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Lesson 3 Nutrition and HIV (Facilitator EN)

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Learning objectives

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

  1. understand the relationship between HIV and nutrition
  2. describe the cycle of HIV, poor nutrition and infection
  3. discuss challenges to good nutrition
  4. discuss seven ways to gain or maintain a healthy weight (adults and children) or to maintain good growth (children)
  5. identify incorrect myths about HIV and food and provide the correct information to counter those myths

Duration: 2.5 hour

Methods

  • Participatory Lecture
  • Brainstorming
  • Demonstration
  • Game
  • Small Group Discussion
  • Plenary Group Discussion

Materials

  • Lesson 3 Learning Objectives written on large paper
  • Large paper, Small paper
  • Purple “enhancer” cards from the Toolkit
  • Soup pictures from the Toolkit and Training Manual
  • Rice pictures from the Toolkit
  • Tape and markers

Introduction:

In Lesson 2 we learned some basic information about nutrition and staying healthy. Good nutrition is important for everyone, but it is especially important for PLHIV, including children living with HIV and OVC. There is a very close relationship between nutrition and infection – people who are malnourished can more easily become sick, and people who are sick can easily become malnourished. PLHIV need to take special care to avoid this dangerous trap. Good nutrition will help PLHIV to avoid getting sick.

In this lesson, we will learn about:

  • The relationship between HIV, nutrition and infection
  • Additional energy required by certain groups of PLHIV
  • ART drugs and nutrition
  • What to do to maintain weight (adults) or maintain good growth (children) or to gain and maintain a healthy weight (adults and children)
  • Incorrect myths about food and what is actually correct.

Does anyone have questions about what you have heard?

Presentation of learning objectives:

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

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

  1. understand the relationship between HIV and nutrition
  2. describe the cycle of HIV, poor nutrition and infection
  3. discuss challenges to good nutrition
  4. discuss seven ways to gain or maintain a healthy weight (adults and children) or to maintain good growth (children)
  5. identify incorrect myths about HIV and food and provide the correct information to counter those myths

LEARNING OBJECTIVE 1:

Participants will be able to understand the relationship between HIV and nutrition.

Methodology: Brainstorming, Participatory Lecture and Discussion

  • STEP 1: BRAINSTORMING

Duration: 10 minutes

Instructions for activity:

Facilitator introduces the session by asking participants the following questions:

  • How are nutrition and HIV related?
  • How does HIV affect the amount of food someone can eat and what they eat?
  • Does HIV affect how our body uses food? How?
  • Post the prepared flipchart with the diagram on good nutrition and HIV
  • Discuss and summarize findings

KEY INFORMATION

The relationship between nutrition and HIV is complex. HIV weakens the body’s defense system against disease and infection. PLHIV are at increased risk of malnutrition (poor nutrition) through various mechanisms, some of which are not related to food intake. Poor nutrition increases vulnerability to infection and weakens the immune system. Frequent infections and diseases make the body weaker and may accelerate the progression of the disease.

In order to fight infections, the immune system needs more energy and nutrients. When HIV weakens the immune system, other infections start to arise, and fighting them also increases the needs for nutrients and energy.

There are three ways in which HIV can affect the nutritional status of PLHIV:

  • Increasing energy needs;
  • Reducing food intake; and
  • Lowering food absorption.
  • STEP 2: PARTICIPATORY LECTURE

INCREASED ENERGY NEEDS

Explain to participants, We will start with the additional energy needs. Can you remember what we discussed about what “energy” is in lesson 2? People have different needs and so eat different amount of foods depending on age, gender, activity and whether pregnant, breastfeeding or ill. Now we will focus on energy needs for PLHIV.

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 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 a variety of foods that are rich innutrients and from the 3 food groups.

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

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.

Does anyone have questions about what you have heard?

  • Step 3: Demonstration and Discussion

Begin by saying, The calorie numbers are difficult to understand by themselves so now we are going to look at how they translate into the amount of food our clients need to eat.

  • Note to Facilitator

    The discussion points with participants are divided into three sections. Facilitator may choose appropriate section/s only, depending on the target groups where participants work.

a. Discussion translating calories into actual food intake for adult PLHIV

Ask the participants to gather around a table at the front of the room so that everyone can see. Place on the table the picture of 200 grams of rice from the nutrition Toolkit and the small bowl of fish soup from the training manual (Annex 5).

Clarifying that the foods and the amounts in the pictures are just examples so that the participants can get a general understanding of the amount of food the average adult person (i.e. a person without HIV) and their PLHIV clients should be eating.

Ask, Are the three food groups represented and which foods are in which food group?

Explain that, The average person should eat about the amount shown in the pictures for each meal three times a day (plus two snacks) and this will make up the approximate 2,000 calorie requirement for each day.

Generate a discussion based on the following questions:

  1. Do you and/or your adult family members each eat at least this amount?
    Why or why not?
  2. If not, place the other rice pictures from the toolkit on the table and ask which amount best represents what they are eating at each meal?

Continue with the discussion by removing the previous pictures and then adding the picture of the 250 gram rice plate from the nutrition Toolkit and the medium sized bowl of soup from the training manual (Annex 6).

From our previous discussion, we talked about our PLHIV clients needing 10% more energy than the average adult as a result of the virus. These plates represent approximately how much more food a PLHIV needs in each meal (plus two snacks). Place the previous two pictures next to these two pictures so that the participants can see the difference.

Generate a discussion based on the following questions:

  1. Do your PLHIV clients eat at least this amount in one meal? Why or why not?
  2. a. If not, place the other rice pictures from the Toolkit and the small bowl of soup from the training manual on the table and ask which amount best represents what they are eating at each meal?

    b. Brainstorm with participants how can the meal be enriched to meet 10% extra energy every day. Ask participants to look at the table showing amount of extra foods needed in a day for PLHIV. The extra energy can be translated to same common snack foods.

  3. 10% is really not a lot more; do you think we can encourage our clients to eat this amount?

