The Thai Red Cross AIDS Research Centre (TRCARC

)
Standard Operating Procedure Number: TRC.AI-EMR09-10-012 Title: Standard Operating Procedure for TRCARC Nutrition Service

Authors:

Chintana Chaturawit, B.Sc., M.Sc., CDT Jureeporn Jantarapakdee, B.Sc., M.Sc., CDT Supabhorn Pengnonyang B.N., M.Sc. Simon Sadler, MPH, APD

Reviewers:

Sunard Taechangam, Ph.D. Chanida Pachotikarn, Ph.D, LD, MPH Nittaya Phanuphak, MD

Version Number: 1.0 Effective Date: February 19, 2010 Next Review Date: February 19, 2014 Copies of the Guide can be obtained from: The Thai Red Cross AIDS Research Centre 104 Rajdamri Road, Pathumwan, Bangkok 10330, Thailand http://www.trcarc.org Tel: +66-2-253-0997 Fax: +66-2-253-0998

Foreword I am pleased to launch the release of the standard Operating Procedure for the Thai Red Cross AIDS Research Centre (TRCARC) Nutrition Service. The standard operating procedure (SOP) is produced by the Thai-Australian Collaboration in HIV Nutrition (TACHIN) project team. Since the commencement of the TACHIN project four years ago, TACHIN has contributed a broad range of achievements, ideas and innovations in promoting best practice models of people living with HIV (PLHIV) care. The achievements have been in the area of awareness raising, sharing knowledge and information, as well as understanding and improving skills on nutrition services for PLHIV, volunteers, health care providers and the general community. Obviously, nutrition plays a very important role in the management of HIV-infected patients throughout the whole spectrum of care. Nutrition interventions have the potential to reduce the incidence of mortality and morbidity, and improve the quality of life. Nutrition is also an excellent strategy in health promotion. This SOP provides nutrition care information for health care workers on how they can assist in making PLHIV live a healthier life through nutrition support throughout their lives. The purpose of this SOP is to assist health care workers in making recommendation on nutrition management for PLHIV. The guide consists of nutrition care processes, relationship between nutrition and HIV, screening and assessment forms, nutrition requirements, education and counseling interventions and nutrition management, etc. The guide was based on the principle that sound nutrition practices will benefit both infected and affected population. Last but not least, I would like to express my sincere appreciation for the work of all TACHIN staff, the support of the TRCARC doctors, nurses, dieticians / nutritionists and PLHIV volunteers participating in the project. I also would like to acknowledge Italian Red Cross for the financial support of the production of this SOP. Best Wishes,

Praphan Phanuphak, M.D., Ph.D. Director, the Thai Red Cross AIDS Research Centre 19 February 2010

TRCARC-SOP TRC.AI-EMR09-10-012 version 1.0 (Effective Date: February 19, 2010) Standard Operating Procedure for TRCARC Nutrition Service

Table of contents

Introduction and Rationale…………………………………………………………….5 Policy/Regulation References...……………………………………………………....6 Contents…………………………………………………………………………………..6 Procedures
Overview of Nutrition care process…………………………………………………………..7 The flow chart for client accessing to TRCARC nutrition service………………….……....13 The procedure of PLHIV nutritional care provided by dietitian/ nutritionist……….…....14

Attachments and Standard Forms
Attachment 1 - Relationship between Nutrition and HIV…………………………………15 Attachment 2 - TACHIN Nutrition Screening Form for Adults with HIV infection……...16 Attachment 3 - TACHIN Nutrition Screening Form for Children with HIV ……………..17 Attachment 4 - TACHIN Nutrition Assessment Form for clients with HIV ……………..18 Attachment 5 - The Energy and Nutrient Requirements for PLHIV……………………..20 Attachment 6 - The example of Nutrition Education and Counseling Interventions for PLHIV……………………………..…………………………………….22 Attachment 7 - The example of IECs materials used in the nutrition clinic…………….22 Attachment 8 - TACHIN Nutrition Management of Asymptomatic HIV Infection Standard of Practice ……………………………………………………...23 Attachment 9 - TACHIN Nutrition Management of Grade 1 or Grade 2 Diarrhea Standard of Practice ………………………………………………………26 Attachment 10- TACHIN Nutrition Management of Grade 3 or Grade 4 Diarrhea Standard of Practice …………………………………………..29 Attachment 11- TACHIN Nutrition Management of Anorexia Standard of Practice ….32 Attachment 12- TACHIN Nutrition Management of Nausea and Vomiting Standard of Practice ……………………………………………………..35 Attachment 13- TACHIN Nutrition Management of Weight Loss Standard of Practice ……………………………………………….........................37 Attachment 14- TACHIN Nutrition Management of Diabetes mellitus Standard of Practice……………………………………………………..40 Attachment 15- TACHIN Nutrition Management of Overweight and Obesity Standard of Practice……………………………………………………..43 Attachment 16- TACHIN Nutrition Management of Dyslipidemia Standard of Practice……………………………………………………………………46 Attachment 17- TACHIN Nutrition Management of Hypertension Standard of Practice…………………………………………………………………49 Attachment 18- TACHIN Nutrition Management of Lipodystrophy Standard of Practice…………………………………………………………………51 Attachment 19- TACHIN Client’s satisfaction Form……..………………………………53
TRCARC-SOP TRC.AI-EMR09-10-012 version 1.0 (Effective Date: February 19, 2010) Standard Operating Procedure for TRCARC Nutrition Service

1.0 Introduction and Rationale
This standard operating procedure provides guidance and tools to support individuals working within the nutrition service integrated into medical management in caring PLHIV to ensure this task is carried out “correctly” and “uniformly”. Malnutrition, both over and under nutrition plays important roles in the pathogenesis of HIV disease and quality of life of PLHIV. Nutritional care and support help to break the vicious cycle by helping individuals improve, maintain or slow the decline of nutritional status; manage symptoms; boost immune response; and improve adherence and response to antiretroviral therapy (ART) and other medical treatment. The two diagrams in the attachment 1 illustrate the relationship between HIV and malnutrition and how nutrition interventions can help transform the cycle of malnutrition and HIV into a cycle of improved nutritional status and stronger immune response. Medical Nutrition Therapy (MNT) with individualized counseling is critical in overall treatment. The goals of Nutrition intervention are as follows: 1. Build awareness about the role of nutrition in HIV care 2. Maintain or restore healthy body weight. 3. Preserve or restore optimal protein status. 4. Prevent nutrient deficiencies or excesses known to compromise immune function. 5. Treat or minimize HIV or medication-related complications that interfere with either intake or absorption of nutrients. 6. Prevent or correct metabolic abnormalities. 7. Support adherence to medications to achieve optimal therapeutic drug levels. 8. Prolong and optimize quality of life. 9. Maintain and expand nutrition knowledge and sense of empowerment. When adequately provided, timely HIV nutrition therapy should decrease health care costs. In the context of the unique HIV disease complications, the dietitian or nutrition practitioner should apply basic nutrition fundamentals in Nutrition interventions including Nutrition Assessment, Education and Counseling (NAEC). It can be used to identify nutrition-related problems Monitoring and Evaluation (M&E) of NAEC should be done continuously. It can be used to inform and improve program design, implementation, supervision and management. Moreover, it can serve other varieties of functions including - Sharing information with other programs and stakeholders to enable improved programming and support advocacy efforts - Reporting progress and results to national governments, donors and others Much of the client data used in M&E (e.g., diet, weight, functional status) are data that service providers should routinely collect from clients as part of effective NAEC interventions. Collected as part of service provision, this information is also used for the following: - Informing and educating clients about progress (improved practices, nutritional and functional status) as part of the treatment, care and counseling process - Keeping service providers and counselors aware of client status and progress to help guide service provision - Determining eligibility for services, e.g., entry and exit criteria for food and other assistances

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Complementing quantitative information with qualitative information about client and staff perceptions and challenges also provides a clearer understanding of situation and action needed. All processes of nutritional care developed as part of the nutrition service aim to improve the standard of care delivered through the nutrition and health care service (TRCARC anonymous clinic). This ensures the specific nutrition interventions are standardized among nutrition care providers using the standard operating procedure to ensure this service is carried out “correctly” and “consistently”.

2.0 Policy/Regulation References
With regard to ICH GCP Section 5.1.1, states that sponsors must use “written standard operating procedures to ensure that trials are conducted and data are generated, documented (recorded), and reported in compliance with the protocol, GCP, and the applicable regulatory requirement(s).” In addition, Food and Nutrition Technical Assistance (FANTA) Project, section 1 states that specific approaches to monitor and evaluate nutrition and HIV interventions are needed because indicators and monitoring processes for nutrition and HIV often differ from those used in other types of nutrition programs. Indicators may differ because some nutritional issues faced and interventions needed by PLHIV (e.g., management of symptoms and drug-food interactions) differ from those faced by general population.

3.0 Contents
3.1 3.2 3.3 3.4 Introduction and Rationale Policy/Regulation References Contents Procedures 3.4.1 Overview of Nutrition care process 3.4.2 The flow chart for client accessing to TRCARC nutrition service 3.4.3 The procedure of PLHIV nutritional care provided by dietitian/ nutritionist 3.5 Attachments and Standard Forms Attachment 1- Relationship between Nutrition and HIV Attachment 2- TACHIN Nutrition Screening Form for Adults with HIV infection Attachment 3- TACHIN Nutrition Screening Form for Children with HIV Attachment 4- TACHIN Nutrition Assessment Form for clients with HIV Attachment 5- The Energy and Nutrient Requirements for PLHIV Attachment 6- The example of Nutrition Education and Counseling Interventions for PLHIV Attachment 7- The example of IECs materials used in the nutrition clinic Attachment 8- TACHIN Nutrition Management of Asymptomatic HIV Infection Standard of Practice Attachment 9- TACHIN Nutrition Management of Grade 1 or Grade 2 Diarrhoea Standard of Practice Attachment 10- TACHIN Nutrition Management of Grade 3 or Grade 4 Diarrhoea Standard of Practice Attachment 11- TACHIN Nutrition Management of Anorexia Standard of Practice Attachment 12- TACHIN Nutrition Management of Nausea and Vomiting Standard of Practice
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Attachment 13- TACHIN Nutrition Management of Weight Loss Standard of Practice Attachment 14- TACHIN Nutrition Management of Diabetes mellitus Standard of Practice Attachment 15- TACHIN Nutrition Management of Overweight and Obesity Standard of Practice Attachment 16- TACHIN Nutrition Management of Dyslipidemia Standard of Practice Attachment 17- TACHIN Nutrition Management of Hypertension Standard of Practice Attachment 18- TACHIN Nutrition Management of Lipodystrophy Standard of Practice Attachment 19- TACHIN Client’s satisfaction Form

4.0 Procedures
4.1 Overview of Nutrition care process The Nutrition activities are a key component of the comprehensive HIV care services provided by TRCARC anonymous clinic. The nutrition clinic room is open from Monday to Friday between 08:30 - 16:30 hrs. The nutrition services are provided free of charge and are open to all PLHIV. Nutrition screening All clients with HIV infection should be screened for nutrition-related problems by their primary care provider at the time of their initial contact and a part of their routine ongoing care. The presence of nutrition-related symptoms (i.e. poor appetite, weight loss, dyslipidemia, etc.) should trigger a referral for medical nutrition therapy by a dietitian/nutritionist. The attachment 2 and 3 provide nutrition screening forms showing nutrition referral criteria specific to adults and children with HIV infection. Nutrition Care Process It is a systematic problem-solving approach used to identify and respond to, and make decisions about addressing nutrition-related problems, and to provide safe and effective nutritional care. A-D-I-M-E is an acronym for the steps of the nutrition care process as the following: 1. 2. 3. 4. 5. Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Monitoring Evaluation

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A- Nutrition Assessment Nutrition assessment refers to measurement of a client’s nutritional status and dietary practices. A comprehensive nutrition assessment should be performed during the initial consultation with the client (The attachment 4 provides Nutrition assessment form for clients as a nutrition progress note). The ABCDEF approach is the way will be used for the assessment as follows: A: Anthropometric measurement These are helpful markers including: 1. Weight and/or percent of usual weight changed, height and Body Mass Index (BMI) 2. Waist, hip circumference and waist-hip ratio (WHR) 3. Measurement of either lean body mass (using triceps skin-fold and mid-arm muscle circumference) or body cell mass (using bioelectric impedance analysis) B: Biochemical assessment Laboratory values are useful when compare over time including: 1. CD4, CBC and viral load 2. Fasting lipids i.e. Total cholesterol, HDL, and LDL 3. Fasting blood sugar 4. Serum albumin 5. Liver function test i.e. SGOT/SGPT 6. Kidney function test i.e. BUN, creatinine and creatinine clearance 7. Others C: Clinical assessment A dietitian/nutritionist could review the information from Medical chart including: 1. Vital sign: BP, Pulse, Temperature 2. Any symptoms that can affect dietary intake such as - Fever - Sore mouth - Poor appetite - Flatulent - Nausea / vomiting - Diarrhea / constipation, etc. 3. Health-related problems such as diabetes mellitus, Hypertension, Dyslipidemia, Renal disease, Anemia, Hepatitis, Gout, etc. 4. ART: Type of ARV, ARV adherence Evaluation of drug therapy is essential since many side effects complicate nutritional status. D: Dietary assessment The diet should be evaluated for overall nutritional adequacy. Particular attention is also important for macronutrients and nutrients involved with immune function. The dietary assessment should also identify a history of erratic and inadequate intakes which may be an indicator of food insecurity.

