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LESSON 2 NUTRITION BASICS (Facilitator EN)

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Learning objectives

At the end of this session, participants will be able to:

  1. define basic nutrition terms
  2. name and provide examples of the three food groups and the role of each group in the body
  3. describe what energy is, and describe the general energy requirements for different people
  4. identify the changing nutritional needs across the lifecycle

Duration: 3.5 hours

Methods

  • Participatory Lecture
  • Brainstorming
  • Group discussion
  • Game

Materials

  • “Good Food Toolkit”
  • Helen Keller International (HKI)/NNP poster of three food groups
  • Large paper or white board
  • Markers
  • Small ball
  • Pictures of rice from the Toolkit
  • Picture of tall and short rice plants
  • Tape/blue tack

Introduction:

Explain, Our bodies are made up of the food we eat and drink. Food and drinks contain different nutrients, and every nutrient has a different benefit for the body – some give us energy, some protect us from illness, and some help our muscles and bones to grow well and stay strong. Our bodies need all of these nutrients to function well and stay healthy and to maintain a good weight. Good nutrition is eating a variety of foods from the different food groups in the correct amounts to give the body the energy and nutrients it needs for good health. Eating a lot of only one kind of food will eventually result in imbalance in the body and illness. Babies can only gain their nutrition from breast milk or commercial safely/correctly prepared infant formula (replacement feeding) for the first six months, after this time first foods can be introduced.

  • Note to the facilitator

    Before presenting the learning objectives, ask: Does anyone have questions about what you have heard?

In this lesson, we will learn some of the basic principles of nutrition for adults and children. Later in the training we will learn about nutrition issues that are specific to PLHIV in Cambodia.

Presentation of learning objectives:

The facilitator shows the learning objectives (written on the large paper) and asks one participant to read the objectives aloud to the group. Discuss each objective with participants to make sure that they understand.

By the end of the lesson, participants will be able to:

  • Define basic nutrition terms
  • Name the three food groups, describe the role of each group in the body, and give examples of foods in each group
  • Describe what energy is, and describe the general energy requirements for different groups/life stages of people
  • Identify the changing nutritional needs across the life cycle

Learning objective 1:

Participants will be able to define basic nutrition terms

Methodology: Participatory Lecture

Begin the session by asking participants, What is the difference between the terms “Food” and “Nutrition”? List responses on a flipchart.

  • Food is anything that can be eaten or drunk that provides energy and nutrients to the body so it can perform its function.
  • Nutrition is the body’s process of taking in and digesting food; using it for growth, reproduction, and maintenance of health.

Ask participants, What is the difference between the terms “Nutrients” and “Macro/micronutrients”?

  • Nutrients are nourishing substances in food that can be metabolised to provide energy to maintain, repair or build body tissues.
  • Nutrients are divided into:
    • Macronutrients = carbohydrates, protein and fat (needed in large amounts)
    • Micronutrients = vitamins and minerals (needed only in small amounts)

Now we have learnt basic nutrition terms, we will continue this session with how nutrients work in our bodies.

Learning objective 2:

Participants will be able to name the three food groups, describe the role of each group in the body, and give examples of foods in each group.

Methodology: Participatory Lecture, Group discussion, Game

  • Step 1: Participatory Lecture and Group Discussion

Tape the HKI/NNP poster with the three food groups in a place where all the participants can see it.

Ask participants, Do you know the three food groups? Let the participants say the three food groups and point them out on the poster.

Using the HKI/NNP poster explain that, Different kinds of food help our bodies in different ways. Three groups of food include:

  1. Energy foods: like rice, noodles, bread, potatoes, oil, etc. Energy foods normally come from plants, and are white or brown in colour. Foods in this group are good sources of carbohydrate or fats, which provide the fuel or energy for bodies to operate.
  2. Body-building foods: like meat, fish, eel, eggs, frog, liver, chicken, milk (soy milk or cow’s milk,) beans, soya, tofu, etc. Body-building foods normally come from animals, but nuts and beans (like soya or mung beans) are also body-building foods. Body-building foods contain protein which is used by the body for growth, maintenance and keeping our muscles strong and functioning well.
  3. Protective foods: like peeled, cooked and mashed vegetables, fruit. Protective foods are fruits or vegetables that are brightly coloured, for example green, orange, or yellow. The colours come from the different kinds of vitamins that are contained inside these fruits and vegetables. Protective foods contain essential vitamins and minerals which work with body-building and energy foods to help our bodies fight infection, maintain a healthy weight, and prevent disease and illness.”

Explain that, To get all the nutrients the body needs, we need to eat a variety of foods. No single food contains all the required nutrients. A good meal should contain foods from the three food groups in adequate amounts. Different people need different amounts of food (e.g. pregnant and breastfeeding women and PLHIV need more food) and different textures of food (e.g. young children need softer food, and sick people may need mashed or soft food). The way the food is prepared/cooked also impacts on the nutritional content of the food e.g. boiling, steaming, peeling, raw etc.

Put a big piece of blank paper on the wall next to or near the HKI/NNP poster. With a marker, divide the paper into three sections (like shown on the left).

Ask, Can you please name (or draw) some of the energy foods that people in your area normally eat?

Write the foods in the top section of the paper. Add any important foods you think they might have forgotten.

Then ask, Please name some of the body-building foods that are common in the community. Write the foods in the middle section of the paper.

Finally, ask, Please name some of the protective foods that are common in the community. Write the foods in the bottom section of the paper.

Explain that, Although some of the foods shown on the poster are expensive for poor people and cannot be bought every day, many of the foods we mentioned are available in our communities and should be eaten every day. We should also try to find new ways to help people have or afford these foods, like community gardens or income generating activities.

  • Step 2: Participatory Lecture and Game

Ask participants to look at the HKI/NNP poster. Point to the top category (Energy group).

Ask, What are the children in the school uniforms doing? and What do you think this means?

Energy foods – the children are running. They have lots of energy from food like rice, noodles, bread, potatoes, oil, etc.

Now point to the middle category (Body-building group). Ask, What are the children in the school uniforms doing? and What do you think this means?

Body-building foods – the children are comparing how tall they are. Their bodies are growing very tall and strong, and their brains are developing well, because of food like meat, fish, eggs, beans, etc.

Now point to the bottom category (Protective group). Ask, “What are the children in the school uniforms doing?” and “What do you think this means?”

Ask, “What are the children in the school uniforms doing?” and “What do you think this means?”