Examples of foods providing the extra 10% (~250 calories) per day for your PLHIV clients:

Food

Amount

Banana

2 medium size (~170grams)

Mung bean porridge

1 cup

Soy milk

2 cups

Pumpkin custard

1 cup

Mango

1 ½ medium size (~300grams)

1 cup = ~250ml

Continue with the discussion by removing the previous pictures and then adding the picture of the 300 gram rice plate from the nutrition Toolkit and the larger sized bowl of soup with the banana from the training manual (Annex 7).

“When our PLHIV clients experience illness symptoms they need even more calories – 20 – 30% more in order to fuel the body to fight the illness. These plates represent approximately how much more food a sick PLHIV needs in each meal.” Place the previous two sets of pictures next to these two pictures so that the participants can see the difference.

Generate a discussion based on the following questions:

  1. Do your PLHIV clients who are sick eat at least this amount in one meal? Why or why not?
  2. a. If not, place the other rice pictures from the Toolkit and the small and medium bowls of soup from the training manual on the table and ask which amount best represents what they are eating at each meal.

b. What can we do to meet the extra energy needs for a sick PLHIV? Ask participants to look at the table showing amount of extra foods needed in a day for PLHIV who are sick. The extra energy can be translated to same common snack foods or an additional meal during the day.

Examples of foods providing the extra 20-30% (~500calories) per day for your PLHIV clients who are sick:

Food

  1. Mung bean porridge (~250grams/1cup)
  2. Banana fritter (2 small size)
  3. Boiled egg (2 large)
  4. Soy milk (2 cups)

PLUS any one of these:

  • Banana (2 medium size) OR,
  • Mango (1 ½ medium size) OR,
  • Jackfruit (1 cup sliced, ~250grams)
  1. Roasted pumpkin seed (~100g)
  2. Dried cashew nut/peanut (~100g)
  3. 1 ½ cups (200grams) rice + medium sized bowl of fish and vegetable soup

b. Discussion translating calories into actual food intake for pregnant and breastfeeding women with HIV

Explain that, When PLHIV are pregnant or breastfeeding they need even more energy – 35% extra energy for the baby’s growth and breast milk production as well as for fighting the virus. Energy requirements will be greatly increased if pregnant and breast feeding women are sick (i.e. on top of already increased requirements for pregnancy and breast feeding).

Place the picture of the 250 grams rice plate and the medium sized bowl of fish soup on the table. Explain to participants, These pictures on the left represent approximately a non-pregnant woman with HIV should eat for each meal, three times a day. When they are pregnant, particularly in their second and third trimesters or breastfeeding they should eat this amount in one meal but at least four times per day. Some pregnant women may find it difficult to eat four meals in the third trimester because they are experiencing symptoms such as heartburn or nausea. Eating at least an extra two nutritious snacks in addition to the regular three meals is recommended. The food group requirements for pregnancy and breastfeeding are different and the amounts required will be discussed in a moment.

Generate a discussion based on the following questions:

  1. Do your HIV-positive pregnant and breastfeeding clients eat at least this amount in one meal? Why or why not?
  2. What can we do to meet the extra energy needs for pregnant and breastfeeding women with HIV? Ask participants to look at the table showing amount of extra foods needed in a day for them. The extra energy can be translated to same common snack foods or an additional meal during the day.

Examples of foods providing the extra 35% (~700calories) per day for your pregnant and breastfeeding women with HIV:

Food

  1. Banana (2 medium size)
  2. Mango (2 medium size)
  3. Jackfruit (2 cups sliced, ~300 grams)
  4. Pineapple (2 cups sliced, ~300 grams)

PLUS any one of these:

  • Mung bean porridge (~250grams/1cup)
  • Banana fritter (2 small size)
  • Boiled egg (3 large)
  • Soy milk (2 cups)
  • Spring roll (2 medium pieces)
  1. Roasted pumpkin seed (~150g)
  2. Dried cashew nut/peanut (~150g)
  3. 2 cups (250grams) rice + 16 tablespoons cooked fish + 1 cup cooked green vegetables plus add an extra 1 ½ tablespoons of oil while cooking to increase the energy content

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

c. Discussion translating calories into actual food intake for children living with HIV

Now, let’s discuss how much children living with HIV should eat every day.

Place the flipchart showing complementary feeding chart for children aged 6 to 24 months without HIV on the far left side of the table (page 11 of the BFCI flipchart). Ask participant to look at the picture.

Generate a discussion based on the following questions:

  1. What do you see in this flipchart? Do you give your child ‘enriched Bobor Khab Krup Kroeung’?
  2. Do you feed your child according this guide? Why or why not?

Then place the other flipchart showing recommended complementary feeding practice for children living with HIV next to the previous flipchart so that the participants can see the difference

Generate a discussion based on the following questions:

  1. Now, what do you see in this flipchart? What are the differences between two flipcharts?
  2. When you visit a household with a child 6-24 months living with HIV, how many times do caregivers feed food to him/her?

Explain that, Like adults, children living with HIV (but not sick) also need 10% more energy to fight the virus. They should receive at least one extra feed per day. It is especially important for children to meet additional energy needs to prevent weight loss and promote growth. If a child is sick, their energy needs are increased by 20-30%. However if a child with HIV is sick and losing weight, his/her energy needs are greatly increased by 50 up to 100% to recover and regain lost weight – this means the child needs to double the amount of foods that they eat (i.e. they should be fed twice as much compared to what a healthy baby without HIV should eat).

Ask participants to look at the table showing daily food guide for babies and children with HIV (6-24 months).

  • Note

    A meal is food that is eaten usually at a specific time, for example a breakfast in the morning. A meal is larger, more varied and more filling than a snack.

    A snack is very small meal eaten between main meals (e.g. fruits, steamed corn, boiled eggs, desserts like mung beans porridge etc.). Snacks are an addition to the main meals – they do not replace the main meals. Good snacks provide additional energy and nutrients.

    A nutritious drink is a liquid that provides additional nutrition and energy e.g. soya milk, fruit juice (not tea, soft drinks, alcohol or coffee). Water should also be consumed.

