7.8 Other ( please specify) ______________________________
8
What
8.1
8.2
8.3
8.4
8.5
8.6
8.7
8.8
8.9
is your training background?
Nurse
Medical doctor
Nutritionist/dietician
Social worker
Psychologist
Teacher
Pharmacists
Health Educator
Other ( please specify) ________________________________
69
9
Put an X in the chapter (s) of the guidelines that you have personally read. If you have not had
A chance to read the guidelines put and X over the None cell
7.1
7.2
7.3
7.4
Chapter
Chapter
Chapter
Chapter
1
2
3
4
7.5.
7.6.
7.7.
7.8.
Chapter
Chapter
Chapter
Chapter
5
6
7
8
7.9 Chapter 9
7.10 Chapter 10
7.11 Chapter 11
7.12 Chapter 12
7.13 Chapter 13
7.14 Chapter 14
None
If you checked NONE in question 9 please exit the questionnaire here. Thank you for
your participation.
10 Which chapter (s) of the Guidelines apply to your service area in your organization,
i.e. where you are assigned to work (select all that apply)
8.1 Chapter 1
8.5 Chapter 5
8.9 Chapter 9
8.13 Chapter 13
9.
8.2. Chapter 2
8.6. Chapter 6
8.10. Chapter 10
8.14. Chapter 14
8.3 Chapter 3
8.7 Chapter 10
8.11 Chapter 11
8.4 Chapter 4
8.8 Chapter 8
8.12 Chapter 12
None
Which chapter (s) is/ are more applicable to most of the services your organization
provides?
9.1
9.5
9.9
9.13
Chapter
Chapter
Chapter
Chapter
1
5
9
13
9.2
9.6
9.10
9.14
Chapter
Chapter
Chapter
Chapter
2
6
10
14
9.3 Chapter 3
9.7 Chapter 7
9.11 Chapter 11
9.4 Chapter 4
9.8 Chapter 8
9.12 Chapter 12
None
10.Please indicate how well you agree with the following statements about the guidelines:
10.1. I find the guidelines easy to read.
10.1. Strongly agree
10.2. Agree
10.3. Agree somewhat
10.4. Disagree somewhat
10.5. Disagree
10.6. Strongly disagree
11. The guidelines have most of the information I need:
11.1 Strongly agree
11.2 Agree
11.3 Agree somewhat
11.4 Disagree somewhat
11.5 Disagree
11.6 Strongly disagree
12. It is easy to find specific information in the guidelines.
12.1 Strongly agree
12.2 Agree
12.3 Agree somewhat
12.4 Disagree somewhat
12.5 Disagree
70
12.6. Strongly Disagree
13. During the 12 months that you have had the guidelines, how have you used them?
13.1 Read and used some information to provide nutrition education/talks
13.2 Conducted in-house training on nutrition care
13.3 Referred to some chapters to look for specific information
13.4 Used them to develop hand outs for our clients
13.5 Other : please explain _____________________________________
14. Is there any information that you would like to see included in the guidelines that is
missing from the current version? Please elaborate.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Thank you!
71