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LESSON 5 HOW TO USE THE “GOOD FOOD TOOLKIT” (Participant EN)

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FIVE STEPS FOR NUTRITION COUNSELLING

  1. Assess – review the health of the client and their dietary habits
  2. Analyze – based on the assessment, determine the problem areas and appropriate solutions (e.g. behavior change or referral)
  3. Suggest – provide a few options/solutions to the client
  4. Negotiate – negotiate ways for the client to overcome barriers to adopt the selected solutions and make a plan of action
  5. Follow-up – revisit the client to determine if the behavior was adopted and further assist the client in maintaining the solutions

USING THE FOOD CARDS

  • What do the colors on the small food cards mean?
  • RED – Body Building Foods
  • GREEN – Vegetables, which are Protective Foods
  • YELLOW – Fruits, which are also Protective Foods
  • WHITE – Energy Foods
  • PURPLE – Purple cards are not a food group; they include “enhancer” foods that can increase the calories and/or the nutritional value of soups and other foods. “Enhancers” are coconut, coconut milk, oil, nuts, condensed milk, fermented soy beans and beans.
  • BLUE – Examples of nutritious fluids that PLHIV can be encouraged to drink so that they consume 2 liters of fluids every day.

HOW TO USE THE SMALL CARDS:

  1. Put all of the cards on the table in front of the client with pictures of the foods/drinks facing up so they can be seen.
  2. Ask the client to collect the cards showing the foods and drinks that are available around their home. Take away the cards that were not selected. Then ask the client to take out any foods that are not affordable for his/her family to buy at the current time of the year. Remove those cards also from the table. Available and affordable mean that the family can have these foods almost every day of the week if they want them.
  3. Check to see if all of the color groups are represented: RED, GREEN, YELLOW, WHITE, PURPLE, and BLUE.
  4. If all the colors are not represented, work with the client to identify some of the foods in the missing color group that are available and affordable sometimes (once a week, or once every 2 weeks). Add those cards to the group of selected small cards. Perhaps these are foods that the person could grow or trade with someone else to get those things.

HOW TO USE THE LARGE FOOD CARDS:

  1. Now take out the rice plates (life size cards). Put all 5 cards in front of the client and ask them to show you the amount of rice that they normally eat in a meal.
  2. Then take out the soup plates. Put the soup cards in front of the client and ask them to show you the type of soup that they normally eat in a meal.
  3. After the first visit using the Nutrition Tool Kit, the HBCT/counselor can ask the client to identify those foods that they identified before but are not now available / affordable or put back any food cards that are now available and affordable.
  4. At this point the HBCT/counselor has enough information available to analyze the diet of the client and negotiate some improvements.

FILLING OUT THE TOOLKIT MONITORING FORMS

There are three different monitoring forms to record nutritional related changes for:

  1. Adults (both gender) and over 6 months post partum women;
  2. Adults pregnant and post-partum within 6 months after delivery; and
  3. Children and adolescents aged 0-19 years of age

1. ADULTS (BOTH GENDER) AND OVER 6 MONTHS POST PARTUM WOMEN (COMMUNITY-BASED)

GENERAL INFORMATION

1.Date of visit: The date that the counseling is conducted.

2. Name of client: The name of the PLHIV being visited.

3. Age: The age of the PLHIV being visited in years

4. Gender: Record the PLHIV’s sex by ticking the appropriate box. If a female, please indicate if the PLHIV being pregnant or breastfeeding

5. Address: Address of the client.

STEP 1 & 2: ASSESS AND ANALYZE

6. Problem told by client: This is an open ended question. Ask the client if they are having problems. Record the types of problems, side-effects, or symptoms the client is experiencing.

7. ARV and OI medication (a, b, c): Tick yes or no. For completion of this question, the counselor does not need to see or record the type of medication that the person is taking. However, the HBCT members should record if they saw the type of medication as part of the Home Visit documenting this on the other records they use to document ART Adherence.

       8.    a. Client’s most recent weight: Insert the client’s weight in kilograms.

b. Client’s height – measured or reported: Insert the height of the client in centimeters. Insert height in meters if you calculate BMI using the formula.

c. Client’s BMI found: The BMI of the PLHIV can be calculated if both height and weight are available. BMI can be calculated by using the formula (kg/m2) or by using the BMI table. We learned to calculate BMI in Lesson 4.
Only NGO staff and/or HCstaff calculate BMI using the formula. Trained HBCT are recommended to use BMI table.

9. Nutritional status:

 Underweight/malnourished, BMI <18.50

Normal, BMI 18.50 – 24.99

Overweight, BMI ≥25.00

This step helps the counselor to analyze the situation and to determine the problem areas. There are two indicators used to assess the client’s nutritional status. Use the information from Question number 8 to tick the appropriate box.

Is the BMI less than 18.5? If so, this is the first sign that the person needs to gain weight. The client is considered malnourished. Besides providing nutrition counseling, this client needs to be referred to the HC and/or OI/ART clinic.

