session 7: integrating nutrition assessment, counselling, and education into hiv and aids care

Session 7:Session 7:Integrating Nutrition Assessment, Integrating Nutrition Assessment, Counselling, and Education into HIV Counselling, and Education into HIV and AIDS Careand AIDS Care Nutrition Management with HIV and AIDS: Practical Tools for Health Workers

Session 7: Integrating Nutrition into HIV and AIDS CareNutrition Management with HIV and AIDS Training

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ObjectivesObjectives

• Appropriately assess and counsel patients on nutrition and HIV

• Identify ways to integrate nutrition into HIV and AIDS care


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Nutrition at Each Stage of HIV: Nutrition at Each Stage of HIV: Stage 1Stage 1• Symptoms

• No other infections• Generalised fatigue

• Nutrition Considerations• Healthy eating and hydration (drink fluids)• Nutrition assessment and education


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Nutrition at Each Stage of HIV: Nutrition at Each Stage of HIV: Stage 2Stage 2• Symptoms:

• Some other infections, but still in good overall health• Weight loss (less than 10 percent of normal weight)

• Nutrition Considerations:• Continue efforts for Stage 1• Follow-up nutrition assessment• Address nutrition-related side effects• Prevent weight loss• Prescribe micronutrient supplements, if indicated


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• More serious infections• Severe weight loss (greater than 10% loss of usual

weight)• Chronic, unexplained diarrhoea for > 1 month• Unexplained anaemia

• Nutrition Considerations:• Continue efforts for Stages 1 and 2• Nutrition management for: weight loss/malnutrition,

ART, and infections• Coping strategies


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• AIDS• More serious infections with life-threatening

complications• HIV Wasting Syndrome

• Nutrition Considerations:• Continue nutrition management of side effects, as

appropriate for client’s prognosis• Provide comfort and manage pain• Fluids for hydration


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Nutrition AssessmentNutrition Assessment

• Anthropometric• Biochemical• Clinical• Dietary• Environmental• Food Security


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AnthropometricsAnthropometrics

• Height (cm) at first visit for adults, at each visit for children

• Weight (kg) at each visit• Percent weight loss, if applicable • Mid Upper Arm Circumference (MUAC) at

each visit• Body Mass Index (BMI) at each visit


Slide 9

Weight Loss CalculationWeight Loss Calculation

• Percent weight loss• UBW = Usual Body Weight• CBW = Current Body Weight• Formula:

% loss = UBW – CBW x 100 UBW


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Mid Upper Arm CircumferenceMid Upper Arm Circumference

• Use measuring tape; measure in cm• Estimates muscle loss• If less than 23 cm, possible muscle

wasting intervene with nutrition counselling


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Body Mass Index (BMI)Body Mass Index (BMI)

• BMI is used to assess an adult’s weight based on their height.

• Not used for children or pregnant women• A quick and easy way to estimate weight status

(e.g. underweight, normal weight, overweight).

Refer to BMI reference chart and calculation sheet


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BMI Reference ChartBMI Reference Chart Underweight Normal Weight Overweight Obese

BMI (kg/m2) 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

Height (cm.) Weight (kg.)

152 37 40 42 44 46 48 50 53 56 58 60 62 64 67 70 72 74 76 78 81 84 86 88 90 92 94 97

154 38 40 42 45 48 50 52 54 57 60 62 64 66 68 71 74 76 78 80 83 86 88 90 92 95 98 100

156 39 42 44 46 48 51 54 56 58 61 64 66 68 70 73 76 78 80 82 85 88 90 92 95 94 100 102

158 40 42 45 48 50 52 55 58 60 62 65 68 70 72 75 78 80 82 85 88 90 92 95 98 100 102 105

160 41 44 46 48 51 54 56 59 62 64 66 69 72 74 77 80 82 84 87 90 92 94 97 100 102 105 108

162 42 44 47 50 52 55 58 60 63 66 68 71 74 76 79 82 84 86 89 92 94 97 100 102 105 108 110