Protective foods – the children are getting the “thumbs up” of approval from the doctor, because they are not sick, and their brains are developing well. They are getting many different vitamins from vegetables and fruits. Ask, What does eating a well-balanced diet mean?

Explain to participants:

A well-balanced diet means that we eat food (and drinks) from all three food groups every day. If we eat food from only one food group like the energy group, then our bodies will not be able to be strong or protect us from infection. Each food group and each food provide some unique nutrients that are essential for our body. Eating well can help PLHIV stay well and respond better to medications. It is important to drink plenty of fluids, especially clean boiled water (at least 8 cups a day).

Drinks and fluids

Water is important for life and is necessary every day. A person needs about two litres of fluid each day. Your body also needs more water when you are:

  • in hot climates;
  • working/more physically active;
  • sweating; or
  • suffering from diarrhoea, vomiting or fever.

Fluids, especially water, are also important for a good supply of breast milk. Many women are very thirsty during breastfeeding, a sign that they need to drink plenty of water. Children also need adequate water but care should be taken to avoid filling a child with watery drinks in place of foods. Please note that exclusive breastfeeding babies (<6 months of age) do not need extra water. If drinking water is collected from a protected well or river the water should be brought to a rolling boil for at least 10 minutes and stored in a clean container.

In addition to drinking clean and safe drinking water, fluid can also come from all other liquids like tea, coffee, juices, coconut water, milk (cows and soy milk), soups, vegetables and fruit as well as meals that have sauces or gravy.

  • Step 3: Group Discussion

Ask, Do your clients eat a well-balanced diet? From which food group do they eat the most? From which food group do they eat the least? What can we do to encourage them to eat from all the food groups? What drinks do they consume?

  • Step 4: Game

Tell participants, Now we’ll play a game to help us remember the benefits of the three different food groups. Get participants to stand in a circle. Get them to agree on a movement that they can do where they are standing, to represent each of the three food groups.

For example:

  • Walking or running in place can be the movement to represent the energy group.
  • Flexing arm muscles, throwing punches in the air, or reaching both hands high above the head can represent the body-building group.
  • Pointing to the head or the heart (or both) can represent the protective group.

Let everyone practice making the movements. The facilitator starts the game by pointing to one participant and saying the name of a food to that person (one food per participant. i.e. coconut, banana, shrimp, jackfruit, etc.). The participant must state the correct food group for that food, and then start making the movement of the food group (i.e. coconut is in the energy group, so the participant starts running or walking in place; bananas are in the protective group, so the participant starts pointing to her head and heart, etc.). Participants must continue making the movement until the facilitator points to them again with another food name, or until the game is over.

  • Note to Facilitator

    Below are some suggestions for other participatory nutrition games which can be used to help participants group the food types according to combinations habitually used in home recipes.

Wrap up:

Ask the participants to review the three food groups with the designated actions and the purpose of eating food from those groups.

Food sorting game:

Give each participant at least two small pieces of paper. Ask them to write or draw the names of an ingredient on the piece of paper. Explain that this can be any type of food – animal source, vegetable, fruit, etc. Each should be a separate food item, not a mixed food that has more than one ingredient such as fish soup.

Collect all the pieces of paper and mix them up together in a basket. Meanwhile write the names of the different food groups on the three large pieces of flip chart paper. Then lay out the pages on the floor in the centre of the room.

Ask each participant to pick two slips of paper from the basket and to place them on the corresponding flip chart paper – into the food category to which it corresponds. Ask the rest of the group to say whether they are correct.

Mixed meal game:

When sorting is complete, draw three large chalk plates on the floor, labelled breakfast, lunch and dinner. Have three participants come forward and to create “meals” using these foods. Ask each volunteer to pick out pieces of paper from flip chart papers that illustrate something they could eat for breakfast, lunch and dinner, and then go stand in the appropriate plate. Try to arrange to include a wide variety of foods.

Lead a discussion with participants with the following questions:

  • Is the meal healthy, mixed and balanced?
  • What kind of healthy drinks can be taken which each meal?
  • How can you encourage PLHIV to eat a wider range of fruit and vegetables?

Learning objective 3:

Participants will be able to describe what “energy” is and describe the general energy requirements for different groups/life stages of people.

Methodology: Participatory Lecture, Quiz

  • Step 1: Participatory Lecture

Explain to participants, We will have a short lecture and then play a quiz game, so you should try to remember what you see and hear.

We eat food to fuel our bodies for energy, growth and repair. A “calorie” is a unit of measure of the energy that we get from the food we eat. Pointing to the Big Paper say, Here are some other examples of units of measurement we use every day for time, distance and weight.

Explain that, ALL food and some drinks contain calories (indicating contained energy). In this Toolkit, when we talk about caloric values of food, we refer to them as “energy”. Not only rice, but also soup, oil, sugar, meat, fish, vegetables, fruit – ALL food and drinks can provide energy (fuel) though some foods provide more energy than others. Foods like oil, meat, and some fruits like bananas have more energy per gram than food like plain rice. Green vegetables also have a low amount of energy BUT this does not mean that green vegetables are not important – they are very important because they also have vitamins, which help to keep us healthy.

Most drinks have energy – juice, milk, soya milk, and drinks that contain sugar, all have energy. Plain water and tea without sugar do not have energy. This does not mean that water is not important – it is very important because the body needs a constant supply of fluids to function well and fight illness.

Examples of Units of Measurement:

  • Minutes and hours measure TIME.
  • Degrees (¡C) measure TEMPERATURE.
  • Meters (m) measure DISTANCE.
  • Grams (g) measure WEIGHT.
  • Calories (kcal) measure ENERGY from the food we eat.

Show the plates of rice in the Toolkit and ask, Which plate of rice provides more energy?

Explain, Different-sized portions of rice provide different amounts of energy. The more you eat the more energy you will consume. People have different needs and so eat different amounts of foods depending on age, gender, activity and whether pregnant, breastfeeding or ill. People who are fat or overweight sometimes try to limit the energy that they eat (diet). People who are thin, or people who are sick, need extra energy to gain weight, or to avoid becoming too thin. It means they need to eat more food in general or add specific food with higher energy to their diets.

Ask participants to look at the table showing the daily energy needs for humans, including PLHIV in Lesson 2 (participant manual).

Explain as you write the information on the Big Paper:

Let’s start with the average adult man and woman:

  • Adult men need about 2,500 calories per day.
  • Adult women need about 2,000 calories per day.

Ask, Why do you think PLHIV need to consume more energy?

A woman who becomes pregnant needs more energy. Why do you think that is?