10.   a. What does the client eat typically each day? Put a tick in the appropriate box to indicate which foods the client eats at breakfast, lunch, dinner and dessert/snacks/drinks

b. Number of meals consumed per day: Ask the client to describe what he/she typically eats in a normal day, “How many meals do you usually eat?” Put tick in the appropriate box.

c. Number of snacks consumed per day: Ask the client “How many times do you usually eat a snack/desert per day?” Put tick in the appropriate box.

d. Number of liquids drank per day: Ask the client “How many glasses of water or other fluids do you usually drink a day?” Show the client the photo of the drinking glasses and ask the client which glass is the same size as the one that they drink from. Ask the client how many glasses he/she usually drinks including medicinal teas, any time of day, with or without meals and medicine. Put a tick in the appropriate box. So if the client drinks a blue glass of water eight times during the day, then tick the ≥ 2 litters box. Record also numbers of cups of water drank per day.

11.  Diet is:  Poor  Fair  Good
This step helps the counselor to analyze the situation and to determine the problem areas. Use the information from Question number 10 to complete this box. There are two indicators to assess the client’s dietary frequency and quality (i.e. the number of meals and snacks consumed per day and food diversity).

Tick “Poor” if the client usually eats 1 meal or less, no snacks and less than 1 liter of liquids per day and/or they only eat foods from one or two food groups each day.

Tick “Fair” if the client usually eats 2 meals, 1 snack and 1 liter of liquid each day, and eats from the 3 food groups each day.

Tick “Good” if the client usually eats at least 3 meals with two snacks every day, drinks at least 2 liters of liquid and they consume a variety of foods from the three food groups – Energy group (white), Body building group (red), and Protective group (yellow/green).

STEP 3 & 4: SUGGEST AND NEGOTIATE

12. Key suggestions provided by the counselor
Based on the assessment (Step 1) and analysis (Step 2), determine what are the problem areas regarding health/nutritional status and provide a few solutions to the client. Recommend and negotiate do-able actions for the client to adopt the selected behaviors/solutions and make a plan of action.

It is important that the recommendations need to be feasible, shaped to fit the client’s means and abilities. We will not be able to solve all of the problems in one nutrition counseling session.

Select the appropriate card or cards to use during the counseling session, depending on the identified problem and the target group. Look at the Card Selection Table to guide which card or cards should be used.

Help the client select one or two practices that are feasible for their situation that they agree to practice.

Tick appropriate boxes, based on the agreed do-able action/s discussed with the client. Have the client repeat what they are going to try to do and make sure that it is clear and answer any questions.

STEP 5: FOLLOW UP

13. Monitoring and Follow Up
Every month  Every 3 months  Every 6 months
Determine the frequency of the monitoring and follow up.

Key times that an adult PLHIV should have a nutrition assessment and counseling:

  • Initial visit
  • Depending on stage of HIV infection:
    • Asymptomatic (without any symptoms): every 6 months
    • Symptomatic: every month or 3 months
  • When initiating or changing ART

Make an appointment to follow up with the client on agreed actions.

2.1 ADULTS PREGNANT AND POST-PARTUM WITHIN 6 MONTHS AFTER DELIVERY (COMMUNITY-BASED)

The community-based monitoring form for this target group is the same to that of the first target group (adults of both gender), except some questions explained here (question 8-9).

8. Client’s MUAC:
Read the MUAC in cm and document in the space provided.

9. Nutritional status:
 Underweight/malnourished, MUAC ≥ 23 cm
 Normal, MUAC < 23 cm

BMI cannot be used for a pregnant woman because a pregnant woman’s weight will be related to the growth of the baby and changes in the body related to pregnancy. MUAC is recommended for pregnant women and up to 6 months post-partum. Use the information from Question number 9 to tick the appropriate box.

Is the MUAC less than 23cm? If so, the client is considered malnourished. Besides providing nutrition counseling, this client needs to be referred to the Health Centre.

2.2 ADULTS PREGNANT AND POST-PARTUM WITHIN 6 MONTHS AFTER DELIVERY (FACILITY-BASED)

For facility-based monitoring form, there are some additional questions:

8. c. If pregnant, what was the pre-pregnancy weight?
How much weight did the client gain to date?

Insert the pre-pregnancy weight in kilograms. Subtract the pre-pregnancy weight in kilograms from the current weight of the client to determine the weight gain so far of the pregnant women. If the woman is not pregnant then write n/a (not applicable) in this section.

3. CHILDREN AND ADOLESCENTS AGED 0-19 YEARS OF AGE

GENERAL INFORMATION

1. Date of visit: The date that the counseling is conducted.

2. Name of child, gender and age: Fill in the name of the child being visited, gender and age.

3. Name and relationship of parent/carer and address: Record the name and the relationship of parent/carer e.g. mother, father, grandmother/father etc.

4. Address: Address of the client.

5. HIV status: Record the HIV status of the child and tick appropriate box, and include the date of the last medical check-up.

