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
i
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

ii
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

iii
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 BallartMidwifery Advisor, ACCESS/Jhpiego
Ms. Lucy IkambaMidwifery Advisor PSE, ACCESS/Jhpiego
Ms. Gaudiosa TibaijukaSenior Midwifery Advisor, ACCESS/Jhpiego
Dr. Muthoni KariukiProgram Manager, Ag. Country Director,
ACCESS/Jhpiego

ACCESS-TANZANIA PARTNERS
Ms. Cindy SerreConsultant, WFP
Mr. Estifano TekleSenior Nutritionist, WFP
Ms. Nancy PrailCountry Director, Helen Keller International

MIDWIFERY TUTORS
Ms. Anna MgangaMidwifery Tutor, Advance Diploma in Midwifery School,
MNH
Ms. Naike ElineemaMidwifery Tutor, School of Nursing Diploma, MNH
Dr. Thecla W. KohiDean, School of Nursing, MUCHS
Mr. Rashid HeriTutorial Assistant, MUCHS
Ms. Mwasham MrishoMidwifery Tutor, Muhimbili School of Nursing

MINISTRY OF HEALTH AND SOCIAL WELFARE
Ms. Lena MfalilaSafe-motherhood Coordinator, MOHSW/

TANZANIA FOOD AND NUTRITION CENTER
Dr. Godwin NdossiManaging Director
Dr. Sabas KimbokaDirector, Community Health and Nutrition
Dr. Simon TatalaPrincipal Biochemist
Dr. Elifatio TowoPrincipal Nutritionist
Mrs. Monica NgonyaniPrincipal Nutritionist
Dr. Jocelyn KagandaPrincipal Nutritionist
Dr. Sauli NkyaSenior Nutritionist
Mrs. Helen SemuSenior Nutritionist
Mrs. Faith MagamboPrincipal Sociologist

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

AUTHORIZING INSTITUTIONS
ACCESSTFNC

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.

1
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
WHOs 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.

2
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:


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.


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
(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.

3
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.

4
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.

5
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

6
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.
10 min Flipchart
Markers
Masking tape
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.
10 min Flipchart
Markers
Masking tape
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

7
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 womens adherence to iron/folic acid supplement use.

8
HANDOUT 1.2
SESSIONS

The sessions are divided into three parts:


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.


Session 3: Nutritional counseling for HIV-negative pregnant women
(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
(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.

9
HANDOUT 1.3
TIMETABLE

Day 1
9:0010:30 Session 1: Introduction
Opening
Introduction of participants
Expectations and objectives and sessions of the workshop
Roles and rules
Pretest
10:3011:00 Tea/Coffee Break
11:0012:15 Session 2: Why Nutrition Matters During Pregnancy
Types and magnitude of malnutrition during pregnancy in Tanzania
Causes of malnutrition during pregnancy in Tanzania
12:151:15 Lunch
1:153:30 Session 2
Consequences of malnutrition during pregnancy
Indicators of maternal malnutrition
3:305:00 Session 3: Nutritional Counseling for HIV-Negative Pregnant Women and Those with
Unknown Status
Energy, vitamin, and mineral needs/requirements
Day 2
9.0010:30 Session 3
Nutritional counselingNutritional assessment
10.3011:00 Tea/Coffee break
11:0012:30
Nutritional counseling
12:3013:30 Lunch
13:3016: 00 Session 4: Nutritional Counseling for HIV-Positive Pregnant Women
Energy, vitamin, and mineral needs/requirements
Nutrition and care messages
Day 3
9:0010:30 Session 4
10:3011:00 Tea/Coffee Break
11:0012: 00
12:001:00 Lunch
1:0 03:30 Session 5: Counseling to improve adherence to iron supplementation
3:305:00 Session 6: Evaluation of the workshop

10
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

11
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 womans 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

12
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

13
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 dayor one snack/day

14
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 womans 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

15
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

16
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

17
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.
malnutrition for the child/baby.
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

18

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.
2. After 10 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 of the
indicators of maternal nutrition during
pregnancy using PowerPoint
presentation 2.3.
The facilitator solicits and answers questions
from participants.
35 min Flipchart
Markers
Masking tape

PowerPoint
presentation
2.4 Indicators of
maternal nutrition
during pregnancy

19

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 womens 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 1519 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 mol/L) whereas 65% of pregnant women have plasma retinol below 1.05
mol/L
2

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

20
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 womans 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
pregnancy
4
.

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

21
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
pregnancy
5
.
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.

Womens 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 services
6
. 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 deliveries
9
.