After participants have a chance to answer, explain that Her body needs more energy to support the baby she is carrying and also when she is breastfeeding/feeding the child. Therefore pregnant and breastfeeding women need more energy to support these extra tasks.

For children, at most times, except for between 15 and 18 years old, their energy requirements are less than adults. However they have higher energy needs per kilogram of body weight. That is, for their size they need to eat a lot compared with adults, especially in the first 3 months of life.

Group

Energy Requirement

Percentage
Increase

Men

2500 Cal*/day

Women

2000 Cal/day

Pregnant Women

Extra 200 – 500 Cal/day

10 (2nd trimester)

25 (3rd trimester)

Breastfeeding Women

Extra 500 Cal/day

25

Children and adolescents (0 to 19 years)

Various (520 – 2755 Cal/day)

People with HIV

Men + HIV

Extra 250 Cal/day

10

Women +HIV

Extra 200 Cal/day

10

Children + HIV

Various + 10%

10

Pregnant Women + HIV

Extra 700 Cal/day

35

Breastfeeding Women + HIV

Extra 700 Cal/day

35

People with HIV who are sick

Children + HIV + poor weight gain/other symptoms

Various + 20%

20

Men + HIV + illness

Extra 500-750 Cal/day

20-30

Women + HIV + illness

Extra 400-600 Cal/day

20-30

Children + HIV + illness (severely malnourished)

Various + 50-100%

50-100

Source: FAO 2001, WHO 2004, WHO 2005

Explain and Show on the flipchart
  • Adult men living with HIV (but not sick) need 10% more energy; a total of 2,750 calories per day.
  • Adult women living with HIV (but not sick) need 10% more energy; a total of about 2,200 calories per day.
  • Children living with HIV (but not sick) also need 10% more energy; a total of 520 to 2755 calories per day, depending on children’s age.

Ask, Why do you think PLHIV need to consume more energy?

Then explain, When a person has an infection such as HIV the body uses more energy and nutrients to protect the body, fight the virus and to keep the body healthy. Therefore, when a PLHIV becomes sick, they need even more energy.

PLHIV have increased energy needs, they need to be encouraged to:

  • Increase the frequency of meals and snacks: extra energy may mean eating an extra meal daily or eating more frequently by having small, frequent meals at 3-4 hour intervals.
  • Increase the amount and variety of food consumed during each meal: increasing energy may also mean consuming additional portions of food such as 1 or 2 extra portions (about 1 or 2 fists full) of the meal.
  • Make every bit count by having a variety of foods that are rich in nutrients and from the three food groups.

It is important to explain to the participants that extra energy needs should not be comprised solely of one food group; rather the proportions of food groups should remain the same.

  • Note

    “It is not important for you to remember the actual numbers of energy requirements for each group, but who needs more energy and why…”

Explain and Show on the flipchart
  • Adult men with HIV (and sick with infections) need 20-30% more energy; a total of about 3,125 calories per day.
  • Adult women with HIV (and sick with infections) need 20-30% more energy; a total of about 2,500 calories per day.
  • Children living with HIV (and sick without weight loss) need 20-30% more energy.
  • Children living with HIV (and sick with weight loss) need 50-100% more energy.

Summarize by asking participants questions and letting them respond:

  1. Who needs more energy – an average man or a pregnant and/or breastfeeding woman?
    Answer – a pregnant and/or breastfeeding woman
  2. Who needs more energy – an HIV-positive person or a person without HIV?
    Answer – an HIV-positive person
  3. Who needs more energy – a person with HIV who is sick or a person with HIV who is not sick?
    Answer – a person with HIV who is sick
  4. Who needs more energy – a child that is sick or a child who is not sick?
    Answer – a child that is sick
  • Step 2: Quiz

Ask participants to stand in a circle. The facilitator will throw a ball to one participant across the circle and ask a question. If the person answers the question incorrectly, he/she must sing a song or do a dance. Then he/she must throw the ball across the circle to another participant who can try to answer the same question. When the question is answered correctly, the ball is thrown to another participant for the next question from the facilitator.

The ball should always be tossed across the circle, never handed to an immediate neighbour.

If someone has already had a question, do not give them another until all the other participants have also had a chance to answer a question.

Questions for the quiz:

  1. What does a calorie measure?
    Answer: A calorie measures ENERGY from the FOOD that we eat.
  2. Do all foods have energy or only some foods?
    Answer: All food has energy.
  3. Who needs more energy – PLHIV or people without HIV?
    Answer: PLHIV need more energy than people without HIV.
  4. Who needs more energy – PLHIV who are sick or PLHIV who are not sick?
    Answer: PLHIV who are sick need more energy than PLHIV who are not sick.
  5. What are the three food groups?
    Answer: Energy group, body-building group, and protective group.
  6. Which group includes food from animals?
    Answer: Body-building group.
  7. Which group includes foods like rice, noodles, and sugar?
    Answer: Energy group.
  8. Which group includes foods like fruit and vegetables?
    Answer: Protective group.
  9. What is a balanced diet?
    Answer: when foods and drinks from all three groups are eaten every day.

The facilitator can add their own questions as needed to review the information in this lesson. At the end of the quiz game, congratulate the participants for their correct answers and thank them for sharing their songs and dances with the group.

Learning objective 3:

Participants will be able to identify the changing nutritional needs across the life cycle

Methodology: Participatory Lecture, Brainstorming

  • Step 1: Participatory Lecture, Brainstorming

Explain that, Nutritional needs vary throughout our life cycle. In all stages of life we need the same basic nutrients. However, each life stage is associated with certain nutritional concerns. Poor nutrition often starts in utero (before birth) and extends, particularly for girls and women, well into adolescent and adult life.

Malnutrition, or the risk of becoming malnourished, may be passed on from one generation to another. Young girls who grow poorly become stunted (small) women and more likely to give birth to small babies who, in turn, are more likely to become small children, small adolescents, and eventually small adults. Adolescent pregnancy increases the risk of low birth weight and the difficulty of breaking the cycle of poor nutrition.

Good nutrition needs supports at all stages – before birth, infancy, childhood, adolescence and adulthood. In this lesson we will be reviewing the nutritional needs of individuals at the various stages of the life cycle, which includes pregnancy (before birth), lactation, infancy, children (young, preschool and school age), adolescents, and adults. At each life cycle stage, nutritional status

can be improved (and malnutrition prevented).

Refer participants to the “Nutrition throughout the life cycle” diagram. Explain that later in this session there will be small group discussion activity to brainstorm strategies to break malnutrition cycle at the various stages of the lifecycle.

