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LESSON 2 NUTRITION BASICS (Participant EN)

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BASIC NUTRITION TERMS

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

Nutrients are nourishing substance in food that can be metabolised to provide energy to maintain, repair or build body tissues. They include macronutrients and micronutrients:

  • Macronutrients = carbohydrates, protein and fat (needed in large amounts)
  • Micronutrients = vitamins and minerals (needed only in small amounts)

THREE FOOD GROUPS

  1. Energy foods: like rice, noodles, bread, potatoes, oil, etc. Energy foods normally come from plants, and are white or brown in color. Energy foods give people energy to do daily activities like walking, working, riding a bicycle, caring for children, etc.
  2. Body-building foods: like meat, fish, eggs, liver, 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 help our muscles to grow and stay strong. They also provide important vitamins that help protect us from illness.
  3. Protective foods: are fruits or vegetables that are brightly colored, for example, green, orange, or yellow. The colors come from the different kinds of vitamins that are contained inside these fruits and vegetables. Protective foods provide vitamins and minerals that help our bodies resist infections.

People should try to eat from all three food groups every day to keep balance in the body and stay healthy. 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 better respond 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 liters of fluid each day. Your body also needs more water when you are-

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

Fluids, especially water, are also important to maintain the 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 exclusively breastfed 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.

ENERGY REQUIREMENTS

A “calorie” is a unit of measuring the energy that we get from the food we eat.

ALL food contains calories (indicating contained energy). Most drinks also contain energy.

People have different needs depending on age, gender, activity and whether pregnant, breastfeeding or ill. So they need to get a certain amount of energy every day from the food that they eat. The table below shows the daily energy needs for humans, including PLHIV.

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

In other words:

  • People with HIV need more energy than people who do not have HIV.
  • People with HIV who are sick need more energy than people with HIV who are not sick.
  • Pregnant and lactating women need more energy to support the growth of the baby, both inside the body, and through breast milk.
  • Children with HIV need more energy than children do not have HIV.

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 eat more frequently by having small, frequent meals every 3 to 4 hours.
  • 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 meal.
  • Make every bit count by having variety of foods that are rich in nutrients and from the 3 food groups.

NUTRITION THROUGHOUT THE LIFECYCLE

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).

Source: Commission on the Nutrition Challenges of the 21st Century (1999). Ending Malnutrition by
2020: An Agenda for Change in Millennium. Final Report to the ACC/SCN

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

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 needs 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
  • Work and activity

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

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

What kinds of foods are good for pregnant and breastfeeding woman?

  • Nutritious meals that contain a mixture of the 3 different food groups
  • More or larger servings of energy and body building (protein-rich) foods
  • Protective foods (foods high in vitamins and minerals)

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

A pregnant woman needs to gain weight during pregnancy because the extra weight is for:

  • The growth and development of the unborn child
  • The mother’s body changes during pregnancy

Weight gain and good nutrition lead to the normal development and growth of the baby which is then born at full term at a healthy weight (between 2.5 and 4 kg). The table below summarizes expected weight gain depending on the mothers’ pre-pregnancy weight.

Pre-pregnancy weight
Body Mass Index (BMI)

Total weight gain

Underweight (<18.5)

12.5-18kg

Healthy weight (18.6 – 24.0)

11.5-16kg

Overweight (25.0 – 29.9)

7.0-11.5kg

Obese (≥30.0)

4.5-9kg

Source: Weight gain during pregnancy: Reexamining the guidelines,
Institute of Medicine (IOM), 2009

Pregnant women are at higher risk of food borne illness. To reduce risk of food borne illness, normal food and safety measures should be undertaken. Pregnant women should avoid raw or undercooked meats, fish and eggs. Milk and dairy food should be pasteurized (heat treated) where possible. In addition to eating well, there are other lifestyle factors that should be avoided during pregnancy and/or breastfeeding – smoking, alcohol, illicit drugs and caffeine.

INFANT AND YOUNG CHILDREN (0-24 MONTHS)

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.

Insufficient nutrition during the first 12 months can quickly lead to malnutrition and either growth faltering (stunting) or, in severe situations, wasting (moderate and 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

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

World Health Organization (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 on 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 the infants.

BENEFITS OF BREASTFEEDING

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

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

  • 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.

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:

  • Mother’s nutritional status – transmission rates increase among breast feeding mothers who are malnourished.
  • Mother’s viral load during lactation – higher maternal viral load increases the risk of HIV transmission through breast milk. Alternatively mothers who are receiving antiretroviral therapy (ART) often have lower HIV viral loads and are therefore at lower risk of transmitting the virus to their child.
  • Duration of breastfeeding – the longer the mother breast feeds a child, the greater 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 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 bloodstream.

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 sanitation 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.

AFTER SIX MONTHS OF AGE

Below are the recommendations from National Guidelines for the Prevention of Mother-to-Child Transmission of HIV (Cambodia Ministry of Health, 2011):

  • 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.
  • Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided.
  • When HIV-positive mothers decide to stop breastfeeding (at any time) they should do so gradually within a month.
  • Stopping breastfeeding abruptly is associated with growth failure (poor growth) and diarrhea.

From 6 to 24 months old, children grow quickly. Not only do their bodies grow, but their brains also develop. 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.

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 in meeting his/her iron requirements.

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.

For an average healthy child, complementary foods should be given as follows:

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

For 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 healthy baby should eat.

CHILDREN 3 – 5 YEARS (PRESCHOOL CHILDREN)

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. Children should always be offered many different foods, not just comfort or simple foods from one group. For example, if children eat mostly only rice they will have no room in their stomachs for vegetables, meat (e.g. frogs), fruit, and milk products, tofu etc. Children may also be given nutritious snacks. For examples, ripe banana, mango and papaya, milk (cows/soy milk).

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 has 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.

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

Good nutrition during preschool age is important for 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 indicating stunting.

CHILDREN OVER 5 YEARS OLD – SCHOOL-AGE CHILDREN

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. They are at less nutritional risk than younger children because they grow more slowly than younger children. Children in this age group have become resistant to common infections. Their stomachs are bigger so they can eat more at one meal.

Malnutrition can be an issue for children in this age group. 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 fund 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 due to diet or infection. 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.

ADOLESCENTS (10-19 YEARS)

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. 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 adolescents 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, crisps that have little nutritional value.

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.

ADULTS (>19 YEARS)

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.

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