Training Module Nutrition hjk

Training Module on Nutritional Counseling for

Pregnant Women in Tanzania

February 2008

Tanzania Food and Nutrition Centre

Training Module on Nutritional Counseling for Pregnant Women in Tanzania

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TABLE OF CONTENTS

Content Page Acronyms ................................................................................................................. ii Acknowledgements ................................................................................................. iii Introduction to the Training Module ......................................................................... 1 PART 1: INTRODUCTION Session 1: Introduction ........................................................................................... 5 Session 2: Why Nutrition Matters During Pregnancy ............................................ 16 PART 2: NUTRITIONAL COUNSELING FOR PREGNANT WOMEN Session 3: Nutritional Counseling for HIV-Negative Pregnant Women of HIV

Unknown Status ................................................................................. 30 Session 4: Nutritional Counseling for HIV-Positive Pregnant Women .................. 47 Session 5: Counseling Pregnant Women to Improve Adherence

to Iron Supplementation ...................................................................... 64 PART 3: EVALUATION Session 6: Final Evaluation .................................................................................. 71 Appendices ........................................................................................................... 72


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ACRONYMS ANC Antenatal Care ARV Anti-retroviral BMI Body Mass Index CDC Centers for Disease Control and Prevention DHS Demographic and Health Survey FANC Focused antenatal care HIV Human Immunodeficiency Virus AIDS Acquired Immunodeficiency Syndrome IUGR Intrauterine Growth Retardation LBW Low Birth Weight MTCT Mother to Child Transmission MUAC Mid-upper-arm circumference PLHA People living with HIV/AIDS TFNC Tanzania Food and Nutrition Center TDHS Tanzania Demographic and Health Survey WHO World Health Organization


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ACKNOWLEDGEMENTS

The training Module on Nutrition Counseling for pregnant women would not have been possible without the contribution, support and collaboration of a wide range of individuals and institutions. Many thanks and gratitude should go to:

ACCESS/Jhpiego - TANZANIA

• Ms. Angelina Ballart—Midwifery Advisor, ACCESS/Jhpiego • Ms. Lucy Ikamba—Midwifery Advisor PSE, ACCESS/Jhpiego • Ms. Gaudiosa Tibaijuka—Senior Midwifery Advisor, ACCESS/Jhpiego • Dr. Muthoni Kariuki—Program Manager, Ag. Country Director,

ACCESS/Jhpiego

ACCESS-TANZANIA PARTNERS • Ms. Cindy Serre—Consultant, WFP • Mr. Estifano Tekle—Senior Nutritionist, WFP • Ms. Nancy Prail—Country Director, Helen Keller International

MIDWIFERY TUTORS

• Ms. Anna Mganga—Midwifery Tutor, Advance Diploma in Midwifery School, MNH

• Ms. Naike Elineema—Midwifery Tutor, School of Nursing Diploma, MNH • Dr. Thecla W. Kohi—Dean, School of Nursing, MUCHS • Mr. Rashid Heri—Tutorial Assistant, MUCHS • Ms. Mwasham Mrisho—Midwifery Tutor, Muhimbili School of Nursing

MINISTRY OF HEALTH AND SOCIAL WELFARE • Ms. Lena Mfalila—Safe-motherhood Coordinator, MOHSW/

TANZANIA FOOD AND NUTRITION CENTER

• Dr. Godwin Ndossi—Managing Director • Dr. Sabas Kimboka—Director, Community Health and Nutrition • Dr. Simon Tatala—Principal Biochemist • Dr. Elifatio Towo—Principal Nutritionist • Mrs. Monica Ngonyani—Principal Nutritionist • Dr. Jocelyn Kaganda—Principal Nutritionist • Dr. Sauli Nkya—Senior Nutritionist • Mrs. Helen Semu—Senior Nutritionist • Mrs. Faith Magambo—Principal Sociologist


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AUTHORS • Dr. Eleonore Fosso Seumo, ACCESS/Academy for Educational Development • Dr. Fatma Abdallah, Tanzania Food and Nutrition Center

AUTHORIZING INSTITUTIONS • ACCESS–TFNC

This publication is made possible through support provided by the Maternal and Child Health Division, Office of Health, Infectious Diseases and Nutrition, Bureau for Global Health, U.S. Agency for International Development, under the terms of the Leader with Associates Cooperative Agreement GHS-A-00-04-00002-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development.


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INTRODUCTION TO THE TRAINING MODULE ACCESS is working with the Tanzania Food and Nutrition Centre (TFNC) to strengthen the capacity of antenatal care (ANC) providers in nutrition and care for pregnant women. Poor nutrition in pregnancy is associated with poor birth outcomes and increased maternal and infant morbidity and mortality. Nutritional deficiencies are exacerbated during pregnancy because of the additional nutrient demands associated with fetal growth. The most common deficiencies in pregnant women include iron, vitamin A and iodine. The 2004 Tanzania Demographic and Health Survey (TDHS) showed that 58% of pregnant women were anemic and only 10% of pregnant women using the ANC services took iron supplements for 90 days, as per WHO’s recommendations. Iron status can be improved by means of iron supplements for women along with improved diets and control of parasitic infections e.g. worms and malaria. The findings of the training needs assessment of ANC providers carried out by TFNC and ACCESS in selected hospitals, health centers, and dispensaries in June 2007 in rural and urban areas revealed that most ANC providers did not receive adequate training in nutritional care during pregnancy. None of them had received any refresher training in nutritional care for pregnant women. It is therefore important to strengthen the capacity of ANC providers to provide effective nutritional care during pregnancy. This module is designed to be integrated into or be delivered as part of focused antenatal care training. It is designed for pre-service, in service, and refresher training, in classroom sessions and for clinical practice. The facilitator is strongly encouraged to review all sections of the training module before beginning the training and to make adjustments as needed. PURPOSE AND OBJECTIVES Purpose The module is intended to contribute to improved quality of nutritional counseling for women using antenatal care services. Women using antenatal care services include HIV-negative and HIV-positive women. Therefore, ANC providers should be equipped with necessary knowledge and skills to provide effective nutritional counseling for both the HIV-positive and HIV-negative pregnant woman. Objectives The objectives of the training are to: 1. Raise awareness among ANC providers on the importance of enhancing the

nutritional status of pregnant women in Tanzania. 2. Enhance ANC providers’ knowledge and strengthen their skills in nutritional

counseling for both the HIV-positive and HIV-negative pregnant women. 3. Strengthen ANC providers’ counseling skills to contribute to improved adherence

to iron and folic acid supplement use by pregnant women.


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1.0 TARGET AUDIENCE The target audience includes tutors in schools of nursing and midwifery, antenatal care providers including medical attendants, public health nurses, nurse midwives (certificate and diploma), and students in the schools of nursing in Tanzania. The training module is competency-based and can be used to train health workers at a wide range of education levels

2.0 TRAINING SESSIONS The sessions are divided into three parts:

PART 1: INTRODUCTION Session 1: Introduction and pretest The purpose of this session is to: (i) Create an atmosphere conducive to learning. (ii) Pre test will enable the facilitators to assess background knowledge of learners Session 2: Why nutrition matters during pregnancy The purpose of the session is to raise awareness on the negative impacts and consequences of poor nutrition during pregnancy for the mother, the baby, the community, and the nation.

PART 2: NUTRITIONAL COUNSELING FOR PREGNANT WOMEN Session 3: Nutritional counseling for HIV-negative pregnant women The purpose of the session is to: (i) Provide an update on nutritional care needs/requirements for HIV-negative

pregnant women or pregnant women whose HIV-status is unknown (ii) Strengthen nutritional counseling skills. Session 4: Nutritional counseling for HIV- positive pregnant women The purpose of the session is to: (i) Share information on the nutritional needs/requirements of HIV-positive pregnant

women (ii) Strengthen ANC providers’ nutritional counseling skills. Session 5: Counseling pregnant women to improve adherence to iron and folic acid supplement use The purpose of the session is to strengthen ANC providers’ counseling skills to help pregnant women take iron and folic acid supplements as prescribed.

PART 3: EVALUATION Session 6: Evaluation The purpose of this session is to evaluate the knowledge gained as well as the level of satisfaction of participants with the logistics, methodologies, duration, and interactions with the facilitators.


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3.0 MATERIALS REQUIRED • Flipcharts and markers • Overhead projector or LCD projector and transparencies for overhead projector • A4 paper • Handouts and checklists • Lecture notes • PowerPoint presentations • Scenario and exercises

4.0 PREREQUISITE KNOWLEDGE • Basic science (physiology and biology) • Basic nutrition concepts such as role of macro and micronutrients • Food sources of, carbohydrates, protein, lipids/fats, vitamins, and minerals. • Basic counseling skills

5.0 ESTIMATED DURATION OF THE TRAINING: THREE DAYS

6.0 STRUCTURE OF THE MODULE The methodologies and activities for each session are summarized below in Table 1.

Table 1: Methodologies and Activities for Each Session

CONTENT SESSIONS

1 2 3 4 5 6

Pre and Post Test

Group activities

PowerPoint presentation

Handouts

Scenario/Exercises

Checklist

Lecture notes

Appendices

Pre test In session 1, a pre-test will be given to participants to assess their knowledge at the beginning of the training. An analysis of the participants’ responses in the pre-test will help determine the knowledge already acquired and the gaps to be filled during the training. Group Activities These activities include questions and answers, work in pairs, group work, and role play with feedback. PowerPoint Presentation The facilitator will use PowerPoint presentations after each group activity to summarize and present the take home messages.


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Handouts Handouts include key information distributed to participants during or after each session. This information will be presented in a format that is easily readable, including printouts of PowerPoint presentations. Handouts contain information that participants should use during counseling sessions. Participants are encouraged to use the handouts as job aids during the clinical practice and when they go back to their respective health facilities. It is expected that, with time, participants will master the content of each handout. Scenarios/Exercises Scenarios and exercises are included in sessions 3 and 4. The facilitator will use the scenario and exercises for role play. The scenarios and exercises are meant to help participants get ready for clinical practice by allowing them to apply new knowledge and skills in a simulated setting. The facilitator will select the most appropriate scenarios and exercises or adapt the proposed ones to be suitable to his/her context. Checklists Sessions 3 and 4 contain observation checklists for counseling sessions that are intended to be used during role play or clinical practice while observing a nutritional counseling session. The checklist helps participants observe and provide feedback in a structured way. Giving and receiving feedback will help participants improve their nutritional counseling skills. Checklists will thus help the participants acquire the knowledge and skills required for providing effective nutritional counseling. Lecture Notes Lecture notes have been written for sessions 2, 3, and 4. The lectures are written for the facilitators. Lecture notes will provide detailed information to elaborate on the statements made in the PowerPoint presentations. These notes are intended to help the facilitator (i) prepare to give the PowerPoint presentations and (ii) answer participants’ questions. Appendices Session 4 includes several appendices. The facilitator should review the lecture notes and the appendices before the training and will decide if a printout of appendices should be distributed to participants. Post test and Evaluation First, participants will be administered the same pre-test. For each participant, the results of the second assessment will be compared to the first assessment to help determine how much knowledge has been gained during the training. Second, participants will thereafter be given prepared questionnaires to fill. This will help determine the level of satisfaction of participants with the logistics, methodologies, duration and interaction with the facilitators.


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PART 1

SESSION 1 INTRODUCTION

1.1 PURPOSE AND OBJECTIVES OF THE SESSION The purpose of the session is to create an atmosphere conducive for learning among participants and facilitators. Objectives of the Session At the end of the session, participants will have: 1. Become acquainted with each other 2. Shared their expectations 3. Discussed the training objectives and time-table 4. Established roles and rules

1.2 HANDOUTS Handout and PowerPoint presentation 1.1: Objectives of the training Handout 1.2: Sessions Handout 1.3: Timetable Handout 1.4: Pre-test

1.3 OUTLINE Duration: 1 hour 10 minutes.

OBJECTIVES ACTIVITIES/METHODOLOGY TIMING MATERIALS

1. Become acquainted with each other

Activity 1: Introduction

1. The facilitator welcomes participants.

2. The facilitator introduces him/herself and asks each participant to introduce her/himself by stating his/her name and something that nobody knows about him/her.

10 min

2. Share expectations Activity 2: Expectations of participants 1. The facilitator asks participants to say aloud

their expectations for the training.

2. The facilitator asks a volunteer to write down the expectations and to read them aloud.

10 min Flipchart Markers Masking tape


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3. Discuss objectives and timetable

Activity 3: Objectives and timetable

1. The facilitator presents the objectives of the training and clarifies the expectations that are not addressed in the objectives. Handout and PowerPoint 1.1 and the sessions, using the Handout or PowerPoint 1.2

2. The facilitator presents the timetable: Handout 1.3

3. The facilitator solicits and answers questions from participants.

10 min Flipchart Markers Masking tape Handout and PowerPoint 1.1: objectives of the training, and 1.2: sessions Handout 1.3: timetable

4. Establish roles and rules

Activity 4: Rules 1. The facilitator asks participants to state the

rules the entire group will follow to help achieve the objectives of the training.

2. The facilitator asks a volunteer to write the rules on a flipchart.

3. The facilitator reads each rule and asks participants if they agree to follow each rule.

4. The facilitator hangs the rules participants have agreed to follow on the wall.


Activity 5: Roles 1. The facilitator explains that participants have

to participate in the training and help with different tasks. S/he explains there are several tasks such as timekeeper, icebreaker, report of the day, and helping with logistics as necessary.

2. The facilitator hangs four flipchart papers on the wall with one of the following headings on each flipchart sheet: timekeeper, icebreaker, report of the day, and helping with logistics

3. The facilitator asks volunteers to write their name under the task they would like to take on during the training.


5. Evaluate participants’ knowledge on nutrition and care during pregnancy

Activity 6: Pre-test

The facilitator distributes the pre-test form (Handout 1.4) to participants to fill out. The facilitator explains to participants that they have 30 minutes to fill out the pre-test.

The facilitator collects the pre-test form after 30 minutes.

30 min Handout 1.4: Pre-test form


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HANDOUT 1.1 OBJECTIVES OF THE TRAINING

The objectives of the training are to: 1. Raise awareness among ANC providers on the importance of enhancing the

nutritional status of pregnant women in Tanzania. 2. Enhance ANC providers’ knowledge and strengthen their skills in nutritional

counseling for both the HIV-positive and HIV-negative pregnant woman. 3. Strengthen ANC providers’ counseling skills to so as to contribute towards

improved pregnant women’s adherence to iron/folic acid supplement use.


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HANDOUT 1.2 SESSIONS

The sessions are divided into three parts:

PART 1: INTRODUCTION Session 1: Introduction and pretest The purpose of this session is to: (i) Create an atmosphere conducive to learning. (ii) Pre test will enable the facilitators to have background knowledge of learners Session 2: Why nutrition matters during pregnancy The purpose of the session is to raise awareness on the negative impacts and consequences of poor nutrition during pregnancy for the mother, the baby, the community, and the nation.

PART 2: NUTRITIONAL COUNSELING FOR PREGNANT WOMEN Session 3: Nutritional counseling for HIV-negative pregnant women The purpose of the session is to: (i) Provide an update on nutritional care needs/requirements for HIV-negative

pregnant women or pregnant women whose HIV-status is unknown (ii) Strengthen nutritional counseling skills. Session 4: Nutritional counseling for HIV-positive pregnant women The purpose of the session is to: (i) Share information on the nutritional needs/requirements of HIV-positive pregnant

women (ii) Strengthen ANC providers’ nutritional counseling skills. Session 5: Counseling pregnant women to improve adherence to iron and folic acid supplement use The purpose of the session is to strengthen ANC providers’ counseling skills to help pregnant women take iron and folic acid supplements as prescribed.

PART 3: EVALUATION

Session 6: Evaluation The purpose of this session is to evaluate the knowledge gained as well as the level of satisfaction of participants with the logistics, methodologies, duration, and interactions with the facilitators.