LIFE STAGES

  • Before birth (-9 to 0 months)
  • Infant (0 – 12 months)
  • Children (1 to 10 years)
  • Adolescents (10 to 19 years)
  • Adults (>19 years)

Pregnancy and Lactation

Explain that, We will now learn about nutrition during pregnancy (fetus from conception to birth). Pregnancy is an important time in a woman’s life. Before birth, the fetus may be exposed to HIV in utero. The weight of an infant at birth is influenced by his/her mother’s nutritional status. If the mother is malnourished or does not have good nutritional reserves due to multiple or short spaced pregnancies, the fetus (unborn child) may not gain weight appropriately. Low birth weight (LBW) babies (less than 2.5kg) are common, and are known to have poorer health outcomes to babies born at weights greater than 2.5kg. A LBW baby is at higher risk of dying in early life and by an early age, he/she is more likely to be stunted (i.e. low height relative to their age, also known as chronic malnutrition). Stunting which starts at a young age, reduces mental capacity and will likely continue throughout adolescence and adulthood.

Ask, Why is good nutrition is important for pregnant women?

Then explain, To grow properly the unborn child needs a healthy and well-nourished mother. Pregnant women have extra nutritional requirements due to the changes in their bodies and the needs of the growing baby. This is the same for all pregnant women, whether they are HIV-infected or not. Energy requirements increase with:

  • Illness and infection
    PLHIV who are pregnant need extra energy for the baby’s growth as well as for fighting the virus. Energy requirements will be greatly increased by the presence of infection or illness, by between 20-30% (i.e. up to 2 extra cups of rice per day).
  • Under nutrition or adolescent pregnancy
    Underweight and adolescent pregnancy also increases the body’s nutritional requirements.
  • Work and activity
    If a pregnant woman is working hard, for example caring for small children and harvesting crops, the energy requirements will be increased compared with a pregnant woman who is not engaging in physically demanding work.

Ideally a mother has adequate access to a varied and abundant diet which meets her complete nutrition needs during pregnancy. Although more calories are needed during pregnancy (an additional 200 – 500 calories/day), increasing the nutrition density of the diet is even more important.

Ask participants to refer to Positive Living topic 21 (Eat well when you are pregnant or breastfeeding). Explain that later in the training we will go over this card in detail.

Continue the lecture, The energy requirements for a pregnant, HIV negative, healthy weight woman are minimal in the first trimester, but increase in the second and third trimesters. The extra energy will ensure that weight gain is adequate and the unborn child has enough nutrition to develop normally.”

Recommended frequency meals for pregnant and breastfeeding women with HIV

Frequency of meals and snacks

Pregnant women

3 meals plus an extra snack

Pregnant women with HIV

1st Trimester

3 meals plus an extra snack

2nd and 3rd Trimesters

3 meals and 2 snacks OR at least 4 meals

Pregnant women with HIV and sick

At least 4 meals and 2 snacks

Breastfeeding women with HIV

3 meals and 2 snacks OR at least 4 meals

Breastfeeding women with HIV and sick

At least 4 meals and 2 snacks

The energy requirement when breastfeeding is similar to the third trimester. Adequate energy consumed while breastfeeding will ensure that the mother’s nutritional status is not excessively depleted in this phase.

Ask participants what they think they could recommend a woman to eat if she needed an extra snack or full meal per day? List examples on white board.

Explain, More or larger servings of body building (protein-rich) foods and protective foods (foods high in vitamins and minerals) are needed. Pregnancy and breastfeeding increases the protein requirements of a woman. The amount of extra protein required is approximately an extra 15% of the protein requirements of non pregnant or breastfeeding women. The increase required is around 10 g of protein, which will be obtained from eating ¼ cup of cooked fish/chicken/pork, 6 tablespoons of tofu 1 cup of milk/soy milk, ¾ cup of cooked mung beans, 2 small eggs or 1/3 cup of nuts. In most environments, the additional protein requirements are easily met by the increase in energy consumption from normal foods. HIV infected women do not require more protein than non HIV infected women.

Ask participants, What else is needed?

Explain, Pregnant and breastfeeding women have increased small nutrient (micronutrient) requirements for normal fetal development. Eating a variety of foods will meet some of the vitamin and mineral requirements for normal baby growth. Women who can access only limited variety are at risk of developing nutrient deficiencies. Calcium, iron, folate, iodine, zinc and vitamin A are important nutrients in pregnancy and breastfeeding and can be obtained from the following sources.

Nutrient

Sources

Calcium

Small fish with bones, shrimp, shrimp paste, fermented fish, milk, tofu, peanuts

At least 3 serves per day e.g. 3 cups of milk

Iron

Meats, fish, shellfish, eggs, dark green leafy vegetables

A supplement is also usually needed in pregnancy to avoid anemia, particularly if red meat is not eaten regularly.

Folate

Leafy green vegetables, whole wheat grains, fruit, wholegrain bread, fortified foods

Women often need a supplement to prevent some fetal conditions that can arise

Iodine

Iodized salt, vegetables

Adding iodized salt in small amounts regular to food will be adequate to meet needs

Zinc

Meats, fish, nuts, legumes

Vitamin A

Papaya, mango, milk, egg, liver, leafy green vegetables, carrots

  • Note to Facilitator

Pregnant women and babies are vulnerable to iron deficiency anemia, and HIV infection further increases this risk. Animal foods are particularly valuable to eat during pregnancy as they are a good source of iron. The iron from animal foods is well absorbed by the body. Iron reduces anemia. It is therefore important to increase daily intake of animal foods. Dark green leafy vegetables and beans contain iron but this iron may not be well absorbed by the body. However, iron absorption can be increased by eating foods rich in vitamin C such as tomatoes or limes.

Although vitamin A requirements do increase during pregnancy, caution must be taken to not exceed recommended levels of vitamin A consumption, as high doses are associated with birth deformities. The best way to increase vitamin A intake, if it is low, is through food sources.

Vitamin supplementation for HIV positive pregnant women should be recommended as per national standards for antenatal care for all pregnant women. For more information please see Safe Motherhood Clinical Management Protocols, Ministry of Health (MOH), July 2010 and National Policy and Guidelines for Micronutrient Supplementation to Prevent and Control Deficiencies in Cambodia, National Nutrition Program, February 2011.

Ask participants “What are some food preparation practices you would suggest to pregnant women to avoid food borne illness?” Record points and expand on white board or flip chart.