    In order to fight infections, the immune system needs more energy and nutrients. When HIV weakens the immune system, other infections start to arise, and fighting them also increases the needs for nutrients and energy.

Daily food guide for babies and children (6-24 months) withouth and with HIV

 Age

 Child without HIV

Healthy child with HIV
(10% more energy needed)

Child with HIV
who is sick
(20-30% more energy needed)

Child with HIV who is sick and losing weight
(50-100% more energy needed)

 Texture

 Drink (frequency/day)

6 month

Introduction of solid foods

2 times/day

2-3 tablespoons per feed

2 times/day of energy dense foods

2-3 tablespoons per feed

2 times/day of energy dense foods

2-3 tablespoons per feed

2 times/day of energy dense foods

3-4 tablespoons per feed

Thick enriched bobor/ well mashed foods e.g. mashed cooked banana, sweet potato, pumpkin etc

Continued frequent breastfeeds or any kind of milk at least 8x/day

7-8 months

3 meals of ½ chan chang koeh (bowl)

3 to 4 meals of ½ chan chang koeh (bowl) foods

5 to 6 meals of ½ chan chang koeh (bowl) foods

5 to 6 smaller frequent meals of ½ bowl food

Thick enriched bobor/ well mashed foods

Continued frequent breastfeeds at least 8x/day or 1-2 cups of any kind of milk

Adequate intake clean boiled water

9-11 months

3 meals of nearly full bowl foods

+ 1 snack between meals

4 meals of nearly full bowl foods

+ 1-2 snacks between meals

4 to 5 meals of nearly full bowl foods

+ 1-2 snacks between meals

5 to 6 meals of nearly full bowl foods

+ 2-3 snacks between meals

Thick enriched bobor/ mashed foods and foods that baby can pick up

Continued frequent breastfeeds at least 6x/day or 1-2 cups of any kind of milk

Adequate intake clean boiled water

12-24 months

3 meals of full bowl foods

+ 2 snack between meals

4 meals of full bowl foods

+ 2 snacks between meals

5 to 6 meals of full bowl foods

+ 2 snacks between meals

6 to 8 meals of full bowl foods

+ 2 snacks between meals

6 to 8 meals of full bowl foods

+ 2 snacks between meals

Continued breastfeeds on the demand at least 3x/day

or 1-2 cups of any kind of milk

Adequate intake clean boiled water

If baby is not breastfeed, give in addition 1-2 extra meals per day.
One bowl =250 ml

We will now learn more about healthy eating for children over 2 years old. Good nutrition during preschool age (2-5 years old) is important to a child’s future. This is the time when a child needs adequate food to grow and build his/her body, to give the child plenty of energy for play and to help fight infections. Children in this age group are always trying to do more for themselves and do things their way. They may refuse to eat certain foods (i.e. picky and choosy – only eat what they like) or refuse to eat at all, and may not eat enough. Mothers need to try and offer many different foods, not just comfort or simple foods from one group.

Most eating habits are learned in childhood. These habits affect food choices and health throughout life. Eat family meals together and give children mixture of foods from the three food groups. Where families eat from the same pot, it is a good idea to give young children their own plate or bowl so they receive their fair share of food. Many children living with HIV struggle to meet their increased needs so young children under 5 years of age are the most vulnerable to malnutrition. Caregivers of these children need to work on appropriate meal plan. Below is the daily food guide for children living with HIV 2-5 years of age.

Daily food guide for children aged 2-5 years old, withouth and with HIV

 Age

 Child without HIV

Healthy child with HIV

Child with HIV who is sick

Child with HIV who is sick
and losing weight

Additional energy needs

10% more energy to maintain growth

Plus extra ~150 cal/day (i.e. an extra snack/small meal/day)

20-30% more energy needed

Plus extra 300 -500 kcal/day (i.e. an extra full meal + extra snack /day)

50-100% more energy needed

Plus extra 600 – 1600 kcal/day
(i.e. extra two to four full meals)

Frequency & amount/day

3 meals and 2 snacks in between meals

3 meals and 3 snacks in between meals

4 main meals + 3 snacks in between meals

6 to 8 small energy dense meals/snacks

Note: Extra food needs for this group can be obtained by eating small frequent high energy meals. It is recommended to enrich the meals by adding ’enhancer foods’

Example of extra serve foods

Example of extra serve foods (~150 cal) include:

  • 1 cup soy/cows milk, 2 boiled eggs, 2 small fried bananas, 1 cup mango or 3 small bananas OR
  • ~ ¼ plate of rice/noodles (125grams) with ¼ cup (4 tablespoons) of cooked fish and vegetables.

Example of extra serve foods
(~300 -500 cal ) include:

An extra full meal (~400cal):

  • ¼ plate of rice (125grams) with 8 tablespoons of fish and 8 tablespoons mix of green vegetables and beans plus 1 small banana

An extra snack (~150 cal):

  • 1 cup soy milk, 2 boiled eggs, 2 small fried bananas, 1 cup mango or 3 small bananas

Increase the energy of meals/snacks by adding one of following high energy food s at each meal/snacks (~100cal):

  • 2 teaspoons oil
  • 4 teaspoons honey
  • 1.5 tablespoons sugar

Understanding these amounts will greatly aid you in your nutrition counseling sessions with your clients. It’s important to remember that with PLHIV there are no particular food groups that we need to promote − just increase proportionally the amount of food for all three group with foods that are available, affordable and able to be prepared by the PLHIV.

Conclude the step with the following questions:

  1. What are you thinking as you see these different proportion sizes?
  2. Do you see these different bowl and plate sizes in the community?
  3. With this information how can you advise PLHIV now about the amount of food and drinks they should be eating?

We will learn more about counseling using all of these tools later in the training.

  • Step 4: Participatory Lecture

Continue the session with discussion on other HIV’s effect on nutrition:

Reduced Food Intake

  • Note to Facilitator

    Invite participants to share knowledge and experience by giving examples of common symptoms experienced by PLHIV that impact on food intake and nutritional status.