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A quantitative and qualitative approach is employed to assess nutritional intake using tools such as 24 hr Dietary Recall, Usual Food Intake, Food Frequency Questionnaire (FFQ), 4-day Food Diaries and Food habit (including meal pattern). Food records or ‘diaries’ may be required among particular client groups where a detailed understanding of a client’s nutrient intake is required. Examples of these include overweight and obesity, or nutrition based research. In addition, a dietitian/ nutritionist needs to document Food-ARV interactions the client has experienced. Based on this record of dietary intake the following assessments are made: 1. Overall energy intake & requirement. (The attachment 5 illustrates how to calculate energy requirement for PLHIV) 2. Assess food belief, dietary knowledge, and use of dietary supplements or herbal remedies. 3. Assess factor affecting dietary intake such as socio-economic aspects, food-drug interaction. 4. Assess stage of client’s behavior change E: Exercise assessment A dietitian/ nutritionist should ask clients covering the issues as follows: 1. Type: aerobic and/or resistance exercise 2. Duration 3. Frequency 4. Motivating Factors and Barrier F: Family history and support The family situation of the client can have a critical impact on the development of the nutrition management plan as well as the subsequent implementation of strategies formulated. An assessment should be made of primary food provider of the family, number people in the household, other dependents, cooking and storage facilities. The dietitian/ nutritionist should also make an assessment of the client family history of disease, particularly familial related disease such as cardiovascular disease and diabetes. This is particularly important in relation to the clients history ARV use, especially protease inhibitors, given there potential correlation with insulin resistance, type 2 diabetes, hypercholesteroldemia, pancreatitis, and hypertriglyceridemia . In addition, family support and psychological health (fear, anxiety, depression, and social isolation) can have a significant effect on appetite, nutrient intake, the nutrition management plan and how to manage their nutrition- related problems. Illness or ostracism often leads to a lack of employment and subsequent loss of social contact, as well as income and medical insurance. Therefore these issues should also be addressed during nutrition assessment.

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D- Nutrition Diagnosis The dietitian/ nutritionist should carefully consider all the information collected during the assessment phase of the intervention the problem, its etiology, and signs and symptoms (PES statement). The specific etiology determines the interventions that will lead to the desired outcome. I- Nutrition Intervention - Goals: Short and long-term goals, as designed with client, family and caregiver - Plan: Diagnostic studies needed; suggestions for gaining further relevant data, work-up, data gathering - Nutrition education: Nutrition education refers to the provision of information by service providers to clients about nutritional needs, dietary practices, nutrient content of foods, meal planning, symptom management and other topics. Before providing individual nutrition counseling, group nutrition education would be performed to provide nutrition information in general to save time and have a chance for clients in sharing their experience. - Nutrition (dietary) counseling: Nutrition counseling refers to an interactive process between provider and client to assess nutritional status and needs; understand client preferences, constraints and options; and plan a feasible course of action that supports healthy nutritional practices. Patient-centered therapy: It encourages the clients to be an active participant in the development of their plan. Time duration for education and counseling: 60-90 minutes for 1st visit 30-45 minutes for follow up visits The attachment 6 shows the example of Nutrition Education and Counseling Interventions for PLHIV. All people living with HIV need early, ongoing medical nutrition therapy. It is essential to educate individuals about the importance of consuming a wellbalanced diet, to provide adequate food and nutrients for maintenance or improvement in nutrition status, and to prevent protein-energy malnutrition and, vitamin and mineral deficiencies. Dietary counseling should be individualized, considering barriers to adequate intake and supported with practical written materials (The attachment 7 shows the example of IECs materials used in the nutrition clinic) Mapping out one’s meal and medication schedule is part of medical nutrition therapy and is an important component for supporting adherence to the drug regimen.
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In addition, a dietitian/ nutritionist may need to consult with other health care providers, make client referrals to other providers or agencies; and make recommendations for nutrition care in new settings and discharge planning. The notes of subjective, objective, assessment and plan in nutrition care (SOAP Note) would be useful for health professional communication. In order to ensure consistency and that the service provide information built on current best practice in HIV Nutrition education and dietary counseling a series of Standard Of Practices (SOP) for nutritional management have been developed (See the attachment 8-18) M- Monitoring and E- Evaluation (M&E): - Outcome evaluation to determine level of success, improvement in signs and symptoms, resolution of nutrition diagnoses - Evaluation of client’s ability to function independently without frequent or intense dietitian/ nutritionist interventions - Evaluation of client’s satisfaction to nutrition service (The attachment 19) - Measurable goal evaluations selected and monitored through the followup visits or an ongoing basis. § Logical Framework for Nutrition Assessment, Education and Counseling of PLHIV Inputs § Nutrition assessment equipment (e.g., scales, food models, tools and documentation materials) § Trained Service Providers § Education and counseling materials § Adequate space for nutrition education and counseling Processes § Flow of clients for nutrition assessments § Flow of clients to counselor or educator § Quality of nutrition assessment and documentation of client information § Quality of counseling: counselor practice, provision of information, identification and planning of options § Quality of group education § Number of clients eligible but not seen Outputs § Number of clients presenting for counseling § Provision of Nutrition assessment, education and counseling as part of HIV treatment and care services § PLHIV receipt of Nutrition assessment, education and counseling services, such as weight monitoring and individualized nutrition counseling § PLHIV receipt of followup nutrition counseling § Nutrition Information recorded Outcomes § Changes in PLHIV attitude, knowledge, dietary practices and other related practices (e.g. food purchase and preparation, food and water safety and sanitation, dietary response to symptoms, metabolic complications, management of drug-food interactions) Impacts § Nutritional status (weight, body composition, nutrient deficiencies, metabolic abnormalities) § Food security § Daily functional status and physical activity § Severity, frequency and duration of symptoms § Adherence to treatment § Response to treatment

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Special Considerations in Pediatric Patients 1. In addition to supporting optimal function of the immune system. Nutrition is especially important for promoting the normal growth and development of children living with HIV. 2. Each child with HIV should receive a baseline nutrition assessment with follow-up every 4 to 6 months, depending on the child’s age, nutritional status, and nutrition related symptoms. 3. General nutrition recommendations for children include high-energy, high-protein, nutrient-dense foods because protein and energy need are significantly increased. 4. Stunting and failure to thrive have been identified in nearly all HIV infected children 5. Change in adipose and muscle stores may occur as a result of metabolic changes. The goal is to preserve lean body mass. 6. Promoting adequate nutritional status should be achieved through foodbased strategies. Where a multivitamin supplement is affordable and available Dietitians/ Nutritionist should ensure the supplement meets at least 100% of the Recommended Daily Allowance (RDA). Poor absorption may be a problem for vitamins A, C, B6, B12 and folate; iron; selenium and zinc. 7. Resolving barriers to adequate nutrition intake, ensuring regular access to food, eliminating stress in the environment, and increasing financial resources can help to improve the child’s nutrition. 8. Children and their caregivers need assistance from dietitians in identifying creative ways of adhering to medication schedules and reducing the flavor and smells of medications. Medications can be mixed into foods or beverages such as shakes, ice cream, citrus sauces, so that they are consumed in sufficient quantities to be effective.

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4.2 The flow chart for client accessing to TRCARC nutrition service The flow chart illustrates how clients can access TRCARC nutrition service

Nutrition screening and assessment Flow Chart Clients access to TRCARC Anonymous clinical service Nutrition screening by nurses, social workers, counselors, doctors, PLHIV volunteers at the time of client’s first contact Not-at-risk Re-screen - At regularly specified interval - When nutritional or clinical change Clients referred by other care providers for nutrition services

At-risk Notifying Nutrition Team (Dietitian/ nutritionist) Nutrition team Provide feedback to referring service

Stable

Nutritionally at-risk

Nutrition Assessment: using the ABCDEF approach

Re-assessment: According to follow up visit* 2 week- or 3 month- or 6 month-follow up, etc as appropriated.

Nutrition Diagnosis Nutrition Intervention: Nutrition education and counseling (Including communication with health care team) Monitoring and Evaluation

* Follow up visits depended on their nutritional problems and/or physician appointments. Adapted from: The American Society for Parenteral and Enteral Nutrition (ASPEN) 2008

4.3 The procedure of PLHIV nutritional care provided by dietitian/ nutritionist The procedure illustrate how dietitian/ nutritionist provides nutritional care to PLHIV 1. Greeting clients (introduce yourselves)
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2. Review the completed nutrition screening form (the attachment 2, 3). 3. Review medical chart in parallel with asking clients about their nutritionrelated problems. 4. Assess client’s nutritional status using ABCDEF approach 5. Record the nutrition assessment information (Nutrition progress note, the attachment 4). 6. Diagnose client’s nutritional problems and its related factors 6.1 Describe the result of their nutritional status as part of nutrition assessment. 6.2 Motivate clients to identify their problems. 6.3 Help client to prioritize their problems. 6.4 Record the problems diagnosed in the Nutrition progress note (as the attachment 4). 7. Provide Nutrition Intervention based on patient-centered therapy 7.1 Help clients to set the realistic goals. 7.2 Develop nutrition care plan. 7.3 Give clients nutrition education and counseling to solve their nutritional problems. 7.4 Help clients to set a sample of meal planning and to map out one’s meal and medication for supporting adherence to the drug regimen. 7.5 Make sure that each meal plan would be possible and appropriate for individual. 7.6 Consider the other professional consultations if necessary. 7.7 Make an appointment for the follow up visits, depended on their nutritional problems and/or physician appointments. 7.8 Record the information from this process in the Nutrition progress note (as the attachment 4). 7.9 Ask clients to assess satisfaction for nutrition service they received (as the attachment 20) 8. Monitor and Evaluation (M&E) 8.1 Review Previous Dietary Goals, please document if the individual client goal has been reached. 8.2 Complete nutrition assessment (Re-assessment). 8.3 Help clients to set any new dietary goal and document them in the form (as the attachment 4) 8.4 Re-nutrition intervention process followed by M&E continuously.

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5.0 Attachments and Standard Forms Attachment 1- Relationship between Nutrition and HIV Malnutrition and HIV: A vicious cycle
Poor Nutritional status (Weight loss, muscle wasting, macro- and micronutrient deficiency)

Increased Nutrition Needs (Due to mal-absorption, decreased food intake, infections, and viral replication

Impaired Immune System

HIV

(Poor ability to fight HIV and other infections)

Increased vulnerability to infections (Increase frequency and duration of OI and possibly faster progression to AIDS)

Nutrition and HIV: The cycle of benefits from Nutrition interventions
Good Nutritional status (Weight regained or maintained; no macro- and micronutrient deficiency

Nutritional Needs Met (Additional energy needs met; consumption of adequate diet with foods from all food groups; Symptom management

Strengthened immune system

HIV

(Improve ability to fight HIV and other infections)

Reduced vulnerability to Infections (Reduced frequency and duration of OI and possibly slower progression to AIDS) Adapted from: Regional Centre for Quality of Health Care and FANTA, Handbook: Developing and Applying National Guidelines on Nutrition and HIV/AIDS, March 2003. Semba RD and AM Tang, “Micronutrients and the pathogenesis of human immunodeficiency virus infection, “British Journal of Nutrition, Vol.81, 1999.