STEP 1 & 2: ASSESS AND ANALYZE

6. Child’s problem told by parent/carer: This is an open ended question. Ask the parent/carer if the child is having problems. Record the types of problems, side-effects, or symptoms the child is experiencing. Depending on the child’s age, the question may be asked directly to the child.

7. ARV and OI medication (a, b, c): Tick yes or no. For completion of this question, the counselor does not need to see or record the type of medication that the person is taking. However, the HBCT members should record if they saw the type of medication as part of the Home Visit documenting this on the other records they use to document ART Adherence.

8. For children aged 0-6 months of age:
Tick yes or no for the presence of edema. If there is a presence of bilateral pitting edema then the child is severely malnourished and should be referred to the health centre.

For children aged 6-59 months:
Measure the MUAC which is taken on the left arm using a MUAC tape measure. Read the MUAC in cm.

Is the MUAC less than 11.5cm? If so, the client is at risk of malnutrition or malnourished.

Classification

MUAC

Normal/growing well

>12.5

Moderately malnourished

≤12.5 – ≥11.5cm

Severely malnourished

< 11.5cm

For children and adolescents aged 5-19 years
Calculate the child’s BMI using the FANTA BMI Look-up Table for Children and calculate the child’s BMI-for-age using the WHO BMI for Age Table. This table is different than the BMI table for adults.

Classification

BMI-for-age

Normal/growing well

≥ -2SD

Moderately malnourished

Between -3 and -2SD

Severely malnourished

≤ -3SD

9. Nutritional status
Use information from question 8 to tick an appropriate box. If there is a presence of bilateral pitting edema then the child is severely malnourished and should be referred to the health centre.

10. What does the child eat/drink typically each day? Put a tick in the appropriate box.

For children aged 0-6 months of age
Exclusively breastfed or replacement feeding? If the child is cup fed, is the formula prepared correctly? Hygienically? In this box tick yes or no for each question, based on the feeding being provided to the child aged under 6 months.

For children aged 6-59 months or children and adolescents aged 5-19 years

What does the child eat typically each day? Put a tick in the appropriate box to indicate which foods the child eats at breakfast, lunch, dinner and snacks/drinks.

Number of meals consumed per day: Ask the parent/carer to describe what the child typically eats in a normal day. Put tick in the appropriate box.

Number of snacks consumed per day: Record how many snacks consumed per day. Put tick in the appropriate box.

Number of liquids (other than water) and cups of water drank per day:  Ask the parent/carer “How many glasses of liquids other than water does the child usually drink a day?” Show the parent/carer the photo of the drinking glasses and ask which glass is the same size as the one that the child drinks from. Put tick in the appropriate box. So if the child drinks a blue glass of water four times during the day, then tick the 1 liter box.
Record also numbers of cups of water drank per day.
If the child is aged 6-59 months: specify the liquid (milk, infant formula) and quantity in cups.

11. Dietary intake analysis

Diet of child aged 0-6 months of age:  Poor  Good
This step helps the counselor to analyze the situation and to determine the problem areas. Use the information from the Dietary intake questions to complete this box.

Tick “Poor” if the client is not being exclusively breastfed or the replacement feeding is deemed unsafe.

Tick “Good” if the client is exclusively breastfed or has safe replacement feeding.

Diet of child aged 6-59 months:  Poor  Fair  Good
This step helps the counselor to analyze the situation and to determine the problem areas. Use the information from the Dietary intake questions to complete this box. There are two indicators to assess the client’s dietary frequency and quality (i.e. the number of meals and snacks consumed per day and food diversity)

Tick “Poor” if the client usually eats less than 2 meals and snacks per day and/or they only have one food group and 0-1 cups of milk per day and no breastfeeding.

Tick “Fair” if the client usually eats 2 meals, 1-2 snacks and 1-2 cups of liquid, and eats from 1-2 food groups each day.

Tick “Good” if the client usually eats at least 3 meals with two snacks every day and consumes a variety of foods from the three food groups, and at least 2 cups of milk per day if no breastfeeding.

Diet of child or adolescent aged 5-19 years:  Poor  Fair  Good
This step helps the counselor to analyze the situation and to determine the problem areas. Use the information from the Dietary intake questions to complete this box. There are two indicators to assess the client’s dietary frequency and quality (i.e. the number of meals and snacks consumed per day and food diversity)

Tick “Poor” if the client usually eats 1 meal or less and no snack, and less than one liter of liquid per day, and eats from 1-2 food groups per day.

Tick “Fair” if the client usually eats 2 meals, 1 snack and 1 liter of liquid each day, and eats from 3 food groups each day.

Tick “Good” if the client usually eats at least 3 meals with two snacks and consumes a variety of foods from the three food groups, and 2 liters of milk per day.

Note: For the rest of the questions of this monitoring form (question 12 and 13) of step 3, 4, and 5, please follow instruction of the form for adults (community-based).

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