Session 7: Integrating Nutrition Assessment, Counselling, and Education into HIV and AIDS Care Nutrition Management with HIV and AIDS: Practical Tools for Health Workers Objectives • Appropriately assess and counsel patients on nutrition and HIV • Identify ways to integrate nutrition into HIV and AIDS care Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 2 Nutrition at Each Stage of HIV: Stage 1 • Symptoms • No other infections • Generalised fatigue • Nutrition Considerations • Healthy eating and hydration (drink fluids) • Nutrition assessment and education Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 3 Nutrition at Each Stage of HIV: Stage 2 • Symptoms: • Some other infections, but still in good overall health • Weight loss (less than 10 percent of normal weight) • Nutrition Considerations: • • • • • Continue efforts for Stage 1 Follow-up nutrition assessment Address nutrition-related side effects Prevent weight loss Prescribe micronutrient supplements, if indicated Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 4 Nutrition at Each Stage of HIV: Stage 3 • Symptoms: • More serious infections • Severe weight loss (greater than 10% loss of usual weight) • Chronic, unexplained diarrhoea for > 1 month • Unexplained anaemia • Nutrition Considerations: • Continue efforts for Stages 1 and 2 • Nutrition management for: weight loss/malnutrition, ART, and infections • Coping strategies Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 5 Nutrition at Each Stage of HIV: Stage 4 • Symptoms: • AIDS • More serious infections with life-threatening complications • HIV Wasting Syndrome • Nutrition Considerations: • Continue nutrition management of side effects, as appropriate for client’s prognosis • Provide comfort and manage pain • Fluids for hydration Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 6 Nutrition Assessment • • • • • • Anthropometric Biochemical Clinical Dietary Environmental Food Security Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 7 Anthropometrics • Height (cm) at first visit for adults, at each visit for children • Weight (kg) at each visit • Percent weight loss, if applicable • Mid Upper Arm Circumference (MUAC) at each visit • Body Mass Index (BMI) at each visit Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 8 Weight Loss Calculation • • • • Percent weight loss UBW = Usual Body Weight CBW = Current Body Weight Formula: % loss = UBW – CBW x 100 UBW Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 9 Mid Upper Arm Circumference • Use measuring tape; measure in cm • Estimates muscle loss • If less than 23 cm, possible muscle wasting intervene with nutrition counselling Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 10 Body Mass Index (BMI) • BMI is used to assess an adult’s weight based on their height. • Not used for children or pregnant women • A quick and easy way to estimate weight status (e.g. underweight, normal weight, overweight). Refer to BMI reference chart and calculation sheet Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 11 BMI Reference Chart Underweight BMI 2 (kg/m ) 16 17 18 Normal Weight 19 20 21 22 23 Overweight 24 25 26 27 28 Height (cm.) Obese 29 30 31 32 33 34 35 36 37 38 39 40 41 42 Weight (kg.) 152 37 40 42 44 46 48 50 53 56 58 60 62 64 67 70 72 74 76 78 81 84 86 88 90 92 94 97 154 38 40 42 45 48 50 52 54 57 60 62 64 66 68 71 74 76 78 80 83 86 88 90 92 95 98 100 156 39 42 44 46 48 51 54 56 58 61 64 66 68 70 73 76 78 80 82 85 88 90 92 95 94 100 102 158 40 42 45 48 50 52 55 58 60 62 65 68 70 72 75 78 80 82 85 88 90 92 95 98 100 102 105 160 41 44 46 48 51 54 56 59 62 64 66 69 72 74 77 80 82 84 87 90 92 94 97 100 102 105 108 162 42 44 47 50 52 55 58 60 63 66 68 71 74 76 79 82 84 86 89 92 94 97 100 102 105 108 110 164 43 46 48 51 54 56 59 62 64 67 70 72 75 78 81 84 86 89 92 94 97 100 102 105 108 110 113 166 44 47 50 52 55 58 61 64 66 69 72 74 77 80 83 86 88 91 94 96 99 102 105 108 110 113 116 168 45 48 51 54 56 59 62 65 68 70 73 76 79 82 85 88 90 93 96 99 102 104 107 110 113 116 118 170 46 49 52 55 58 61 64 66 69 72 75 78 81 84 87 90 92 95 98 101 104 107 110 113 116 118 120 172 47 50 53 56 59 62 65 68 71 74 77 80 83 86 90 94 97 100 103 106 108 110 112 115 118 120 124 174 48 51 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97 100 103 106 109 112 115 118 120 124 127 176 50 53 56 59 62 65 68 71 74 77 81 84 87 90 93 96 99 102 105 108 111 115 118 120 124 127 130 178 51 54 57 60 63 67 71 74 76 79 82 85 89 92 95 98 101 105 108 111 114 117 120 124 127 130 133 180 52 55 58 61 65 68 71 75 78 81 84 87 97 94 97 101 104 107 110 113 117 120 123 126 130 133 136 182 53 56 59 63 66 69 73 76 79 83 86 89 93 96 98 103 106 109 113 116 119 123 126 129 132 136 139 184 55 57 61 64 68 71 74 78 81 85 88 91 95 98 102 105 108 112 115 118 122 125 129 132 135 139 142 186 55 59 63 66 67 73 76 79 83 87 90 93 97 101 104 107 111 114 117 120 124 128 131 135 138 142 145 188 57 60 63 67 71 74 77 81 85 89 92 95 99 103 106 109 113 117 120 124 127 131 134 138 141 145 148 190 57 61 65 69 73 76 79 83 87 91 94 97 101 104 108 112 115 119 123 126 130 133 137 141 144 148 152 192 59 63 67 70 73 77 81 85 89 93 96 99 103 107 111 115 118 120 125 129 133 136 140 144 147 151 155 194 61 64 67 71 75 79 83 87 91 94 97 101 105 109 113 117 120 124 128 132 135 139 143 147 151 154 158 196 61 65 69 73 77 81 85 89 93 96 99 103 107 111 115 119 123 127 131 134 138 142 146 150 154 157 161 198 63 67 71 75 79 83 87 91 95 98 101 105 109 113 117 120 125 129 133 137 141 145 149 153 157 161 165 200 63 67 71 75 79 83 87 91 95 99 103 107 111 115 119 124 128 132 136 140 144 148 152 156 160 164 168 Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Adapted from: RCQHC/FANTA Slide 12 Biochemical • Laboratory values as available • CD4 count and all other routine values with: • • • • Blood cholesterol (fat) Blood glucose (sugar) Haemoglobin (blood iron) Urine test, look for ketones • Parasites (e.g. worms) Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 13 Clinical • Assess and counsel on management of complications • • • • • Diarrhoea Nausea/vomiting Poor appetite Mouth sores Changes in taste • Medication Regimen • Discuss food effects, interactions, and herbal/traditional therapies Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 14 Dietary • How many times a day does the client eat? • What does the client eat in a typical day? • How does the client: • Keep foods cold (refrigerator, freezer, other methods)? • Cook food (stove, open fire)? • Keep dishes, utensils, and cooking areas clean (soap, water)? Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 15 Environmental • Assess hygiene and sanitation situation at home and community • Where does the family get water from? • Is there a latrine in the home or communal latrine? If so, how is it maintained? • Is garbage removed often and safely? • Are client and family aware of basic food and water safety practices Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 16 Food Security • Where does the food come from? Market, supermarket, home garden? • Are there community or village gardening projects that client can be referred to? • Know which local, nutritious foods are available in the community, and promote these instead of expensive foods from shops Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 17 Additional Information • Other illness or opportunistic infections • E.g. Tuberculosis, malaria, pneumonia, or skin problems • Lifestyle practices (smoking, alcohol use, and unsafe sex) • Family/community support system • Educational level • Living environment (housing, income, and number of members per household) Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 18 Anthropometric Measurement and BMI Calculation Practice Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 19 Nutrition Assessment Action Plan Assessment Nutrition Assessment Weight, Height, BMI, Record nutrition symptoms Diagnosis Action Plan Severe Malnutrition BMI <16kg/m2, weight loss > 10%, persistent diarrhoea, fever, with or without other symptoms Consider hospitalization with enteral, parenteral or supplemental feedings, treat infections, rehydrate, and promote weight gain with high calorie foods. Moderate Malnutrition BMI 16.5 – 18.5 kg/m2, weight loss < 10%, mild symptoms Treat symptoms/infection and prevent further weight loss and infections with high energy, protein, vitamin and mineral foods. Follow up in 1 month Follow up in 1-2 months Well Nourished BMI > 19 kg/m2, no weight loss or symptoms Praise good eating behaviours. Encourage continued healthy eating and weight maintenance Regular follow up Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 20 Integration of Nutrition into HIV and AIDS Care • Begin at VCT services • Address food availability and access • Weight loss prevention can improve survival Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 21 First HIV Visit • Complete full nutrition assessment • Obtain baseline height and weight, calculate BMI, and measure MUAC • Ask about recent weight loss or inability to eat (due to illness) • Ask about food availability, food storage, and cooking facilities in home • Provide nutrition counselling on healthy eating Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 22 Follow-up Visits • Continue with nutrition assessment • Obtain height (if not already done), weight, calculate BMI, MUAC and % weight loss, if necessary • Ask if any problems eating • Ask if any change in food availability, storage or cooking facilities at home Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 23 For Patients in the Hospital • Take note of whether the patient is eating and how much • If the patient needs help and family members are not there, provide help with eating • Weigh patients • Counsel patient on adjusting food intake for management of side effects Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 24 Integration into ART Programme • Before ART, assess food availability and intake situation • Assess weight status • Use Food and Medication Time Table when discussing medication schedule • At each follow-up, obtain current weight and side effects • Counsel appropriately on side effect management and good nutrition Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 25 Integration into PMTCT and Ongoing Paediatric Care • Counsel mothers and partners on all infant feeding options for PMTCT • Support infant feeding choice • Educate on dangers of mixed feeding • Monitor growth and feeding of infant • For infants on replacement feeding, educate on and monitor formula/milk supply and preparation Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 26 Nutrition Counselling • Listen to client; assess individual situation • Ask open-ended questions (who, what, when, where, why, how?) • Be realistic and practical with counselling; set realistic goals with client • Encourage good eating habits • Be a role model for clients • Maintain confidentiality always Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 27 Making Suggestions, not Commands • Commands use the imperative form of verbs (give, do, bring) and words like always, never, must, should • Suggestions include: • • • • Have you considered …? Would it be possible …? What about trying … to see if it works for you? Would you be able to …? Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 28 Making Suggestions, not Commands • Suggestions include: • Have you thought about …? Instead of …? • You could choose between … and … and … • It may not suit you, but some mothers … a few women … • Perhaps … might work • Usually … Sometimes … Often … • Follow-up with open-ended questions using: who, what, when, where, how, why Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 29 Counselling Role Play Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 30 Integration Case Study Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 31 Key Points 1. All persons with HIV and AIDS need nutrition counselling and assessment 2. Obtain weight and calculate body mass index 3. Integrate nutrition and food security assessment into regular HIV care Session 7: Integrating Nutrition into HIV and AIDS Care Nutrition Management with HIV and AIDS Training Slide 32