    Answers might include:

    • Nausea/Vomiting
    • Diarrhea
    • Reduced appetite
    • Changes in taste
    • Dry mouth
    • Mouth sores
    • Pain with swallowing
    • Fatigue
    • Anemia

Explain that, Infections and illness lead to poor appetite, which leads to reduction in food intake. Painful sores in the mouth and/or throat can make eating difficult. Some medicines can reduce taste sensation or alter the taste of food, or cause nausea and vomiting as side effects. Reduced poor intake can also result from tiredness, depression and other psychological factors. Less quality and quantity of food in household due to insufficient money, inability to grow crops and/or difficulties in shopping and preparing food may lower food intake. In the late stages of the disease, PLHIV may find it difficult to take care of themselves and this may lead to reduced food intake.

Lower food absorption

Explain that, During digestion, the food we eat is broken down into small parts called nutrients. These nutrients are absorbed through the gut into the blood stream to be used by the body. The lining of the gut can be damaged due to HIV and other infections and this affects the ability of the gut to digest and absorb food. The gut is unable to take up nutrients from foods. Infections such as diarrhea can affect the gut and make the food pass too quickly, reducing the time for digestion and absorption.

Learning objective 2:

Participants will be able to describe the cycle of HIV, poor nutrition and infection

Methodology: Participatory Lecture and Game

  • Step 1: Participatory Lecture

The facilitator gives the following short lecture using a pre-prepared flipchart paper on the ‘Cycle of HIV Poor Nutrition and Infection’.

Explain, PLHIV, including children have a chronic illness that makes it difficult for their bodies to fight other illnesses. Their bodies’ immune systems do not function as well as those of people who do not have HIV. Because of this, PLHIV are prone to become sick often.

When people become sick, they often lose the desire to eat. They are not hungry and cannot eat the normal amount of food. Often, people lose weight

  • Note to Facilitator

    Highlights the inter-relationship between HIV and nutrition, and how both progressing HIV infection and declining nutritional status both lead to a progressive weakening of the immune system which increases the individual’s risk for other infections and illness.

    Potential questions are to ask the group to share their observations about people with advancing HIV disease and how they have seen this impact on their food access and intake.

when they are sick, or children stop growing well when they are sick, even to the point where they become malnourished. It is important to remember that children, pregnant and breastfeeding women need to continue to put on weight. No weight gain in these groups can mean they are malnourished. When people are malnourished, they are even more vulnerable to other infections and illnesses. This is the unhealthy cycle of malnutrition and illness. Pregnant and breastfeeding women and children under 5 years old are more at risk of malnutrition as they have increased nutritional needs.

  • Step 2: Game

Duration: 20 minutes

Instructions for activity:

The facilitator asks for five volunteers.

On five pieces of A4 paper, write the following phrases (1 phrase per A4 page).

  1. Get sick
  2. Not hungry, cannot eat
  3. Lose weight or poor growth (children)
  4. Malnutrition
  5. PLHIV

Tape each piece of paper to the chest of each of the five volunteers. Ask them stand in a line facing the rest of the participants.

Ask the group to read all the signs aloud.

Ask the group: What happens to a person’s appetite when they get sick? (Answer: they are not hungry, cannot eat).

Instruct the two volunteers with the signs “Get sick” and “Not hungry, cannot eat” to hold hands.

Ask the group: What happens to the body weight of a person who is not hungry and cannot eat? (Answer: they lose weight or have poor growth if they are a child).

Instruct the volunteer with the sign “Not hungry, cannot eat” to hold the hand of the person wearing the “Lose weight/poor growth (children)” sign.

Ask the group: What happens to a person who continues to lose weight or the child that continues to have poor growth? (Answer: they become malnourished).

Instruct the volunteer with the “Lose weight/poor growth (children)” sign to hold the hand of the person wearing the “Malnutrition” sign.

Ask the group: When people are malnourished, are they more likely to get sick or less likely to get sick? (Answer: malnourished people are more likely to get sick).

Instruct the volunteer with the “Malnutrition” sign to walk around the person wearing the “PLHIV” sign, and take the hand of the person wearing the “Get sick” sign.

The volunteers holding hands should now be in a circle with the “PLHIV” standing “trapped” in the middle of the circle.

Tell the volunteers holding hands that they should again read aloud what is written on their signs: “Get sick”, “Not hungry, cannot eat”, “and Lose weight/poor growth (children)”, “Malnutrition”.

Now ask participants: What do you think PLHIV need to do to get out of this dangerous circle?

Record each of the participants’ responses on a separate piece of A4 paper. Answers should include: Eat well, good food and drinks, ART drugs, treatment of OIs, regular check-ups with health clinic, small frequent meals, eating foods high in energy, drinking drinks with energy in them not just water etc. Select a few more volunteers and give each one of the A4 paper responses. Ask these additional volunteers to go to the front of the group and “help” the PLHIV out of the dangerous circle. Explain to the participants, The new volunteers represent the solutions to the malnutrition / illness circle problem such as “food” “medicine” “good body weight” etc. Encourage the new helping volunteers to pull the PLHIV out from the inside of the circle of illness and malnutrition.

Thank all of the volunteers for their help with the activity!

  • Step 3: Participatory Lecture

Now continue the session with the small lecture on ART and nutrition.

ART has a good impact on improving the nutritional status of PLHIV. ART can improve:

  • Growth rates (children)
  • Weight in PLHIV who are underweight (as long a adequate food is available)
  • Recovery from other illness and infections as the immune system becomes stronger

PLHIV can live healthier and longer lives and can keep working and have fewer OIs and other symptoms. The transmission of the HIV/AIDS virus to the baby can be greatly reduced if medicines are taken correctly in pregnancy and during breastfeeding. It is important for babies exposed to HIV to take any medicines as directed by the health staff to protect them from HIV and also other illnesses. For children with HIV, it is important for them to take medicines so they can be healthy (i.e. to ensure normal growth and development).

