TOPIC 10. FEEDING SICK PEOPLE

NUTRITION NOTES

Why sick people need good meals and plenty to drink

Eating well helps to fight infections

Sick people should eat well even if they are not active. They need nutrients to keep alive, fight infections and replace lost nutrients.

Infection often reduces appetite. It also increases the need for some nutrients if:

nutrients are poorly absorbed by the gut;
the body uses nutrients faster than usual (e.g. to repair the immune system).

Infections can cause malnutrition. Malnutrition makes infections worse

If sick people do not eat enough, they use their own body fat and muscles for energy and nutrients. They lose weight and become undernourished. Their immune systems may become less effective and they are less able to fight infections.

Sick people often lose or use more water than usual (e.g. during diarrhoea or fever). They need plenty of clean, safe drinks.

Helping sick children and adults to eat well

Feed sick people frequently and give them plenty to drink

Advise families to:

offer small amounts of food frequently, especially if the person is not hungry. Often a sick person prefers soft foods (e.g. gruel, mashed bananas or soup) or sweet foods. For a few days it does not matter what the person eats, provided he or she eats often;
give a sick person plenty to drink every 1-2 hours. For example, give boiled water, fresh fruit juice, coconut water, sodas, soup or watery porridge. Or give boiled or soured milk or milky tea unless the person has diarrhoea;
prepare food and drinks in a clean, safe way (see Topic 4) to prevent foodborne infections

If people are ill for more than a few days, they need a variety of foods to help their immune systems recover and to prevent weight loss (see Box 16). So families should give small, frequent meals that contain a combination of foods (see Topic 3). Adding a little fat-rich food or sugar is an easy way to increase energy without making the meal too big and bulky; including a variety of fruits and vegetables provides micronutrients.

If a young, breastfeeding child is sick, the mother should breastfeed more often. Breastmilk may be the only food and drink the child wants. Advise the mother to express her milk and feed it from a small cup or spoon if a child is too ill to suckle.

In areas where vitamin A deficiency is a problem, children with measles, diarrhoea, respiratory infections or malnutrition often benefit from vitamin A supplements. However, when giving these, health workers should emphasize the need for vitamin A-rich foods as well.

Feeding people with diarrhoea

People with diarrhoea need extra liquids to drink

Children and adults with diarrhoea and/or vomiting lose much water and so must drink frequently to prevent dehydration. Suitable drinks are oral rehydration solution made from packets of oral rehydration salts (from the clinic or pharmacy) or ordinary home-made fluids containing normal amounts of salt, such as soups or rice water.

People with diarrhoea must also eat because food helps the gut to recover and absorb water. Breastfeeding children who have diarrhoea should breastfeed frequently.

BOX 16 · HOW TO HELP SICK PEOPLE EAT MORE

· Offer food every 1-2 hours; give snacks between meals.

· Encourage the person to eat more at each meal.

· Give easy-to-eat foods that the person likes, but include energy-rich and nutrient-rich foods in the meals. For example, give meat, offal, poultry, fish, eggs, and milk foods when possible (adding dry milk powder to porridges and other foods provides extra milk); add extra fat or fatty foods and/or sweet foods, such as sugar or honey.

· Feed when the person has a low temperature, has been washed and has the mouth clean and the nose unblocked.

· Feed the person sitting up (especially if vomiting is likely); feed a child sitting on someone’s lap.

· Keep water and food nearby if a person has to stay in bed.

· Never force sick children to eat, as they may choke or vomit.

Feeding people who are recovering

Give extra food during recovery

During recovery from disease most people are hungrier than usual. They can eat more food and quickly regain lost weight. Children can grow faster than normal (catch-up growth). Sick people may have used up their stores of vitamin A, iron and other micronutrients. They need a variety of nutrient-rich foods to fill up these stores again. People can eat more during recovery if they eat extra food at each meal and/or more meals and snacks each day. Breastfeeding children who are recovering from illness should breastfeed more often.

Feeding people living with HIV/AIDS

A healthy, balanced diet helps people who are HIV+ to remain well longer

It is especially important that people living with HIV/AIDS eat healthy, balanced diets. Good diets prevent weight loss and help people to stay healthy longer.

BOX 17 · NUTRIENT NEEDS OF PEOPLE LIVING WITH HIV/AIDS

A WHO expert consultation in 2003 reached the following conclusions regarding nutrient requirements.

Energy needs

HIV+ adults and children with no symptoms of HIV or other (opportunistic) infections are likely to need 10 percent more energy than non-infected people (see Appendix 2, Table 4, for energy needs of non-infected people) in order to maintain normal weight, activity and growth. HIV+ adults with signs of other infections or AIDS need 20-30 percent more energy to maintain normal weight, and HIV+ children who are losing weight need 50-100 percent more energy.

Protein and fat needs

There is no evidence at the moment that HIV+ adults or children need extra protein or that fat needs are different from the norm.