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HANDOUT 1.3 TIMETABLE

Day 1

9:00–10:30 Session 1: Introduction

Opening

Introduction of participants

Expectations and objectives and sessions of the workshop

Roles and rules

Pretest

10:30–11:00 Tea/Coffee Break

11:00–12:15 Session 2: Why Nutrition Matters During Pregnancy

Types and magnitude of malnutrition during pregnancy in Tanzania

Causes of malnutrition during pregnancy in Tanzania

12:15–1:15 Lunch

1:15–3:30 Session 2

Consequences of malnutrition during pregnancy

Indicators of maternal malnutrition

3:30–5:00 Session 3: Nutritional Counseling for HIV-Negative Pregnant Women and Those with Unknown Status

Energy, vitamin, and mineral needs/requirements

Day 2

9.00–10:30 Session 3

Nutritional counseling–Nutritional assessment

10.30–11:00 Tea/Coffee break

11:00–12:30 Nutritional counseling

12:30–13:30 Lunch

13:30–16: 00 Session 4: Nutritional Counseling for HIV-Positive Pregnant Women

Energy, vitamin, and mineral needs/requirements

Nutrition and care messages

Day 3

9:00–10:30 Session 4

Nutritional counseling

10:30–11:00 Tea/Coffee Break

11:00–12: 00 Nutritional counseling

12:00–1:00 Lunch

1:0 0–3:30 Session 5: Counseling to improve adherence to iron supplementation

3:30–5:00 Session 6: Evaluation of the workshop


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HANDOUT 1.4 PRE- AND POST-TEST

Put a check mark next to the correct answer

1.0 WHY NUTRITION MATTERS DURING PREGNANCY

1.1 MALNUTRITION IN TANZANIAN WOMEN a. Most women of reproductive age in Tanzania suffer from acute

malnutrition b. Most women of reproductive age in Tanzania have BMI < 18.5 c. Almost of 20% of women of the age group 15 - 19 in Tanzania suffer from

malnutrition and almost the same number of adult women are overweight. 1.2 MICRONUTRIENT DEFICIENCY

a. Vitamin A deficiency is the most prevalent micronutrient deficiency in pregnant women in Tanzania

b. Iodine disorder is the most prevalent micronutrient deficiency in pregnant women in Tanzania

c. Anemia is widespread in pregnant women in Tanzania 1.3 INDICATORS OF GOOD MATERNAL NUTRITIONAL STATUS ARE

a. Weight b. Hemoglobin ≥ 11g/dl c. Presence of clinical signs of micronutrient deficiency

1.4 INDICATORS OF NUTRITIONAL STATUS OF HIV-POSITIVE

PREGNANT WOMEN a. Are different from HIV-negative pregnant women b. Are the same as for HIV-negative pregnant women

2.0 NUTRITIONAL COUNSELING FOR HIV-NEGATIVE PREGNANT WOMEN

OR PREGNANT WOMEN OF UNKNOWN HIV STATUS 2.1 ADDITIONAL ENERGY NEEDS FOR HIV-NEGATIVE PREGNANT

WOMEN ARE: a. The same as for non pregnant women b. Increased only in the last trimester of the pregnancy c. 300 kcal/per day –or one snack/day


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2.2 NUTRITIONAL ASSESSMENT FOR HIV-NEGATIVE PREGNANT WOMEN SHOULD: a. Not be part of medical assessment b. Include physical assessment, dietary assessment, medical history, medical

profile, biochemical profile, and psychosocial c. Include anthropometry and dietary practices

2.3 NUTRITIONAL COUNSELING MESSAGES FOR HIV-NEGATIVE

PREGNANT WOMEN DEPEND: a. On the BMI during pregnancy b. On the BMI pre-pregnancy, weight gain, and micronutrient status c. On the micronutrient status of the pregnant woman

2.4 ESSENTIAL NUTRITION ACTION MESSAGES FOR HIV-

NEGATIVE PREGNANT WOMEN INCLUDE: a. Meal frequency, rest, iron tablet intake, and the use of ITNs b. Meal frequency, rest, diversified diet, iron and folic acid tablet intake,

treatment of hookworm and malaria, and use of ITNs c. Meal frequency, diversified diet, monitoring weight, iron and folic acid

tablet intake, treatment of hookworm and malaria, and monitoring of vitamin A deficiency

3.0 NUTRITIONAL COUNSELING FOR HIV-POSITIVE PREGNANT WOMEN

3.1 ENERGY AND VITAMIN AND MINERAL REQUIREMENTS FOR HIV-POSITIVE PREGNANT WOMEN ARE: a. Independent of the pregnant woman’s HIV-status b. Linked to pregnancy c. A combination of the energy, vitamin, and minerals needed during

pregnancy + additional energy due to the presence of the virus 3.2 THE ENERGY NEEDS OF HIV-POSITIVE PREGNANT WOMEN

ARE: a. Higher than the energy needs of HIV-negative pregnant women b. The same as the energy needs of HIV-negative pregnant women c. Lower than the energy needs of HIV-negative pregnant women

3.3 AN HIV POSITIVE PREGNANT WOMAN NEEDS TO:

a. Eat more often than an HIV-negative pregnant woman b. Eat as often as an HIV-negative pregnant woman c. Have a more diversified diet compared to an HIV-negative pregnant

woman


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3.4 NUTRITIONAL ASSESSMENT FOR HIV-POSITIVE PREGNANT WOMEN DEPENDS ON: a. The stage in the disease b. The nutritional status of the HIV-positive pregnant woman c. The type of medication she is taking

3.5 NUTRITIONAL COUNSELING MESSAGES FOR HIV-POSITIVE

PREGNANT WOMEN: a. Are the same as for all pregnant women b. Vary according to the presence of micronutrient deficiency c. Vary according to the stage in the disease.

4.0 COUNSELING PREGNANT WOMEN FOR IMPROVING ADHERENCE TO

IRON SUPPLEMENTS The key points to cover during counseling pregnant women for improving adherence to iron supplement use are:

a. When to take the tablets and the management of side effects b. How to store the tablets and the importance of taking all the supplements c. When and how to take the supplements, how to store tablets, how to

manage the side effects, the importance of taking all the supplements, and where to return for more tablets


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PRE AND POST TEST ANSWER KEY

The correct answers are in bold.

1.0 WHY NUTRITION MATTERS DURING PREGNANCY

1.1 MALNUTRITION IN TANZANIAN WOMEN a. Most women of reproductive age in Tanzania suffer from acute

malnutrition b. Most women of reproductive age in Tanzania have BMI < 18.5 c. Almost of 20% of women of the age group 15 - 19 in Tanzania suffer

from malnutrition and almost the same number of adult women are overweight.

1.2 MICRONUTRIENT DEFICIENCY

a. Vitamin A deficiency is the most prevalent micronutrient deficiency in pregnant women in Tanzania

b. Iodine disorder is the most prevalent micronutrient deficiency in pregnant women in Tanzania

c. Anemia is widespread in pregnant women in Tanzania 1.3 INDICATORS OF GOOD MATERNAL NUTRITIONAL STATUS ARE

a. Weight b. Hemoglobin ≥ 11g/dl c. Presence of clinical signs of micronutrient deficiency

1.4 INDICATORS OF NUTRITIONAL STATUS OF HIV-POSITIVE

PREGNANT WOMEN a. Are different from HIV-negative pregnant women b. Are the same as for HIV-negative pregnant women

2.0 NUTRITIONAL COUNSELING FOR HIV-NEGATIVE PREGNANT WOMEN

OR PREGNANT WOMEN OF UNKNOWN HIV STATUS 2.1 ADDITIONAL ENERGY NEEDS FOR HIV-NEGATIVE PREGNANT

WOMEN ARE: a. The same as for non pregnant women b. Increased only in the last trimester of the pregnancy c. 300 kcal/per day–or one snack/day


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2.2 NUTRITIONAL ASSESSMENT FOR HIV-NEGATIVE PREGNANT WOMEN SHOULD: a. Not be part of medical assessment b. Include physical assessment, dietary assessment, medical history,

medical profile, biochemical profile, and psychosocial c. Include anthropometry and dietary practices

2.3 NUTRITIONAL COUNSELING MESSAGES FOR HIV-NEGATIVE

PREGNANT WOMEN DEPEND: a. On the BMI during pregnancy b. On the BMI pre-pregnancy, weight gain, and micronutrient status c. On the micronutrient status of the pregnant woman

2.4 ESSENTIAL NUTRITION ACTION MESSAGES FOR HIV-

NEGATIVE PREGNANT WOMEN INCLUDE: a. Meal frequency, rest, iron tablet intake, and the use of ITNs b. Meal frequency, rest, diversified diet, iron and folic acid tablet intake,

treatment of hookworm and malaria, and use of ITNs c. Meal frequency, diversified diet, monitoring weight, iron and folic acid

tablet intake, treatment of hookworm and malaria, and monitoring of vitamin A deficiency

3.0 NUTRITIONAL COUNSELING FOR HIV-POSITIVE PREGNANT WOMEN

3.1 ENERGY AND VITAMIN AND MINERAL REQUIREMENTS FOR HIV-POSITIVE PREGNANT WOMEN ARE: a. Independent of the pregnant woman’s HIV-status b. Linked to pregnancy c. A combination of the energy, vitamin, and minerals needed during

pregnancy + additional energy due to the presence of the virus 3.2 THE ENERGY NEEDS OF HIV-POSITIVE PREGNANT WOMEN

ARE: a. Higher than the energy needs of HIV-negative pregnant women b. The same as the energy needs of HIV-negative pregnant women c. Lower than the energy needs of HIV-negative pregnant women

3.3 AN HIV POSITIVE PREGNANT WOMAN NEEDS TO:

a. Eat more often than an HIV-negative pregnant woman b. Eat as often as an HIV-negative pregnant woman c. Have a more diversified diet compared to an HIV-negative pregnant

woman


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3.4 NUTRITIONAL ASSESSMENT FOR HIV-POSITIVE PREGNANT WOMEN DEPENDS ON: a. The stage in the disease b. The nutritional status of the HIV-positive pregnant woman c. The type of medication she is taking

3.5 NUTRITIONAL COUNSELING MESSAGES FOR HIV-POSITIVE

PREGNANT WOMEN: a. Are the same as for all pregnant women b. Vary according to the presence of micronutrient deficiency c. Vary according to the stage in the disease.

4.0 COUNSELING PREGNANT WOMEN FOR IMPROVING ADHERENCE TO

IRON SUPPLEMENTS The key points to cover during counseling pregnant women for improving adherence to iron supplement use are:

a. When to take the tablets and the management of side effects b. How to store the tablets and the importance of taking all the supplements c. When and how to take the supplements, how to store tablets, how to

manage the side effects, the importance of taking all the supplements, and where to return for more tablets


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SESSION 2 WHY NUTRITION MATTERS DURING PREGNANCY

2.1 INTRODUCTION

This session provides information on the importance of good nutrition, types and magnitude of malnutrition during pregnancy in Tanzania, causes of maternal malnutrition, the consequences of poor nutrition during pregnancy on the mother, the baby, and the nation.

2.2 PURPOSE AND OBJECTIVES The purpose of this session is to raise awareness of the consequences of poor nutrition during pregnancy for the woman, the child, the community and the nation. Objectives At the end of this session, participants will be able to: 1. Describe the types and the magnitude of malnutrition during pregnancy in

Tanzania 2. Discuss causes of malnutrition during pregnancy 3. Describe the consequences of malnutrition during pregnancy for the woman, the

child, the community, and the nation 4. List the indicators of maternal nutrition during pregnancy

2.3 HANDOUTS PowerPoint presentation and Handout 2.1: Nutritional deficiencies in women: types and magnitude of malnutrition during pregnancy in Tanzania PowerPoint presentation and Handout 2.2 Causes of malnutrition and 2.3: Consequences of malnutrition during pregnancy PowerPoint presentation and Handout 2.4: Indicators of malnutrition during pregnancy

LECTURE NOTES 2: WHY NUTRITION MATTERS DURING PREGNANCY


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2.4. OUTLINE

Duration: 3 hours 15 minutes


1. Describe the nutritional deficiencies in women: types and magnitude of malnutrition during pregnancy in Tanzania

Activity 1: Nutritional deficiencies women: types and magnitude of malnutrition during pregnancy in Tanzania: Work in pairs

1. The facilitator asks participants to work in pairs for 20 minutes to: (i) list on the flipchart the types of malnutrition that occur during pregnancy in Tanzania, and (ii) for each type, list the causes and provide an estimate of the proportion of pregnant women in Tanzania suffering from that specific type of malnutrition.

2. After 20 minutes, the facilitator asks a volunteer to present.

3. The facilitator asks other participants to add what is missing.

4. The facilitator presents a summary using PowerPoint 2.1.

The facilitator solicits and answers questions from participants.

45 min Flipchart Markers Masking tape PowerPoint presentation 2.1 Nutritional deficiencies in women: types and magnitude of malnutrition in pregnant women in Tanzania

2. Discuss causes of malnutrition during pregnancy

Activity 2: The Facilitator asks participants to list the causes of malnutrition among pregnant women in Tanzania. The facilitators writes down the participants’ answers

20 min Flipchart, Markers Masking tape

3. Describe the consequences of malnutrition during pregnancy for the woman, the child, the community, and the nation

Activity 3: Consequences of malnutrition during pregnancy: Group work

1. The facilitator hangs three flipcharts on the wall. On the first flipchart, s/he writes group 1, on the second, s/he writes group 2, and the third, s/he writes group 3.

2. The facilitator asks participants to write their name on the group of their choice (5 minutes). The facilitator ensures that participants are equally distributed in the groups.

3. The facilitator distributes and reads the work to be done by each group.

Group 1: Describe the consequences of malnutrition for the pregnant woman.

Group 2: Describe the consequences of malnutrition for the child/baby.

Group 3: Describe the consequences of malnutrition during pregnancy for the community and the nation.

4. Group work (20 minutes)

5. After 20 minutes, the facilitator asks each group to present. After each group presentation, the facilitator solicits questions from other participants and asks the members of the group who presented to answer. (60 minutes)

1h 45 min

Flipchart Markers Masking tape PowerPoint presentation 2.2 and 2.3 Causes and Consequences of malnutrition during pregnancy


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6. The facilitator presents a summary of the causes and consequences of malnutrition during pregnancy using PowerPoint presentation 2. 2. and 2.3 (10 minutes)

7. The facilitator solicits and answers questions from participants.(5 minutes)

4. List the indicators of maternal nutrition during pregnancy

Activity 3: Indicators of maternal nutrition during pregnancy: Work in pairs

1. The facilitator asks participants to continue to work in the same pair for 10 minutes to: (i) list on a flipchart the indicators for maternal nutrition during pregnancy, and (ii) for each indicator, indicate the cut-off points.



4. The facilitator presents a summary of the indicators of maternal nutrition during pregnancy using PowerPoint presentation 2.3.


35 min Flipchart Markers Masking tape PowerPoint presentation 2.4 Indicators of maternal nutrition during pregnancy


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LECTURE NOTES 2 WHY NUTRITION MATTERS DURING PREGNANCY

The physiological changes that occur during pregnancy require extra nutrients and energy to meet the demand of an expanding blood supply, the growth of maternal tissue, the developing fetus, loss of maternal tissue at birth, and preparation for lactation. Poor nutritional status and inadequate nutritional intake for women during pregnancy not only directly affect women’s health status, but also have a negative impact on birth weight and the early development of the infant.

2.1 NUTRITIONAL DEFICIENCIES IN WOMEN CONSTITUTE PUBLIC

HEALTH PROBLEMS IN TANZANIA More than a third of women of reproductive age are underweight in sub-Saharan Africa. Iron deficiency anemia is the most prevalent micronutrient deficiency in the world today. Anemia is common in women of reproductive age in Tanzania, particularly during pregnancy. Pregnant women are also at risk of other nutrient deficiencies. The 2004 Tanzania Demographic Health Survey (TDHS) revealed that: • 19% of women of the age group 15–19 suffer from acute malnutrition

(BMI<18.5)1. Short stature is associated with small pelvis size, which increases the likelihood of difficulty during delivery and the risk of bearing low birth weight babies

• 18% of women are overweight or obese with 4% being obese. • 58% of pregnant women are anemic. Only 10% of pregnant women take iron

tablets at least for 90 days. • Prevalence of vitamin A deficiency in pregnant women in Tanzania: 69% of

lactating women in Tanzania have vitamin A deficiency (breastmilk retinol below 1.05 µmol/L) whereas 65% of pregnant women have plasma retinol below 1.05 µmol/L2

• An estimated 30 % of the perinatal mortality may be attributable to iodine deficiency (1980 estimates, no national survey done)3

• 43% of households tested use salt that is adequately iodized. Although a survey conducted by TFNC 2004 showed that 83.6% of households were consuming iodized salt.