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

22
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 USAIDs 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
questionable
10
.

Poor hygiene and sanitation have negative impacts on womens 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

23
degradation, deforestation, pest outbreak and drought add to the problems.
Drought affects about 45% and high food prices 12% of the population
11
.

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 babys 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

24
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 1519 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 damageCretinism
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.

25
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 mortality
12

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.

26
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 Profiles
13
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 11.516 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/height) 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

27
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 1116 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
7.011.5 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 12.518
19.825.9 11.516.0
26.029.0 7.011.5
>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.

28
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 bodys 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 anemic
15

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 mothers 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 mol/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.

29
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 womans 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.

30
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.


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.

31
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?
2. After 10 minutes, the facilitator asks a volunteer
to present.
3. The facilitator asks other participants to add what
is missing.
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.
The facilitator solicits and answers questions from
participants.
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.
3. The facilitator asks other participants to add what
is missing.
4. The facilitator wraps-up the session with a
PowerPoint presentation on the vitamin and
mineral requirements during pregnancy using
PowerPoint presentation 3.3.
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

32
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?
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 womans
nutritional situation (status, eating habits, and
food availability)
25 min Flipchart
Markers
Masking tape

Activity 2: Components of nutritional assessment:
Questions and answers
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

33
b) Nutritional
counseling
Activity 3: Nutritional counseling
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 womans 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
from participants
20 min

34
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)
19.825.9 300 11.516
2629 < 300 711.5
19.8 > 300 12.518.0

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

SNACKS300 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 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
KitumbuaRice bun 1 50 180
Kitumbua- Rice bun 2 75 205
Scone/bun (Standard) 2 96 263
Bread (sliced) 3 slices 99 270

35
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-statusDaily recommended intake of each nutrient

MICRONUTRIENT
PREGNANT AND
LACTATING WOMEN
GOOD FOOD SOURCES OF EACH NUTRIENT
Vitamin A 800g 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 5g 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

36
MICRONUTRIENT
PREGNANT AND
LACTATING WOMEN
GOOD FOOD SOURCES OF EACH NUTRIENT
Folic acid 400g 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 65g Liver, milk, onions, sea foods, liver, carrots, beef,
rice, chicken, and egg
Iodine 150g 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, B
12
, 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)

37
HANDOUTS 3.5
SCENARIO A, B, AND C.

ROLE PLAYSCENARIO A

Mary, 26, is married and is six months pregnant. Mary is expecting her second child.
In Marys 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 Marys nutritional status/problems?
Provide nutritional counseling to Mary

ROLE PLAYSCENARIO B

Jane is 30 and is pregnant for the first time. Jane is HIV-negative. Janes weight was
55 kg before she became pregnant. Jane is seven month pregnant. Janes weight at
seven months of pregnancy is 59 kg. According to Janes 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 PLAYSCENARIO C

Martha, 32, is married and is six months pregnant. Martha is expecting her second
child. In Marthas 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.
Marthas 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 Marthas nutritional status/problems?
What additional information do you need to collect to be able to accurately define
Marys nutritional status/problems and how will you get that information?
Provide nutritional counseling to Mary for 10 minutes.

38
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 400g 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 g
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

39
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
clients 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
Clients 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

40
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

41
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 womans nutritional requirements/ needs. Extra energy is
needed for the growth of the fetus, placenta, and associated maternal tissues. If a
womans 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)
19.825.9 300 11.516
2629 < 300 711.5
19.8 > 300 12.518.0

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.

42
Table 3.4: List of available and affordable snacks (300kcal) for pregnant
women. Pregnant women need an additional 300 kcal/day
SNACKS300 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 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 g 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 g 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

43
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 babys 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.

44
BOX 3.2.1: NUTRITION RECOMMENDATIONS FOR PREGNANT WOMEN

Weight gain: 1216 kg
Daily additional energy intake: 300kcal/day
Diversified diet
Iron and folic acid supplementation: 60mg of iron and 400 g folic acid every day
Prevention and treatment of malaria
Provide presumptive hookworm treatment
Adequate rest

3.3 NUTRITIONAL COUNSELING FOR HIVNEGATIVE 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)

45
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, B
12
, 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.

46
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
Pre-pregnancy BMI is
normal and weight gain
is regular (1kg/month in
the last trimester)
Counsel on:
Increasing food intake and
frequency of meals
Reducing workload
Diet diversification
Eat three meals and one snack every day
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
Take 60 mg of iron and 400g 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 g 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
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 womans
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

47

SESSION 4
NUTRITIONAL COUNSELING FOR
HIVPOSITIVE 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.