Micronutrient needs

More research is needed on requirements and the role of supplements. It is likely that HIV increases the need for some micronutrients and HIV+ adults and children should have diets that are as healthy and balanced as possible.

- When pregnant and breastfeeding women cannot have a good diet, they can be given a multiple micronutrient supplement that provides no more than the daily needs of each micronutrient (see Appendix 2, Table 4, for daily needs of some micronutrients).

- HIV+ children aged six months to 5 years can receive high doses of vitamin A if this is normally given to young children (see Topic 11, page 92).

- Pregnant women should receive the same iron/folic acid supplements as non-infected women (see Topic 11, page 91).
Otherwise high doses of micronutrients (particularly vitamin A, zinc and iron) should not be given as these may have negative effects on HIV transmission or progression.

These recommendations may change when more research is reported, so look for the latest information from a reliable source.

Source: WHO. 2003. Nutrient requirements of people living with HIV/AIDS (listed in Appendix 3).

People living with HIV/AIDS often become malnourished or more severely malnourished because:

the HIV infection, other infections and drugs can reduce the appetite, change the taste of food and/or prevent the body from absorbing nutrients;
they may eat less if they have sore mouths, nausea or vomiting;
they have increased energy needs because the immune system is working harder than normal (see Box 17);
they may be tired and depressed, so it is an effort for them to prepare and eat food;
they may be short of money for food.

Like other sick people, people living with HIV/AIDS who do not eat or absorb enough nutrients use their own body tissues for energy and vital nutrients. They lose weight and become malnourished, and:

they are less resistant to other infections because the immune system is damaged. This speeds up the downward cycle of additional infections leading to worse malnutrition, leading to additional infections;
they may absorb smaller amounts of nutrients and drugs (e.g. drugs for tuberculosis, antibiotics, antiretroviral drugs);
their wounds heal more slowly;
they feel weak and are less able to work and live a normal life.

It is easier to prevent weight loss during the early stages of HIV infection. Make sure that people living with HIV/AIDS (and their families) know that they should:

eat healthy, balanced diets (see Topic 3). They do not need a special diet but should have three good meals containing a variety of energy-rich and nutrient-rich foods (including plenty of vegetables and fruits), and they should eat frequent energy- and nutrient-rich snacks each day. People who are already malnourished when they become infected with HIV have especially high energy and nutrient needs. It is essential that they have sufficient food (especially energy-rich foods) and a combination of foods;
be especially careful about food hygiene. The immune system is under stress so it is important to avoid food-borne infections (see Topic 4);
take regular exercise because this improves the appetite and builds muscles;
seek early treatment for infections;
eat as well as possible when sick and eat extra when they are feeling better in order to regain any weight lost;
adjust their food intake when they have diarrhoea, a sore mouth, lack of appetite or nutrient malabsorption to make sure they eat enough and choose foods that help recovery.

If people living with HIV/AIDS lose weight, advise them about how to regain it. Discuss how to eat more good foods and encourage physical activity so they rebuild their muscles. See Box 16 on page 83 for ways to help sick people eat more.

Figure 13. People living with HIV/AIDS need to eat often

There are different interactions between different antiretroviral drugs and different foods. For example, a drug may affect the absorption of a food or a food may affect the absorption of a drug. Health workers may need to consult their supervisors to find out what dietary advice to give people taking antiretroviral drugs (see FANTA/AED. 2003. Food and nutrition implications of antiretroviral therapy in resource limited settings listed in Appendix 3).

See FAO/WHO. 2002. Living well with HIV/AIDS. A manual on nutritional care and support for people living with HIV/AIDS (listed in Appendix 3) for detailed information on feeding people living with HIV/AIDS, including feeding when there are complications (e.g. diarrhoea).

SHARING THIS INFORMATION

Before sharing this information with families, you may need to:

1. Find out. Which foods and drinks are given to sick children and adults (including those with HIV/AIDS). What the local beliefs about feeding sick people and people living with HIV/AIDS are. Who chooses and prepares food for sick people.Who feeds sick people. Whether recovering children and adults are given more food. What the blocks to the better feeding of sick and recovering people are (e.g. caregiver’s time).

2. Prioritize. Decide which information is most important to share with groups or individual families.

3. Decide whom to reach. For example: caregivers of sick adults and children; people living with long-term diseases such as HIV/AIDS.

4. Choose communication methods. For example: discussions with community and self-help groups and at clinics and during home visits; demonstrations of good meals and snacks for sick people, and people living with HIV/AIDS and their families.

Examples of questions to start a discussion
(choose only a few questions that deal with the information families need most)

Why do sick people need to eat well?

How can we encourage sick people to eat?

Why do recovering children need extra food? How can we give them extra food?

Discuss feeding people living with HIV/AIDS only if a group wants to. If so, do this in a sensitive way. It is usually better to counsel people living with HIV/AIDS and their families individually and, if possible, at home.

Why is it important that people with HIV/AIDS eat well?

Why is it that some people with HIV/AIDS do not want to eat?

Why is it dangerous for people living with HIV/AIDS to lose weight?