Maternal malnutrition has consequences for maternal, fetal, and infant health.

2.2 CAUSES OF MALNUTRITION DURING PREGNANCY Conceptual framework of malnutrition Referring to the conceptual framework of malnutrition in the Box 2.2, malnutrition in pregnancy has immediate causes, underlying causes and root causes.

1 http://www.fantaproject.org/downloads/pdfs/Uganda_BMI.pdf 2 Ballart et al. 1997 National Survey on Vitamin A deficiency 3 Festo P. Kavishe Nutrition Relevant actions in Tanzania -1993


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Box: 2.2 Conceptual Framework of Malnutrition in Women

2.2.1 IMMEDIATE CAUSES OF MALNUTRITION DURING PREGNANCY ARE INADEQUATE FOOD INTAKE AND POOR HEALTH Food intake is low, highly variable over seasons, and often of low nutrient density. Roots and tubers, in particular, have an insufficient protein content to meet the pregnant woman’s nutritional needs. Maize-based diets lack niacin as well as certain key amino acids. Monotonous grain or tuber based diets often provide insufficient micronutrients and even hinder absorption of those same nutrients. In some areas in Tanzania, pregnant women are advised to eat less than before pregnancy because of the belief that eating more during pregnancy will cause a difficult delivery, placing women and their newborns at greater risk of complications and death. This has been reported in the Masai tribe.

Women commonly suffer from nausea, vomiting and heartburn during pregnancy. These symptoms may lead to reduced food intake. Furthermore during pregnancy some women have abnormal cravings (Pica) to eat non-food substances of little or no nutritional value such as soil and charcoal. Consumption of soil has been associated with increase in anemia cases in pregnancy4.

4 Gretchen A et al. Nutritional factors and infectious diseases contribute to Anaemia among pregnant women with Human Immunodeficiency virus in Tanzania. Journal of Nutrition2000; 130:1950-1957


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Food taboos during pregnancy deprive women of necessary nutrients and foods that may be available, even in homes that are food insecure. Studies conducted in the southern part of Tanzania showed that pregnant women were restricted to consume fish and meat and this contributed to anemia during pregnancy5.

In some areas, intra-household food distribution does not favor women as women and children eat last. Women in rural areas of Tanzania work longer hours at home and in agriculture and are responsible for all food preparation, and women frequently consume the poorest-quality foods available to the family.

Women’s health in Tanzania is compromised by poor hygiene, heavy workloads, undernourishment, frequent births and high levels of poverty. Maternal mortality rates had increased due to heavy disease burden and poor quality of health services6. Although there has been some significant improvement on most health indicators over the last five years, maternal mortality ratio (MMR) has remained stagnant at 578/100,000 live births (2004). Nearly 9,000 women in Tanzania die annually due to pregnancy related causes (HSSP2003). The leading causes of maternal mortality are hemorrhage (ante-partum and post-partum), anemia 7 8 and eclampsia mainly due to poor access to emergency obstetric services. Further, the poor access and quality of care (2004-05 TDHS), exemplified by shortage of qualified staff, low staff morale, lack of quality control and patient management, is contributing to the low rate of deliveries at health facilities, resulting in high MMR. Recent data from the Demographic and Health Survey demonstrate that the rate of caesarean sections in the country is also low indicating that Tanzanian mothers have insufficient access to essential maternal health services and specifically services for complicated deliveries9. Infections and other diseases increase nutritional needs and at the same time hinder nutrient absorption. Poor access to basic health services and inadequate knowledge worsen the nutrition-infection cycle. According to the 2004 Tanzania demographic health survey, 62% of women whose last birth occurred in the five years before the survey made four or more ANC visits and 47% of women delivered in health facility while 53% delivered at home. Multiple and frequent pregnancies put nutritional stresses on women and women's requirements for various nutrients increase. When these needs are often not met, they lead to "maternal depletion”.

5 Marchant T et al, Anaemia during pregnancy in Southern Tanzania, Annals of Tropical Medicine and Parasitology, volume 96,number 5,July 2002 6 United Republic of Tanzania, Support to Maternal Mortality Reduction Project, Appraisal report. Human Development Department oshd.3 Health Division August 2006 7 Justesen A. An analysis of maternal mortality in Muhimbili Medical Centre, Dar es Salaam, July 1983 to June 1984. J Obstet.Gynecol. East. Cent. Afr.1985;4:5-8 8 Kazaura MR et al, Maternal mortality at Muhimbili National Hospital, Tanzania 1999-2005.East Africa Journal of Public Health,2006Oct,3(2):23-25 9 United Republic of Tanzania, Support to Maternal Mortality Reduction Project, Appraisal report. Human Development Department oshd.3 Health Division August 2006


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2.2.2 THE UNDERLYING CAUSES OF MALNUTRITION IN WOMEN ARE FOOD INSECURITY, POOR HEALTH CARE, AND POOR HYGIENE AND SANITATION Food insecurity Food security is defined by USAID’s Office of Food for Peace as “when all people at all times have both physical and economic access to sufficient food to meet their dietary needs for a productive and healthy life”. In Tanzania, issues of infrastructure, economic and agricultural policy, governance, education and provision of health care play important roles in household food security. Food security is also threatened by generalized poverty that exists throughout the country and also recurring droughts (and flooding in certain locations). A survey done by Comprehensive Food Security and Vulnerability Analysis (CFSVA) showed that 15% of the rural households are food insecure; 15% are vulnerable to becoming food insecure; 5.6% of children under 5 are wasted or too thin for their height, a sign of acute malnutrition; 34.3% of children under 5 are stunted or too short for their age, a sign of chronic malnutrition; and 21.1% of children under 5 are underweight. Further more, food insecurity and vulnerability vary regionally with regions such as Dodoma, Singida and Tabora having 45-55% of the households being food insecure. In Mwanza, Manyara and Kagera regions food insecurity affects between 20 to 30% of the households while in Ruvuma and Iringa 15% of households are food insecure. There is also a high rate (between 24 to 27%) of households vulnerable to food insecurity in the regions of Singida, Tabora, Dodoma and Mwanza. In Lindi, 21.4% of the households are vulnerable. Poor/limited care given to pregnant women The previous good habits about care of a pregnant woman and extended family support to reduce her workload are now non-existent. There is high ANC attendance of about 98% however; the quality of services remains questionable10. Poor hygiene and sanitation have negative impacts on women’s health status. Frequent parasites and infections increase the nutrient needs of pregnant women. Food and health behaviors can either compensate for or exacerbate the environmental nutrition risks e.g. soil ingestion during pregnancy.

2.2.3 THE ROOT CAUSES OF MALNUTRITION IN PREGNANT WOMEN ARE DUE TO POLITICAL AND IDEOLOGICAL STRUCTURE AND ECOLOGICAL CONDITIONS The causes of food insecurity and vulnerability are mainly related to developmental issues such as low productivity, rising and widespread poverty, poor investment, high transportation costs, inadequate expert advice and technologies suitable for diverse environments, lack of competitive markets for agriculture, demographic growth with a high dependence ratio, poor credit systems for farming small holders, etc. Environmental issues such as soil

10 The United Republic of Tanzania, Ministry of Health. National Policy Guidelines for Reproductive and Child Health Services. Ministry of Health, Reproductive and Child health Section, Dar es Salaam Tanzania, 2003


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degradation, deforestation, pest outbreak and drought add to the problems. Drought affects about 45% and high food prices 12% of the population11.

2.3 CONSEQUENCES OF MALNUTRITION DURING PREGNANCY 2.3.1 MATERNAL MALNUTRITION INCREASES MORBIDITY AND

MORTALITY IN WOMEN Women who suffer from chronic energy deficiency: • Are at increased risk of maternal complications and death. • Have a higher prevalence of infections because of reduced immuno-

competence. • Are at increased risk of obstructed labor because of the disproportion

between the size of the baby’s head and the space in the birth canal. Iron deficiency anemia is the most widespread nutritional problem among women and has severe consequences for both their productive and reproductive roles. Maternal mortality rates are significantly higher among anemic women, as are infant mortality rates and the incidence of prematurity. Anemia is associated with increased maternal mortality. Twenty percent (20%) of maternal deaths in Tanzania are associated with anemia during pregnancy. High morbidity has been noted in pregnant anemic women in Tanzania. Iron deficiency anemia is also associated with inadequate maternal weight gain and labor and delivery complications with an increased risk of maternal mortality. There are many consequences of anemia in pregnant women, including: • Anemic women are more likely to die from blood loss during delivery. • Obstetric hemorrhage is the leading cause of maternal death in developing

countries, accounting for approximately 25% of all maternal deaths. • Severe anemia can lead to heart failure or circulatory shock at the time of

labor and delivery. • Anemic women are more susceptible to puerperal infection. Vitamin A Deficiency is associated with an increased risk of night blindness. Night blindness is associated with low levels of serum retinol. In pregnant women, vitamin A deficiency leads to severe xerophthalmia, which increases vulnerability to infections. Vitamin A deficiency in pregnant women has been associated with an increased risk of maternal mortality and miscarriage. Poor nutrition reduces the mother's resistance to infection and infections contribute to the poor nutritional status of the mother. Folic Acid Deficiency is associated with an increased risk of neural tube birth defects such as spina bifida. The body needs folic acid for the production, repair, and functioning of DNA, our genetic map and a basic building block of cells, so getting enough is particularly important for the rapid cell growth that occurs during pregnancy. Folate also helps make normal red blood cells,

11 Tanzania Comprehensive Food Security and vulnerability Analysis, United Nation World Food Programme February 2007


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prevent anemia, and produce the nervous system chemicals nor epinephrine and serotonin.

2.3.2 MALNUTRITION IN PREGNANT WOMEN AFFECTS BIRTH OUTCOMES Maternal malnutrition may lead to: • Increased risk of fetal, neonatal, and infant death • Intra-uterine growth restriction, low birth weight and prematurity • Birth defects • Cretinism • Brain damage • Increased risk of infection In Tanzania, 19% of women in the age group 15–19 suffer from acute malnutrition. Adolescent mothers are more likely to have low birth weight babies. This is due to a combination of shorter average maternal height, competition for nutrients between the still-growing mother and the fetus, and poorer placental function in adolescents. Adolescent mothers need to gain more weight than older mothers to have a normal-weight baby. Concurrent pregnancy and growth in low-income adolescent girls also has a significant negative effect on the micronutrient status of these mothers. Poor nutritional status before and during pregnancy has been associated with intrauterine growth restriction (IUGR), low birth weight (LBW) and premature delivery. There is strong epidemiological evidence of an association between maternal weight gain during pregnancy and LBW/IUGR, especially in undernourished women, i.e. those who begin pregnancy in a nutritionally disadvantaged state. Women are at the greatest risk of having a LBW infant if low pre-pregnancy weight and low weight gain during pregnancy are combined. Anemia: 58% of pregnant women in Tanzania are anemic. Anemic women are more likely to deliver low birth weight infants. Vitamin A: Vitamin A deficiency in pregnant women has also been associated with an increased risk of stillbirth and low birth weight. Iodine Deficiency Disorders: Brain damage–Cretinism Only 43% of households tested during the 2004 TDHS use salt that is adequately iodized. Dietary iodine deficiency during pregnancy negatively affects the development of the fetus and can result in the birth of cretins. About 3% of babies born of iodine deficient mothers will be cretins and 10% will have moderate mental retardation while the rest (87%) will have mild intellectual deficit .The mental retardation resulting from iodine deficiency during pregnancy is irreversible.


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Iodine is required for the synthesis of thyroid hormones that in turn are required for the regulation of cell metabolism throughout the life cycle. Thyroid hormones ensure normal growth, especially of the brain, which occurs from fetal life to the end of the third postnatal year. Iodine deficiency during pregnancy, when severe, will impair thyroid function resulting in a lower metabolic rate, growth restriction, brain damage and increased perinatal mortality. Iodine deficiency in pregnant women also increases: • the risk of miscarriage • pre-eclampsia, anemia • fetal growth restriction • early rupture of the membranes • perinatal morbidity, and mortality12 Maternal folic acid deficiency: Low folic acid levels around the time of conception may cause neural tube defects in infants. Folic acid supplementation of women during the peri-conceptional period reduces the incidence of neural tube defects such as anencephaly and spina bifida. Low folic acid levels are associated with an increased risk of low birth weight. Special considerations for HIV-positive women Effects of HIV infection on body weight and composition during pregnancy: • HIV-positive women tend to gain less weight than HIV-negative women

during pregnancy. • Wasting during pregnancy is more common in HIV-infected women than

in the general population. • Anemia is often more severe in HIV-infected women than in other women.

Anemia in HIV-infected women is an independent predictor of more rapid HIV progression and mortality.

Nutrition and prevention of mother to child transmission (MTCT) of HIV Malnutrition during pregnancy may increase the risk of MTCT by: • Resulting in low fetal stores of some nutrients. This impairs immune

function and fetal growth and may increase the vulnerability of infants to HIV.

• Impairing the integrity of the placenta, genital mucosal barrier and gastrointestinal tract. Transmission of HIV from mother to infant may be facilitated, although data confirming such relationships independently of maternal HIV disease progression are limited.

• Causing low serum retinol levels that are associated with an increased risk of MTCT.

• Increasing the risk of MCTC in pregnant women who are anemic.

12 Thilly, C.H., Lagasse, R., Roger, G., Bourdoux, P., and Ermans, A.M. 1980. Impaired fetal and postnatal development and high perinatal death-rate in a severe iodine deficient area. In Thyroid Research VIII. J.R. Stockigt, S. Nagataki, E. Meldrum, J.W. Barlow, and P.E. Harding, editors. Canberra: Australian Academy of Science publ. 20-23.


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2.3.3 MALNUTRITION IN PREGNANT WOMEN AFFECTS THE PRODUCTIVITY AND THE ECONOMY OF THE NATION The maternal mortality ratio in Tanzania is estimated in the TDHS as 578 maternal deaths per 100,000 live births. Anemia is associated with increased maternal mortality. 20% of maternal deaths in Tanzania are associated with anemia during pregnancy. According to the 2007 Profiles13 in Tanzania, in the next ten years, losses of female labor force productivity due to iron deficiency anemia are estimated to 295 billion Tanzanian shillings. The findings of the 2007 Profiles in Tanzania showed that a 1% drop in iron status leads to a 1% reduction in productivity.

2.4 INDICATORS OF MATERNAL NUTRITIONAL STATUS DURING PREGNANCY Maternal weight, height, and weight-for-height ratio are frequently used as indirect measures of nutritional status. The indicators of maternal nutritional status are listed in Box 2.4.