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Attachment 2- TACHIN Nutrition Screening Form for Adults with HIV infection
Nutrition Screen and Referral Criteria For Adults (18+ yrs) with HIV/AIDS TRCARC ID:___________ Date:________________

Have you ever seen dietitian before? q No q Yes The topics is………………………………..……………………………..………….. Automatically refer/see to a dietitian for any of the following:(check and tick all that apply) A. Medical Diagnosis and Nutrition Assessment q Newly Diagnosis HIV/AIDS or never been seen by Dietitian q HIV with symptom or AIDS/asymptomatic: not seen by Dietitian in the past 6 month to 1 year q Any change in disease, diet or nutrition status B. Physical Changes and Weight Concerns q > 3% unintentional weight loss from usual body weight within the last 6 month or since the last visit q Visible wasting, < 90% ideal body weight, BMI < 18.5 kg/m2 q Lipodystrophy q Abdominal obesity: Waist circumference > 90 cm (men) and > 80 cm (women) q Client or MD initiated weight management, or obesity: BMI ≥ 25 kg/m2 C. Oral/GI Symptoms q Loss of appetite or poor oral intake of food or fluid for > 3 days q Difficulty chewing, swallowing, Severe dental carries, mouth sores, thrush or Herpes simplex type 1 q Persistent gas, bloating, heart burn, nausea/vomiting, diarrhea, constipation, change in stool (color, consistency, frequency, smell) q Change in perception of taste or smell q Food allergy/intolerance: fat, lactose, wheat, etc. q Recieves or needs evaluation oral supplyment or enteral or parenteral nutrition q Medication involving food or meal modification D. Metabolic Complications and Other Medical Condition q Concomitant Diabetes, Hypertension, Hepatic or Renal insufficiency, Heart disease., Cancer, other nutrition-related condition or Pregnancy q Dyslipidemia: Cholesterol < 120 mg/dl or > 200 mg/dl, Triglycerides > 150 mg/dl, LDL >100 mg/dl, HDL (men < 40 mg/dl, women < 50 mg/dl) q Albumin < 3.5 mg/dl q Schedule Chemotherapy or radiation therapy E. Behavioral concern or Unusual Eating Behaviors q Client initiated vitamin and/or mineral supplementation, or complimentary or alternative diet q Vegetarianism q Alcoholic consumption: > 2 drinks/day(men), > 1 drink/day(women) q Cigarettes smoking q Well-nourished q Referred to dietitian q Not referred to dietitian because.................................................... ** Apply from ADA MNT Evidence Based Guides for Practice © 2005

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Attachment 3- TACHIN Nutrition Screening Form for Children with HIV
Nutrition Referral Criteria for Children and adolescent (Less than 18 Years) with HIV/AIDS Refer to a dietitian when anyone of the following conditions exist:
TRCARC ID:___________ Date:________________

 Not seen by a dietitian in 3 months  Weight for age < 10 percentile  Height for age < 10 percentile if Weight for age < 10 percentile for age  Weight for height <95 % of standard or weight for height< 25 percentile  Downward crossing of one major “weight for age “ percentile measurement  Visible wasting, < 95 % ideal body weight, body mass index <25 percentile for age and
th th th th

gender, or any decrease in body cell mass

 Poor appetite, food or fluid refusals  Prolong bottle feeding or severe dental carries  Change in stool (color, consistency, frequency, smell)  For children 0-12 months: low birth weight  For children 0-12 months: No weight gain for 1 months  For children 0-12 months: Diarrhea or vomiting for 2 days  For children 0-12 months: Poor suck  For children 1-3 years: No weight gain for several consecutive months  For children 1-3 years: Diarrhea or vomiting for 3 days  For children 4-16 years: No weight for 3 consecutive months  For children 4-18 years: Diarrhea or vomiting for 4 days  Poor feeding skill  Food allergies or intolerances (e.g.; formula, fat, lactose, wheat)  Inborn error of metabolism  Cholesterol < 65 mg/dl or > 175 mg/dl  Triglycerides < 40 mg/dl or > 160 mg/dl  Well-nourished
 Referred to dietitian  Not referred to dietitian
because....................................................
** Apply from Fenton M et al: Nutrition referral criteria for pediatrics (< 18 years) with HIV/AIDS. In guidelines for implementing HIV medical nutrition therapy, Los Angeles, 1999, Los Angeles Country Commission on HIV Health Services.

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Attachment 4- TACHIN Nutrition Assessment Form for clients with HIV
Nutrition Progress Note (Page 1) Adjusted from ADA MNT Evidence Based Guides for Practice @ 2001, The American Dietetic Association

TRCARC ID:___________ Date:________________

Clinical items

Expected outcome

Clinical outcomes 1st visit/ Date ..................... 2nd visit/Date ................... 3rdvisit/Date ....................

CD4 %CD4 Hb/ Hct FBS Total cholesterol Triglycerides HDL LDL SGOT/SGPT Creatinine/ Creatinine clearance Albumin Blood pressure Height………... / Weight BMI W/H ratio MNT Goal (Kcal) Behavioral items 1. Eat meals/snacks at appropriate time 2. Chooses food and amounts per meal plan 3. Chooses a diet that is low in saturated fat and cholesterol and moderate in total fat 4. Chooses and prepare food with less salt 5. Accurately reads food labels 6. Food safety 7. Verbalizes symptom management skills 8. Modifies medication/ food for activity/lifestyle 9. Verbalizes potential food/ drug interaction Drug……………………… 10. Verbalizes importance of smoking cessation 11. Limits alcohol use to 1-2 drinks/day 12. Participates in aerobic activity per exercise prescription Stage of behavior change**

W=

H=

Ratio=

W=

H=

Ratio=

W=

H=

Ratio=

q Yes q Probably q no q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No
……..…..x/week……..min 1

q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No
……..…..x/week……..min

q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No q Yes q Probably q No
…..…..x/week……..min 5

Please circle stage of behavior change, follow with number 1-5 as indicated 2 3 4 5 1 2 3 4 5 1 2 3 4

* Key for the behavior outcomes: Yes = consistency demonstrate, Probably = rarely – often demonstrate, No = Never demonstrate ** Key for the stage of behavior change: 1 = Pre-contemplation, 2 = Contemplation, 3 = Preparation, 4 = Action,5 = Maintenance

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Nutrition Progress Note (Page 2)

TRCARC ID:___________ Date:________________

Date………….……Beginning Time:………………Ending time:…..….……….Total Minutes :…………... Usual Food Intake……………………………..………………………………………………………............... …………………………………………………………..……………………………………………..…………. Diagnosis: Nutrition status q Underweight q Normal q Overweight Energy intake q Inadequate q Adequate q Excessive Protein intake q Inadequate q Adequate q Excessive Food pattern q High refine sugar q High sat. fat diet q High Na diet q High CHO diet q High fat diet q Low fiber diet q Others…………………………………………..……………………….. Lab test q Hyperglycemia q Hypertriglyceridemia q Hypercholesterolemia q Low HDL qMalnutrition q Anemia q Others…………..…………….............................................................. Physical activity qLow q Moderate q High Note: ………............... Intervention: Client Goals: ……………………….…………..………………………………………........... Strategies: ………………………………….……….…………….…………..……………………................... Material Provided: …..…………………………………………………………....…………………………… Next visit: ………………………………..…..…RD Signature…….……………….…………....................... Date………….……Beginning Time:………………Ending time:…..….……….Total Minutes :………… Usual Food Intake……………………………..…………………………………………………………......... …………………………………………………………..………………………………………………………. Diagnosis: Nutrition status q Underweight q Normal q Overweight Energy intake q Inadequate q Adequate q Excessive Protein intake q Inadequate q Adequate q Excessive Food pattern q High refine sugar q High sat. fat diet q High Na diet q High CHO diet q High fat diet q Low fiber diet q Others…………………………………………..……………….......... Lab test q Hyperglycemia q Hypertriglyceridemia qHypercholesterolemia q Low HDL q Malnutrition q Anemia q Others…………..……………............................................................... Physical activity qLow q Moderate q High Note: ...............……… Intervention: Client Goals: ……………………….…………..……………………………………………....Strategies: ………… ……………………….……….…………….…………..………………………............... Material Provided: …..…………………………………………………………....………………................... Next visit: ………………………………..…..…RD Signature…….……………….………………………... Date………….……Beginning Time:………………Ending time:…..….……….Total Minutes :…………. Usual Food Intake……………………………..…………………………………………………...................... …………………………………………………………..………………………………………………………. Diagnosis: Nutrition status q Underweight q Normal q Overweight Energy intake q Inadequate q Adequate q Excessive Protein intake q Inadequate q Adequate q Excessive Food pattern q High refine sugar q High sat. fat diet q High Na diet q High CHO diet q High fat diet q Low fiber diet q Others…………………………………………..…………………….. Lab test q Hyperglycemia q Hypertriglyceridemia q Hypercholesterolemia q Low HDL qMalnutrition q Anemia q Others…………..…………… Physical activity qLow q Moderate q High Note: ………………… Intervention: Client Goals: ……………………….…………..………………………...........................…… Strategies: ………………………………….……….…………….…………..……............…………………. Material Provided: …..…...........……………………………………....……………………………………... Next visit:………………………………………RD Signature……………………………………………… TRCARC-SOP TRC.AI-EMR09-10-012 version 1.0 (Effective Date: February 19, 2010) Standard Operating Procedure for TRCARC Nutrition Service

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Attachment 5- The Energy and Nutrient Requirements for PLHIV
Energy and Nutrient Requirements of People Living with HIV/AIDS Good nutrition for all individuals, but especially PLHIV, requires the consumption of an adequate amount in the appropriate portions of macronutrients and micronutrient. The nutrition needs of HIV-infected person depend on the stage of disease progression. Required intake levels are suggested based on the absence or presence of symptoms such as fever, diarrhea, weight loss and wasting. WHO’s Nutrient Requirements for People living with HIV/AIDS HIV Positive phase Asymptomatic Symptomatic Asymptomatic Pregnancy** Symptomatic Energy 10 % increase 20-30 % increase 10 % increase 20-30 % increase Protein1 No change No change No change No change Fat1 No change No change No change No change Micronutrient2 No change No change No change No change

Adults and Adolescents*

Asymptomatic Children*** Symptomatic with no wt. loss Symptomatic with wt. loss

10 % increase 20-30 % increase

No change No change

No change No change

No change No change

50-100 % increase

No change

No change

No change

* % increase from the level recommended for healthy non-HIV-infected persons of the same age, sex, and physical activity level ** % increase from the level recommended for healthy non-HIV-infected pregnant adolescents or women of the same age, sex, and physical activity level *** % increase from the level recommended for healthy non-HIV-infected children of the same age
1

Although the quantity of protein and fat are increased with the % energy increased, the proportion of protein and fat distributions have no change.
2

It is commonly recommended dietary allowances (RDAs) and a basic B-complex supplement, and that they receive nutrition counseling (Woods et al, 2002)

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The example of meal planning for PLHIV who requires energy approximately 1,600 or 1,800 or 2,000 or 2,200 Kcal per day Meal planning for 1600 Kcal/day Meal Breakfast Lunch Snack Dinner Bedtime Starch 2 3 2 Vegetable 1 1 2 Fruit 1 1 1 Milk 1 Meat 2 2 2 Fat 2 2 2 -

Meal planning for 1800 Kcal/day Meal Breakfast Lunch Snack Dinner Bedtime Starch 3 3 2 Vegetable 1 1 2 Fruit 1 1 1 Milk 1 Meat 2 2 3 Fat 2 3 2 -

Meal planning for 2000 Kcal/day Meal Breakfast Lunch Snack Dinner Bedtime Starch 3 3 2 Vegetable 1 1 2 Fruit 1 1 1 Milk 1 1 Meat 2 2 3 Fat 2 3 3 -

Meal planning for 2200 Kcal/day Meal Breakfast Lunch Snack Dinner Bedtime Starch 3 3 3 Vegetable 1 2 2 Fruit 1 1 1 Milk 1 1 Meat 2 3 3 Fat 3 3 3 -