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 messagesessential
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

48
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


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:

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

49
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:

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
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.

50
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 womans 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.
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

51
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

52
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

the last trimester)
Eat at least three meals and two extra snacks every day
Increase daily consumption of fruits and vegetables, animal products, and fortified
foods
Take 60 mg of iron and 400g of folic acid every day for 180 days along with
orange, pineapple, or citrus juice. Restrict consumption of tea, coffee, and cocoa.
Take presumptive treatment of hookworm
Use insecticide-treated nets. Take anti malarial drugs. Seek treatment for fever.
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 providers advice on the dietary management of common HIV-
related problems
Follow the ANC providers 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

53
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

54
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. Judiths weight
was 55 kg before she became pregnant. Judith is seven month pregnant. Judiths
weight at seven months of pregnancy is 62 kg. According to Judiths 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 Judiths nutritional assessment and counseling for 15 minutes

Scenarios/Exercises (ii)
Sally is 35 and is pregnant for the first time. Sally is HIV-positive. Sallys weight was
55 kg before she became pregnant. Sally is seven month pregnant. Sallys weight at
seven months of pregnancy is 60 kg. According to Sallys 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 Sallys 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

55
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
clients 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
Clients 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

56
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
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

57

LECTURE NOTES 4
MEETING THE NUTRITIONAL NEEDS OF
HIVPOSITIVE 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 weightEncourage diversified diet
Prevent food-borne illnessesEnsure 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.

58
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-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

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

WHOs 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

59
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

60
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
women
16
are listed in Table 4.3.

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

61
Table 4.3: Actions for the Health Worker and Essential Nutrition Actions
Messages for the Pregnant Woman (HIV-negative, HIV-positive, or
Malnourished)
HIV- NEGATIVE PREGNANT WOMAN
the last trimester)
Counsel on:
increasing food intake and
frequency of meals
reducing workload
diet diversification
Eat three meals and one extra snack per
day
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 60 mg of iron and 400g of folic acid
every day for 180 days along with orange,
pineapple, or citrus juice. Restrict
consumption of tea, coffee, and cocoa.

Take presumptive treatment for hookworm
in pregnant women
Use insecticide-treated nets. Take anti
malarial drugs. Seek treatment for fever.
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
babys 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.

62
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 400g 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
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 2030%
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.
As per existing
WHO/guidelines;
daily intake not to
exceed 1 RDA.
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.

63
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 womans 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

64

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.


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

65
5.4 OUTLINE


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

66
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 (1,190610) 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
Clients concerns of the perceived negative effects of the tablets
How to store iron tablets

67
SCENARIOS FOR ROLE-PLAYS

Scenario (i)
Judith is 20 and is pregnant for the first time. This is Judiths 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

68
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 (1,190610) 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.

69
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 babys birth weight (i.e., it does not cause large
babies)
Iron does not increase the amount of blood or cause high blood pressure.

70
How to store tablets
Keep the tablets in a cool storage out of the reach of children.

Return for more tablets to the health center.

71
PART 3

SESSION 6
FINAL EVALUATION

1. Post test45 minutes

2. Evaluation30 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
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

72
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 babys 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

73
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
vomiting
17

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.

74
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

75
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)
regard to food.
St. Johns 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)
regard to food.
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)
regard to food.
Alcohol. Nausea, vomiting, headache,
dizziness, diarrhea, abdominal
pain, nasal symptoms, cough,
fatigue, pancreatitis, anemia,
insomnia, muscle pain, rash.
Stavudine
(d4T)
regard to food.
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.

76
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 Johns Wort.
Nausea, abdominal pain,
headache, kidney stones, taste
changes, vomiting, regurgitation,
diarrhea, insomnia, ascites,
weakness, dizziness.

May increase the risk of
lipodystrophy.
Lopinavir
(LPV)
regard to food.
St Johns Wort. Abdominal pain, diarrhea,
headache, weakness, nausea.

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 Johns Wort. Diarrhea, flatulence, nausea,
abdominal pain, rash.

lipodystrophy.
Ritonavir
(RTV)
Take with a meal if
possible
St Johns Wort. Nausea, vomiting, diarrhea,
hepatitis, jaundice, weakness,
anorexia, abdominal pain, fever,
diabetes, headache, dizziness.
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 Johns Wort.
Mouth ulceration, taste changes,
nausea, vomiting, abdominal pain,
diarrhea, constipation, flatulence,
weakness, rash, headache,
insomnia.

lipodystrophy.
FANTA, 2004

77
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.

78
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