BOX 2.4: INDICATORS OF MATERNAL NUTRITIONAL STATUS Indicators of good nutritional status during pregnancy include:

• Weight gain: within 11.5–16 kg

• Hemoglobin level ≥ 11g/dl

• Absence of clinical signs of micronutrient deficiencies Indicators of malnutrition in pregnant women include:

• Weight gain ≤ 11.5 kg

• Weight gain ≤ 1 kg/month in the last trimester of the pregnancy

• Mid-upper arm circumference (MUAC) < 23 cm

• Hemoglobin level < 11g/dl

• Presence of goiter

• Presence of clinical signs of micronutrient deficiencies

2.4.1 WEIGHT GAIN DURING PREGNANCY

The most sensitive measure of acute nutritional stress during pregnancy is indeed the lack of maternal weight gain. Poor weight gain during pregnancy reflects maternal malnutrition. Adequate weight gain during pregnancy is important for optimal fetal growth and development and for maternal fat store deposits. Inadequate weight gain is associated with intrauterine growth restriction and perinatal mortality. Body Mass Index (BMI)14 measures weight in relation to height (weight/height²) to estimate thinness. In adult women, BMI<18.5 kg/m2 is used as an indicator of chronic energy deficiency as is indicated in Box 2.4.1

13 Tanzania Food and Nutrition Centre, 2007. Nutrition for Human and Economic Development in Tanzania: Invest Now for the Year 2025 14 You can calculate the BMI using the chart on the document on http://www.fantaproject.org/downloads/pdfs/Uganda_BMI.pdf


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BOX 2.4.1: BMI REFERENCES

BMI WEIGHT STATUS

BMI < 18.5 Underweight

18.5 <BMI< 24.9 Normal weight

25 <BMI<29.9 Overweight

BMI >30 Obese

Source: WHO, 1995

It is recommended that women starting their pregnancy with a normal body mass index gain 11–16 kg during pregnancy. Of this weight gain, approximately 4 kg will be deposited as maternal fat stores. Excessive gestational weight gain is also a concern because it may lead to post-partum obesity. An underweight woman who enters pregnancy should gain more than 12 kg during the pregnancy. An overweight woman entering pregnancy should gain 7.0–11.5 kg during the pregnancy. An obese woman entering pregnancy should gain less than 7 kg during the pregnancy. Table 2.4.1 shows the recommended weight gain during pregnancy depending on the nutritional status of the woman pre-pregnancy.

Table 2.4.1 Weight Gain: Recommendation for Pregnancy

BMI BEFORE PREGNANCY TOTAL WEIGHT GAIN (KG)

<19.8 12.5–18

19.8–25.9 11.5–16.0

26.0–29.0 7.0–11.5

>29.0 <7.0

Nutrition during Pregnancy. Institute of Medicine, 1990

2.4.2 MONTHLY WEIGHT GAIN DURING THE SECOND AND THE THIRD TRIMESTER Weight gain under 1 kg per month during the second and third trimester is a sign of malnutrition for women with a normal BMI pre-pregnancy. During the second and especially during the third trimester, additional nutrients are mainly used by the fetus for rapid growth and storage.


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2.4.3 INDICATORS OF MICRONUTRIENT STATUS During pregnancy, vitamin and mineral needs are increased and, if these needs are not met, the pregnant woman will present signs of micronutrient deficiencies over time. Iron deficiency Iron deficiency occurs when an insufficient amount of iron is absorbed to meet the body’s requirements. The major clinical manifestation of iron deficiency is anemia or low blood hemoglobin concentration. • If Hb 7 - 10 g/L, the pregnant woman is moderately anemic15 • If Hb <7 g/L, the pregnant woman is severely anemic. In Tanzania, pregnant women are more likely to be anemic (58 %) than women who are breastfeeding (48 %) and women who are neither pregnant nor breastfeeding (47 %). This could be a result of the high demand of iron and folate during pregnancy. Dietary iron deficiency is the result of insufficient iron intake to meet requirements. Dietary iron deficiency results from: • Low dietary iron intake (resulting, for example, from a diet with low iron

density), and/or • Low bioavailability of dietary iron (when dietary iron is not easily

absorbed by the body). The causes of low iron bioavailability are: • Diet with a high content of non-heme iron. Non-heme iron comes from

vegetable sources. Its bioavailability is low compared to that of the iron coming from animal products (heme iron) such as red meat.

• Diet with a high content of iron absorption inhibitors. Inhibitors such as tannins, fiber, phytates, and calcium decrease the bioavailability of dietary iron. On the other hand, iron absorption enhancers (such as heme iron sources and vitamin C and some fermented or geminated foods) can increase the bioavailability of non-heme iron.

Vitamin A deficiency in pregnant women The mother’s vitamin A deficiency is demonstrated by the high prevalence of night-blindness during this period. Other clinical indicators are the breastmilk and plasma retinol (below 1.05 µmol/L). Vitamin A deficiency occurs especially during the last trimester when demand by both the unborn child and the mother is highest. Causes of vitamin A deficiency include: • Inadequate dietary intake of vitamin A rich foods e.g. liver, whole fish and

Beta-carotene (pro-vitamin A) rich foods • Poor preparation of pro-vitamin A rich foods which cause a loss of the

vitamin.

15 WHO defines the minimum hemoglobin concentration in normal pregnant women as 11.0 g/dl (WHO, 1972). World Health Organization. Nutritional anemia. Technical Report Series No. 503. WHO, Geneva 1972.


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• Recurrent infections, which reduce the efficiency of absorption, conservation, and utilization of vitamin A and can reduce vitamin A intake by depressing appetite

• Frequent reproductive cycling and short intervals between pregnancies Iodine deficiency The most common sign of iodine deficiency is goiter (enlargement of the thyroid). The goiter rate in Tanzania is 7%. The cause of iodine deficiency is the consumption of water and foods grown on iodine-deficient soil resulting in low levels of iodine. Indicators of nutritional status in HIV-infected pregnant women An HIV-infected woman’s nutritional status before and during pregnancy influences both her health and survival and those of her newborn child. HIV infection increases energy requirements because of elevated resting energy expenditure. The indicators of nutritional status in HIV-infected pregnant women are the same as in the non-infected pregnant women.


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PART 2 NUTRITIONAL COUNSELING FOR PREGNANT WOMEN

SESSION 3 NUTRITIONAL COUNSELING FOR HIV-NEGATIVE

PREGNANT WOMEN OR WITH HIV UNKNOWN STATUS

3.1 INTRODUCTION This session addresses the nutritional requirements and the essential nutrition action messages for pregnant women who are HIV-negative or whose HIV status is unknown.

3.2 PURPOSE AND OBJECTIVES The purpose of this session is to enhance participants’ knowledge and skills on nutritional counseling of HIV-negative pregnant women or whose HIV status is unknown. Objectives At the end of this session participants will be able to: 1. Describe the energy and vitamin and mineral needs/requirements and the key

essential nutrition action messages for HIV-negative pregnant women and women of unknown HIV status

2. Demonstrate how to carry out nutritional counseling for HIV-negative pregnant women or whose HIV status is unknown.

3.3 HANDOUTS

PowerPoint presentation and Handout 3.1: Energy needs/requirements for HIV- negative women or whose HIV status is unknown. PowerPoint presentation and Handout 3.2: List of available and affordable snacks to meet the additional energy needs of HIV- negative pregnant women or whose HIV status is unknown. PowerPoint presentation and Handout 3.3: Vitamins and minerals requirements of HIV-negative pregnant women or whose HIV status is unknown. PowerPoint presentation and Handout 3.4: on the components of nutritional assessment Handout 3.5: Scenarios and Exercises A, B, and C. PowerPoint and Handout 3.6: Essential nutrition actions messages for HIV-negative pregnant women or whose HIV status is unknown.


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PowerPoint presentation and Handout 3.7: Observation checklist for nutritional counseling for HIV-negative pregnant women or whose HIV status is unknown.

LECTURE NOTES 3: MEETING THE NUTRITIONAL NEEDS/REQUIREMENTS FOR HIV-NEGATIVE PREGNANT WOMEN OR WHOSE HIV STATUS IS UNKNOWN.

3.4 OUTLINE Duration: 3 hours 55 min

OBJECTIVES ACTIVITIES/ METHODOLOGY TIMING MATERIALS

1. Describe the energy and vitamin and mineral needs/ requirements and key nutrition and care messages for HIV-negative pregnant women or whose HIV status is unknown.

Activity 1: Energy needs/requirements during pregnancy : Work in pairs

1. The facilitator asks participants to work in pairs for 10 minutes to answer the following questions: What is the daily additional recommended

energy intake for a pregnant woman who (i) started the pregnancy in good nutritional status (18.5<BMI< 25), (ii) was underweight at the beginning of the pregnancy (BMI<18.5), and (iii) was overweight at the beginning of the pregnancy (BMI>26)?

What is the daily recommended frequency of meals (meals and snacks) for pregnant women?



4. The facilitator present a summary of “Energy needs/requirements for pregnant women” using PowerPoint presentation 3.1 and the list of available and affordable snacks to help meet the additional energy needs of HIV-negative pregnant women or whose HIV status is unknown PowerPoint and Handout 3.2.


30 min Flipchart Markers Masking tape PowerPoint presentation 3.1: Meeting the energy needs of HIV-negative pregnant women or women with unknown HIV-status PowerPoint and Handout 3.2: List of available and affordable snacks to help meet the additional energy needs for HIV- negative pregnant women or with unknown HIV-status

Activity 2: Vitamin and mineral requirements during pregnancy: Work in pairs

1. The facilitator asks participants to continue to work in the same pair for 20 minutes to (i) list/describe the vitamin and mineral requirements during pregnancy and (ii) explain how to meet these requirements.

2. The facilitator asks for a volunteer to present.


4. The facilitator wraps-up the session with a PowerPoint presentation on the vitamin and mineral requirements during pregnancy using PowerPoint presentation 3.3.

5. The facilitator solicits and answers questions from participants.

40 min PowerPoint presentation 3:3: Vitamin and mineral needs/require-ments during pregnancy for HIV-negative women or with unknown HIV status


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2 Nutritional counseling for pregnant women

a) Nutritional assessment

Activity 1: Nutritional assessment Questions and answers

1. The facilitator asks participants the following question: What activity should take place before any

counseling session?

2. The facilitator asks a volunteer to write the participants’ answers on the flipchart.

3. The facilitator walks participants through each answer and asks each time: Should this activity take place right before the counseling? Why?

4. The facilitator concludes by explaining that the assessment should be carried out before nutritional counseling. The assessment helps the ANC provider gain better knowledge and understanding of the pregnant woman’s nutritional situation (status, eating habits, and food availability)


Activity 2: Components of nutritional assessment: Questions and answers

1. The facilitator asks participants the following question:

• What are the indicators and information to be collected during the nutritional assessment?

2. The facilitator asks a volunteer to write participants’ answers on the flipchart.

3. The facilitator asks a volunteer to regroup the indicators and information to collect during nutritional assessment.

4. The facilitator concludes by presenting the PowerPoint 3.4, Nutritional assessment, and stresses the importance of integrating nutritional assessment in the assessment carried out in the ANC visit.

5. The facilitator solicits questions and answers from participants.

30 min Flipchart Markers Masking tape PowerPoint 3.4 Nutritional assessment


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b) Nutritional counseling

Activity 3: Nutritional counseling

1. The facilitator asks participants to work in pairs for 5 min to prepare role play on providing a 10 minute nutritional counseling session. He distributes the following topics:

A) Pregnant woman gaining weight regularly

B) Pregnant woman not gaining weight

C) Pregnant woman feeling tired and is anemic

2. The facilitator distributes the key messages on nutrition during pregnancy to participants

3. The facilitator distributes observation checklist to participants to help them observe the counseling session in a structured manner

4. The facilitator asks group A to do the role play for 10 minutes. The facilitator asks group A to explain what the pregnant woman’s situation is.

5. The facilitator asks the other participants to provide feedback by stating what worked well, what needed to be improved, and suggestions on how to improve.

6. After each session of feedback, the facilitator summarizes by stating all the points to cover in the counseling session.

7. The facilitator proceeds the same way with group B and group C

80 min PowerPoint and Handout 3.5 Case studies / exercises A, B, C Handout 3.6 Key nutritional care messages for pregnant women PowerPoint and Handout 3.7: Observation checklist of nutritional counseling for HIV- negative pregnant women

Activity 4: Demonstration of a model counseling for HIV-negative pregnant women

1. The facilitator presents a model role play counseling session

2. The facilitator solicits and answers questions from participants

20 min


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HANDOUTS PowerPoint presentation and Handout 3.1: Recommended energy intake during pregnancy for HIV-negative women or of unknown HIV status

RECOMMENDED ENERGY INTAKE AND WEIGHT GAIN DURING PREGNANCY

BMI INCREASE IN ENERGY

INTAKE (KCAL/DAY) WEIGHT GAIN (KG)

19.8–25.9 300 11.5–16

26–29 < 300 7–11.5

≤ 19.8 > 300 12.5–18.0

PowerPoint and Handout 3.2: List of available and affordable snacks to meet the additional 300kcal/day for pregnant women

SNACKS—300 KCAL

1. Chapati with oil (1)

2. Mandazi (2)

3. Kitumbua (2)

4. Scone/bun (2)

5. Bread (3 slices)

6. Cake (2 slices)

7. Bhajia (3 pieces)

PLUS any One of these

Orange (1 medium size) OR,

Guava ( 2 medium size) OR,

Mango (1 small or ½ of a medium size) OR,

Papaya (1/5 of a medium size) OR,

Banana (1 big size or 3 small)

8. Dried cashew nut 1 package

9. Roasted groundnut 1 package

10. Roasted cashew nut 1 package

11. 2 cups of milk

12. 2/3 cup of sour milk

Table 3.4: List of Foods and Quantity/Amount and Energy Content

FOOD LOCAL MEASUREMENT/QUANTITY

AMOUNT (GRAM)

ENERGY CONTENT (KCAL)

1. Cereals

Chapati (dry) 1 50 104

2 100 208

Chapati (with oil) 1 50 186

Chapati 2 100 372

Mandazi 2 50 239

Kitumbua–Rice bun 1 50 180

Kitumbua- Rice bun 2 75 205

Scone/bun (Standard) 2 96 263

Bread (sliced) 3 slices 99 270


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FOOD LOCAL MEASUREMENT/QUANTITY

AMOUNT (GRAM)

ENERGY CONTENT (KCAL)

Maize (boiled)

Maize (roasted)

Cake 2 slices 50 187

Cake 3 (slices) 100 374

2. Dried legumes

Bhajia (small) 4 88 356

Groundnut (roasted) 1 package 55 327

Cashew nut (roasted) 1 package 55 302

Dried cashew nut 1 package 55 297

Sesame seed

3. Milk products

Milk 1 cup 250 ml 150

Sour milk 1 cup 250 ml 300

PowerPoint presentation and Handout 3.3: Vitamins and minerals needs/requirements for HIV-negative pregnant women or pregnant women with unknown HIV-status–Daily recommended intake of each nutrient

MICRONUTRIENT PREGNANT AND

LACTATING WOMEN GOOD FOOD SOURCES OF EACH NUTRIENT

Vitamin A 800μg Liver, eggs, milk, cheese, dagaa, papaya, carrot, palm oil, mango, tomato, avocado, pumpkin, yellow sweet potatoes, okra, dark green leafy vegetables such as sweet potato leaves, spinach, amaranths

Vitamin D 5μg Egg yolks, saltwater fish, liver, and vit D fortified foods e.g. margarine and milk

Vitamin E 10mg Avocado, groundnuts, cashew nuts, oyster nuts , corn oil, spinach, liver, egg yolk and mango

Vitamin C 70mg Orange, tangerines, tamarind, lime, lemon, guava, baobab fruits, grape fruits, grapes, passion fruit, mabungo, strawberries, tomatoes, broccoli and other leafy greens.

Thiamine (vitamin B1) 1.4mg Whole grain cereals, wheat germ, maize, millet and sorghum, lean meat especially pork, liver, poultry, eggs, fish, dried beans, peas and soybeans.

Riboflavin (vitamin B2) 1.4mg Whole grain cereals, wheat germ, maize, millet and sorghum, fish , lean meats, eggs, legumes, nuts (groundnuts, cashew nuts, oyster nuts), pumpkin seeds, sunflower seeds, sesame seeds , green leafy vegetables, dairy products, and milk

Niacin (vitamin B3) 18mg Whole grain cereals wheat germ, maize, millet and sorghum , dairy products and milk, poultry, fish, lean meats, nuts especially groundnuts, legumes, mushroom, avocado, baobab fruits and eggs.