% Energy distribution is Carbohydrate: Protein: Fat: = 55:15:30

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Attachment 6- The example of Nutrition Education and Counseling Interventions for PLHIV
Target Population General population in area with high HIV prevalence PLHIV, caregivers and other clinic visitors Group of PLHIV, caregivers PLHIV PLHIV Intervention Social marketing or mass dissemination of nutrition and HIV messages Nutrition and HIV education materials in clinic waiting areas Group nutrition education classes Individual nutrition education sessions Individual nutrition counseling sessions Implementers Governments, private sector companies, NGOs, mass media or social marketing institutions Health facility managers, Dietitians, Nutritionists Dietitians, Nutritionists, nurses, community educators Dietitians, Nutritionists, nurses, home-based care providers Dietitians, Nutritionists, trained counselors

Attachment 7- The example of IECs materials used in the nutrition clinic
HIV Nutritional Booklets: 1) Healthy eating 2) Diet for gaining weight 3) Diet for losing weight 4) Diet and ARV 5) Diet for symptom management HIV Nutritional Brochures: 1) Diet for hypercholesteroldemia 2) Diet for hypertriglyceridemia 3) Diet for hypertension 4) Diet for hyperglycemia

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Attachment 8- TACHIN Nutrition Management of Asymptomatic HIV Infection Standard of Practice
Background Nutrition management is thought to have an important role in the comprehensive care of people living with HIV infection(1-3). There is anecdotal evidence to suggest that early intervention during the asymptomatic phase of HIV infection may play an important role in enhancing the quality of life and reducing morbidity. A review of research in HIV has found that among PLWHA resting energy expenditure is around 10% higher than in non-HIV infected individual. Despite this total energy expenditure is approximately the same as non-infected individuals (4, 5). There is insufficient evidence to suggest that PLHIV require higher intakes of protein(6). Research in this area has been difficult given the general hypo-caloric diets followed by many PLWHA, particularly in resource poor settings. The aim of this SOP is to outline nutrition management for people living with HIV infection during the asymptomatic phase of infection. Definition Client may present or report one or more of the following characteristics or indications: • No other symptoms of HIV infection or treatment • Good appetite • Client may be requesting information on health maintenance Goal of Nutrition Management • • • • • Maintain a healthy body weight and lean body mass Achieve and maintain adequate nutritional intake for macro and micronutrients. Prevention of food related illness Reduce risk of other complications such as dyslipidaemia through diet and lifestyle Enhance overall quality of life

Nutrition Assessment • • • • • Assess and monitor body weight and body composition, comparing to usual body weight prior to HIV infection and ideal body weight Assess dietary intake and compare to Thai Recommended Dietary Intake Assess dietary intake and food practices in terms of food hygiene Assess lifestyle factors that may contribute to food security1 Assess other social, biochemical (where available hemoglobin, albumin, cholesterol, triglyceride, glucose and other micronutrients such as Zinc, Vitamin B12, Vitamin A where available), mental health status e.g. depression, food beliefs and practices, and alternative therapies. Assess medical history that may contribute to chronic disease and/ or reduced nutritional status Assess amount of regular exercise including aerobic & anaerobic (8, 9) For asymptomatic client follow up assessment is recommended at least 1-2 times a year (10) Assess client use of herbal and vitamin supplements (11)

• • • •

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Nutrition Management Advocacy • Advocate for the role of food and nutrition as an important component of HIV care and health maintenance. Eating Behavior Strategies • Enjoy a range of foods from each of the 5 foods groups • Maintain adequate intake for macro and micronutrients, including o staple foods with every meal o animal and milk products every day o vegetables and fruit every day o fats and oils, and sugary foods each day • Maintain a regular intake of foods • Purchase, prepare and consume foods that minimize risk of food borne illness • Drink plenty of safe clean water each day, goal is to aim for 8 cups a day • If affordable and accessible recommend client take one broad spectrum multivitamin and mineral supplement, with nutrient levels based on the Recommended Dietary Intake, once a day. Lifestyle Strategies • Encourage regular exercise, incorporating both aerobic and resistive exercise(8). Dietary Education Consideration of each individual patient’s living conditions and the potential for various factors to impact on the success of patients implementing the nutrition management plan should be taken into account by the nutrition educator. Where appropriate patient’s food preferences, budget and social situation should be factored into the development of the nutrition management plan. At the end of the dietary counseling session the patient should receive a summary of the nutrition management plan and all dietary strategies checked with the patient for understanding and practicality (2). References 1. Brown D, Batterham M. Nutritional management of HIV in the era of highly active antiretroviral therapy: a review of treatment strategies. Aust J Nutr Diet 2001;58(4):224233. 2. Fields-Gardner C, Fergusson P. Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection. J Am Diet Assoc 2004;104(9):1425-41. 3. Nerad J, Romeyn M, Silverman E, Allen-Reid J, Dieterich D, Merchant J, et al. General nutrition management in patients infected with human immunodeficiency virus. Clin Infect Dis 2003;36(Suppl 2):S52-62. 4. Macallan DC, Noble C, Baldwin C, Jebb SA, Prentice AM, Coward WA, et al. Energy expenditure and wasting in human immunodeficiency virus infection. N Engl J Med 1995;333(2):83-8. 5. Sheehan LA, Macallan DC. Determinants of energy intake and energy expenditure in HIV and AIDS. Nutrition 2000;16(2):101-6. 6. Friis H. Micronutrients and HIV infection: a review of current evidence. Durban, South Africa: WHO; 2005 10 - 13 April, 2005. 7. FAO. Rome Declaration on World Food Security and World food Summit Plan of Action. Rome, Italy: FAO; 1996 13-17 November 1996. 8. Dudgeon WD, Phillips KD, Bopp CM, Hand GA. Physiological and psychological effects of exercise interventions in HIV disease. AIDS Patient Care STDS 2004;18(2):81-98.
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9. Bopp CM, Phillips KD, Fulk LJ, Dudgeon WD, Sowell R, Hand GA. Physical activity and immunity in HIV-infected individuals. AIDS Care 2004;16 (3):387-93. 10. Knox TA, Zafonte-Sanders M, Fields-Gardner C, Moen K, Johansen D, Paton N. Assessment of nutritional status, body composition, and human immunodeficiency virus-associated morphologic changes. Clin Infect Dis 2003;36 (Suppl 2):S63-8. 11. Raiten D, Grinspoon S, Arpadi S. Nutritional considerations in the use of ART in resource-limited settings. In: Consultation on Nutrition and HIV/AIDS in Africa: Evidence, lessons and recommendations for action; 2005 10-13 April 2005; Durban, South Africa: World Health Organisation; 2005.

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Attachment 9- TACHIN Nutrition Management of Grade 1 or Grade 2 Diarrhoea Standard of Practice
Background Acute and chronic diarrhoea can be a common symptom experienced by many people living with HIV. Symptoms can vary from slight alterations in bowel movement, resulting in an increase in the number of motions and a change in stool consistency from loose but formed stool to watery or liquid motions. The symptoms may be self-limiting or intractable. The causes of diarrhoea in HIV infection are diverse. It has been suggested that parasites, bacteria and viruses account for up to 80% of diarrhoea experienced by people living with HIV (1). A significant proportion of these can be related to food and water borne contaminants (2). Other possible causes of diarrhoea include Kaposi’s Sarcoma (KS), B-Cell lymphoma, opportunistic neoplasms, and HIV enteropathy (3). HIV enteropathy is a poorly defined clinical entity often diagnosed when other pathogenic factors have been eliminated as potential sources of diarrhoea (3). Another potential cause of diarrhoea in HIV infection is a side effect of Antiretroviral Therapy (ART) and some other medication such as antibiotics. The classification of diarrhoea for the purpose of this SOP uses the definition provided by the World Health Organisation (WHO)(4). The aim of this SOP is to outline nutrition management for Grade 1 and Grade 2 Diarrhoea. Table 1.0 WHO Classification of Gastrointestinal Symptoms(4) Grade 1* Grade 2* Grade 3 Grade 4 Mild OR Moderate OR Bloody Hypotensive transient diarrhoea; persistent; 5−7 diarrhoea OR shock OR 3−4 loose stools loose stools per orthostatic hospitalisation per day OR day OR hypotension OR >7 required mild diarrhoea diarrhoea loose lasting <1week lasting >1week stools/day OR intravenous Rx required * Guidelines in this SOP are for management of Grade 1 and 2 diarrhoea. Definition Client may present or report one or more of the following indications and symptoms: • Changes in bowel habit include number of motions up to 7 loose motions per day and consistency of stool. • Aversion to food or a loss of appetite • Skipping meal • Reduced food intake • Weight loss Goal of Nutrition Management • Reduce risk of weight loss • Maintain adequate nutritional intake of macro and micronutrients • To reduce overall number of bowel motions • To improve consistency of bowel motions • Reducing risk and prevention of dehydration, and electrolyte imbalance • Enhance overall quality of life
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Nutrition Assessment • • • • • Assess body weight and compare to UBW Record number of motions and stool consistency and classify using WHO guidelines Record duration of symptom Review dietary intake with attention to energy intake, food hygiene, caffeine, alcohol, dietary fat, spicy food, fibre and lactose Review biochemistry for electrolyte imbalance.

Nutrition Management Advocacy • Stress the importance of maintaining an adequate nutritional intake to prevent weight loss and malnutrition Food Based Strategies • Maintaining adequate macronutrients to promote weight gain and maintenance (1) • Increase intake of Soluble Fiber, as this delays gastric emptying, increases absorption of bile salts, prolongs intestinal transit time, supplies Short Chain Fatty Acids (SCFA) and acts as a bulking agent (7) • Advice intake of fatty foods and lactose containing foods based on severity of symptom or as tolerated (5, 6) • Advice reducing intake of insoluble fiber as this shortens gastric emptying time • Advise to reduce intake of caffeine containing foods and drinks as this reduces gastric pH, stimulating peristalsis (8) • Maintain good fluid balance by encouraging regular fluid intake, consider the use of Oral Re-hydration Solution (ORS) • Review intake of foods such as cabbage, beans, broccoli, onions, green peppers, spicy foods and include as tolerated Referral • Refer to medical or nursing staff for investigation of diarrhoea cause e.g. pathogen Dietary Education Consideration of each individual patient’s living conditions and the potential for various factors to impact on the success of patients implementing the nutrition management plan should be taken into account by the nutrition educator. Where appropriate a patient’s food preferences, budget and social situation should be factored into the development of the nutrition management plan. At the end of the dietary counseling session the patient should receive a summary of the nutrition management plan and all dietary strategies checked with the patient for understanding and practicality (9). References 1. Anastasi JK, Capili B, Kim AG, McMahon D, Heitkemper MM. Symptom management of HIV-related diarrhea by using normal foods: A randomized controlled clinical trial. J Assoc Nurses AIDS Care 2006;17(2):47-57. 2. Aragón T, Novotny S, Enanoria W, Vugia D, Khalakdina A, Katz M. Endemic cryptosporidiosis and exposure to municipal tap water in persons with acquired immunodeficiency syndrome (AIDS): A casecontrol study. BCM Public Health 2003;3(2). 3. Kotler DP. HIV infection and the gastrointestinal tract. Aids 2005;19(2):107-17.
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4. WHO. Antiretroviral therapy for HIV infection in adults and adolescents in resource-limited settings: towards universal access recommendations for a public health approach; 2006 Rev. Geneva: WHO; 2006. 5. Tinmouth J, Kandel G, Tomlinson G, Walmsley S, Steinhart AH, Glazier R. The effect of dairy product ingestion on human immunodeficiency virus-related diarrhea in a sample of predominantly gay men: a randomized, controlled, double-blind, crossover trial. Arch Intern Med 2006;166(11):1178-83. 6. Taylor C, Hodgson K, Sharpstone D, Sigthorsson G, Coutts M, Sherwood R, et al. The prevalence and severity of intestinal disaccharidase deficiency in human immunodeficiency virus-infected subjects. Scand J Gastroenterol 2000;35(6):599606. 7. Heiser CR, Ernst JA, Barrett JT, French N, Schutz M, Dube MP. Probiotics, soluble fiber, and L-Glutamine (GLN) reduce nelfinavir (NFV)- or lopinavir/ritonavir (LPV/r)- related diarrhea. J Int Assoc Physicians AIDS Care (Chic Ill) 2004;3(4):121-9. 8. Bowers JM, Dols CL, Barreuther CJ. Diarrhea in HIV-infected individuals: a review. AIDS Patient Care STDS 1996;10 (1):25-31. 9. Fields-Gardner C, Fergusson P. Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection. J Am Diet Assoc 2004;104(9):1425-41.