Despite the good things about ART, there are a number of interactions between ART and some foods. One hard part about taking ART is side effects. Sometimes at the beginning of ART, the side effects of the drugs can make a person feel worse than they did before taking ART. If a client is on ART, it is very important that they have enough to eat. Some ARV drugs should be taken with food, others should not and others have specific food restrictions. Good nutrition will improve the effect of ART helping the PLHIV recover their defense system and improving general well-being. Poor nutrition reduces the ability to absorb medication and the PLHIV may find it harder to cope with side effects. Some traditional therapies/herbs may also reduce the effectiveness of ARV drugs.

Negative cycle of malnutrition

We will look more at managing side effects in lesson 6.

Now refer participants to the Lesson 3 (participant manual). Continue the small lecture:
It is possible for PLHIV to break out of the negative cycle of malnutrition and illness. To do this they must continue to eat well and maintain a good body weight, so that they can better fight off infections and delay getting sick. This is the CIRCLE OF HEALTH that we can teach to PLHIV:

Refer to the lesson and ask the participants to read out loud one by one.

  1. Eat well this means at least 3 meals and 2 snacks every day with foods from all 3 food groups (pregnant and breastfeeding women need 4 meals). HIV increases the body’s need for food. When sick, more food is needed for recovery.
  2. Maintain a good body weight in the normal range of BMI or maintain good growth in children (i.e. above -2 z-scores). Eating well helps maintain weight/good growth (children) and increases strength.
  3. Better able to fight off infection a good body weight/good growth (children) and ART drugs will help the body to fight infection. Eating well will help the ART drugs to be more effective, and easier to take. Good health reduces the time and money spent on health care.
  4. Delay getting sick from AIDS Good nutrition and prompt treatment of Opportunistic Infections delay the onset of AIDS. PLHIV, including children who are not sick can have a good appetite, continue to eat well, and the CIRCLE OF HEALTH continues.

Circle of Health

Learning objective 3:

Participants will be able to discuss challenges to good nutrition

Methodology: Participatory Lecture and Small Group Work

  • Step 1: Participatory Lecture

The facilitator begins with a small lecture: Now that we know good nutrition is important for PLHIV, even if the person is not ill, because it can delay getting sick. However, sometimes there are some challenges to food security and good nutrition. Food security depends on the individual or family having physical and economic access to a safe, nutritious and reliable food source all year round. Inadequate food consumption may vary from a short term experience to a lifelong condition and may also be impacted by available skills in food preparation.

  • Step 2: Small Group Work

Duration: 20 minutes

Instructions for activity:

  • Divide participants into 3 groups and ask them to brainstorm challenges and potential solutions to good nutrition for the following target groups:
    • Group 1 (Mangoes) – PLHIV adults
    • Group 2 (Bananas) – Children living with HIV
    • Group 3 (Papayas) – Pregnant and breastfeeding women with HIV
  • Explain that each group should discuss the following questions:
  • What problems might keep PLHIV from eating enough food?
  • What problems might keep PLHIV from eating a variety of food?
  • How can they solve these problems?
  • Allow 10 minutes for each to discuss, write down on flipchart paper and ask each group to present back to group. Ask participants to divide the flipchart paper as follows.

Problems

Solutions

Facilitator can walk around to each group and provide prompts for issues/reasons if they are stuck.

Some issues that could come up are lack of food, illness and related symptoms, lack of money, no one to help buy and prepare meals, lack of time to prepare food, lack of support, inadequate information, healthy foods not in season, food taboos/beliefs and other causes of food avoidance, stigma, loneliness during meals, lack of cooking facilities and/or cooking fuel etc. One of the most common problems that PLHIV face is not having enough food to eat or not having different kind of foods to eat. PLHIV may have little income and a large family or they may not be able to work or feel like preparing food because of illness or other reasons like weather. Often what little income the family has will go to medicines or health care which leaves very little money for food.

There are many ways that we can help PLHIV to make sure that they have enough food at different times. Below are some ways to help get food to PLHIV and their families:

  • Encourage households to improve food security by growing a variety of foods, raising animals like chickens, pigs or gathering foods like water cress, ivy leaves, frogs, crabs, shrimp, small fish, snails from rice fields etc.
  • Purchase local and seasonal fruits and vegetables and other foods from the markets – these are cheaper and have more nutrition than packaged foods from stores.
  • Help households reallocate their food expenditure so they can increase purchase of nutritious foods.
  • Encourage PLHIV to start income generating activities or save a small amount of money for food for times when they will not able to work and this might help ensure they have enough food.
  • Link them with any local food and nutrition programs that can help PLHIV and their families with their food needs.
  • Provide easy pictorial recipes for food preparation to increase skills and knowledge.

Summarize this section by saying As a counselor, you have an important role to play in helping clients and their families meet their nutritional needs. Encourage PLHIV to make small steps towards good nutrition.

Learning objective 4:

Participants will be able to describe seven ways to gain or maintain weight/good growth (children).

Methodology: Participatory Lecture, Brainstorming, Group Discussion

  • Step 1: Participatory Lecture
  • Note to Facilitator

    Prior to giving the short lecture, the facilitator can post the pre-prepared flipchart paper on the “Cycle of HIV Poor Nutrition and Infection”.

The facilitator begins with a small lecture:

You can help PLHIV find ways to gain weight or to maintain a good body weight. Most PLHIV know from their monthly OI/ART clinic visits if they are losing weight or not growing well. For children, losing weight or not gaining weight is a sign that the child is in poor health. The Yellow Child Health Card is a tool that helps track the growth of the child over time and so children should be measured regularly. Mother Support Group (MSG) volunteers or HC staff (midwives) often measure and weigh babies. They then record the measurements and plot them on the chart. Later in this training, we will learn how to tell if a person’s body weight is in the normal, healthy range for his or her height.

  • Step 2: Brainstorming

Duration: 10 minutes

Instructions for activity:

The facilitator asks the participants to recap on the inter-relationship between HIV and nutrition.

The facilitator then asks the participants to discuss “What factors contribute to poor nutritional status in PLHIV?”