Then explain, In addition to eating well, there are other lifestyle factors that should be avoided during pregnancy and/or breastfeeding.

  • Smoking: Smoking while pregnant exposes a woman and her unborn child to an increased risk of health problems such as miscarriages, premature labour. Woman who smoke are twice as likely to give birth to a low birth weight baby compare to non-smokers. All pregnant women are advised not to smoke during pregnancy.
  • Alcohol: Excessive alcohol consumption during pregnancy is harmful to the unborn baby, especially in the first trimester. It is generally recommended that pregnant women abstain from alcohol, as there are no guidelines for an upper limit of safe alcohol consumption. It is acknowledged that a small quantity of alcohol in the late stages of pregnancy is unlikely to cause harm.
  • Drugs: Pregnant and breastfeeding women should be advised to not use any type of illicit drugs and to check all over the counter medications to not cause any adverse events in pregnancy. During breastfeeding, drugs can be passed through the breast milk and could lead to drug dependency in new born babies.
  • Caffeine: It is recommended that pregnant women drink less than 4 cups of coffee per day, as excessive caffeine consumption is associated with restricted growth of their unborn babies. Caffeine could also affect the sleep patterns of infants who are breastfed.

Infant and young children (0-24 months)

Explain that, The life stage of infancy spans from birth to 12 months of age. In the case of a mother choosing to breastfeed, the infant will be exposed to HIV in very small quantities. There is a risk of HIV transmission through breast milk, but this risk is greatly decreased if the mother exclusively breastfeeds and is taking ART.

As we discussed earlier, the energy requirements of infants are very high, as this is a time of very rapid growth and development. High energy requirements increase susceptibility to malnutrition at this age.

Infancy is also a very vulnerable time for illness and infection due to environmental pathogens and unsafe feeding practices. Unsafe feeding practices commonly cause diarrheal disease in infants, which is a major cause of death worldwide.

HIV infection can be detected when an infant exhibits symptoms of infection and the mother is known to be HIV positive. ART may not be available, and a child may experience diarrhea and infection from unsafe replacement feeding practices. Insufficient nutrition during the first 12 months can quickly lead to malnutrition and either growth faltering (stunting) or in severe situations wasting (severe acute malnutrition). At six months of age, both breast milk and replacement milk must be supplemented with iron rich foods to meet the requirements of an infant. Iron deficiency anemia is common in infants where the diet is inadequate. A mother, for many diverse reasons may have reduced capacity for care for her child, especially if she is very unwell.

Infant Feeding

Explain that, Infant feeding has critical influence on infant and child survival. Optimal infant and young child feeding is fundamental for the survival, health, nutrition, growth, and development of a child, but many children are not fed in the recommended way. Global recommendations for infant and young child feeding:

  • Start breastfeeding within 1 hour of birth
  • Breastfeed exclusively from 0-6 months
  • Give complementary foods to all children from 6 months
  • Continue breast feeding up to 2 years or beyond

WHO recommends that all mothers, regardless of their HIV status, practice exclusive breastfeeding – which means no other liquids or food are given – in the first six months. After six months, the baby should start complementary foods. Mothers who are not infected with HIV should breastfeed until the infant is two years or older. Exclusive breastfeeding provides nutritional, health and psychosocial benefits to infants.

  • Note to Facilitator

    Exclusive breastfeeding means:

    • Infant must receive: breast milk
    • Infant may also receive: drops, syrups (vitamins, minerals, medicines)
    • Infant may not receive: anything else.

Brainstorming activity

Ask participants, “What are the benefits of breastfeeding?”

Brainstorm on the advantages of breastfeeding. The brainstorming should bring out the main points below:

Breast milk

Breast feeding

Perfect nutrients – provide all nutrients a baby needs

Builds close relationship with mother and baby

Easily digested, efficiently used

Helps baby to feel safe and happy

Protects against infection or sickness

Protects mother’s health

Free, hygienic, ready to use

Helps delay a new pregnancy

Contains enough water even when hot

Discuss breastfeeding risks and challenges:

  • Risk of transmission of HIV infection from mother to baby. The infant can still contract HIV through breastfeeding. However a combination of exclusive breastfeeding and the use of antiretroviral treatment can significantly reduce the risk of transmitting HIV to babies through breastfeeding.
  • Must exclusively breastfeed for the first 6 months – no mixed feeding (i.e. breast and bottle/food at same time)
  • Lack of mixed feeding may result in stigma as mixed feeding is a common norm
  • If mother is very sick it may be difficult to breastfeed

Infant feeding in the context of HIV

Birth to six months of age

Exclusive breastfeeding

Explain that, National Guidelines for the Prevention of Mother-to-Child Transmission of HIV (Cambodia Ministry of Health, 2011) recommends all women, irrespective of HIV status, are encouraged to exclusively breastfeed their infants for the first 6 months of life. All HIV positive breastfeeding mothers should take antiretroviral (ARV) drugs until 1 week after complete cessation of breastfeeding to prevent HIV transmission through breast milk. All HIV-exposed infants should receive daily ARV drugs from birth to 6 weeks of age – irrespective of the feeding option chosen by their mother.

Although the maternal transmission rate of breast feeding is estimated to be around 5-20% at a population level, there are many influencing factors. It is impossible to estimate the actual risk of transmission on an individual basis. Factors increasing the risk of HIV transmission during breastfeeding include:

  • Important terms
    • Exclusive breastfeeding is when the baby receives only breast milk and no other liquids or solids, not even water, with the exception of drops or syrups consisting of vitamins, mineral supplements, or medicines.
    • Replacement feeding is the way babies are fed who are not receiving breast milk. This is normally an infant formula.
    • Mixed feeding means giving the baby both breast milk and any other foods or liquids, including infant formula, animal milks or water. Mixed feeding before 6 months greatly increases the chances of an HIV-positive mother passing HIV to her baby.
  • Mother’s nutritional status – transmission rates increase among breast feeding mothers who are malnourished.
  • Mother’s viral load during lactation –higher the maternal viral load increases the risk of HIV transmission through breast milk. Alternatively mothers who are receiving ART often have lower HIV viral loads and therefore at lower risk of transmitting the virus to the child.
  • Duration of breastfeeding – the longer the mother breast feeds a child the higher the risk of HIV viral transmission. Some research suggests this risk increases significantly after 6 months.
  • Type of feeding practiced – mixed feeding (breast milk and replacement feeding) is thought to be one of the most significant factors for increasing the risk of transmission.
  • Breast abscesses (pus build up, usually due to infection), nipple fissures (cracked nipples), and mastitis (inflammation often due to infection) – allow the transfer of blood and plasma which has higher levels of HIV virus.
  • Mothers with advanced HIV disease – have very weak immune systems and are more vulnerable to other infections.
  • Oral disease in the infant, such as thrush and mouth sores – this damage allows for the transfer of virus contained in breast milk directly into the child’s blood.