Vitamin B6 1.9mg Nuts, legumes, eggs, meats, fish, whole grains, sweet potatoes ,avocado and cabbage

Vitamin B12 2.6mg Eggs, meat, poultry, shellfish, milk, and milk products, fermented foods e.g. yoghurt and togwa


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MICRONUTRIENT PREGNANT AND LACTATING WOMEN GOOD FOOD SOURCES OF EACH NUTRIENT

Folic acid 400μg Beans and legumes, orange, tangerines, tamarind, lime, lemon, guava, baobab fruits, grape fruits, grapes, passion fruit, mabungo, strawberries, whole grains cereals, dark green leafy vegetables, meat, poultry, shellfish, fish , liver, oranges and avocado

Iron 60mg Whole grain cereals especially finger millet, liver, red meat, chicken, soybean, legumes especially dried such as pigeons peas, cow peas, chick peas, lentils, dark green leafy vegetables and fish

Selenium 65μg Liver, milk, onions, sea foods, liver, carrots, beef, rice, chicken, and egg

Iodine 150μg Iodized salt, fish and sea foods

PowerPoint presentation and Handout 3.4 on the components of nutritional assessment

• Physical assessment Anthropometric measurements: Weight gain during pregnancy and, if available, BMI and

MUAC (Mid-upper-arm circumference). MUAC of less than 23 cm indicates nutrition risk.

• Dietary assessment Eating patterns: foods regularly consumed and frequency of meals Foods available and affordable Food intolerance and aversions Dietary problems (e.g., poor appetite, difficulty chewing and swallowing, gastrointestinal

problems, pain in mouth and gums) Hygiene and food preparation and handling practices Psychosocial factors contributing to inadequacy of intake, such as social isolation,

depression, stigma, inability to prepare food Fatigue and physical activity Use of vitamin and mineral supplements and alternative practices

• Medical history GI problems (e.g., diarrhea, abdominal pain, nausea, vomiting) Pattern of bowel movements (constipation) Presence of opportunistic infections Concurrent medical problems (e.g., diabetes, hypertension, malaria) Physical condition (Examination)

• Medication profile Medication taken Side effects of medications: Negative effects of food intake or malabsorption of nutrients

• Biochemical profile (where available) Serum albumin Evaluation of anemia (iron, B12, and folate status) Urinalysis (for proteinuria)

• Psychosocial Living environment and functional status (income, housing, amenities to cook, access to food,

attitude regarding nutrition and food preparation)


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HANDOUTS 3.5 SCENARIO A, B, AND C.

ROLE PLAY–SCENARIO A Mary, 26, is married and is six months pregnant. Mary is expecting her second child. In Mary’s medical note book, it is recorded that she weighed 52 kg before she became pregnant for the second time and she is HIV-negative. Mary is 1.60 m tall. Mary came to the first antenatal visit when she was four months pregnant and her weight was 54 kg. Her actual weight is 56 kg. Mary explained that she is tired. Mary takes iron and folic acid every day. • Conduct a nutritional assessment with Mary. What additional information do you

need to collect to be able to accurately define Mary’s nutritional status/problems? • Provide nutritional counseling to Mary

ROLE PLAY–SCENARIO B

Jane is 30 and is pregnant for the first time. Jane is HIV-negative. Jane’s weight was 55 kg before she became pregnant. Jane is seven month pregnant. Jane’s weight at seven months of pregnancy is 59 kg. According to Jane’s medical records, Jane has regularly gained weight between the second and fifth months. Since last month, Jane did not gain any weight. Jane complains of loss of appetite. Jane said that she takes iron and folic acid tablets every day. • Carry out a nutritional assessment and counseling session with Jane. Explain the

information you will collect during the nutritional assessment and demonstrate and you will use this information during nutritional counseling with Jane.

ROLE PLAY–SCENARIO C

Martha, 32, is married and is six months pregnant. Martha is expecting her second child. In Martha’s medical note book, it is recorded that she weighed 60 kg before she became pregnant for the second time and she is HIV-negative. Martha is 1.60 m tall. Martha’s is 64 kg. Martha explains that she is tired. Martha does not take any supplements. She said she was given some tablets to take every day when she came the first time to the ANC. She stopped taking the tablets because she said they made her really sick • From the information provided, what is Martha’s nutritional status/problems? • What additional information do you need to collect to be able to accurately define

Mary’s nutritional status/problems and how will you get that information? • Provide nutritional counseling to Mary for 10 minutes.


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PowerPoint presentation and Handout 3.6: Key nutritional and care messages: essential nutrition actions for HIV-negative pregnant women or pregnant women with HIV unknown status

NUTRITIONAL ASSESSMENT ESSENTIAL NUTRITION ACTIONS MESSAGE FOR HIV-NEGATIVE PREGNANT WOMEN

Pre-pregnancy BMI is normal and weight gain is regular (1kg/month in the last trimester)

Eat three meals and one snack every day

Rest more during pregnancy

Increase daily consumption of fruits and vegetables, animal products, and fortified foods

No sign of micronutrient deficiency Take 60 mg of iron and 400μg of folic acid every day for 180 days along with orange, pineapple, or citrus juice. Restrict consumption of tea, coffee, and cocoa.

Take supplements between meals or before going to bed with a little fruit juice or water. Side effects may include dark or black stools, gastric upset, nausea, diarrhea, or constipation. They are not serious and should subside in a few days. To manage side effects, take supplements with meals (instead of between meals or before bed). Split scored tablets in half and take each half at different time of the day.

Take presumptive treatment for hookworm

Use insecticide-treated nets. Take anti malarial drugs. Seek treatment for fever.

For malnourished pregnant women

If anemic Consume a daily dose of 120 mg iron + at least 400 μg folic acid for 3 months along with orange, pineapple, or citrus juice. Restrict consumption of tea, coffee, and cocoa

If weight gain is less than 1kg/month during the second and third trimester

Eat more than three meals and one extra snack per day Rest more


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PowerPoint presentation and Handout 3.7: Checklist for the observation of a counseling session with HIV-negative pregnant women. This checklist should be used to observe the counseling session during role-play in classroom setting and during clinical practice. After the counseling session, the ANC provider who did the observation will provide feedback to her/his peer following the sequence on the checklist.

OBSERVATION POINTS YES NO COMMENTS

The ANC provider:

1. Contact with the client

Greets the client

Introduces her/himself

Treats the client with respect and acceptance

Listens carefully and actively and shows empathy to the client’s need and concerns

Makes eye contact when talking with the client

The counselor asks the client about:

2. Assessment

2.1. Dietary practices

Food frequently eaten

Number of meals per day

Period of food shortage

Food affected by shortage

Client’s coping strategy during food shortage

Most available and affordable foods

Supplements being taken (Including iron and folic acid)

Adherence to iron supplements

2.2. Medication profile

Drugs the client is taking

Types and frequency of problem experienced with these drugs

3. Proposed options


Meal frequency

Food diversity

Increased amount of food intake

Daily consumption of iodized salt

Having enough rest


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How many iron tablets to take daily

When to take iron supplements

Management of side effects of iron and folic acid side effects

Foods or drinks to take with iron tablets

Foods or drinks to avoid when taking iron tablets

How to store iron supplements

Where to return for more tablets

4. Follow up

4.1. Schedule a follow up meeting


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LECTURE NOTES 3 NUTRITIONAL COUNSELING FOR HIV-NEGATIVE

PREGNANT WOMEN OR WITH HIV UNKNOWN STATUS The physiological changes that occur during pregnancy require extra nutrients for adequate gestational weight gain in order to support the growth and development of the fetus.

3.1 ENERGY REQUIREMENTS Pregnancy increases a woman’s nutritional requirements/ needs. Extra energy is needed for the growth of the fetus, placenta, and associated maternal tissues. If a woman’s nutritional intake is inadequate during pregnancy, her fetus keeps growing at the expense of her own nutritional status. The recommended additional energy intake and weight gain during pregnancy is listed in Box 3.1. A pregnant woman in good nutritional status (19.8 <BMI< 26) before the pregnancy needs an additional 300 kcal per day to meet her energy needs, ensure proper growth for the fetus, and store fat reserves to prepare for lactation. Women who enter pregnancy underweight (BMI < 19.8) need more calories to achieve adequate weight gain. Women who are overweight (26 <BMI< 29) when they enter pregnancy do not need up to 300 kcal additional per day. Health workers should assess the nutritional status of the pregnant women and tailor the message to her specific situation. Furthermore, maternal requirements for protein, folate, niacin, zinc, iron and iodine in particular are higher than before pregnancy. During the first half of pregnancy, extra nutrients are primarily required for the increase in maternal tissues, such as expansion of blood and extra-cellular fluid volume, enlargement of the uterus and mammary tissue and fat deposition. During the third trimester, the additional nutrients are mainly used by the fetus for rapid growth and storage. Frequency of meals Pregnant women should increase the frequency of meals to meet their daily energy needs. It is recommended that pregnant women have a snack every day in addition to the regular 3 meals per day to meet their daily energy requirement.

BOX 3.1: RECOMMENDED ENERGY INTAKE AND WEIGHT GAIN DURING PREGNANCY

BMI INCREASE IN ENERGY INTAKE (KCAL/DAY) WEIGHT GAIN (KG)

19.8–25.9 300 11.5–16

26–29 < 300 7–11.5

≤ 19.8 > 300 12.5–18.0

Table 3.4 gives a list of available and affordable snacks in Tanzania that can be used by ANC care providers in Tanzania during nutritional counseling for pregnant women to help the clients visualize the types and amount of foods required to meet the additional 300 kcal/day.


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Table 3.4: List of available and affordable snacks (300kcal) for pregnant women. Pregnant women need an additional 300 kcal/day

SNACKS—300 KCAL

1. Chapati with oil (1)

2. Mandazi (2)

3. Kitumbua (2)

4. Scone/bun (2)

5. Bread (3 slices)

6. Cake (2 slices)

7. Bhajia (3 pieces)

PLUS any One of these

Orange (1 medium size) OR,

Guava ( 2 medium size) OR,

Mango (1 small or ½ of a medium size) OR,

Papaya (1/5 of a medium size) OR,

Banana (1 big size or 3 small)

8. Dried cashew nut 1 packet (55grams)

9. Roasted groundnut 1 packet

10. Roasted cashew nut 1 packet

11. 2 cups of milk

12. 2/3 cup of sour milk

3.2 VITAMIN AND MINERAL REQUIREMENTS

Vitamin and mineral needs are increased during pregnancy. Daily iron and folic acid supplementation (60 mg of iron and 400 µg of folic acid) is recommended for all pregnant women for six months during pregnancy and, if the woman is anemic, she should continue the supplementation for six months post-partum (WHO 2001). Currently the Tanzania policy on micronutrient supplementation recommends pregnant women to be supplemented with 200 mg iron and 1.0 mg folic once a day throughout pregnancy. Tanzania policy on micronutrient needs to be updated to reflect WHO recommendations on the topic which are 60 mg iron and 400 µg folic acid per day. Women taking iron supplements may have dark or black stools, gastric upset, nausea, diarrhea, or constipation. ANC providers should explain to the pregnant woman that the side effects will subside in a few days. ANC providers should also counsel the pregnant woman on the management of the side effects if they are persistent. Refer to Box 2. Some foods contain substances that can inhibit the absorption of iron. These substances are: • Phytates in whole grains • Polyphenols such as tannins in legumes, coffee, tea, and cocoa • Calcium salts in milk products • Oxalates in green leafy vegetables • Plant protein such as in soybeans and nuts


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Other foods contain substances that enhance iron absorption. These substances are: • Vitamin C in fruits and raw vegetables • Animal blood, organ, and muscle products • Some fermented and germinated foods such as soy sauce and leavened bread • Citric and other organic acids ANC providers should counsel the pregnant woman on the type of foods to eat while taking iron and folic acid supplements to enhance iron absorption. Refer to Box 3.2 for the counseling points.

BOX 3.2: COUNSELING PREGNANT WOMEN AND MOTHERS ABOUT IRON SUPPLEMENTS COUNSELING POINTS When and how to take supplements Take supplements between meals or before going to bed with a little fruit juice or water. How to store supplements Keep tablets in a cool storage Where to return for tablets Return for more tablets at the health center Side effects They may include dark or black stools, gastric upset, nausea, diarrhea, or constipation. They are not serious and should subside in a few days. Managing side effects Take supplements with meals (instead of between meals or before bed). Split scored tablets in half and take each half at different time of the day. Importance of taking all supplements Take all supplements to ensure the health of the baby and the health and strength of the mother. No negative effects Iron is not a medicine and will not harm the unborn baby. Iron does not increase the baby’s weight. Iron does not increase the amount of blood or cause high blood pressure. Galloway et al. (2002)

It is recommended that pregnant women have a diversified diet with fruits, vegetables, cereals and bananas roots and tubers, fats, oil sugar and honey, pulses, nuts and foods of animal origin (fish, meat, milk, eggs, edible insects). Pregnant women and their household should also consume iodized salt every day to meet their iodine needs. Nutrition recommendations for pregnant women are listed in Box 3.2.1.


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BOX 3.2.1: NUTRITION RECOMMENDATIONS FOR PREGNANT WOMEN

• Weight gain: 12–16 kg

• Daily additional energy intake: 300kcal/day

• Diversified diet

• Iron and folic acid supplementation: 60mg of iron and 400 μg folic acid every day

• Daily consumption of iodized salt

• Prevention and treatment of malaria

• Provide presumptive hookworm treatment

• Adequate rest

3.3 NUTRITIONAL COUNSELING FOR HIV–NEGATIVE PREGNANT

WOMEN AND WITH UNKNOWN HIV STATUS ANC providers should: • Assess the nutritional status of all pregnant women • Treat, educate and provide nutrition counseling • Carry out follow up sessions 3.3.1 NUTRITIONAL ASSESSMENT

The nutritional counseling session should always start with a proper nutritional assessment to help the ANC provider gather information on nutritional status and eating patterns to help identify risk factors for developing nutritional complications. Nutritional assessment also helps identify and track body changes. It has to be part of the medical assessment. The nutritional assessment should include: • Physical assessment

• Anthropometric measurements: Weight gain during pregnancy and, if available, BMI and MUAC (Mid-upper-arm circumference). MUAC of less than 23 cm indicates nutrition risk.

• Dietary assessment • Eating patterns: foods regularly consumed and frequency of meals • Foods available and affordable • Food intolerance and aversions • Dietary problems (e.g., poor appetite, difficulty chewing and

swallowing, gastrointestinal problems, pain in mouth and gums) • Hygiene and food preparation and handling practices • Psychosocial factors contributing to inadequacy of intake, such as

social isolation, depression, stigma, inability to prepare food • Fatigue and physical activity • Use of vitamin and mineral supplements and alternative practices

• Medical history • GI problems (e.g., diarrhea, abdominal pain, nausea, vomiting) • Pattern of bowel movements (constipation)


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• Presence of opportunistic infections • Concurrent medical problems (e.g., diabetes, hypertension, malaria) • Physical condition (swelling of hands and face, blood pressure

measurement) • Medication profile

• Medication taken • Side effects of medications: Negative effects of food intake or

malabsorption of nutrients • Biochemical profile (where available)

• Serum albumin • Evaluation of anemia (iron, B12, and folate status) • Urinalysis (for the proteinuria)

• Psychosocial • Living environment and functional status (income, housing, amenities

to cook, access to food, attitude regarding nutrition and food preparation)

The ANC provider should review the information collected during the nutrition assessment to identify the positive actions/behaviors/practices that should be maintained and the actions/behaviors/practices that are not appropriate that should be changed or adjusted. The ANC provider will also propose to the pregnant woman some actions/practices to help improve her nutritional status.

3.3.2 TREAT, EDUCATE AND COUNSEL The ANC provider should treat any vitamin or mineral deficiency. Nutrition education and counseling are important to help the mother understand the need to maintain an adequate food intake and diet. During education and counseling sessions with the HIV-negative pregnant woman, the ANC provider should always: • Assess current diet and food availability. • Congratulate the pregnant woman for the positive actions/practices that

she is already implementing. • Always propose options that are acceptable, affordable, and feasible for

the woman. • Encourage the pregnant woman to try new options that could help improve

her nutritional status. The health worker should highlight the benefits the pregnant woman should expect when she implements the recommended actions.

The actions for the ANC provider and the essential nutrition actions messages for HIV-negative women are listed in Table 3.5.