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Attachment 10- TACHIN Nutrition Management of Grade 3 or Grade 4 Diarrhoea Standard of Practice
Background Severe diarrhoea in HIV infection is often caused by an infection. Acute and chronic diarrhoea can be a common symptom experienced by many people living with HIV. Symptoms can vary from slight alterations in bowel movement, resulting in an increase in the number of motions and a change in stool consistency from loose but formed stool to watery or liquid motions. The symptoms may be self-limiting or intractable. The causes of diarrhoea in HIV infection are diverse. It has been suggested that parasites, bacteria and viruses account for up to 80% of diarrhoea experienced by people living with HIV (1). Other possible causes of diarrhoea include Kaposi’s Sarcoma (KS), B-Cell lymphoma, opportunistic neoplasms, and HIV enteropathy (2). HIV enteropathy is a poorly defined clinical entity often diagnosed when other pathogenic factors have been eliminated as potential sources of diarrhoea (2). Another potential cause of diarrhoea in HIV infection is a side effect of Antiretroviral Therapy (ART) and other medication such as some antibiotics. The classification of diarrhoea for the purpose of this SOP uses the definition provided by the World Health Organisation (WHO)(3). The aim of this SOP is to outline nutrition management for Grade 3 and Grade 4 Diarrhoea. Table 1.0 WHO Classification of Gastrointestinal Symptoms(3) Grade 1 Grade 2 Grade 3* Grade 4* Mild OR Moderate OR Bloody Hypotensive transient diarrhoea; persistent; 5−7 diarrhoea OR shock OR 3−4 loose stools loose stools per orthostatic hospitalization per day OR day OR hypotension OR >7 required mild diarrhoea diarrhoea loose lasting <1 week lasting >1 week stools/day OR intravenous Rx required * Guidelines in this SOP are for management of Grade 3 and 4 diarrhoea. Definition Client may present or report one or more of the following indications and symptoms: • Severe changes in bowel habit of more than 7 loose or watery motions per day, may include blood • Dehydration, sunken eyes • Feelings of listlessness, fatigue • Tenesmus or spiking fevers • Aversion to food or a loss of appetite • Skipping meals regularly and reduced food intake • Rapid weight loss Goal of Nutrition Management • • • • • Prevent dehydration and maintain hydration status Minimize risk of weight loss Promote adequate nutritional intake To reduce overall number of bowel motions and improve stool consistency To enhance quality of life

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Nutrition Assessment • • • • • • Assess body weight and compare to UBW Record number of motions and stool consistency Record duration of symptom Reclassify diarrhoea based on WHO guidelines Review biochemistry to monitor electrolyte balance Review dietary intake with attention to energy intake, fluid intake, potassium, food hygiene, caffeine, alcohol, spicy foods, dietary fat, fibre and lactose

Nutrition Management of Severe Diarrhoea Food Based Strategies • Initiate use of Oral Re-hydration Solution (ORS) • Advise low fat diet • Avoid lactose free diet • Avoid caffeine and alcohol containing drinks • Low fiber and low residue diet (containing no seeds skins, or pips) • Consider TPN or use of elemental feeds if available • Maintaining adequate calories for weight gain / maintenance (1) • Avoid spicy foods and cruciferous vegetables Referral • Refer to medical or nursing staff for investigation of diarrhoea cause e.g. pathogen Dietary Education Consideration of each individual patient’s living conditions and the potential for various factors to impact on the success of patients implementing the nutrition management plan should be taken into account by the nutrition educator. Where appropriate a patient’s food preferences, budget and social situation should be factored into the development of the nutrition management plan. At the end of the dietary counseling session the patient should receive a summary of the nutrition management plan and all dietary strategies checked with the patient for understanding and practicality(8). References 1. Anastasi JK, Capili B, Kim AG, McMahon D, Heitkemper MM. Symptom management of HIV-related diarrhea by using normal foods: A randomized controlled clinical trial. J Assoc Nurses AIDS Care 2006;17(2):47-57. 2. Kotler DP. HIV infection and the gastrointestinal tract. Aids 2005;19(2):107-17. 3. WHO. Antiretroviral therapy for HIV infection in adults and adolescents in resource-limited settings: towards universal access recommendations for a public health approach; 2006 Rev. Geneva: WHO; 2006. 4. Tinmouth J, Kandel G, Tomlinson G, Walmsley S, Steinhart AH, Glazier R. The effect of dairy product ingestion on human immunodeficiency virus-related diarrhea in a sample of predominantly gay men: a randomized, controlled, double-blind, crossover trial. Arch Intern Med 2006;166(11):1178-83. 5. Taylor C, Hodgson K, Sharpstone D, Sigthorsson G, Coutts M, Sherwood R, et al. The prevalence and severity of intestinal disaccharidase deficiency in human immunodeficiency virus-infected subjects. Scand J Gastroenterol 2000;35(6):599606.
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6. Heiser CR, Ernst JA, Barrett JT, French N, Schutz M, Dube MP. Probiotics, soluble fiber, and L-Glutamine (GLN) reduce nelfinavir (NFV)- or lopinavir/ritonavir (LPV/r)-related diarrhea. J Int Assoc Physicians AIDS Care (Chic Ill) 2004;3(4):121-9. 7. Bowers JM, Dols CL, Barreuther CJ. Diarrhea in HIV-infected individuals: a review. AIDS Patient Care STDS 1996;10(1):25-31. 8. Fields-Gardner C, Fergusson P. Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection. J Am Diet Assoc 2004;104(9):1425-41.

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Attachment 11- TACHIN Nutrition Management of Anorexia Standard of Practice
Background Anorexia or loss of appetite is a common symptom experienced by PLHIV(1, 2). Anorexia has a number of contributing factors such as psychosocial factors (such as stress, anxiety and depression), drug side effects (including ART, tobacco, caffeine(3) and illicit drugs such as amphetamines), biological contributors as seen in chronic immune stimulation(4) and hypogonadism (5) and is a significant contributor to malnutrition, weight loss and cachexia among PLHIV(6, 7). Definition Client may present or report one or more of the following indications and symptoms: • Skipping meals on a regular basis • Reduced food intake • Poor appetite or an aversion to food • Feelings stress, depression or anxiety • Weight loss Goals of Nutritional Management • • • • Maintain a adequate dietary intake Minimize risk of weight loss and promote a healthy weight Attain and maintain good nutritional status Enhance overall quality of life

Nutrition Assessment • • • • • Review meal habit including dietary intake, meal size, food preferences and meal timing (1) Review appetite history including times when appetite is particularly poor or improved Assess body weight compared to usual body weight and healthy weight references Review dietary intake of foods and substances known to impact appetite such as caffeine, nicotine(3, 8) and other medication Review possible causes of anorexia including other symptoms i.e. sore mouth, dysphagia, nausea, vomiting, diarrhoea or other health problems and psychosocial and environmental factors. Investigate possible causes of anorexia including stress, depression and anxiety (6)

Nutrition Management Advocacy • Stress the importance of maintaining an adequate nutritional intake to prevent weight loss and malnutrition Eating Behavior Strategies • Avoid skipping meals (9, 10) • Frequent small regular meals and snacks every 2 – 3 hours to maintain energy intake (10) • Utilize high energy, protein containing foods and liquids to supplement nutritional intake
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• • •

• •

Avoid low energy or ‘diet’ foods with limited nutritional value Eat more during times when appetite is better, including at unconventional times Limit substances that reduce appetite such as tobacco, caffeine, illicit drugs. Prescribed medication should be taken as directed by their physician, however a medical review may be required. Use preferred food flavors and aromas to stimulate appetite Consider recommending a multivitamin and mineral supplement

Environmental Strategies • Encourage light exercise • Encourage relaxation to reduce symptoms of stress and anxiety • Have ready prepared convenience food and snacks available at all times • Keep the favorite foods at easy access • Change eating atmosphere, venue and environment • Find a change to eat together with friends or relatives Referral • If required refer client to medical staff for further investigation of physiological, medical and biochemical causes of anorexia • If required refer client to other services such as counseling, psychology and social services for investigation and management of depression, stress and anxiety. Dietary Education Consideration of each individual patient’s living conditions and the potential for various factors to impact on the success of patients implementing the nutrition management plan should be taken into account by the nutrition educator. Where appropriate a patient’s food preferences, budget and social situation should be factored into the development of the nutrition management plan. At the end of the dietary counseling session the patient should receive a summary of the nutrition management plan and all dietary strategies checked with the patient for understanding and practicality(11). References 1. Nerad J, Romeyn M, Silverman E, Allen-Reid J, Dieterich D, Merchant J, et al. General nutrition management in patients infected with human immunodeficiency virus. Clin Infect Dis 2003;36(Suppl 2):S52-62. 2. Beal J, Flynn N. AIDS-associated anorexia. J Physicians Assoc AIDS Care 1995;2(1):19-22. 3. Fredholm BB, Battig K, Holmen J, Nehlig A, Zvartau EE. Actions of caffeine in the brain with special reference to factors that contribute to its widespread use. Pharmacol Rev 1999;51(1):83-133. 4. Arnalich F, Martinez P, Hernanz A, Gonzalez J, Plaza MA, Montiel C, et al. Altered concentrations of appetite regulators may contribute to the development and maintenance of HIV-associated wasting. Aids 1997;11(9):1129-34. 5. Morley JE, Thomas DR, Wilson MM. Cachexia: pathophysiology and clinical relevance. Am J Clin Nutr 2006;83(4):735-43. 6. Lennie TA, Neidig JL, Stein KF, Smith BA. Assessment of hunger and appetite and their relationship to food intake in persons with HIV infection. J Assoc Nurses AIDS Care 2001;12(3):66-74. 7. Sheehan LA, Macallan DC. Determinants of energy intake and energy expenditure in HIV and AIDS. Nutrition 2000;16(2):101-6. 8. Jessen A, Buemann B, Toubro S, Skovgaard IM, Astrup A. The appetite-suppressant effect of nicotine is enhanced by caffeine. Diabetes Obes Metab 2005;7(4):327-33.
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9. FAO/WHO. Living Well with HIV/AIDS; A Manual on Nutritional Care and Support for People Living with HIV/AIDS. Rome: WHO, FAO; 2002. 10. FANTA FANTAP. HIV/AIDS: A Guide for Nutrition, Care and Support. Washington DC: Academy for Educational Development; 2004. 11. Fields-Gardner C, Fergusson P. Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection. J Am Diet Assoc 2004;104(9):1425-41.