Plenary discussion – Ask participants, What do you think are some of the barriers to exclusive breastfeeding in Cambodia?

Facilitate discussion and summarize.

Replacement feeding

Explain, Now we will talk about replacement feeding. HIV-positive mothers, who choose not to breast feed their babies, should only give international standard commercial infant formula milk as a replacement feed to their HIV-uninfected infants or to infants who are of unknown status, when specific conditions are met. Replacement feeding with fresh cow’s milk, soy milk and condensed milk is NOT recommended. It is important to give commercial infant formula milk exclusively for the first 6 months, no breast milk or other foods at all. DO NOT reintroduce breastfeeding: avoid any mixed feeding.

In order to safely feed an infant using commercial infant formula, the following conditions must be met:

  • Safe water and sanitations are assured at the household level and in the community, and
  • the mother, or other caregiver can reliably provide sufficient infant formula milk to support growth and development of the infant, and
  • the mother, or other caregiver can prepare it cleanly and frequently enough so that it is safe and carries a low risk of diarrhea and malnutrition, and
  • the mother, or other caregiver can, in the first six months, exclusively give infant formula milk, and the family is supportive of this practice, and
  • the mother, or other caregiver can access health care that offers comprehensive child health services

Replacement feeding with formula milk may be associated with an increased risk of diarrhea, respiratory illness and malnutrition if the feed is not prepared safely and correctly. However, it carries no risk of HIV transmission.

Discuss replacement feeding risks and challenges:

  • Formula does not have antibodies that protect babies from infection
  • Stigma
  • Adequate time, knowledge and skills to prepare the formula.
  • Maintaining supply of the formula
  • Safety – risk of illnesses
  • Cost – expensive

After six months of age

Then, explain the following recommendations from National Guidelines for the Prevention of Mother-to-Child Transmission of HIV:

  • HIV positive mothers whose infants are HIV-infected (HIV DNA PCR test positive) should introduce complementary feeding and continue to breastfeed for up to 24 months or longer
  • HIV positive mothers whose infants are HIV-uninfected (HIV DNA PCR test negative) or unknown HIV status should introduce complementary foods and continue breastfeeding for up to 12 months
  • In Cambodia, most children grow well from 0-6 months old because they receive lots of breast milk. However, after 6 months, most children cannot grow at the rate they should because they do not receive appropriate and sufficient complementary foods. However it is also very important that they continue to breastfeed because the nutrients in the breast milk help them to grow and to fight diseases.
  • Note to Facilitator

    Complementary foods refer to foods provided from age 6 months that complement or are additional to nutrition provided by either breast milk or replacement milk. At six months, children are developmentally ready for textured foods and have increasing capacity to use their hands, tongue and mouth to coordinate the physical process of eating. A child is at increased risk of malnutrition when complementary foods are introduced as they are often of inadequate nutritional quality or provided in too small amounts (or both). It takes time and effort to meet a child’s nutritional requirements at this age as a child must be assisted many times through the day to eat and drink.

Brainstorming activity

Show participants the picture of rice growing. If it is difficult to show, then you can also draw the picture on the big paper.

Ask participants, What makes rice grow tall? Write their answers on the big paper (water, fertilizer, sunshine, protection from birds and weeds (other unwanted plants), etc.).

Taller, healthier rice plants have higher yields. But we have to provide the right inputs and take good care of the field. The same is true with children – we have to try to provide the right foods for the children to grow tall, healthy, and clever, so they can be productive in their lives.

Continue with the lecture, Complementary foods should be rich in energy, protein and micronutrients. Foods should be chosen that are easy to eat and suit the developmental stage of the child, such as foods that a child can pick up easily and move to their mouth. Animal foods including, meats, offal, fish, seafood, eggs and milk are dense in nutrients including iron and vitamin A. If iron fortified flours, biscuits, cereals and other foods are available they will assist a child meet their iron requirements.

  • Note

    Iron requirements for babies and little kids:

    • 7-12 months: 11mg of iron per day which can be obtained by adding 6 tablespoon liver and ¾ cup dark green leafy vegetables to bobor or 3 cups of mashed pumpkin/sweet potato + 4.5 tablespoons cooked liver + ½ cup cooked dark green leafy vegetables
    • 1-5 years: 9-10 mg of iron per day which can be achieved by eating ½ cup liver and 1 cup dark green leafy vegetables or ¼ cup cooked kidney and 1 cup cooked dark green leafy vegetables/ 1 cup tofu

    Source: FAO/WHO Human Vitamin and Mineral Requirements, 2002

Rice and soup, and plain rice bobor are NOT enough for young children to grow well. Children need thick “enriched bobor” that cannot fall/drip off spoon in the correct amount. “Enriched bobor” is bobor mixed with:

  • fish, egg, blood, chopped meat, tofu and beans
  • vegetables: morning glory leaves, amaranth leaves, pumpkin, yellow sweet potato and other vegetables
  • cooking oil
  • iodized salt

This picture shows some of the foods that can be used to make enriched bobor, full of nutrition. It will help children to be tall and strong, clever and quick learners.

The following table shows meal frequency and additional meals needed for children aged 6-24 months.

Age

Frequency

Amount at each meal

Additional

6 months

2 times/day

2-3 tablespoons

Breast milk or infant formula

7-8 months

3 times/day

½ bowl (250ml)

Breast milk or infant formula

9-11 months

3 times/day

Nearly full bowl

1 snack/day + breast milk or infant formula

12-24 months

3 times/day

Full bowl

2 snacks + breast milk or infant formula

Source: National Policy on Infant and Young Child Feeding, NNP NMCHC 2009

Reinforce the previous information that milk is an important source of nutrition up to the age of 2 years. Explain that, In a breastfed child, from 6 to 12 months around 50% of nutrient and energy needs are met by breast milk. After the age of 12 months as more complementary foods are increased and the child eats more family foods, this decreases to around 30%. To compensate for no breast milk, infants need more nutrient dense foods in greater quantities. It is recommended that non breast fed infants receive 4-5 meals per day plus 1-2 snacks as required. WHO recommends that infants are fed on demand, or as often as the child wants