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Table 3.5: Actions for the ANC Provider and Essential Nutrition Actions for HIV- Negative Pregnant Women

ASSESSMENT ANC PROVIDER ACTIONS ESSENTIAL NUTRITION ACTIONS FOR HIV-NEGATIVE PREGNANT WOMEN


Counsel on:

Increasing food intake and frequency of meals

Reducing workload

Diet diversification

Eat three meals and one snack every day



No sign of micronutrient deficiency

Prescribe iron and folic acid tablets, and counsel about taking the full dose

Promote consumption of foods that enhance iron absorption

Counsel on coping with side effects of supplements

Provide presumptive hookworm treatment, starting the second trimester

Prevent and treat malaria

Take 60 mg of iron and 400μg of folic acid every day for 180 days along with orange, pineapple, or citrus juice. Restrict consumption of tea, coffee, and cocoa.

Refer to Box 3.2 Presumptive treatment for hookworm in

pregnant women Use insecticide-treated nets. Take anti

malarial drugs. Seek treatment for fever.


If Anemic Treat severe anemia Consume a daily dose of 120 mg iron + at least 400 μg folic acid for 3 months along with orange, pineapple, or citrus juice. Restrict consumption of tea, coffee, and cocoa.


Counsel on increasing food intake and frequency of meals

Eat more than three meals and one extra snack per day

Rest more

3.3.3 FOLLOW UP AND ADJUST

At the end of the counseling session, the ANC provider should schedule a follow-up meeting with the pregnant woman. The items to review and address during the follow-up counseling session are listed in Box 3.4. The ANC provider should meet with the pregnant woman at least once every three months to monitor the pregnant woman’s weight gain and food intake and counsel accordingly. The ANC provider should also make sure that the pregnant woman is taking iron and folic acid supplements as prescribed. The ANC provider should always look for and treat vitamin and mineral deficiencies.

BOX 3.3.3: ITEMS TO REVIEW AND ADDRESS DURING FOLLOW-UP OF NUTRITIONAL COUNSELING SESSIONS WITH HIV-NEGATIVE PREGNANT WOMEN • Weight gain and food intake

• Adherence to iron and folic acid supplements

• Micronutrient deficiencies


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SESSION 4 NUTRITIONAL COUNSELING FOR

HIV–POSITIVE PREGNANT WOMEN

4.1 INTRODUCTION This session provides information on nutritional care needs for HIV-positive pregnant women and contains practical exercises/role play on nutritional counseling for HIV- positive pregnant women. Most essential nutrition actions for HIV-negative pregnant women are the same as for HIV-positive women; selected information that is relevant for both HIV-negative and HIV-positive pregnant women are repeated in this session.

4.2 PURPOSE AND OBJECTIVES The purpose of this session is to enhance participants’ knowledge and skills on nutritional counseling for HIV-positive pregnant women. Objectives At the end of this session, participants will be able to: • Describe the energy and vitamin and mineral needs/ requirements and key

nutritional care messages for HIV-positive pregnant women • Demonstrate how to counsel HIV-positive pregnant women

4.3 HANDOUTS PowerPoint presentation and Handout 4.1.a: Energy needs/requirements for HIV- positive women PowerPoint presentation and Handout 4.1.b: Vitamin and mineral needs/ requirements and key nutrition and care messages for HIV-positive women PowerPoint presentation and Handout 4.2: Key nutrition and care messages–essential nutrition actions for HIV-positive pregnant women PowerPoint presentation and Handout 4.3: Components of nutritional assessment for HIV-positive women Handout 4: Scenario/Exercises A and B. PowerPoint presentation and Handout 4.5: Observation checklist for nutritional counseling for HIV-positive pregnant women

LECTURE NOTES 4: MEETING THE NUTRITIONAL CARE NEEDS OF HIV-POSITIVE PREGNANT WOMEN


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4.4 APPENDICES Appendix 1: Food safety Appendix 2: Dietary management of common AIDS problems Appendix 3: Food and nutrition implications of ARVs Appendix 4: Dietary management of food/nutrition and drugs interactions

4.4 OUTLINE Duration: 3 hours 25 minutes


1. Energy and vitamin and mineral needs/ requirements and key nutrition and care messages for HIV-positive women

a) Energy and

micronutrient requirements

Activity 1: Energy needs/requirements for HIV-positive pregnant women: Questions and answers

1. The facilitator distributes to participants the handout on the energy and vitamin and mineral needs/ requirements for HIV-negative pregnant women.

2. The facilitator asks participants the following questions:

a) Do energy needs/requirements for HIV-positive pregnant women differ from HIV-negative pregnant women? If so how is it different?

b) How are vitamin and mineral needs/requirements for HIV-positive pregnant women different from those of HIV-negative pregnant women?

3. The facilitator hangs two flipcharts on the wall, one with the heading “Energy needs/requirements for HIV-positive pregnant women”, and the second with the following heading “Vitamins and mineral needs/requirement for HIV-positive pregnant women”

4. The facilitator asks a volunteer to write the answers on the flipchart. The facilitator asks participants to give the answer to question A first and then to question B.

5. The facilitator wraps up the session by presenting PowerPoint presentation 4.1 on energy and vitamins and minerals needs/requirements for HIV positive pregnant women

40 min Flipchart Markers Masking tape PowerPoint presentation 4.1 Energy and Vitamin and mineral needs/requirements for HIV-positive of pregnant women


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b) Nutrition and care messages for HIV-positive pregnant women: Essential nutrition actions for HIV-positive women

Activity 2: Nutrition and care for HIV-positive pregnant women: Questions and answers

1. The facilitator asks participants to list the additional nutrition and care needs for HIV-positive pregnant women

2. The facilitator asks each participant to give one specific nutrition and care service/message and explain why the specific care service is required/ recommended for HIV-positive pregnant women.

3. The facilitator concludes by presenting key nutrition and care messages for HIV-positive pregnant women using PowerPoint presentation 4.2

30 min PowerPoint and Handout 4.2 Nutrition and care messages for HIV positive pregnant women

4. Nutritional counseling for HIV-positive pregnant women

a) Nutritional

assessment

Activity 1: Nutritional assessment: Work in pairs

1. The facilitator asks participants to work in pairs for 10 minutes; each pair should review the information in the handouts on nutritional assessment for HIV-negative pregnant women and:

(i) add the additional indicators and information that should be collected for HIV-positive pregnant women, and

(ii) delete the indicators and information that do not apply to HIV-positive pregnant women.

2. The facilitator asks each participant to read his/her answer and to indicate the information to be added and why and the information to be deleted and why.

3. The facilitator concludes by presenting indicators and information to be collected during nutritional assessment for HIV-positive pregnant women (PowerPoint 4.3).

25 min PowerPoint presentation 4.3 Nutritional assessment for HIV-positive pregnant women.


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b) Nutritional counseling

Activity 2: Nutritional counseling

1. The facilitator asks participants to work in pairs to prepare a counseling session role play for 5 minutes. He distributes the following scenarios/exercises:

(i) Nutritional counseling for HIV-positive asymptomatic pregnant woman

(ii) Nutritional counseling for HIV-positive symptomatic pregnant woman

2. The facilitator distributes the observation checklist to help participants observe the counseling session and give feedback in a structured manner

3. The facilitator asks pairs working on scenario (i) to do the role play for 10 minutes. The facilitator asks each pair to start by explaining what the pregnant woman’s situation/problem is.

4. After the counseling session, the facilitator asks other participants to provide feedback by stating by what was well done, what needed to be improved, and how to improve.

5. After each session of feedback, the facilitator summarizes by stating all the points to be covered in the nutritional counseling session for HIV-positive asymptomatic pregnant women.

6. The facilitator proceeds the same way with the pairs working on scenario (ii)

80 min Handout 4.4 Exercises i) and ii) Handout 4.2 Key nutrition and care messages for HIV-positive pregnant women Handout 4.5 Nutritional counseling observation checklist for HIV-positive pregnant women

Activity 3: Demonstration of a model nutritional counseling for HIV-positive symptomatic pregnant woman

1. The facilitator presents a model role play nutritional counseling for HIV-positive symptomatic pregnant woman

2. The facilitator solicits and answers questions from participants

20 min


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HANDOUTS PowerPoint presentation and Handout 4.1a: Energy needs/requirements for HIV- positive women

WHO recommendations are the following: Asymptomatic HIV-positive pregnant women need to increase energy intake by 10% to maintain body weight and physical activity. During symptomatic HIV infection and subsequently during AIDS, HIV-positive pregnant women should increase energy intake by about 20% to 30% to maintain body weight. HIV-positive pregnant women should increase the quantity of foods and the frequency of meals in order to meet their energy needs. Recommended Frequency of Meals for HIV-Positive Pregnant Women

HIV-NEGATIVE HIV-POSITIVE ASYMPTOMATIC

HIV-POSITIVE SYMPTOMATIC

Frequency of meals

3 meals and one snack At least 4 meals or 3 meals and 2 snacks

At least 4 meals and 2 snacks

PowerPoint presentation and Handout 4.1b: Vitamins and mineral requirements for HIV-positive pregnant women

Adequate micronutrient intake is best achieved through an adequate diet. However, in settings where these intakes and status cannot be achieved, multiple micronutrient supplements may be needed in pregnancy and lactation. Pending additional information, micronutrient intakes at the RDA level are recommended for HIV-infected women during pregnancy and lactation. WHO, 2003


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PowerPoint presentation and Handout 4.2: Key nutrition and care messages; essential nutrition actions for HIV-positive pregnant women.

ASSESSMENT ESSENTIAL NUTRITION ACTIONS FOR THE HIV-POSITIVE PREGNANT WOMAN

If asymptomatic Pre-pregnancy BMI is normal and weight gain is regular (1kg/month in the last trimester)

Eat at least three meals and two extra snacks every day




Take presumptive treatment of hookworm


Drink clean water and wash hands before meals and after using toilet

Keep hands and food preparation areas clean

Separate raw foods from cooked foods and the utensils used with

them

Cook fresh and reheated foods thoroughly

Keep food at safe temperatures

If symptomatic Follow the ANC provider’s advice on the dietary management of common HIV-related problems

Follow the ANC provider’s advice on the dietary management of food and drug interactions to maintain or increase food intake and to reduce nutrient absorption.

If symptomatic and wasting

Eat small and frequent meals

Rest more


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PowerPoint presentation and Handout 4.3: Components of nutritional assessment for HIV-positive pregnant women

Nutritional assessment for HIV-positive pregnant women For HIV-positive asymptomatic pregnant women, the information to collect during the nutritional assessment is the same as for HIV-negative pregnant women. For HIV-positive symptomatic pregnant women:

In addition to the information for HIV-negative pregnant women, ANC providers should research and collect information on:

• Symptoms that have negative impact of food intake or food absorption

• Side effects of medications that have negative effects on food intake or malabsorption of nutrients

• Stigma


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HANDOUT 4.4 SCENARIOS/EXERCISES (i) AND (ii)

Scenarios/Exercises (i) Judith is 20 and is pregnant for the first time. Judith is HIV-positive. Judith’s weight was 55 kg before she became pregnant. Judith is seven month pregnant. Judith’s weight at seven months of pregnancy is 62 kg. According to Judith’s medical records, Judith gains weight every month. Judith said she is fine and does not have any complaints. She takes iron and folic acid tablets every day. • Carry out Judith’s nutritional assessment and counseling for 15 minutes Scenarios/Exercises (ii) Sally is 35 and is pregnant for the first time. Sally is HIV-positive. Sally’s weight was 55 kg before she became pregnant. Sally is seven month pregnant. Sally’s weight at seven months of pregnancy is 60 kg. According to Sally’s medical records, Sally gained weight between the second and fifth months. Since last month, Sally did not gain any weight. Sally complains of thrush. Sally reported that she takes iron and folic acid tablets every day. • What is Sally’s nutritional status/problems? • Carry out the nutritional assessment and counseling session with Sally for 15

minutes and explain what information you are planning to collect during the assessment and demonstrate how you will use that information during the counseling session


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PowerPoint presentation and Handout 4.5: Checklist for the observation of a counseling session with HIV-positive pregnant women. This checklist should be used to observe the counseling session during role-play in the classroom setting and during clinical practice. Not all the points should be covered during the same counseling session. The points related to HIV-positive women should be addressed when the problem occurs. For example, for an HIV-positive asymptomatic woman who is not taking any medication, skip the sections on dietary management of AIDS-related symptoms and management of food/nutrition and drugs when you are presenting the options. After the counseling session, the ANC provider who did the observation will provide feedback to her/his peer following the sequence on the checklist.


The ANC provider:

1. Contact with the client

Greets the client

Introduces her/himself

Treats the client with respect and acceptance

Listens carefully and actively and show empathy to the client’s need and concerns

Makes eye contact when talking with the client

The counselor asks the client about:

2. Assessment


Food frequently eaten

Number of meals per day

Period of food shortage

Food affected by shortage

Client’s coping strategy during food shortage

Most available and affordable foods

Supplements being taken (Including iron and folic acid)

Adherence to iron supplements

2.2. Medication profile

Drugs the client is taking

Types and frequency of problem experienced with these drugs

2.3. Food safety

Hand washing

Drinking water and cooking and storing foods

2.4. Psycho-social support

Stigma and depression


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2.5. AIDS-related symptoms

Symptoms that affect food intake

Symptoms that affect nutrient absorption

3. Proposed options


Meal frequency

Food diversity

Increased amount of food intake

Daily consumption of iodized salt

Having enough rest

How many iron tablets to take daily

When to take iron supplements

Management of side effects of iron and folic acid side effects

Foods or drinks to take with iron tablets

Foods or drinks to avoid when taking iron tablets

Where to store the iron tablets

Where to get the tablets

3.2. Food and water safety

Hand washing

Drinking water and food cooking and storage

3.3. Psycho-social support

Referral to community support group

3.4. Dietary management of AIDS-related symptoms

Food to use to address each symptom

Care and nutritional practice for each symptom

3.5. Management of food/nutrition and drugs interactions

Management of the side effects of each drug including iron and folic acid. Foods to alleviate the side effects

Recommended timing for food and each drug

Foods to avoid while taking the medication

4. Follow up

4.1. Schedule a follow up meeting


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LECTURE NOTES 4 MEETING THE NUTRITIONAL NEEDS OF

HIV–POSITIVE PREGNANT WOMEN

4.1 NUTRITIONAL CARE FOR HIV-POSITIVE WOMEN HIV infection affects nutritional status by causing increased energy requirements, reductions in dietary intake, nutrient malabsorption and loss, and complex metabolic alterations that culminate in the weight loss and wasting that are common in AIDS. HIV-positive pregnant women need additional nutritional care to mitigate the impact of HIV on their nutritional status and slow the progression of disease. Goals of nutritional care for HIV-positive women are to: • Maintain or increase weight–Encourage diversified diet • Prevent food-borne illnesses–Ensure that food and water are not contaminated and

that storage and handling are safe • Promptly treat opportunistic infections and manage the symptoms that affect food

intake to minimize the nutritional impact of secondary infections The components of nutritional care are: • Adequate energy intake • Adequate vitamins and minerals intake • Food safety • Dietary management of AIDS-related symptoms • Dietary management of food/nutrition and drugs interactions • Psycho-social support Energy requirements (Refer to table 4.1) HIV infection increases energy requirements because of elevated resting energy expenditure. Wasting syndrome, as defined by the Centers for Disease Control and Prevention (CDC), is an involuntary loss of >10% of the baseline (usual) body weight plus either chronic diarrhea, weakness, or documented fever, in the absence of a concurrent illness or condition. WHO recommendations are the following: Asymptomatic HIV-positive pregnant women need to increase energy intake by 10% to maintain body weight and physical activity. During symptomatic HIV infection and subsequently during AIDS, HIV-positive pregnant women should increase energy intake by about 20% to 30% to maintain body weight.


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HIV-positive pregnant women should increase the quantity of foods and the frequency of meals in order to meet their energy needs. Table 4.1 provides an indication of the frequency of meals for HIV-positive pregnant women.