Key information on contributing factors to poor nutrition:

  • It is not always a single factor that causes weight loss and malnutrition (poor nutrition) in PLHIV. Many factors can contribute to poor nutritional status in PLHIV. Some of these are not a direct effect of HIV infection e.g. poverty and cultural beliefs about food. Examples of contributing factors to poor nutrition:
  • Social and cultural factors – include stigma and discrimination of PLHIV, an individual’s ability to earn income, access to health care, and gender inequality.
  • Food availability and access – refers to access to food through local markets, what foods are available during certain times of the year, food prices, and food quality.
  • Household Income and Food Insecurity – households often affected by HIV are more at risk of food insecurity. HIV often infects the most productive members of a household reducing the potential income available to the family.
  • Personal beliefs – includes nutritional attitudes and beliefs, information received from often unreliable sources such as peers, family, media, companies. At an individual level this includes issues such as depression and anxiety. This also includes attitudes towards behaviors such as using “herbal remedies” and “nutritional supplements’.
  • Metabolic changes – HIV infection affects the ability of the body to absorb food and lowers food intake, while increasing nutritional needs. Poor nutrition (malnutrition) happens when the body does not have enough of the required nutrients.
  • Medication – For the ART to work well a regular food supply is needed, as well as good nutrition and continuous support to ensure healthy eating.
  • Gastrointestinal problems – HIV and other infections can affect the ability of gut to digest and absorb food (malabsorption). The malabsorption results in diarrhea, leading to loss of water and nutrients.
  • Step 3: Participatory Lecture

Continue with the short lecture. Explain that, Weight loss can be the result of illness or poor appetite. When a person is sick and has poor appetite, food intake is reduced because he/she does not eat enough food, or the food eaten is poorly absorbed. As a result, the body draws on its reserve stores of energy from body fat and protein from muscle. The person loses weight because body weight and muscles are lost. Infections can increase a person’s need for food so even if you have not changed the amount you eat you may lose weight.

HIV positive infants and children have special nutritional challenges, including poor growth or growth faltering, moderate or severe under nutrition, feeding difficulties, and frequent opportunistic infections. In addition, many signs and symptoms in HIV positive children also overlap with those of other common childhood diseases. Growth is an optimal nutrition indicator in infants and children. Abnormalities in growth are common in HIV positive children. Growth abnormalities can occur throughout the course of HIV infection.

  • Note to Facilitator

    It is not always a single factor that causes weight loss and malnutrition (poor nutrition) in PLHIV. Many factors can contribute to poor nutritional status in PLHIV. Some of these are not a direct effect of HIV infection e.g. poverty and cultural beliefs about food.

HIV-positive children face a number of problems with nutrition implications which contribute to growth failure, such as:

  • Inadequate food intake because of socioeconomic factors: food insecurity, symptoms e.g. diarrhea, poor appetite, mouth ulcers or oral thrush
  • Increased nutrient losses due to inability to process food (malabsorption), diarrhea, vomiting
  • Increased nutrient needs because of HIV itself
  • Feeding difficulties
  • Other socioeconomic factors e.g. illnesses of parents or carer, poverty.

Two characteristics of growth failure:

  • Weight is not increasing; or
  • Weight is increasing but the growth line is rising slower than the standard curve for
    • >1 month in babies aged less than 4 months
    • or >2 months in older children

In pregnancy, energy and nutrients needs increase for adequate gestational weight gain and fetal growth and development. Women need to eat more food to provide enough energy for the baby to grow, particularly in the later stages of pregnancy. HIV positive pregnant women are at risk of becoming malnourished.

For every patient that you visit, ask yourself:

  • Is this person losing weight?
  • Is this person underweight (low BMI or under -2 z-scores)?
  • If a child, is the child not growing well (losing weight or not gaining weight for some time)?
  • If a pregnant woman, has the pregnant woman not had any weight gain in the second and third trimester?

If the answer to any of these questions is YES, we must counsel PLHIV on ways to gain weight. And even if they are not losing weight, we must counsel them on how to maintain their body weight. There are seven main ways to gain and maintain weight.

Seven Ways to Gain or Maintain Weight/Good Growth

  1. Eat more meals – aim for three meals a day (4 meals if pregnant/breastfeeding).
  2. Eat more food at each meal from the 3 food groups.
  3. Eat snacks and desserts after and between meals – at least two times a day.
  4. Improve the quality of your food with “enhancers” (by adding coconut, peanuts, oil, soya beans, condensed milk to foods, or by thickening watery soups etc.).
  5. Have drinks with energy in them (e.g. juice, soy milk etc) rather than just water, coffee or tea for all drinks
  6. If an infant or young child, increase the frequency of milk feeds (breast milk or safely and appropriately prepared infant formula).
  7. Have infections and illnesses treated quickly and properly, and increase food intake after illness until the weight lost during illness is regained.

Explain to participants, It is important to note, as with other illnesses, when a child with HIV experiences diarrhea, fever, mouth thrush or other infections, their appetite declines while their nutritional needs increase. This can result in weight loss and poor growth. It is, therefore, important for children to maintain their food intake as much as possible during illness and to increase food in the recovery period. Give the child additional meals/snacks (or offer foods very frequently, always have food around the child in case they feel like eating) after the child has recovered. This will help him/her regain weight loss during the illness. If the child is breastfed, increase the number of times each day the breast is offered and offer both sides for each feed.

Write the seven ways to gain weight on the big paper and use the corresponding Positive Living Cards (numbers 8, 11 and 13) to help explain some of the ways to gain weight. For number 4, and 5 show the purple “enhancer” and the blue cards, respectively from the Toolkit.