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Attachment 12- TACHIN Nutrition Management of Nausea and Vomiting Standard of Practice
Background Nausea is a common symptom in PLHIV (1). It refers to an uneasy feeling of the stomach, and may or may not be accompanied by vomiting. Nausea reduces the appetite and can be caused by certain foods, hunger, infections, stress and dehydration. In PLHIV, ART can have many potential side effects, including nausea (2, 3). Nausea is problematic when it causes a significant reduction in appetite, oral intake and over time is a significant contributor to malnutrition and weight loss. If accompanied by prolonged vomiting, there is a risk of dehydration and serious injury. Definition Client may present or report one or more of the following indications and symptoms: • Regular feelings of nausea with or without vomiting • Skipping meals on a regular basis • Reduced food intake • Poor appetite or an aversion to food • Feelings stress, depression or anxiety • Weight loss Goals of Nutritional Management • • • • • Minimize risk of weight loss Maintain optimal nutritional status Maintain an adequate dietary intake, and reduce risk of dehydration and electrolyte imbalance (in clients with vomiting) Enhance overall quality of life Minimize the severity and frequency of symptom

Nutrition Assessment • Review meal habit including dietary intake, meal size, food preferences and meal timing (4) • Assess body weight compared to usual body weight • Assess food hygiene and possible contamination of food and water • Assess eating environment • Investigate possible causes of stress and anxiety • Investigate medications and that may be contributing to nausea • Review timing of medications and meals • Assess dosage and timing of supplements that may be contributing to nausea. • Review biochemistry for electrolyte imbalance • Investigate medical problems such as liver disease, heart disease, renal disease that may be the underlying cause of nausea. Nutrition Management Advocacy • Stress the importance of maintaining an adequate nutritional intake to prevent weight loss and malnutrition

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Food Based Strategies • Frequent small meals and snacks every 2 – 3 hours to maintain energy intake (5) • Eat slowly and avoid lying down immediately after meal (5, 6) • Reduce intake of fatty and oily food as they slow gastric emptying • Avoid caffeine, spicy foods and alcohol (5) • Advise eating plain, salted crackers if unable to tolerate other foods (5). If vomiting use energy containing liquids to maintain energy intake. • Suggest using sour or salty foods, or ginger tea • Avoid foods that are too hot or too cold • If vomiting, maintain fluids and seek medical attention if symptom lasts more than 3 days • Avoid skipping meals (5, 6) • Avoid strong odors Environmental Strategies • Eat in a calm environment and rest between meals (5) • Avoid the kitchen when foods are being prepared (6) • Eat meals in environments that are open and have good air circulation • Avoid any strenuous exercise soon after eating • Rinse mouth before eating Referral (if required) • Referral to medical for further investigation of physiological cause of nausea • Referral to other services such as psychology and social services for investigation of stress and anxiety. Dietary Education Consideration of each individual patient’s living conditions and the potential for various factors to impact on the success of patients implementing the nutrition management plan should be taken into account by the nutrition educator. Where appropriate a patient’s food preferences, budget and social situation should be factored into the development of the nutrition management plan. At the end of the dietary counseling session the patient should receive a summary of the nutrition management plan and all dietary strategies checked with the patient for understanding and practicality (7). References 1. Cuff PA. Acquired immunodeficiency syndrome and malnutrition: role of gastrointestinal pathology. Nutr Clin Pract 1990;5(2):43-53. 2. Reynolds NR, Neidig JL. Characteristics of nausea reported by HIV-infected patients initiating combination antiretroviral regimens. Clin Nurs Res 2002;11(1):71-88. 3. Ammassari A, Murri R, Pezzotti P, Trotta MP, Ravasio L, De Longis P, et al. Selfreported symptoms and medication side effects influence adherence to highly active antiretroviral therapy in persons with HIV infection. J Acquir Immune Defic Syndr 2001;28(5):445-9. 4. Nerad J, Romeyn M, Silverman E, Allen-Reid J, Dieterich D, Merchant J, et al. General nutrition management in patients infected with human immunodeficiency virus. Clin Infect Dis 2003;36(Suppl 2):S52-62. 5. FANTA FANTAP. HIV/AIDS: A Guide for Nutrition, Care and Support. Washington DC: Academy for Educational Development; 2004. 6. FAO/WHO. Living Well with HIV/AIDS; A Manual on Nutritional Care and Support for People Living with HIV/AIDS. Rome: WHO, FAO; 2002. 7. Fields-Gardner C, Fergusson P. Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection. J Am Diet Assoc 2004;104(9):1425-41.
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Attachment 13- TACHIN Nutrition Management of Weight Loss Standard of Practice
Background Weight loss is a common symptom among PLWHA, and has been correlated with disease progression and mortality (1). Up to 90% of people with HIV/AIDS who are not receiving ART will experience weight loss during the course of the disease (2). One study has shown that the incidence of hospitalization increases by 32% for every 5% weight loss (3). Weight loss and malnutrition is associated with impaired quality of life, accelerated disease progression and reduced survival. In HIV, lean muscle mass is often used as energy for the body, causing a depletion in muscle stores. Depletion of muscle mass is often referred to as ‘wasting’. Weight loss in HIV infection can either be slow and progressive, or rapid, often related to concurrent infection. A figure of 10% weight loss from usual weight is often used as a screening tool for nutritional intervention. There is evidence, particularly from health practitioners in the USA, that for aggressive intervention the figure should be lowered to 5% weight loss (3). There has been significant interest in the type of weight loss that occurs in HIV/AIDS and the use of weight and body composition changes as an indicator of HIV disease progression (4-6). Weight loss occurs when energy expended exceeds energy consumed. In HIV infection, baseline energy expenditure is increased from normal (5, 7-11), which increases nutritional requirements. In times of infection or acute illness baseline energy requirements may increase by 30% (9, 10). Along with weight loss, body composition and serum albumin levels have also been studied in relation to disease progression. It is possible to influence each of these factors through improved nutritional intake; given this, it may be achievable to enhance the prognosis of someone living with HIV/AIDS by identifying and treating the underlying causes of weight loss and muscle wasting (3). Weight loss may be a direct result of increased energy requirements due to the virus, opportunistic infections, or inadequate dietary intake. Poor dietary intake may be caused by poverty and not being able to buy sufficient food. Feeling unwell often reduces appetite and inclination to eat. Depression and anxiety may also have a negative impact on food intake and lead to weight loss. The aim of this SOP is to outline nutrition management for weight loss. Definition In addition to weight loss client may also present or report one or more of the following indications and symptoms: • Reduced food intake • Skipping meals on a regular basis • Poor appetite or an aversion to food • Feelings stress, depression or anxiety

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Goals of Nutritional Management • • • • Promote a healthy weight Maintain adequate lean body mass Promote and adequate dietary intake of both macro and micronutrients Enhance overall quality of life

Nutrition Assessment • • • • • • Review meal habit including dietary intake, meal size, food preferences and meal timing (12) Assess body weight, and percentage weight loss Assess body composition (percentage fat, lean body mass) Assess oral health and difficulty eating Investigate other social and medical reasons that may be contributing to weight loss, for example diarrhoea, nausea or poor appetite Investigate possible socio-economic and psycho-social reasons behind weight loss, such as poverty, food beliefs, body image and depression.

Nutrition management Advocacy • Stress the importance of maintaining an adequate nutritional intake to prevent further weight loss and malnutrition Food Based Strategies • Eat regularly, incorporating snacks between meals • Increase overall macro and micronutrient intake through increase portion sizes • Enhance overall energy density of foods eaten by adding protein, fat and carbohydrate to meals and snacks. • Avoid over-consumption of low energy foods such as diet soft drinks, tea and coffee • Consider advice on food fortification and supplementation, using homemade or commercial supplements. Lifestyle Strategies • Increase resistive exercise to maintain and rebuild muscle mass. Referral • Refer to relevant health professionals for further investigations of possible contributing factors to weight loss. Dietary Education Consideration of each individual patient’s living conditions and the potential for various factors to impact on the success of patients implementing the nutrition management plan should be taken into account by the nutrition educator. Where appropriate a patient’s food preferences, budget and social situation should be factored into the development of the nutrition management plan. At the end of the dietary counseling session the patient should receive a summary of the nutrition management plan and all dietary strategies checked with the patient for understanding and practicality (13).

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References 1. Ludy M, Hendricks K, Houser RF, Chetchotisakd P, Mootsikapun P, Anunnatsiri S, et al. Body composition in adults infected with Human Immunodeficiency Virus in Khon Kaen, Thailand. The American Society of Tropical Medicine and Hygiene 2005;73(4):815-819. 2. Chlebowski RT, Grosvenor M, Lillington L, Sayre J, Beall G. Dietary intake and counseling, weight maintenance, and the course of HIV infection. J Am Diet Assoc 1995;95(4):428-32; quiz 433-5. 3. Kotler DP, Tierney AR, Wang J, Pierson RN, Jr. Magnitude of body-cell-mass depletion and the timing of death from wasting in AIDS. Am J Clin Nutr 1989;50(3):444-7. 4. Kotler DP, Wang J, Pierson RN. Body composition studies in patients with the acquired immunodeficiency syndrome. Am J Clin Nutr 1985;42(6):1255-65. 5. Melchior JC, Salmon D, Rigaud D, Leport C, Bouvet E, Detruchis P, et al. Resting energy expenditure is increased in stable, malnourished HIV-infected patients. Am J Clin Nutr 1991;53(2):437-41. 6. Trujillo EB, Borlase BC, Bell SJ, Guenther KJ, Swails W, Queen PM, et al. Assessment of nutritional status, nutrient intake, and nutrition support in AIDS patients. J Am Diet Assoc 1992;92(4):477-8. 7. Hommes MJ, Romijn JA, Endert E, Sauerwein HP. Resting energy expenditure and substrate oxidation in human immunodeficiency virus (HIV)-infected asymptomatic men: HIV affects host metabolism in the early asymptomatic stage. Am J Clin Nutr 1991;54(2):311-5. 8. Hommes MJ, Romijn JA, Godfried MH, Schattenkerk JK, Buurman WA, Endert E, et al. Increased resting energy expenditure in human immunodeficiency virus-infected men. Metabolism 1990;39(11):1186-90. 9. Melchior JC, Raguin G, Boulier A, Bouvet E, Rigaud D, Matheron S, et al. Resting energy expenditure in human immunodeficiency virus-infected patients: comparison between patients with and without secondary infections. Am J Clin Nutr 1993;57(5):61410. Grunfeld C, Pang M, Shimizu L, Shigenaga JK, Jensen P, Feingold KR. Resting energy expenditure, caloric intake, and short-term weight change in human immunodeficiency virus infection and the acquired immunodeficiency syndrome. Am J Clin Nutr 1992;55(2):455-60. 11. Macallan DC, Noble C, Baldwin C, Jebb SA, Prentice AM, Coward WA, et al. Energy expenditure and wasting in human immunodeficiency virus infection. N Engl J Med 1995;333(2):83-8. 12. Nerad J, Romeyn M, Silverman E, Allen-Reid J, Dieterich D, Merchant J, et al. General nutrition management in patients infected with human immunodeficiency virus. Clin Infect Dis 2003;36(Suppl 2):S52-62. 13. Fields-Gardner C, Fergusson P. Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection. J Am Diet Assoc 2004;104(9):1425-41.

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Attachment 14- TACHIN Nutrition Management of Diabetes mellitus Standard of Practice
Background As treatment with anti-retroviral therapy has become more prevalent, the number of metabolic complications associated with treatment has increased (1). These have made a significant contribution to the burden of HIV disease in the form of increased prevalence of problems such as cardiovascular disease, insulin resistance and non-alcohol fatty liver disease(2). DAD Study: In non-HIV communities the prevalence of lifestyle related metabolic complications is becoming increasingly prevalent. Overweight and obesity is associated with increased risk of morbidity and mortality, as well as contributing to a range of metabolic complications such as heart disease, diabetes and non-alcoholic fatty liver disease. Definition Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels. The classification of diabetes mellitus for the purpose of this SOP uses the definition provided by the American Diabetes Association (ADA). The aim of this SOP is to outline nutrition management for diabetes mellitus. Table 1 — Criteria for the diagnosis of diabetes mellitus 1. Symptoms of diabetes plus casual plasma glucose concentration 200 mg/dl (11.1mmol/l). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss. OR 2. FPG 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h. OR 3. 2-h plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. In the absence of unequivocal hyperglycemia, these criteria should be confirmed by repeat testing on a different day. The third measure (OGTT) is not recommended for routine clinical use. Goals of MNT that apply to individuals with diabetes To decrease the risk of diabetes and cardiovascular disease (CVD) by promoting healthy food choices and physical activity leading to moderate weight loss that is maintained. 1. Achieve and maintain o Blood glucose levels in the normal range or as close to normal as is safely possible o A lipid and lipoprotein profile that reduces the risk for vascular disease
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2. 3. 4. 5.

Blood pressure levels in the normal range or as close to normal as is safely possible To prevent, or at least slow, the rate of development of the chronic complications of diabetes by modifying nutrient intake and lifestyle To address individual nutrition needs, taking into account personal and cultural preferences and willingness to change To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence Enhance overall quality if life
o

Nutrition Assessment Family Factors • Assess family history of disease include CHD and diabetes Physical Factors • Assess and monitor body weight and body composition, Biochemistry • Assess and monitor biochemical data i.e. blood sugar, lipid profiles, blood pressure, BUN, creatinine and albumin Dietary Intake • Assess dietary intake and compare to dietary requirement • Review meal habit including meal size, food preferences, food beliefs meal timing

and

Lifestyle Factors • Assess amount of regular exercise and activity level • Review the kind and quantities of medication i.e. Oral glycemic agent and insulin • Review frequency and severity of hypoglycemia episode • Assess client use of herbal and vitamin supplements • Assess socioeconomic i.e. education, finance, ethnics and culture Psychological Factors • Assess the stage of change Nutrition Management Advocacy • Advocate for the role of food and nutrition as an important component of Diabetes care and health maintenance. Eating Behavior Strategies • A dietary pattern that includes carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk is encouraged for good health. • Monitoring carbohydrate, whether by carbohydrate counting, exchanges, or experienced-based estimation remains a key strategy in achieving glycemic control. • Sucrose-containing foods can be substituted for other carbohydrates in the meal plan or, if added to the meal plan, covered with insulin or other glucoselowering medications. Care should be taken to avoid excess energy intake. • Sugar alcohols and nonnutritive sweeteners are safe when consumed within the daily intake levels established by the Food and Drug Administration (FDA). • Limit saturated fat to <7% of total calories.