Table 4.1: Recommended Frequency of Meals for HIV-Positive Pregnant Women

HIV-NEGATIVE HIV-POSITIVE ASYMPTOMATIC

HIV-POSITIVESYMPTOMATIC

Frequency of meals

3 meals and one snack At least 4 meals or 3 meals and 2 snacks

At least 4 meals and 2 snacks

The content of nutrition care counseling for pregnant women living with HIV/AIDS will vary according to nutritional status and the extent of disease progression. 4.1.1 VITAMIN AND MINERAL REQUIREMENTS

WHO’s recommendation for HIV-positive pregnant women is to consume a diet that is nutritionally adequate rather than to rely on high-dose supplements of vitamins and minerals. When available and affordable, a daily multiple micronutrient supplement given to HIV-positive pregnant and lactating women may improve both birth outcomes and maternal health. Refer to Box 4.1.1 for WHO recommendations for multiple micronutrient supplements in pregnant women.

BOX 4.1.1: MULTIPLE MICRONUTRIENT SUPPLEMENTS Adequate micronutrient intake is best achieved through an adequate diet. However, in settings where these intakes and status cannot be achieved, multiple micronutrient supplements may be needed in pregnancy and lactation. Pending additional information, micronutrient intakes at the RDA level are recommended for HIV-infected women during pregnancy and lactation. WHO, 2003

4.1.2 FOOD AND WATER SAFETY

Because of their compromised immune system, people living with HIV/AIDS (PLWHA) are susceptible to many types of infection including illness from food and water-borne pathogens. They are at higher risk than healthy individuals for severe illness or death. PLWHA must be especially vigilant when handling and cooking foods. Messages on food safety are listed in Appendix 1.

4.1.3 DIETARY MANAGEMENT OF AIDS-RELATED SYMPTOMS Symptoms appear in HIV-infected people at a critical time when the virus is gradually hindering the capacity of the body to fight opportunistic infections. Some symptoms such as loss of appetite, anorexia, nausea, oral thrush, constipation, and heartburn will negatively affect food intake. Symptoms such as diarrhea and vomiting will affect nutrient absorption. Anemia and fever will increase nutrient needs. Symptoms affecting food intake, nutrient absorption, and nutrient needs should be managed in a timely fashion to prevent their


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negative impact on nutritional status that could hasten the progression of the disease. The messages for the management of AIDS-related symptoms are listed in Appendix 2.

4.1.4 DIETARY MANAGEMENT OF FOOD/NUTRITION AND DRUG INTERACTIONS Food and nutrition can interact with drugs taken by pregnant women and may: • Affect drug efficacy • Affect nutrient absorption and metabolism • Affect food intake and nutrient absorption • Cause unhealthy side effects Side effects of medications that affect food intake and nutrient absorption may negatively affect the nutritional status of PLHA and therefore speed up the progression of the disease. Food/nutrition and drug interactions should be managed in a timely fashion to maintain food intake, nutrient absorption and medication efficacy. Refer to Appendices 3 and 4 for the management of food/nutrition and drug interactions. The steps to follow for the nutritional management of food/nutrition and drug interactions are listed in Box 4.2.

BOX 4.2: STEPS TO FOLLOW FOR NUTRITIONAL MANAGEMENT OF FOOD/NUTRITION AND DRUG INTERACTIONS

1. List all the medications being taken (modern and traditional)

2. For each medication define:

• The recommended foods as well as foods to avoid

• Foods that should be taken before, during, and after meals

3. When taking multiple drugs, consider the interactions of each drug with food

4.1.5 PSYCHO-SOCIAL SUPPORT

PLWHA often suffer from depression. They need extra emotional care and psychological support to cope with the implications of having a life-threatening disease, as well as the potential stigma from family and community members. ANC providers will counsel HIV-positive pregnant women and refer them to support groups in the community.

4.2 KEY ACTIONS FOR ANC PROVIDERS TO ENHANCE NUTRITIONAL STATUS OF PREGNANT WOMEN Irrespective of HIV status, ANC providers should: • Assess the nutritional status of all pregnant women • Treat, educate and provide nutrition counseling • Carry out follow up sessions


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4.2.1 NUTRITIONAL ASSESSMENT Information to collect during the nutritional assessment with HIV-positive pregnant women will depend of the stage in HIV. For HIV-positive asymptomatic pregnant women, the information to collect during the nutritional assessment is the same as for HIV-negative pregnant women. For HIV-positive symptomatic pregnant women, in addition to the information for HIV-negative pregnant women, ANC providers should research and collect information on: • Symptoms that have negative impact of food intake or food absorption • Side effects of medications that have negative effects on food intake or

malabsorption of nutrients • Stigma ANC providers should review the information collected during the nutritional assessment to identify the positive actions/behaviors/practices that should be maintained and the actions/behaviors/practices that are not appropriate that should be changed or adjusted. ANC providers will also propose to the HIV-positive pregnant woman some actions/practices to help improve her nutritional status.

4.2.2 TREAT, EDUCATE AND COUNSEL ANC providers should treat any micronutrient deficiency. Nutrition education and counseling are important to help the HIV-positive woman understand the need to maintain an adequate food intake and diet and to help her manage (i) common symptoms related to HIV that can affect food intake or nutrient absorption and (ii) side effects of medications that have negative impacts on food intake and/or nutrient absorption. During education and counseling sessions with the woman, ANC providers should always: • Assess current diet and food availability • Congratulate the HIV-positive pregnant woman for the positive

actions/practices that she is already implementing. • Always propose options that are acceptable, affordable, and feasible for

the woman. • Encourage the HIV-positive pregnant woman to try new options that could

help improve her nutritional status. ANC providers should highlight the benefits the pregnant woman should expect when she implements the recommended actions.

The actions for ANC providers and the essential nutrition actions messages for HIV-negative and HIV-positive pregnant women and malnourished pregnant women16 are listed in Table 4.3.

16 The messages are for the pregnant woman, her partner and community members


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Table 4.3: Actions for the Health Worker and Essential Nutrition Actions Messages for the Pregnant Woman (HIV-negative, HIV-positive, or Malnourished)

ASSESSMENT ANC PROVIDER ACTIONS ESSENTIAL NUTRITION ACTIONS FOR THE HIV- NEGATIVE PREGNANT WOMAN


Counsel on:

increasing food intake and frequency of meals

reducing workload

diet diversification

Eat three meals and one extra snack per day

Rest more during pregnancy Increase daily consumption of fruits and

vegetables, animal products, and fortified foods

No sign of micronutrient deficiency

Prescribe iron and folic acid tablets, and counsel about taking the full dose

Promote consumption of foods that enhance iron absorption

Counsel on coping with side effects of supplements

Provide presumptive hookworm treatment, starting the second trimester

Prevent and treat malaria

Refer to Box 2 (Session 3).


Take presumptive treatment for hookworm in pregnant women


For HIV-positive pregnant women

If asymptomatic In addition the actions listed above, counsel on:

Increasing food intake

Hygiene and food/ water safety

Provide psycho-social support and refer to community support groups

In addition to the messages above,

Eat at least two extra snacks every day

Drink clean water and wash hands before meals, after using toilet and washing baby’s bottom

Keep hands and food preparation areas clean

Separate raw foods from cooked foods and the utensils used with them

Cook fresh and reheated foods thoroughly

Keep food at safe temperatures

If symptomatic Dietary management of complications such as diarrhea, vomiting, anorexia, and thrush

Dietary management of food and drug interactions

Refer to messages in Appendix 2.

Refer to messages in Appendices 3 and 4.


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ASSESSMENT ANC PROVIDER ACTIONS ESSENTIAL NUTRITION ACTIONS FOR THE HIV- NEGATIVE PREGNANT WOMAN

If symptomatic and wasting

Screen for causes and treat as needed

Counsel on increased food consumption

Refer for ARV treatment and family food assistance as needed

Eat small and frequent meals

Rest more


If anemic Treat severe anemia Consume a daily dose of 120 mg iron + at least 400μg folic acid for 3 months along with orange, pineapple, or citrus juice. Restrict consumption of tea, coffee, and cocoa.


Counsel on increasing food intake and frequency of meals

Eat more than three meals and one extra snack per day

Rest more

Table 4.4 provides a summary of WHO-recommended actions for HIV-positive women.

Table 4.4: WHO Summary Recommendations for HIV-Positive Women

RECOMMENDATIONS HIV-POSITIVE

ASYMPTOMATIC HIV-POSITIVE

SYMPTOMATIC ON ARV TREATMENT

Nutrition assessment Yes Yes Yes

Dietary recommendations

Energy intake Increased by 10% Increased by 20–30%

Protein intake No change No change

Micronutrient intake One RDA One RDA

Food safety Yes Yes Yes

Symptom-based nutritional advice

No Yes Yes

Iron supplementation As per existing WHO/guidelines

As per existing WHO/guidelines

As per existing WHO/guidelines

Vitamin A supplementation

As per existing WHO/guidelines; daily intake not to exceed 1 RDA.



Management of wasting No Screen for causes and treat as needed; counsel on increased food consumption; refer for ARV treatment and family food assistance as needed.

Screen for causes and treat as needed; counsel on increased food consumption; refer for review of ARV treatment as it may indicate treatment failure/need to switch to second line therapy; refer for family food assistance as needed.

Nutritional considerations for persons on ARV treatment

No No Provide advice on dietary needs and restrictions; counsel on management of nausea and related side-effects; manage toxicity and treatment failure as per WHO/guidelines.


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4.3 FOLLOW-UP AND ADJUST At the end of the counseling session, the ANC provider should schedule a follow-up meeting with the HIV-positive pregnant woman. Items to review and address during follow-up nutritional counseling sessions with the HIV-positive pregnant woman are listed in box 4.3 The ANC provider should meet with the pregnant woman at least once every three months to monitor the pregnant woman’s weight gain and food intake and counsel accordingly. If the pregnant woman needs to return before the next scheduled visit because of danger signs or other concerns she should do that. The ANC provider should also make sure that the pregnant woman is taking the iron and folic acid supplements as prescribed. The ANC provider should always look for and treat micronutrient deficiencies. The ANC provider should look for symptoms that can affect food intake or nutrient absorption and counsel the pregnant woman on the dietary management of these symptoms. If the pregnant woman is on ART, the ANC provider should ensure that side effects of ART do not affect food or nutrient absorption. If the side effects of ART affect food intake or are causing nutrient malabsorption (diarrhea and vomiting), the ANC provider will counsel the pregnant woman on the dietary management of the side effects and/or the nutrient malabsorption.

BOX 4.3: ITEMS TO REVIEW AND ADDRESS DURING FOLLOW-UP NUTRITIONAL COUNSELING SESSIONS WITH HIV-POSITIVE PREGNANT WOMEN

• Weight gain and food intake

• Adherence to iron and folic acid supplementation

• Micronutrient deficiencies

• AIDS-related symptoms and their management

• Side effects of medications and their management


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SESSION 5 COUNSELING PREGNANT WOMEN TO IMPROVE

ADHERENCE TO IRON SUPPLEMENTATION

5.1 INTRODUCTION This session provides tips to help pregnant women adhere to iron supplementation.

5.2 PURPOSE AND OBJECTIVES The purpose of this session is to strengthen participants’ counseling skills to help pregnant women take iron and folic acid supplements as prescribed by the ANC provider. Objectives At the end of this session participants will be able to: • Explain all the points to be covered during counseling session with pregnant

women about taking iron supplements. • Demonstrate how to counsel pregnant women about taking iron supplements.

5.3 HANDOUTS PowerPoint presentation and Handout 5: 1 Demands for iron in pregnancy PowerPoint presentation 5.2 and observation checklist for a counseling session to improve adherence to iron supplementation Scenarios/exercise for role-plays

LECTURE NOTES 5


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5.4 OUTLINE Duration: 2 hours 20 minutes


1. Explain all the points to be covered during counseling session with pregnant women about taking iron supplements

Activity 1:

1. The facilitator asks participants to work in pairs for 10 minutes and list the demands for iron in pregnancy. The list should include

(i) iron losses;

(ii) iron gains,

(iii) and explain why they are additional needs.

2. After 10 minutes, the facilitator asks a volunteer to present. After the presentation, the facilitator solicits questions and suggestions from other participants.

3. The facilitator summarizes by presenting the power point 5:1on the demands for iron during pregnancy.

Activity 2

1. The facilitator asks participants to continue to work in the same pairs for 10 minutes and list the points to cover during counseling to improve adherence to iron supplementation.

2. The facilitator asks a volunteer to present. After the presentation, the facilitator solicits questions and suggestions from other participants.

3. The facilitator summarize by presenting the power point 5:2 on the points to address during the counseling to improve adherence to iron supplementation.

30min 30 min

PowerPoint 5:1 Demands for iron during pregnancy. PowerPoint 5:2 Points to address during the counseling to improve adherence to iron supplementation

2. Demonstrate how to counsel pregnant women about taking iron supplements.

1. The facilitator asks participants to work in pairs to prepare a counseling session role play for 10 minutes. He distributes the following scenarios/exercises:

(i) Counseling a pregnant woman who is given iron tablets for the first time

(ii) Counseling a pregnant woman who has been taking iron tablets and is concerned about constipation that is she thinks is created by the iron tablets.

2. The facilitator distributes the observation checklist to help participants observe the counseling session and give feedback in a structured manner

3. The facilitator asks pairs working on scenario (i) to do the role play for 5min minutes. Before the role play, the facilitator asks each pair to explain the points they will cover during the role play and why.

4. After the counseling session, the facilitator asks other participants to provide feedback by stating by what was well done, what needed to be improved, and how to improve.

5. After each session of feedback, the facilitator summarizes by stating all the points to be covered.

6. The facilitator proceeds the same way with the pairs working on scenario (ii)

20 min 60min

Observation checklist 5:1 counseling to improve adherence to iron supplementation


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HANDOUTS PowerPoint presentation and Handout 5.1: Demands for Iron in Pregnancy

DEMANDS FOR IRON IN PREGNANCY*

Iron losses Amount (mg)

Fetus 270

Umbilical cord and placenta 90

Expansion of maternal red cells 450

Obligatory losses from the gut, etc. 230

Maternal blood loss 150

Subtotal 1,190

Iron gains Amount (mg)

Contraction of red cell mass after delivery 450

Absence of menstruation in pregnancy 160

Subtotal 610

Net Losses (1,190–610) 580

* Estimated demands for a 55kg iron replete woman Source: Bothwell (2000)

PowerPoint presentation 5.2 and Observation Checklist for a counseling session to improve adherence to iron supplementation

THE ANC PROVIDER COUNSELS ON: YES NO OBSERVATION

The importance of taking iron tablets in pregnancy

Taking iron tablets for at least 90 days

When to take iron tablets

How to take iron tablets

Recommended drinks to take with iron tablets

Foods and drinks to avoid while taking iron tablets

Side effects of iron tablets

Management of the side effects of iron tablets

Client’s concerns of the perceived negative effects of the tablets

How to store iron tablets

Where to return for more tablets


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SCENARIOS FOR ROLE-PLAYS Scenario (i) Judith is 20 and is pregnant for the first time. This is Judith’s first visit to the ANC clinic. She is 4 months pregnant. You prescribe iron and folic acid to Judith. Counsel Judith about taking and adhering to iron and folic acid supplementation Scenario (ii) Sally is 35 and is pregnant for the first time. Sally is seven months pregnant and this is her second visit to the ANC clinic. Sally reported that she was prescribed iron and folic acid tablets to take every day, but she stopped taking these medications because they made her very sick. She was very constipated when she was taking the tablets and she said she feels better now after she has stopped taking the tablets. Counsel Sally about resuming taking iron and folic acid tablets


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LECTURES NOTES 5 COUNSELING PREGNANT WOMEN TO IMPROVE

ADHERENCE TO IRON SUPPLEMENTATION

5.1 DEMANDS FOR IRON IN PREGNANCY Pregnant women need to take iron tablets on a daily basis because of their high iron requirements. Table5.1 shows the demands for iron in pregnancy.