Note about HIV positive babies

  • Children living with HIV (i.e. have had a positive HIV test result) need extra energy and nutrients to grow and fight infections so they need more food than children without HIV
  • A baby with HIV who is not sick should receive at least one extra feed per day
  • A baby with HIV who is sick and/or losing weight should be fed twice as much compared with what a health baby should eat

Then summarize strategies for infants and young children (6-24 months):

  • PMTCT
  • Safe water and complementary foods
  • High standards of hygiene
  • Mother supported to provide care and attention to infant
  • A good mixture of foods to support rapid growth in the first 2 years
  • Food consistency should be appropriate to child development
  • Mother or caregiver should encourage the child eat sufficient amount of meals appropriate for their ages
  • Responsive feeding – be patient and actively encourage the baby to eat
  • Infants 6-24 months are at high risk of malnutrition
  • It is important to address poor growth and poor nutrition quickly, as soon as they are identified.
  • Step 2: Group Discussion – Break the malnutrition life cycle

Duration: 15 minutes

Instruction for activity:

  • Divide participants into 6 groups
  • Ask participants to brainstorm strategies to break malnutrition cycle at the various stages of the lifecycle
    • Group 1 & 2: infancy and early childhood (0-24 months)
    • Group 3 & 4: childhood (2-9 years)
    • Group 5 & 6: adolescent (10-19 years)
  • Ask each group to present its work in plenary
  • Facilitate discussion and summarize

Key information

Strategies to break malnutrition cycle — Answers might include:

Infancy and early childhood (0-24 months)

  • Exclusive breastfeeding of infants 0-6 months
  • Early initiation of breastfeeding (within one hour of birth
  • Complementary foods at 6 months
  • Responsive feeding
  • High standards of hygiene
  • Addressing poor growth and poor nutrition quickly
  • Giving children “enriched bobor” in the correct amount
  • Ensuring more frequent breastfeeding of a sick child
  • Immunization

Childhood (2-9 years)

  • Providing nutrient rich foods from all food groups
  • Attending regular growth monitoring and monitoring sessions
  • Early treatment of HIV symptoms and infections
  • Immunization
  • Practising good hygiene
  • Providing foods rich in vitamin A, iron, iodine

Adolescent (10-19 years)

  • Increasing food intake to accommodate “growth spurts”
  • Fighting iron deficiency through consuming foods rich in iron, particularly for adolescent girls
  • Preventing and treating infections
  • Step 3: Participatory Lecture and Brainstorming

Children 3 – 5 years (Preschool children)

Continue with the lecture, The preschool age is not a fast growing period; so it is not a time when the child has a big appetite. Some children in this age group are fussy, if they do not like the food, they will not eat it. Therefore, offer a wide variety of foods and regular meals and snacks and allow the child to eat according to their appetite without force or arguments. A regular intake of food is needed throughout the day to keep children active. Serve them small portions over 5-6 regular meals. Children in this age group are very active; they may be busy playing and may not think about eating. Often children will just want to eat rice because they like the taste and don’t have to worry about other tastes or textures, the family have to work hard to try and get the child to eat a variety of foods, this can be a very difficult job when a child is not feeling well.

A preschool child has a small stomach which prevents them consuming large quantities of food at one time. Much of the food offered should be high nutrient density to meet micronutrient as well as energy requirements. Important micronutrients for children in this age group are:

  • Vitamin A: meat, liver, kidney, egg yolks, fish and small fish, orange and yellow vegetables, orange and yellow fruits (e.g. jackfruit, ripe mango, ripe papaya), dark leafy vegetables (e.g. spinach, morning glory)
  • Iron: red meat, chicken, eggs, beans, tofu, dark leafy vegetables
  • Iodine: use iodized salt for cooking
  • Calcium for bone development: milk, tofu.

Ask participants, Why poor eating is common in preschool children?

Explain, Children need to be offered many different foods, not just comfort or simple foods from one group. For example, if children eat mainly rice they will have no room in their stomachs for vegetables, meat (e.g. frogs), fruit, and milk products, tofu etc. Give nutritious snacks to your child. Examples are ripe banana, mango and papaya, milk (cows/soy milk).

Good nutrition during preschool age is important to a child’s future. Young children under five years of age with HIV are the most vulnerable to malnutrition. HIV positive children have more frequent common childhood infections such as ear or lung infections than HIV negative children. Diarrhea and fever are usually more persistent and severe in children with HIV. HIV symptoms such as diarrhea and infections will exacerbate malnutrition. Children who are chronically malnourished will not be growing as expected, and will have low height for age scores which indicates stunting.

Children over 5 years old (School-age children)

Begin by saying, School-age children need good nutrition that allows them to grow, work, play and learn. They need 3 meals and 2 snacks each day including foods from all food groups.

Ask participants, Do you remember the three food groups we learnt earlier in this lesson?

Continue with the lecture, School-age children are at la lower nutritional risk than younger children because they grow more slowly than younger children. There are three distinct stages in childhood when growth is rapid: during infancy, adolescence and between the age of 6 and 8 years (often called mid-growth spurt). Children in this age group have become resistant to common infections. Their stomachs are bigger so they can eat more at one meal.

The issues in children include malnutrition. School-age children may be short for their age (stunted) from having been malnourished when younger. Children are most vulnerable to the effects of poverty, and may be forced out of school into work in order to meet basic necessities of food and shelter. Children often miss meals when money is scarce, increasing the risk of malnutrition and poor health. They often walk long distances to school with little or no breakfast. Poverty also increases a child’s vulnerability to mental health disorders.

School-age children may be anemic or vitamin A deficient due to iron and vitamin A deficiency in their diets or from infections. Maintaining adequate iron status is important for growth, cognitive function and immune system. A school age child with HIV needs more food to meet their increased nutritional needs resulting from the HIV infection as well as to support his/her normal growth.

Ask participants, What are strategies for children? Review Group 3 & 4 answers and fill in gaps as needed.

The answers are provided below:

  • Nutrient rich foods from all food groups
  • Enough energy for growth
  • Appetite and food intake will vary. Children are good at regulating energy intake when they are well.
  • Practice good hygiene e.g. washing hands with soaps and clean water.
  • Healthy drinks, no caffeine (e.g. tea, coca cola)
  • Drink juices in moderation, avoid drinks with no nutritional value such as tea, coffee, sodas and other sugary or colored drinks
  • Limit snacks with low nutritional values e.g. chips, shrimp crackers, candies, soft drinks.
  • Early treatment of HIV symptoms and infections (Lesson 6)
  • Attend regular growth monitoring and promotion sessions to make sure young children are growing well and identify any nutrition problems they may have (e.g. severe thinness or swelling)
  • Treatment of malnutrition
  • Importance of establishment of lifelong healthy eating habits

ADOLESCENTS (10-19 YEARS)

Begin by saying, Now, we will learn the importance of adolescent nutrition. Tomorrow’s adults are today’s adolescents. WHO defines adolescence as the period between 10 and 19 years old.