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• • • •

Intake of trans-fat should be minimized. In individuals with diabetes, limit dietary cholesterol to <200 mg/day. Two or more servings of fish per week (with the exception of commercially fried fish filets) provide n-3 polyunsaturated fatty acids and are recommended. In overweight and obese insulin-resistant individuals, modest weight loss has been shown to improve insulin resistance (ref - (3, 4)?). Thus, weight loss is recommended for all such individuals who have or are at risk for diabetes. The dietary intake of protein for individuals with diabetes and normal renal function is usually 15-20% of energy intake. In individuals with diabetes and macro-albuminuria, reducing protein from all sources to 0.8 g · kg body wt–1 · day–1 (on average, 10%) of calories has been associated with slowing the decline in renal function.

• •

Lifestyle Strategies • Exercise and physical activity are to be encouraged to improve insulin sensitivity independent of weight loss, acutely lower blood glucose, and are important in long-term maintenance of weight loss. Dietary Education Consideration of each individual patient’s living conditions and the potential for various factors to impact on the success of patients implementing the nutrition management plan should be taken into account by the nutrition educator. Where appropriate patient’s food preferences, budget and social situation should be factored into the development of the nutrition management plan. At the end of the dietary counseling session the patient should receive a summary of the nutrition management plan and all dietary strategies checked with the patient for understanding and practicality (7). References 1. The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 26:3160– 3167, 2003 2. John P. Bantle (Co-Chair), Judith Wylie-Rosett (Co-Chair), Ann L. Albright, Caroline M. Apovian, Nathaniel G. Clark, Marion J. Franz, Byron J. Hoogwerf, Alice H. Lichtenstein, Elizabeth Mayer-Davis, Arshag D. Mooradian, and Madelyn L. Wheeler. Nutrition Recommendations and Interventions for Diabetes. Diabetes Care 2007. 31: S61-S78. 3. Carr A, Samaras K, Burton S, Law M, Freund J, Chisholm DJ, et al. A syndrome of peripheral lipodystrophy, hyperlipidaemia and insulin resistance in patients receiving HIV protease inhibitors. AIDS 1998;12(7):F51-8. 4. Fields-Gardner C, Fergusson P. Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection. J Am Diet Assoc 2004;104(9): 1425-41. 5. Mann JI. Nutrition recommendations for the treatment and prevention of type 2 diabetes and the metabolic syndrome: an evidenced-based review. Nutr Rev 2006;64(9):422-7. 6. Mann JI. Evidence-based nutrition recommendations for the treatment and prevention of type 2 diabetes and the metabolic syndrome. Food Nutr Bull 2006;27(2):161-6. 7. Fields-Gardner C, Fergusson P. Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection. J Am Diet Assoc 2004;104(9): 1425-41.
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Attachment 15- TACHIN Nutrition Management of Overweight and Obesity Standard of Practice
Background As anti-retroviral therapy has become more available, the prevalence of overweight and obesity experienced by many PLHIV has increased (Hodgson LM 2001, Shor-Posner 2000). The causes of overweight and obesity in HIV are numerous and can be separated into biological and including enhanced absorption and utilization of macro and micronutrients as a result of reduced HIV viral load and antiretroviral therapy. The effect overweight and obesity has on HIV progression is relatively unknown, although a small amount of research has focused on this issue (Amorosa). DAD Study: In non-HIV populations overweight and obesity has been strongly correlated with increased risk of morbidity and mortality, particularly evident through increased experience of metabolic complications such as cardiovascular disease, diabetes and nonalcoholic fatty liver disease. Despite limited evidence about the contribution of overweight and obesity to metabolic complications in HIV, managing symptoms has the potential to reduce the risk of other risk factors. Obesity should be the primary target for intervention in patients with metabolic syndrome. Weight loss is associated with a decrease in markers of inflammation, decreased blood pressure, and improved insulin sensitivity. Definition Overweight is a state in which weight exceeds a standard based on height; obesity is a condition of excessive fatness, either generalized or localized. The determination of body mass index (BMI) and waist circumference are the most commonly used methods for overweight/obesity assessment Classification of Overweight and Obesity Classification Underweight Normal Overweight Obesity Body Mass Index (kg/m2) <18.5 18.5-22.9 23-24.9 >25

Waist circumference over 36 inches (90 cm) in men and over 32 inches (80 cm) are undesirable. When waist circumference and percentage of fat are included together, they are significant predictors of heart failure and risk associated with obesity (Nicklas et. Al., 2006) The purpose of this document is to outline the nutrition assessment and dietary management of overweight and obesity among PLHIV. Goals of Nutritional Management • Attain and maintain a healthy weight • Maintain an adequate dietary intake • Reduce risk factors for cardiovascular disease and diabetes • Enhance overall nutritional status • Improve overall quality of life

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Nutrition Assessment • Screen patient history for presence of other risk factors of cardiovascular disease and metabolic syndrome, such as blood glucose level, hypertension, smoking, hyperlipidaemia. • Complete the ABCDEF approach, by focusing especially on: • Assess body weight history and compare to current body weight and healthy weight references • Investigate possible causes of overeating i.e. stress, depression and anxiety • Review dietary intake, meal size and meal timing (1) • Assess the stage of change • Lifestyle behavior change such as exercise. Nutrition management • Emphasize the relationship between overweight/ obesity and other risk factors such as cardiovascular disease, diabetes and other metabolic complications • Gradually wt. loss 1-2 kg per month • Provide necessary follow-up based on presence of additional risk factors of cardiovascular disease and metabolic syndrome. • Encourage client to commence light aerobic and resistive exercise (2, 3) • Referral to medical for further investigation of physiological, medical and biochemical causes of overweight and obesity • Referral to other services such as counseling, psychology and social services for investigation and management of depression, stress and anxiety as required. Eating Behavior Strategies • Don’t skip meal but reduce the portion or amount of food, especially Dinner • Keep balance & variety in diet; Healthy eating guideline • Drink more water • Regular exercise at least 30 minutes, 3 times/week Lifestyle Modification Strategies Setting Easy-To-Achieve Short-term Goals - Increase number of minutes of walking on weekends - Include one fruit at Lunch Self-Monitoring - Food and activity records - Regular weigh in (i.e., daily or weekly) Stimulus Control - Shop when not hungry and with a grocery list - Make eating a singular activity (e.g., turn off the television) Confronting Barriers - Problem-solving steps - Planning ahead (e.g., healthful snacks on hand) Stress Management - Daily meditation or yoga - Progressive relaxation and visual imagery exercises Social support - Organized commercial support meetings or classes - Family, friends, co-workers as support systems Contracting - Realistic, simple, and achievable healthful goals - Useful for short-term change
Modified from Foreyt JP: Need for lifestyle intervention: how to begin, Am J Cardiovasc 96:11E14E, 2005. TRCARC-SOP TRC.AI-EMR09-10-012 version 1.0 (Effective Date: February 19, 2010) Standard Operating Procedure for TRCARC Nutrition Service

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Referral • Refer to relevant health professionals for further investigations of possible contributing factors to weight gain. Dietary Education Consideration of each individual patient’s living conditions and the potential for various factors to impact on the success of patients implementing the nutrition management plan should be taken into account by the nutrition educator. Where appropriate a patient’s food preferences, budget and social situation should be factored into the development of the nutrition management plan. At the end of the dietary counseling session the patient should receive a summary of the nutrition management plan and all dietary strategies checked with the patient for understanding and practicality (7). References 1. Nerad J, Romeyn M, Silverman E, Allen-Reid J, Dieterich D, Merchant J, et al. General nutrition management in patients infected with human immunodeficiency virus. Clin Infect Dis 2003;36(Suppl 2):S52-62. 2. Bopp CM, Phillips KD, Fulk LJ, Dudgeon WD, Sowell R, Hand GA. Physical activity and immunity in HIV-infected individuals. AIDS Care 2004;16(3):387-93. 3. Dudgeon WD, Phillips KD, Bopp CM, Hand GA. Physiological and psychological effects of exercise interventions in HIV disease. AIDS Patient Care STDS 2004;18(2):81-98. 4. FAO/WHO. Living Well with HIV/AIDS; A Manual on Nutritional Care and Support for People Living with HIV/AIDS. Rome: WHO, FAO; 2002. 5. FANTA FANTAP. HIV/AIDS: A Guide for Nutrition, Care and Support. Washington DC: Academy for Educational Development; 2004. 6. Molley Gee, L. Kathleen Mahan and Sylvia Escott-Stump. Weight Management. Krause’s Food & Nutrition Therapy: 865-883, 2008 7. Fields-Gardner C, Fergusson P. Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection. J Am Diet Assoc 2004;104(9):1425-41.

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Attachment 16- TACHIN Nutrition Management of Dyslipidemia Standard of Practice
Background As treatment with anti-retroviral therapy has become more prevalent, the number of metabolic complications associated with treatment has increased, especially dyslipidemia. These have made a significant contribution to the burden of HIV disease in the form of increased prevalence of problems such as cardiovascular disease, insulin resistance and non-alcohol fatty liver disease. Definition Dyslipidemia includes hypertriglyceridemia hypercholesterolemia, high LDL-c, low HDL-c and/or

Total blood cholesterol: Its level less than 200 mg/dl is desirable. This level is associated with the least risk of heart disease. High-Density Lipoprotein (HDL) cholesterol: HDL-c is known as “good” cholesterol because a high level seems to protect us against heart attacks by carrying cholesterol away from your arteries. On the average, men should have HDL-c levels more than 40 mg/dl, and woman should have the levels more than 50 mg/dl. Low-Density Lipoprotein (LDL) cholesterol: LDL-c can slowly build up on the walls of arteries that feed the heart or brain. It is known as “bad” cholesterol, because a high level indicates an increased risk of heart disease. LDL-c levels less than 130 mg/dl are desirable. Triglyceride: High triglyceride levels often appear with higher levels of total cholesterol and LDL cholesterol, and low levels of HDL cholesterol. Ideal triglyceride levels are considered to be less than 200 mg/dl Goals of Nutritional Management • Maintain a balanced dietary intake • Optimize a fasting lipid profile • Reduce risk factors for cardiovascular disease and diabetes • Maintain a healthy weight • Improve nutritional status • Enhance overall quality of life

§ IDSA/NCEP ATP III LDL-c Goals (1)
Risk category Very high High Moderately high Moderate Low CHD Risk Factors or Equivalents High risk + recent acute coronary syndrome, diabetes, smoking, metabolic syndrome CAD or risk equivalent and 10-year risk > 20% > 2 risk factors and 10-year risk 10% to 20% > 2 risk factors and 10-year risk <10% 0-1 risk factor < 70 < 130 < 130 < 160 LDL-c Goal (mg/dl) < 70

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Count risk factors: (If > 2 risk factors, calculate absolute risk using Framingham calculator) 1. Cigarette smoking 2. Hypertension (blood pressure > 140/90 mmHg or on antihypertensive medication) 3. Low HDL cholesterol (< 40 in Men, < 50 in women) (note: subtract one if HDL cholesterol > 60 mg/dl) 4. Family history of premature coronary heart disease in a. Male first degree relative < 55 years b. Female first degree relative < 65 years 5. Age (men > 45 years, women > 55 years) Nutrition Assessment • Screen patient history for presence of other risk factors of cardiovascular disease and metabolic syndrome, such as blood glucose level, hypertension, smoking, hyperlipidaemia. • Complete the ABCDEF approach, by focusing especially on: • Assess body weight history and compare to current body weight and healthy weight references • Assess and monitor biochemical data i.e. Total cholesterol, HDL-c, LDL-c, triglyceride, etc. • Review dietary intake, meal size and meal timing (2) • Assess the stage of change. • Lifestyle behavior change such as exercise. Nutrition Management Lifestyle and Eating Behavior Strategies (3) (Modified from American Heart Association Cardiovascular Disease Risk Reduction) • • • • • 2006 Diet Recommendations for