164 43 46 48 51 54 56 59 62 64 67 70 72 75 78 81 84 86 89 92 94 97 100 102 105 108 110 113

166 44 47 50 52 55 58 61 64 66 69 72 74 77 80 83 86 88 91 94 96 99 102 105 108 110 113 116

168 45 48 51 54 56 59 62 65 68 70 73 76 79 82 85 88 90 93 96 99 102 104 107 110 113 116 118

170 46 49 52 55 58 61 64 66 69 72 75 78 81 84 87 90 92 95 98 101 104 107 110 113 116 118 120

172 47 50 53 56 59 62 65 68 71 74 77 80 83 86 90 94 97 100 103 106 108 110 112 115 118 120 124

174 48 51 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97 100 103 106 109 112 115 118 120 124 127

176 50 53 56 59 62 65 68 71 74 77 81 84 87 90 93 96 99 102 105 108 111 115 118 120 124 127 130

178 51 54 57 60 63 67 71 74 76 79 82 85 89 92 95 98 101 105 108 111 114 117 120 124 127 130 133

180 52 55 58 61 65 68 71 75 78 81 84 87 97 94 97 101 104 107 110 113 117 120 123 126 130 133 136

182 53 56 59 63 66 69 73 76 79 83 86 89 93 96 98 103 106 109 113 116 119 123 126 129 132 136 139

184 55 57 61 64 68 71 74 78 81 85 88 91 95 98 102 105 108 112 115 118 122 125 129 132 135 139 142

186 55 59 63 66 67 73 76 79 83 87 90 93 97 101 104 107 111 114 117 120 124 128 131 135 138 142 145

188 57 60 63 67 71 74 77 81 85 89 92 95 99 103 106 109 113 117 120 124 127 131 134 138 141 145 148

190 57 61 65 69 73 76 79 83 87 91 94 97 101 104 108 112 115 119 123 126 130 133 137 141 144 148 152

192 59 63 67 70 73 77 81 85 89 93 96 99 103 107 111 115 118 120 125 129 133 136 140 144 147 151 155

194 61 64 67 71 75 79 83 87 91 94 97 101 105 109 113 117 120 124 128 132 135 139 143 147 151 154 158

196 61 65 69 73 77 81 85 89 93 96 99 103 107 111 115 119 123 127 131 134 138 142 146 150 154 157 161

198 63 67 71 75 79 83 87 91 95 98 101 105 109 113 117 120 125 129 133 137 141 145 149 153 157 161 165

200 63 67 71 75 79 83 87 91 95 99 103 107 111 115 119 124 128 132 136 140 144 148 152 156 160 164 168

Adapted from: RCQHC/FANTA


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BBiochemicaliochemical

• Laboratory values as available• CD4 count and all other routine values

with:• Blood cholesterol (fat)• Blood glucose (sugar)• Haemoglobin (blood iron)• Urine test, look for ketones

• Parasites (e.g. worms)


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CClinicallinical

• Assess and counsel on management of complications• Diarrhoea• Nausea/vomiting• Poor appetite• Mouth sores• Changes in taste

• Medication Regimen• Discuss food effects, interactions, and

herbal/traditional therapies


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DietaryDietary

• How many times a day does the client eat?• What does the client eat in a typical day?

• How does the client:

• Keep foods cold (refrigerator, freezer, other methods)?

• Cook food (stove, open fire)? • Keep dishes, utensils, and cooking areas clean

(soap, water)?


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EnvironmentalEnvironmental

• Assess hygiene and sanitation situation at home and community• Where does the family get water from?• Is there a latrine in the home or communal

latrine? If so, how is it maintained?• Is garbage removed often and safely?

• Are client and family aware of basic food and water safety practices


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Food SecurityFood Security

• Where does the food come from? Market, supermarket, home garden?

• Are there community or village gardening projects that client can be referred to?