  • Step 4: Group Discussion

Use the following questions to get participants to discuss each of the seven ways to gain weight:

  1. How many meals do the PLHIV that you work with normally eat? How could they add another meal to their daily routine to make it three meals a day or four meals a day if pregnant and breastfeeding?
  2. Is it easy or difficult for PLHIV to eat more food at each meal? Why do you think it is easy or difficult?
  3. What kinds of healthy dessert do people commonly eat in your area? (Show examples of nutritious dessert from the Cooking Demonstration Manual)
  4. What kinds of snacks are commonly available to people in your area that we can promote with PLHIV? [Answers to be included if not already mentioned: different fruit like bananas and papaya (grilled banana, steamed banana etc.), vegetables like steamed corn, and others like boiled eggs, mung beans in coconut milk and soy milk].
  5. How many snacks do most people eat in one day? Can we encourage them to eat at least two?
  6. Some common ingredients like coconut milk, oil, peanuts and fermented soya beans can be added to soups to make them more nutritious – this is what is meant by “enhancers.” Show the purple “enhancer” cards from the Toolkit again. What are some common recipes that we can use with these “enhancer” ingredients?
  7. Another way to make soups more nutritious is to make them less watery – How can we make soup more thick? (Show the pictures from the Toolkit of the different consistencies of soups). Are there other ways we can thicken soup?
  8. What healthy drinks that have energy in them could PLHIV drink?
  9. When should a PLHIV seek medical care? What are some common signs of illness and even malnutrition that indicate when a PLHIV should seek medical care? What is the most appropriate place we should advise them to go for medical care?
  10. Do you notice during illness that you lose weight? Why do you think that is? (Answer: body needs more energy to fight the illness). Because of the weight loss, the body is then more vulnerable to getting sick again. How can PLHIV break this cycle? (Answer: Focus on regaining the weight after illness and maintaining the weight).
  11. If you needed to gain weight, which of these seven strategies would you want to try first? Why would you choose that strategy?
  12. What about foods and drinks for pregnant and breastfeeding women – how could these be improved? Are there any food taboos that need to be considered?

Refer participants to Lesson 3 (participant manual). Ask them to read aloud together the seven ways to gain weight.

Learning objective 5:

Participants will be able to identify incorrect myths about food and provide the correct information to counter those myths

Methodology: Participatory Lecture, Questions and Answers, Group Discussion

  • Step 1: Participatory Lecture

The facilitator begins with a small lecture:

Did you ever receive advice from someone, and then later find out that the advice was not correct? Think about times that this has happened to you. Can someone share an experience or a story about a time that you received advice/information and then later found out that it was not correct?

Give participants a few minutes to think and share one or two stories. Encourage participants to also think of examples of incorrect myths about food and food taboos related to children, pregnant and breastfeeding women, sick individuals and PLHIV. The facilitator may think of his/her own story in advance to share with participants. Continue the lecture:

Sometimes we receive wrong information. Even the information that we receive from important people can sometimes be wrong. Many people in Cambodia receive advice about food – grandmothers, neighbors, and even some doctors have advice about food. Often the advice is good, but sometimes it is not correct. Today we will learn about some of the incorrect advice that people give about nutrition for PLHIV, and we will learn what is really correct.

  • Step 2: Questions and Answers

Use the following questions to stimulate discussion. After the participants respond, ask them where they heard the information and what was the basis for this information? After discussing each question, provide correct information.

1. Did you ever hear that PLHIV/recently delivered and breastfeeding women should avoid uncooked vegetables?

Correct information:

Uncooked vegetables are good for health, but they have to be cleaned very well before eating. Some fresh vegetables can have small pieces of dirt or animal feces on them. If someone eats the dirt or feces they can become sick. But the sickness is not caused by the fresh vegetable; it is caused by the bacteria in the dirt.

Fresh vegetables have vitamins and minerals that protect health. PLHIV and recently delivered and breastfeeding women can eat fresh vegetables but they must be sure to wash them very well with boiled/cooled water before eating.

2. Did you ever hear that PLHIV should not eat seafood?

Correct information:

Seafood is an important source of protein (body-building food) for many people, especially those living near the sea. Some people are allergic to seafood, and eating it can cause a rash on the skin. But this allergy is not related to having HIV. In other words, if a person was allergic to seafood before they contracted HIV, then they are probably still allergic and they should avoid seafood. If a person was not allergic to seafood before they contracted HIV, then they can continue to eat seafood with no problems.

Seafood should always be cooked very well before eating and be fresh.

Note on mercury in fish

Fish can be regular part of healthy eating plan but pregnant and breastfeeding women and young children should choose wisely. Mercury from fish is generally not a health consideration for most people however some fish and shellfish contain higher levels of mercury that may harm unborn baby or young child’s developing nervous system. Large fish that live a long time and eat other fish such as shark, swordfish, king mackerel and tilefish can contain higher levels of mercury. Women who might become pregnant, women who are pregnant or are breastfeeding and young children should avoid or rarely eat fish that are high in mercury. If they do eat a small portion of this fish (~100g), they should not eat any other fish during the same week.

3. Did you ever hear that PLHIV should not eat fermented or sour foods?

Correct information:

Fermented and sour foods can be eaten by PLHIV. In fact, sometimes fermentation increases the nutritional value of a food.

If a food causes someone to have diarrhea or an upset stomach, that person should avoid that kind of food. But other people should not be encouraged to avoid the food because of another person’s experience. If a person can tolerate and enjoy the fermented or sour foods, there is no reason to avoid them.

4. Did you ever hear that people with HIV should not eat chili or spicy food?

Correct information:

Spicy foods can irritate the stomach, and therefore can cause diarrhea or heartburn. People who suffer from mouth sores (thrush), stomach problems or diarrhea due to infection should avoid spicy food and chili. However, people who are healthy and do not experience these problems can still enjoy chili or moderately spicy food as long as it does not upset their stomachs. If spicy foods begin to cause stomach problems, they should be avoided.

Spices can make food more enjoyable for some people, and therefore they will be able to eat more. Every person must decide individually how much chili he/she is able to eat and remain well.

Spices can make food more appetizing by adding more flavor – there are alternatives to using chili. Other spices to consider are lemon grass, ginger, coriander leaves, spring onions and garlic.

5. Did you ever hear that PLHIV should reduce their consumption of fatty or fried foods?

Correct information:

Most PLHIV in Cambodia are underweight or at risk of malnutrition. Oil and fat are an important source of energy, and the foods that are normally fried (fish, chicken, pork, frog, etc.) are an important source of protein and should be encouraged. Fruit battered and fried such as banana is also good source of energy and make good snacks.