DEMANDS FOR IRON IN PREGNANCY*

Iron losses Amount (mg)

Fetus 270

Umbilical cord and placenta 90

Expansion of maternal red cells 450

Obligatory losses from the gut, etc. 230

Maternal blood loss 150

Subtotal 1,190

Iron gains Amount (mg)

Contraction of red cells mass after delivery 450

Absence of menstruation in pregnancy 160

Subtotal 610

Net Losses (1,190–610) 580

* Estimated demands for a 55kg iron replete woman Source: Bothwell (2000)

5.2 COUNSELING POINTS

The TDHS revealed that although 58% of pregnant women were anemic only 10% took iron tablets for at least 90 days. Research has reported that side effects of iron tablets can be an obstacle to adherence to iron supplementation. Therefore it is important for ANC providers to counsel pregnant women about taking iron tablets to meet their iron needs, and how to manage the side effects if they occur. The points to address during the counseling session with the pregnant woman are explained below. The importance of taking all the iron tablets In resource poor settings, people usually take tablets only when they are sick. Pregnant women may be wondering why they should take iron tablets and for such a long time. Therefore, it is very important for ANC providers to explain to pregnant women why it is important to take iron tablets for at least 90 days. Taking iron tablets during pregnancy is critical to help meet the high iron requirements of pregnant women. Iron is an essential component of hemoglobin, which is needed to make red cells. Pregnant women should take iron tablets every day to meet the additional needs due to the growth of the fetus, and other physiological changes that occur during pregnancy as shown in table 1.


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When and how to take iron tablets • Take a minimum of one iron tablet per day, with water or fruit juice, between

meals or before going to bed. • Avoid taking iron tablets with tea, coffee, or cocoa because they reduce the

advantages of iron tablets • Restrict consumption of tea, coffee, and cocoa to between meals or at least one

hour after meals • Take a minimum of 90 tablets during pregnancy Substances that enhance or inhibit iron absorption are listed in table 5.2

SUBSTANCES THAT INHIBIT AND ENHANCE ABSORPTION OF IRON

Inhibitors Enhancers

Phytates Food sources: Whole grain (maize, millet, rice, wheat sorghum), grains, flour made from whole grain, legumes (beans), nuts, and seeds

Vitamin C (ascorbic acid) Food sources: Fruits and vegetables

Polyphenols (e.g., tannins) Food sources: Legumes (green and brown lentils), tea, coffee, cocoa, eggplant, green leafy vegetable (spinach, etc.)

Animal blood and muscle products Food sources: Meat, poultry, fish, and other sea food

Calcium salts Food sources: Milk products

Food processing Food sources: Some fermented & germinated foods (soy sauce, leavened bread…)

Oxalates Food sources: Green leafy vegetables (spinach, etc.)

Citric and organic acids

Plant protein Food sources: Legumes (beans), nuts

Sources: Allen & Ahuluwala (1997); WHO/UNICEF/UNU (2001)

Side effects Side effects include nausea, constipation, black stools, and upset stomach It is important to inform pregnant women that side effects may occur while taking iron tablets. Pregnant women who were not informed of the side effects of taking iron tablets may stop taking them as soon any side effect occurs. Side effects are not serious and will go away in a few days. Managing side effects • Take the tablets with meals (instead of between meals or before bed) • Split scored tablets in half at a different time of day No negative effects Messages to help improve adherence to iron supplementation should be based on a good understanding of the practices, perceptions, and beliefs regarding taking medications during pregnancy. ANC providers should reassure the pregnant woman that: • Iron is not a medicine and will not harm the unborn baby if taken as directed. • Iron does not increase the baby’s birth weight (i.e., it does not cause “large

babies”) • Iron does not increase the amount of blood or cause high blood pressure.


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How to store tablets Keep the tablets in a cool storage out of the reach of children. Where to return for more tablets Return for more tablets to the health center.


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PART 3

SESSION 6 FINAL EVALUATION

1. Post test–45 minutes 2. Evaluation–30 minutes

2.1 Put a check mark next to your answer.

a. Relevance of the training content to your work ____Very relevant ____ Relevant ____ Not relevant b. Facilitation of the training ____Excellent ____Good ____Fair c. Methodology used during the training ___Very appropriate ____ Appropriate ____Not appropriate d. Duration of the training ____Sufficient ____Too long _____Too short e. Meals ____Excellent ____Good ____ Fair

2.2 Sessions of the training Topic you liked most _________________________________________________________ Topic that should be removed from the training _____________________________________ Topic to be added to the training ________________________________________________ Suggestions on how to improve the training ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________


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APPENDICES

APPENDIX 1 MESSAGES ON FOOD AND WATER SAFETY

This handout can be used by participants when role-playing or in clinical practice to counsel on safe food handling practices.

Wash hands with soap or ash, rubbing hands together at least three times and drying by air, before preparing, handling, and eating food and after using the toilet or washing the baby’s bottom

Wash and keep food preparation surfaces, utensils, and dishes clean

Wash all fruit and vegetables with clean water before eating, cooking, or serving

Avoid allowing raw food to come into contact with cooked food

Ensure all food is cooked thoroughly, especially meats and chicken

Avoid storing cooked food unless one has access to a refrigerator

Keep food covered and stored away from insects, flies, rodents, and other animals

Use safe water (boiled or bottled) for drinking, cooking, and cleaning dishes and utensils.

Do not eat moldy, spoiled, or rotten foods

Do not eat raw eggs or foods that contain raw eggs

Serve all food immediately after preparation, especially if it cannot be kept hot

Treat drinking water at the point of use (Chlorine, boiling, or filtration)

Store clean drinking water in a narrow mouth container or Jerican

When serving, pour water, and use a clean cup

Wash drinking water container with soap once a week

Adapted from: Lwanga 2001


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APPENDIX 2 MESSAGES ON THE DIETARY MANAGEMENT OF

COMMON HIV-RELATED PROBLEMS This can be used during role-play or in clinical practice to help counsel on the dietary management of common HIV-related problems.

DIETARY PROBLEM

MESSAGES

Anorexia or loss of appetite

Eat small frequent meals spaced throughout the day (5-6 meals/day).

Schedule regular eating times.

Eat protein from animal or plant sources with snacks and meals whenever possible.

Drink plenty of liquids, preferably between meals.

Take walks before meals to stimulate appetite.

Choose and prepare food that look and smell good to you

Use spices such as onions, garlic, cinnamon and ginger to stimulate appetite, improve flavor and digestion

Eat with others as this makes food more enjoyable

Sores in the mouth or throat

Avoid citrus fruits, tomatoes, and spicy, salty, sweet, or sticky foods.

Drink liquids with a straw to ease swallowing.

Eat foods at room temperature or cold.

Eat soft, pureed, or moist foods such as porridge, mashed bananas, potatoes, carrots, or other non-acidic vegetables and fruits.

Avoid smoking, caffeine, and alcohol.

Drink sour milk to prevent yeast from growing

Rinse mouth daily to prevent thrush with 1 teaspoon baking soda mixed in a glass (250 ml) of warm boiled water. Do not swallow the mixture.

Nausea and vomiting17

Avoid having an empty stomach, which makes the nausea worse.

Eat small, frequent meals.

Try dry, salty, and bland foods, such as dry bread or toast, or other plain dry foods and boiled foods.

Drink plenty of liquids between meals rather than with meals.

Avoid foods with strong or unpleasant odors, greasy or fried foods, alcohol, and coffee.

Do not lie down immediately after eating; wait 1-2 hours.

Try eating sour or salty food or drinking lemon juice, herbal or ginger drink to reduce nausea.

If vomiting, drink plenty of fluids to replace fluids and prevent dehydration.

17 The management of nausea and vomiting in the first trimester of the pregnancy is the same.


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DIETARY PROBLEM MESSAGES

Diarrhea Drink plenty of fluids (8-10 cups a day) such as diluted fruit juices, soup, and water.

Consume fermented drinks such as sour milk, yoghurt or togwa

Eat small, frequent meals.

Use low fibre foods such as refined flour, mashed potatoes, green bananas and cassava

Eat bananas, mashed fruit, soft, boiled white rice, and porridge, which help slow transit time and stimulate the bowel.

Avoid intake of high fat or fried foods and foods with insoluble fiber; remove the skin from fruits and vegetables.

Avoid coffee and alcohol because they inhibit absorption of some vitamins and minerals.

Avoid strong spices such as curry and pepper because they irritate the gut

Eat food at room temperature; very hot or very cold foods stimulate the bowels and diarrhea worsens.

If diarrhea is severe:

Give oral rehydration solution to prevent dehydration.

Withhold food for 24 hours or restrict food to clear fluids (e.g., soups, soft foods, white rice, porridge, and mashed fruit and potatoes).

Constipation Drink plenty of fluids, especially water.

Increase intake of fiber by eating vegetables and fruits.

Do not use laxatives or enemas.

Eat high fibre foods such as fresh fruits, vegetables and unrefined cereals and legumes.

Increase physical activities to improve digestion.

Bloating Avoid foods associated with cramping and bloating (cabbage, beans, onions, green peppers, eggplant).

Eat slowly and try not to talk while chewing.

Altered taste Use a variety of flavor enhancers such as salt, spices, and herbs to increase taste acuity and mask unpleasant taste sensations.

Try different textures of food.

Chew food well and move around mouth to stimulate taste receptors.

Fever Drink plenty of fluids throughout the day.

Eat smaller, more frequent meals at regularly scheduled intervals.

Take energy rich foods such as germinated cereal porridge , togwa or enriched soup

Fat malabsorption Eliminate oils, butter, ghee, margarine, and foods that contain or are prepared with these.

Trim all visible fat from meat and remove the skin from chicken.

Avoid deep fried, greasy, or high fat foods.

Eat smaller, more frequent meals spaced out evenly throughout the day.

Take a daily multivitamin, if available.

Muscle wasting Increase quantity of food and frequency of consumption.

Eat a variety of foods.

Eat protein from animal and vegetal origin.

Increase intake of cereals and staples.

Eat small, but frequent meals .

High triglycerides Limit sweets and excessive carbohydrate and saturated fat intake.

Eat fruits, vegetables, and whole grains daily.

Avoid alcohol and smoking.

Exercise regularly according to capacity.

Adapted from: Lwanga 2001 and from National Guide on Nutrition Care and Support for PLHAs, Tanzania 2003


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APPENDIX 3 FOOD AND NUTRITION IMPLICATIONS OF ARVS This can be used as handout during the nutritional counseling on the dietary management of food and nutrition implications of ARVs. This document lists the type of foods to avoid while on medication and the possible side effects of ARVs. Refer to Handout 1 for the management of the side effects that are diet related.

MEDICATION GENERIC NAME (ABBREVIATION)

FOOD RECOMMENDATIONS

AVOID POSSIBLE SIDE EFFECTS

ARV Type: Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI)

Efavirenz (EFZ)

Can be taken without regard to meals, except do not take with a high-fat meal. (A high fat meal reduces drug absorption.)

Alcohol Elevated blood cholesterol levels, elevated triglyceride levels, rash, dizziness, anorexia, nausea, vomiting, diarrhea, dyspepsia, abdominal pain, flatulence.

Nevirapine (NVP)

Can be taken without regard to food.

St. John’s Wort. Nausea, vomiting, rash, fever headache, skin reactions, fatigue, stomatitis, abdominal pain, drowsiness, paresthesia. High hepatotoxicity.

ARV Type: Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTI)

Abacavir (ABC)


Nausea, vomiting, fever, allergic reaction, anorexia, abdominal pain, diarrhea, anemia, rash, hypotension, pancreatitis, dyspnea, weakness, insomnia, cough, headache.

Didanosine (ddI)

Take 30 minutes before or two hours after eating. Take with water only. (Taking with food reduces absorption.)

Alcohol. Do not take with juice. Do not take with antacids containing Aluminum or Magnesium.

Anorexia, diarrhea, nausea, vomiting, pain, headache, weakness, insomnia, rash, dry mouth, loss of taste, constipation, stomatitis, anemia, fever, dizziness, pancreatitis.

Lamivudine (3TC)


Alcohol. Nausea, vomiting, headache, dizziness, diarrhea, abdominal pain, nasal symptoms, cough, fatigue, pancreatitis, anemia, insomnia, muscle pain, rash.

Stavudine (d4T)


Limit the consumption of alcohol.

Nausea, vomiting, diarrhea, peripheral neuropathy, chills and fever, anorexia, stomatitis, anemia, headaches, rash, bone marrow suppression, pancreatitis. May increase the risk of lipodystrophy.

Tenofovir (TDF)

Take with a meal. Abdominal pain, headache, fatigue, dizziness.


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MEDICATION GENERIC NAME (ABBREVIATION)

FOOD RECOMMENDATIONS

AVOID POSSIBLE SIDE EFFECTS

Zidovudine (ZDV/AZT)

Better to take without food, but if it causes nausea or stomach problems, take with a low-fat meal. Do not take with a high-fat meal.

Alcohol. Anorexia, anemia, nausea, vomiting, bone marrow suppression, headache, fatigue, constipation, dyspepsia, fever, dizziness, dyspnea, insomnia, muscle pain, rash.

ARV Class: PROTEASE INHIBITORS

Indinavir (IDV)

Take on an empty stomach, one hour before or two hours after a meal. Or take with a light, non-fat meal. Take with water. Drink at least 1500 ml of fluids daily to prevent kidney stones.

Grapefruit. St John’s Wort.

Nausea, abdominal pain, headache, kidney stones, taste changes, vomiting, regurgitation, diarrhea, insomnia, ascites, weakness, dizziness. May increase the risk of lipodystrophy.

Lopinavir (LPV)


St John’s Wort. Abdominal pain, diarrhea, headache, weakness, nausea. May increase the risk of lipodystrophy. May increase the risk of diabetes.

Nelfinavir (NFV)

Take with a meal or light snack. Taking with acidic food or drink will cause a bitter taste.

St John’s Wort. Diarrhea, flatulence, nausea, abdominal pain, rash. May increase the risk of lipodystrophy.

Ritonavir (RTV)

Take with a meal if possible

St John’s Wort. Nausea, vomiting, diarrhea, hepatitis, jaundice, weakness, anorexia, abdominal pain, fever, diabetes, headache, dizziness. May increase the risk of lipodystrophy.

Saquinavir (SQV)

Take with a meal or light snack. Take within two hours of a high fat and high calcium meal.

Garlic supplements. St John’s Wort.

Mouth ulceration, taste changes, nausea, vomiting, abdominal pain, diarrhea, constipation, flatulence, weakness, rash, headache, insomnia. May increase the risk of lipodystrophy.

FANTA, 2004


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APPENDIX 4 SIDE EFFECTS AND RECOMMENDED FOOD INTAKES

WITH MODERN MEDICATIONS This can be used during the nutritional counseling on the dietary management of food and nutrition implications of common modern medications taken by PLWHA. The document lists the medication, the purpose, the recommendations on how to take the drug, and the potential side effects. Refer to Appendix 2 for the management of the side effects that are diet related.

MEDICATION PURPOSE RECOMMENDED TO BE TAKEN

POTENTIAL SIDE EFFECTS

Sulfonamides: Sulfamethoxazole, Cotrimoxazole (Bactrim ®, Septra ®)

Antibiotic for treatment of pneumonia and toxoplasmosis

With food Nausea, vomiting and abdominal pain.

Rifampin Treatment of tuberculosis

On an empty stomach one hour before or two hours after meals

Nausea, vomiting, diarrhea and loss of appetite. Altered change and may interfere with folate and vitamin B12 levels. Avoid alcohol

Isoniazid Treatment of tuberculosis

One hour before or two hours after meals.

Anorexia and diarrhea May cause possible reactions with foods such as bananas, beer, avocados, liver, smoked pickled fish, yeast and yogurt. May interfere with Vitamin B6 metabolism, therefore may require Vitamin B6 supplement. Avoid alcohol

Quinine Treatment of malaria

With food Abdominal or stomach pain, diarrhea, nausea, vomiting; lower blood sugar.

Sulfadoxine and Pyrimethamine (Fansidar ®)

Prevention of malaria

With food and continuously drink clean boiled water

Nausea, vomiting, taste loss and diarrhea. Not recommended if folate deficient. Not recommended for women who are breastfeeding.

Chloroquine Treatment of malaria

With food Stomach pain, loss of appetite, nausea, vomiting. Not recommended for women who are breastfeeding.

Fluconazole Treatment of candida (thrush)

With food Nausea, vomiting, diarrhea. Can be used during breastfeeding.

Nystatin Treatment of thrush

With food Infrequent occurrence of diarrhea, vomiting, nausea.


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