• • • •

Balance calorie intake and physical activity to achieve/maintain a healthy body weight. Consume a diet rich in vegetables and fruits. Choose whole grain, high fiber diets. Consume fish, especially oily fish, at least twice a week. Limit intake of saturated fat to <7% of energy, trans-fat <1% of energy, and cholesterol to < 300 mg/day by: o Choosing lean meats and vegetable alternatives. o Select fat-free (skim), low fat dairy products. o Minimizing intake of partially hydrogenated fats. Minimize your intake of beverages and foods with added sugars. Choose and prepare foods with little or no salt. Avoid alcohol drinking No smoking Exercise regularly

Dietary Education Consideration of each individual patient’s living conditions and the potential for various factors to impact on the success of patients implementing the nutrition management plan should be taken into account by the nutrition educator. Where appropriate a patient’s food preferences, budget and social situation should be factored into the development of the nutrition management plan. At the end of the dietary counseling session the patient should receive a summary of the nutrition management plan and all dietary strategies checked with the patient for understanding and practicality (4).
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References 1. Peter Reiss and et.al. Application of Non-HIV Specific Management Strategies for Dyslipidemia in HIV-Infected Patients. Clinical Care Options, 2006. 2. Nerad J, Romeyn M, Silverman E, Allen-Reid J, Dieterich D, Merchant J, et al. General nutrition management in patients infected with human immunodeficiency virus. Clin Infect Dis 2003;36(Suppl 2):S52-62. 3. Debra A. Krummel. Medical Nutrition Therapy for Cardiovascular Disease. Krause’s Food & Nutrition Therapy: 865-883, 2008 4. Fields-Gardner C, Fergusson P. Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection. J Am Diet Assoc 2004;104(9):1425-41.

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Attachment 17- TACHIN Nutrition Management of Hypertension Standard of Practice
Background With access to HAART, HIV infection may be considered a chronic manageable disease. Chronic treatment of HIV raises new issues such as adherence and tolerability of antiretroviral medications, emergence of viral resistance, and to sequencing of drug selection and treatment regimens. Many patients are living longer with HIV disease and may be susceptible to other diseases that are increasingly common with aging, such as cardiovascular disease, diabetes, obesity, and hypertension. Definition Hypertension is persistently high arterial blood pressure, the force exerted per unit area on the wall of the arteries. To be defined as hypertension, the systolic blood pressure (SBP), the blood pressure during the contraction phase of the cardiac cycle, has to be 140 mm Hg or higher; or the diastolic blood pressure (DBP), the pressure during the relaxation phrase of the cardiac cycle, has to be 90 mm Hg or higher, and they are reported as 140/90 mm Hg. The classification of Hypertension for the purpose of this SOP uses the definition provided by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of high blood pressure. The aim of this SOP is to outline nutrition management for Hypertension. Table 1 — Classification of blood pressure for adults Blood pressure classification SBP Normal < 120 Pre-hypertension 120-139 Stage 1 Hypertension 140-159 Stage 2 Hypertension ≥ 160 DBP and <80 or 80-89 or 90-99 or ≥ 100

The defining point of hypertension is arbitrary because any level of elevated blood pressure is associated with increase incidence of CVD and renal disease. Therefore normalization of blood pressure is important for all stage of hypertension. Goals of MNT that apply to individuals with Hypertension To decrease the risk of Hypertension and cardiovascular disease (CVD) by promoting healthy food choices and physical activity leading to moderate weight loss that is maintained. 1) Achieve and maintain
o Blood pressure levels in the normal range or as close to normal as is safely

possible 2) To prevent, or at least slow, the rate of development of the chronic complications of Hypertension by modifying nutrient intake and lifestyle 3) To address individual nutrition needs, taking into account personal and cultural preferences and willingness to change 4) To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence 5) Enhance overall quality if life
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Nutrition Assessment • Assess and monitor biochemical and clinical data i.e. body weight, body composition, blood pressure, blood sugar, lipid profiles, BUN, creatinine and albumin • Assess dietary intake and compare to dietary requirement • Review meal habit including meal size, food preferences/beliefs and meal timing • Assess amount of regular exercise and activity level • Assess the stage of change • Review the kind and quantities of medication • Assess client use of herbal and vitamin supplements • Assess socioeconomic i.e. education, finance, ethnics and culture Nutrition Management Advocacy • Advocate for the role of food and nutrition as an important component of care and health maintenance. Eating Behavior Strategies • Weight reduction and maintenance of a healthy body weight has been shown to improve Hypertension. Thus, weight loss is recommended for all such individuals who have or are at risk for Hypertension. • Adopt DASH eating plan by consume a diet rich in fruits, vegetables, and low fat diary products with a reduce content of saturated and total fat is encouraged for good health. • • Reduce dietary sodium intake to no more than 2.4 g of sodium or 6 g of sodium chloride per day. Moderation of alcohol consumption by limit intake to no more than 2 drink (e.g.; 24 oz of beer, 10 oz of wine, or 3 oz of 80-proof whiskey) per day to most men and to no more 1 drink per day in women and lighter weight persons.

Lifestyle Strategies • Engage in regular aerobic physical activity such as brisk walking (at least 30 minutes/day most day of the week). Dietary Education Consideration of each individual patient’s living conditions and the potential for various factors to impact on the success of patients implementing the nutrition management plan should be taken into account by the nutrition educator. Where appropriate patient’s food preferences, budget and social situation should be factored into the development of the nutrition management plan. At the end of the dietary counseling session the patient should receive a summary of the nutrition management plan and all dietary strategies checked with the patient for understanding and practicality (3). References 1. Sarah C. Couch and Debra A. Krummel. Medical Nutrition Therapy for Hypertension. Krause’s Food & Nutrition Therapy: 865-883, 2008 2. Chobanian AV et al: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure : the JNC 7 Report, JAMA 289:2560. 2003. 3. Fields-Gardner C, Fergusson P. Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection. J Am Diet Assoc 2004;104(9):1425-41.
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Attachment 18- TACHIN Nutrition Management of Lipodystrophy Standard of Practice
Background (1) Antiretroviral therapy (ART) has dramatically modified the natural history of HIV infection, leading to a significant reduction in morbidity and mortality and a better quality of life. Unfortunately, long-term toxicity from ART is coming more and more recognized. It often results in generalized lipodystrophy, bone disorder, mitochondrial toxicity, and lactatemia. Treatment for lipodystrophy or body shape changes has been both difficult and confusing. The stigma and psychological discomfort associated with the condition can be devastating. Discontinuing ART is not a favorable option, and less offending regimens are under active study. Those who can afford them are using cosmetic surgery such as liposuction or implants, anabolic therapy, or combination of these options. Aerobic exercise may have a role in reducing truncal adiposity, along with a moderate-fat, moderate-carbohydrate, and high-fiber diet (Roubenoff et al., 2002). Definition Lipodystrophy: at least one morphological alteration in one of the following sites: face, dorso-cervical, breasts, abdomen, buttocks, and extremities. Lipoatrophy (fat wasting): at least one sign of atrophy of adipose tissue on the face, buttock, or extremities. Lipohypertrophy (fat accumulation): at least one sign of hypertrophy of adipose tissue on the abdomen, dorsocervical, or breasts. Goal of Nutrition Management • Maintain a balanced dietary intake • Minimize body shape change • To preserve lean body mass • To reduce visceral fat • Reduce risk factors for cardiovascular disease and diabetes • Maintain a healthy weight • Improve nutritional status • Enhance overall quality of life Nutrition Assessment • Screen patient history for presence of other risk factors of cardiovascular disease and metabolic syndrome, such as blood glucose level, hypertension, smoking, hyperlipidaemia. • Complete the ABCDEF approach, by focusing especially on: • Assess body weight history and compare to current body weight and healthy weight references • Assess body shape changes and percentage of visceral and subcutaneous fat • Review dietary intake, meal size and meal timing (2) • Lifestyle behavior change such as exercise.

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Nutrition Management Lifestyle and Eating Behavior Strategies • Eat adequate amount of foods that provide CHO § Sources: rice, corn, seeds, milk, fruits & vegetables • Take high protein diet to build up & increase muscle mass § Sources: Dairy products, meat, fish, egg & dry pulses • Eat an appropriate fat § Sources: MUFA, PUFA, Avoid saturated fat and trans-fat • Exercise regularly but do not overtax yourself (Both aerobic & anaerobic (resistance) exercise) Dietary Education Consideration of each individual patient’s living conditions and the potential for various factors to impact on the success of patients implementing the nutrition management plan should be taken into account by the nutrition educator. Where appropriate patient’s food preferences, budget and social situation should be factored into the development of the nutrition management plan. At the end of the dietary counseling session the patient should receive a summary of the nutrition management plan and all dietary strategies checked with the patient for understanding and practicality (3). References 1. Marcy Fenton and Ellyn C. Silverman. Medical Nutrition Therapy for Human Immunodeficiency Virus (HIV) disease. 2. Nerad J, Romeyn M, Silverman E, Allen-Reid J, Dieterich D, Merchant J, et al. General nutrition management in patients infected with human immunodeficiency virus. Clin Infect Dis 2003;36(Suppl 2):S52-62. 3. Fields-Gardner C, Fergusson P. Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection. J Am Diet Assoc 2004;104(9):1425-41.

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Attachment 19- TACHIN Client’s satisfaction Form
Patient Satisfaction Survey
Please put a tick (ü) in the box that best indicates your answer to each of the following statements.
1. The anthropometric assessment made me feel uncomfortable. 2. The dietitian worked with me to identify my nutrition goal 3. The identified nutrition goal is relevant to me 4. The dietitian seemed to have a good understanding of issues that affect my eating patterns 5. The dietitian allowed me to participate in decisions about strategies in my nutrition plan 6. The nutrition strategies developed are very clear 7. The nutrition strategies developed are practical for my situation 8. I feel that I will be able to implement the nutrition strategies developed 9. The dietitian spoke to me in a friendly and courteous manner 10. I have confidence in the dietitian ability 11. The dietitian gave me the opportunity to ask questions 12. The dietitian gave adequate responses to my questions 13. The dietitian was non-judgmental 14. I feel confident that the dietitian will keep my information confidential 15. I am happy with the amount of time I had to wait to see the dietitian 16. Approximately how long did you have to wait to see the nutritionist 17. The information (including IECs material) given to me by the dietitian was useful 18. The nutrition counseling room is appropriate 19. I am happy with the amount of time the dietitian spent with me 20. Overall the session with the dietitian was useful Strongly disagree Strongly disagree Strongly disagree Disagree Disagree Disagree Uncertain Uncertain Uncertain Agree Agree Agree Strongly agree Strongly agree Strongly agree

Strongly disagree

Disagree

Uncertain

Agree

Strongly agree

Strongly disagree Strongly disagree Strongly disagree Strongly disagree Strongly disagree Strongly disagree Strongly disagree Strongly disagree Strongly disagree Strongly disagree Strongly disagree Less than 10 minutes Strongly disagree Strongly disagree Strongly disagree Strongly disagree

Disagree Disagree Disagree Disagree Disagree Disagree Disagree Disagree Disagree Disagree Disagree 10-20 minutes Disagree Disagree Disagree Disagree

Uncertain Uncertain Uncertain Uncertain Uncertain Uncertain Uncertain Uncertain Uncertain Uncertain Uncertain 20–30 minutes Uncertain Uncertain Uncertain Uncertain

Agree Agree Agree Agree Agree Agree Agree Agree Agree Agree Agree 30-60 minutes Agree Agree Agree Agree

Strongly agree Strongly agree Strongly agree Strongly agree Strongly agree Strongly agree Strongly agree Strongly agree Strongly agree Strongly agree Strongly agree More than 1 hours Strongly agree Strongly agree Strongly agree Strongly agree

Other comments:.................................................................................................................................... .........................................................................................................................

Thank you for completing this survey.
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