• Know which local, nutritious foods are available in the community, and promote these instead of expensive foods from shops


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Additional InformationAdditional Information

• Other illness or opportunistic infections• E.g. Tuberculosis, malaria, pneumonia, or skin

problems• Lifestyle practices (smoking, alcohol use, and

unsafe sex)• Family/community support system• Educational level• Living environment (housing, income, and

number of members per household)


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Anthropometric Anthropometric Measurement and BMI Measurement and BMI Calculation PracticeCalculation Practice


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Assessment Diagnosis Action Plan

Nutrition Assessment Weight, Height, BMI,

Record nutrition symptoms

Praise good eating behaviours. Encourage continued healthy eating and weight maintenance

Severe Malnutrition BMI <16kg/m2, weight loss > 10%, persistent diarrhoea, fever, with or without other

symptoms

Moderate Malnutrition BMI 16.5 – 18.5 kg/m2, weight

loss < 10%, mild symptoms

Well Nourished BMI > 19 kg/m2, no weight loss

or symptoms

Regular follow up

Consider hospitalization with enteral, parenteral or supplemental feedings, treat infections, rehydrate, and promote weight gain with high calorie foods.

Treat symptoms/infection and prevent further weight loss and infections with high energy, protein, vitamin and mineral foods.

Follow up in 1-2 months

Follow up in 1 month

Nutrition Assessment Action PlanNutrition Assessment Action Plan


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Integration of Nutrition into HIV Integration of Nutrition into HIV and AIDS Careand AIDS Care• Begin at VCT services• Address food availability and access• Weight loss prevention can improve

survival


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First HIV VisitFirst HIV Visit

• Complete full nutrition assessment• Obtain baseline height and weight, calculate

BMI, and measure MUAC• Ask about recent weight loss or inability to eat

(due to illness)• Ask about food availability, food storage, and

cooking facilities in home• Provide nutrition counselling on healthy eating


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Follow-up VisitsFollow-up Visits

• Continue with nutrition assessment• Obtain height (if not already done), weight,

calculate BMI, MUAC and % weight loss, if necessary

• Ask if any problems eating• Ask if any change in food availability,

storage or cooking facilities at home


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For Patients in the HospitalFor Patients in the Hospital

• Take note of whether the patient is eating and how much

• If the patient needs help and family members are not there, provide help with eating

• Weigh patients• Counsel patient on adjusting food intake for

management of side effects


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Integration into ART ProgrammeIntegration into ART Programme

• Before ART, assess food availability and intake situation

• Assess weight status• Use Food and Medication Time Table when

discussing medication schedule• At each follow-up, obtain current weight and side

effects• Counsel appropriately on side effect

management and good nutrition


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Integration into PMTCT and Integration into PMTCT and Ongoing Paediatric CareOngoing Paediatric Care• Counsel mothers and partners on all infant

feeding options for PMTCT• Support infant feeding choice• Educate on dangers of mixed feeding• Monitor growth and feeding of infant• For infants on replacement feeding,

educate on and monitor formula/milk supply and preparation


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Nutrition CounsellingNutrition Counselling

• Listen to client; assess individual situation• Ask open-ended questions (who, what, when,

where, why, how?)• Be realistic and practical with counselling; set

realistic goals with client• Encourage good eating habits• Be a role model for clients• Maintain confidentiality always


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Making Suggestions, not Making Suggestions, not CommandsCommands• Commands use the imperative form of

verbs (give, do, bring) and words like always, never, must, should

• Suggestions include:• Have you considered …?• Would it be possible …?• What about trying … to see if it works for you?• Would you be able to …?


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Making Suggestions, not Making Suggestions, not CommandsCommands• Suggestions include:

• Have you thought about …? Instead of …?• You could choose between … and … and …• It may not suit you, but some mothers … a

few women …• Perhaps … might work• Usually … Sometimes … Often …

• Follow-up with open-ended questions using: who, what, when, where, how, why


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Counselling Role PlayCounselling Role Play


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Integration Case StudyIntegration Case Study


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Key PointsKey Points

1. All persons with HIV and AIDS need nutrition counselling and assessment

2. Obtain weight and calculate body mass index

3. Integrate nutrition and food security assessment into regular HIV care

session 7: integrating nutrition assessment, counselling, and education into hiv and aids care

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