BRAINSTORMING ACTIVITY

Ask participants, Why is good nutrition important for adolescent? Record points and expand on white board or flip chart.

Continue with the lecture, The adolescence period is a critical part of development in the life cycle, a time of physical and emotional change as the body matures. Growth velocity is only faster in the first year of life, thus adolescence provides a window of opportunity for compensating for early childhood growth failure. Optimal nutrition before the pre-pubertal growth spurt (around 18-24 months immediately preceding menarche in girls) results in catch up growth from nutritional deficits incurred earlier in life.

Achieving optimal height confers many advantages in adulthood including increased work capacity, ease of childbirth and decreased obstetric risk to the mother and decreased risk of delivering a low birth weight baby.

Girls and boys have a different pattern of maturation. Girls begin rapid growth at an average of 10 years and grow at peak velocity at 12 years, while boys begin rapid growth around 12 years of age and peak around 15 years. There is great variation between individuals, and between countries. Girls attain their maximum height around 16 years, and boys around 18 years.

Adolescence is a nutritionally critical period because the rapid growth and development places great pressure on the need for nutrients. The body demands more nutrients (protein, calcium, iron) and energy as a result of the increase in physical growth and maturation and changes in body composition. There may be socioeconomic, cultural, and change of lifestyle factors that affect the food and nutrient intake of adolescents. Nutrient needs are further pressured when catch up growth is required, or adolescent pregnancy occurs. Many adolescent are vulnerable to malnutrition.

Adolescents tend to eat differently as they did as children. Many meals and snacks are routinely obtained outside the home, often without supervision. With after school activities and active social lives, adolescents are not able to sit down for three meals a day. Busy lifestyles may lead to meal skipping and snacking or “grazing” throughout the day. Eating small meals frequently e.g. six occasions during the day is desirable to meet high energy needs in this age group. When adolescents skip meals, they are more likely to eat “junk foods” like soft drinks, sweets, and crisps that have little nutritional value.

GOALS OF ADOLESCENCE:

  • Very high nutrient requirements are met by a diverse and adequate diet
  • Catch up growth occurs, and maximum potential height is reached in adulthood
  • HIV symptoms are treated early, to avoid high energy expenditure and factors that reduce nutrient intake such as anorexia and chronic diarrhea.
  • The adolescent is well enough to attend school and reach optimal cognitive development
  • Plentiful calcium and Vitamin D is consumed to optimize bone development and density
  • Pregnancy is delayed until growth is complete. Pregnancy during adolescence not only focuses major health risks for a girl and her child but also disrupts the physiological, cognitive and social development of the mother. In the event of adolescent pregnancy, her needs for energy and nutrients are in direct competition with those of the fetus.

COMMON ISSUES FOR ADOLESCENTS:

  • HIV symptoms may reduce food intake (this is the same as in adults)
  • Weight loss may result from insufficient intake coupled with high energy requirements
  • Work and intellectual capacity may be reduced due to chronic malnutrition and poor development
  • Iron deficiency anemia may result from low dietary iron intake plus high iron requirements associated with rapid growth in adolescence and menstrual losses in females.
  • Delayed growth and sexual maturation may result from chronic malnutrition
  • Adolescent pregnancy (issues discussed above)
  • Mental and social health may be poor
  • Drug, tobacco and alcohol consumption may exacerbate poor dietary intake, food insecurity and mental health issues.

STRATEGIES FOR ADOLESCENTS:

  • For an adolescent to meet their nutritional requirements, they must have knowledge of what foods to eat, and how much to eat. Food and nutrition education and knowledge will assist adolescents to meet their needs and promote health.
  • Consumption of zinc, calcium, iron and vitamin A rich foods from a variety of both food and supplementary sources will promote adequate nutrition
  • Symptoms and conditions that underlie poor dietary intake should be treated early to reduce the impact of chronic poor dietary intake (See also lesson 6)
  • Access to education and health care, including contraception to delay pregnancy until a girl has reached maximum height and maturity.
  • Access to social support and mental health care

ADULTS (>19 YEARS)

Explain that, By the time we reach adulthood, the majority of our growth and development will be well and truly over. The focus of nutrition can now shift to maintaining a healthy and active lifestyle. In doing this, adults will be able to keep the risk of developing age related diseases to an absolute minimum. No matter what age we are the body needs a diet made up of lots of healthy and nutritious foods in order to function correctly. Adults need nutritionally balanced diets including foods from each of all food groups of sufficient quantity. It is important that foods should be prepared and stored hygienically to prevent illness. Men need more calories than women but women need more iron.

Exercise and physical activity is recommended for more than 30 minutes each day for health maintenance. This can be taken at different times during the day, or in one block. A healthy weight is when a person is not too thin and not too fat. When a person is a healthy weight, they are at lower risk of developing other diseases and illness. They are more likely to be active, feel well and have energy for daily activities.

  • Step 4: Quiz and Game – Stretching game

Duration: 20 minutes

The purpose of the game is to give participants a chance to demonstrate their knowledge, and a chance to stretch their bodies and not feel tired.

Ask participants form a line, from the shortest person at one end to the tallest person at the other end. Give each participant a piece of tape, and write a number on each piece of tape (1 to the highest number). Starting with the shortest person- ask one of the questions from page 48. Once the person has answered the question correctly, tell the person that he/she must reach his/her arms high into the air, stretching all of his/her body to be as tall as possible. Then he/she must stick his/her piece of tape to the wall as high as he/she possibly can. He/she can jump if he/she wants, but he/she should try to place the tape as high as possible.

If there are more participants than questions below, the facilitator can repeat some questions, or create new questions related to this lesson. Each participant must answer the question correctly before they can attempt to tape their number high on the wall. If they do not know the correct answer, they can get help from the other volunteers, but they must state and explain the correct answer before competing in the “stretch”.

The participant who is able to tape the number at the highest place on the wall is the winner of the “stretching” game. Congratulate her (or him) and all of the participants with a round of applause!

Summary

Ask participants to look at Lesson 2 (in the Participant Manual) and explain that all of the information discussed in this lesson is in it.

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