People with moderate to severe diarrhea can benefit from temporarily avoiding fatty or fried foods, but when the diarrhea ends, the person can start eating these foods again.

For PLHIV with no diarrhea and who are underweight, eating more fried foods can be a good way to gain weight.

For PLHIV who are overweight, eating less fatty or fried foods may help those wanting to lose weight.

6. Did you ever hear that eating chicken or beef will prevent an open wound from healing?

Correct information:

As we learned in Lesson 2, chicken and beef are part of the “Body-building” group of foods. The body uses these foods to build and repair tissues like skin and muscle. So in truth, the body building foods (including eggs, fish, chicken, pork, beef, frog, duck and beans) are very beneficial for a person with open wounds.

If a wound does not heal it is normally because it has become infected with bacteria. If PLHIV have an open wound that will not heal or becomes infected, they should seek medical treatment immediately.

7. Did you ever hear that PLHIV should not eat certain sweet foods (mango, longanberry, sticky rice) because they can cause fever?

Correct information:

Sweet foods can be eaten by PLHIV. Eating sweet fruit and sweets (desserts) in fact can help add energy (and also weight), so it is especially important for PLHIV who are losing weight. Sticky rice and ripe mango are great for a high energy snack/dessert. Eating fruit after meals should be also encouraged.

8. Did you ever hear that a pregnant woman should avoid eating more food because it can make her baby much bigger that leads to a difficult delivery?

Correct information:

Pregnant women need to eat more food because they need extra energy for the growth of the baby and to be able to produce enough milk after delivery. The energy needs increase especially for the second and third trimester of pregnancy, which equates to about two boiled eggs and one large banana.

For pregnant women with HIV, the energy needs are greatly increased because they need extra energy for the baby’s growth and breast milk production as well as for fighting the virus. This extra energy can be achieved by eating an extra meal daily or eat more frequently throughout the day (i.e. every 2 to 4 hours).

Expectant mother needs to eat sufficient food to stay healthy and strong. Women who do not gain enough weight during pregnancy have a risk of preterm birth.

9. Did you ever hear that post-partum women are recommended to drink plenty of wine to help fast recovery from labor and the birth?

Correct information:

It is not true that wine (alcohol) will support fast recovery after giving birth. It took the body months to prepare to give birth and it takes time to recover. New mothers should take special care of their bodies.

Mothers need to eat well and drink plenty of fluids to have adequate milk for their babies. Alcohol should be avoided during breastfeeding, particularly in the first month when it is important to establish breastfeeding patterns for the baby. If a mother drinks alcohol, alcohol will get into her breast milk from her blood, moving freely from the blood to the breast milk (and back out again). How much alcohol gets into the breast milk depends on the strength and amount of alcohol in the drink.

Adequate rest and eating well is required for the mothers to recover quickly. Mothers need to eat extra for herself and to make breast milk for the baby also. Doing so will help the mothers to regain energy and strength. Healthy mothers can produce better quality and quantity of milk.

10. Did you ever hear that breastfeeding women should not eat sour soup, fish, pickle and uncooked vegetables?

Correct information:

A healthy diet is always important for everyone, but it is especially important for the nursing mothers. Breastfeeding uses a lot of energy and nutrients so it is important that the mothers need to eat a wide variety of foods to supply nutrients for their health and wellbeing. Breastfeeding women should not be afraid of eating certain fruits, vegetables, pickles and meats as long as they are prepared hygienically.

There is little evidence that certain foods cause diarrhea for the mother or upset babies and give them diarrhea. It is important for breastfeeding women to eat locally available energy giving, protein (body building food), fruit and vegetables (protective food), foods rich in calcium (e.g. milk or soy milk) and iron (e.g. meat, green leafy vegetables etc). They also need to drink plenty of fluids such as water. All fluids count but water is the best source of fluid.

11. Did you ever hear that sick children should avoid certain fruits (guava, watermelon, longanberry, young mango), soup with meats or fish?

Correct information:

As we learnt earlier in this lesson, children often lose weight or stop growing well when they are sick. When a child is sick, he/she needs more food than usual so it is important to continue feeding to maintain the child’s strength and appetite during illness.

Chicken, duck, frog, eggs, crab, pork or fish are part of the “Body-building” group of foods. These foods are important for a sick child because they provide protein for good growth and recovery from illness. Rice soup or porridge is good for sick children but mothers should add fish or egg to it as well. Different vegetables and fruits such as pumpkin, yellow sweet potato, ripe papaya, and ripe mango give a lot of vitamins that help children get better faster.

It is not true that a sick child with diarrhea or vomiting should not eat because foods will irritate the child’s stomach and worsen diarrhea or vomiting. It is better for him/her to keep eating. The child will often want to breastfeed more frequently. It is good to give the child more breast milk. This will help the baby to fight sickness, recover quickly and not lose weight.

Ask:

  • Does anyone have questions about what we have discussed?
  • Are there other food myths that you have heard that you want to discuss?
  • How do you overcome these myths, particularly if they are from family members or other health professionals e.g. doctors, grandparents?
  • Step 3: Group Discussion

Duration: 10 minutes

  • Note to facilitator

    If the participants ask about a particular food myth that you do not know the answer to, or even the complete answer, tell the participants you will ask someone and get the correct information to them as soon as possible. Do not give out incorrect information – this only encourages more food myths.

Instructions for activity:

Divide the participants into 3 groups.

Encourage participants to think of examples incorrect myths about food and food taboos related to children living with HIV, HIV-positive pregnant and breastfeeding women and adult PLHIV who are sick.

Let each group share their experiences or one or two stories.

Summary

Ask participants to look at the “Lesson 3” (participant manual). Ask them to take turns reading the lesson aloud to the group. If there is not enough time to read the it aloud, ask the participants to review and study the it in their free time later that day.

Explain that, We will assess what you have learned with a short quiz.

Pass out the quiz to the participants and allow them 5 – 10 minutes to answer the questions. After the quiz, review the questions out loud, asking for volunteers to give their answers, and clarify any questions the participants may have.

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