A manual on nutritional care and support for people living with HIV/AIDS

Meeting immediate food, nutrition and other basic needs is essential if HIV/AIDS-affected households are to live with dignity and security. Providing nutritional care and support for people living with HIV/AIDS is an important part of caring at all stages of the disease. This manual provides home care agents and local service providers with practical recommendations for a healthy and well balanced diet for people living with HIV/AIDS. It deals with common complications that people living with HIV/AIDS are experiencing at different stages of infection and helps provide local solutions that emphasize using local food resources and home-based care and support.

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Preface

The links between nutrition and infection are well known. Good nutrition is essential for achieving and preserving health while helping the body to protect itself from infections. Consumption of a well-balanced diet is essential to make up for the loss of energy and nutrients caused by infections. Good nutrition also helps to promote a sense of well-being and to strengthen the resolve of the sick to get better. The nutritional advice in this manual can help sick people, including those living with HIV/AIDS, to feel better.

Few crises have affected human health and threatened national, social and economic progress in quite the way that HIV/AIDS has. The pandemic has had a devastating impact on household food security and nutrition through its effects on the availability and stability of food, and access to food and its use for good nutrition. Agricultural production and employment are severely affected and health and social services put under great strain. Families lose their ability to work and to produce. With worsening poverty, families also lose their ability to acquire food and to meet other basic needs. Time and household resources are consumed in an effort to care for sick family members, partners may become infected, families may be discriminated against and become socially marginalized, children may be orphaned and the elderly left to cope as best they can.

Meeting immediate food, nutrition and other basic needs is essential if HIV/AIDS-affected households are to live with dignity and security. Providing nutritional care and support for people living with HIV/AIDS is an important part of caring at all stages of the disease. This manual provides home care agents and local service providers with practical recommendations for a healthy and well-balanced diet for people living with HIV/AIDS. It deals with common complications that people living with HIV/AIDS experience at different stages of infection and helps provide local solutions that emphasize using local food resources and home-based care and support.

The manual was developed following an extensive review of existing guides from both developed and developing countries. Though it is applicable to many real life situations, users may find that they can further improve its usefulness if they adapt sections to local circumstances. The manual was prepared by the Nutrition Programmes Service of the FAO Food and Nutrition Division (ESN) in collaboration with the WHO Department of Nutrition for Health and Development (NHD), Geneva, and is jointly published by FAO and WHO.

Special thanks are due to Maren Lieberum, FAO, who had the primary responsibility for drafting the manual and co-ordinating its preparation and field testing. We would also like to thank Randa Saadeh, WHO, for her technical guidance and oversight of the manual's preparation. We would like to express our appreciation for the valuable contributions made by Marylou Biljsma, University of Zimbabwe, Yvonne Foreseen, Concerned International Angola, Boitshepo D. Giyose, Commonwealth Regional Health Community Secretariat Arusha, John Hubley, International Health Promotion Consultant, Dorcas Lwanga, SARA/SANA Project-USAID, and Micheline Ntiru, Care International South Africa; also to Jethro Dennis, Caribbean Food and Nutrition Institute for preparing the drawings, as well as to Genevieve Becker, WHO consultant, registered dietician and researcher.

Acknowledgements are due Marcela Villarreal and Carol Djeddah of FAO's Population and Development Service and to Ester Zulberti and Kalim Qamar in the Extension, Education and Communication Service for their technical contributions. We also acknowledge the staff of ESNP who assisted in preparing the manual: William D. Clay and Brian Thompson who supervised its preparation; Peter Glasauer who initiated the work and along with Ellen Muehlhoff, Valeria Menza, and Karel Callens provided technical support, and Karen Rautenstrauch and Joanna Lyons who provided editorial and administrative support.

We hope that local service providers, NGOs and family care givers will find this manual useful in their efforts to provide effective and innovative nutritional care and support to people living with HIV/AIDS.

Introduction

NUTRITION FOR PEOPLE LIVING WITH HIV/AIDS:
A VITAL AND OFTEN NEGLECTED COMPONENT OF HOME-BASED CARE

Malnutrition serious danger for people living with HIV/AIDS. Even at the early stages of HIV infection when no symptoms are apparent, HIV makes demands on the body's nutritional status. The risk of malnutrition increases significantly during the course of the infection.

Good nutrition cannot cure AIDS or prevent HIV infection, but it can help to maintain and improve the nutritional status of a person with HIV/AIDS and delay the progression from HIV to AIDS-related diseases. It can therefore improve the quality of life of people living with HIV/AIDS. Nutritional care and support are important from the early stages of the infection to prevent the development of nutritional deficiencies. A healthy and balanced diet will help to maintain body weight and fitness. Eating well helps to maintain and improve the performance of the immune system - the body's protection against infection - and therefore helps a person to stay healthy.

Many of the conditions associated with HIV/AIDS affect food intake, digestion and absorption, while others influence the functions of the body. Many of the symptoms of these conditions (e.g. diarrhoea, weight loss, sore mouth and throat, nausea or vomiting) are manageable with appropriate nutrition. Good nutrition will complement and reinforce the effect of any medication taken.

THE PURPOSE OF THIS MANUAL

The manual provides practical recommendations for a healthy and balanced diet for people living with HIV/AIDS in countries or areas with a low resource base. It aims at improving nutrition in a home-based setting. It is also applicable for people with HIV/AIDS in hospitals and other institutional settings, including hospices.

The food requirements of people with HIV/AIDS are described and recommendations given on foods and eating habits to meet these requirements. The manual also explains how to address the nutritional aspects of HIV-related conditions. Practical recipes using locally available foods are suggested as well as some simple home remedies for easing some of the problems people with HIV/AIDS may experience.

USERS OF THE MANUAL

The summary sheets and leaflets are specifically for use by people who are living with HIV/AIDS or who are caring for a person living with HIV/AIDS, who want to be better informed.

FIGURE 1
Entry points for raising nutritional issues and providing
care and support for people living with HIV/AIDS

Malnutrition in this publication refers to:
a) lack of food energy (undernutrition); and b) lack of micronutrients.

Adapting and using the manual

ADAPTING THE MANUAL FOR LOCAL USE

Although the recommendations in this manual are generic, the general principles will be relevant for most people living with HIV/AIDS. However, specific nutrition recommendations should be adapted to the needs of individuals and the local community.

In developing these recommendations, research findings and experience gained in a wide range of settings have been incorporated. Nevertheless, many of the countries and organizations using this manual will have their own experience and knowledge on caring for people living with HIV/AIDS. It is important that this local knowledge and experience be incorporated in the recommendations of the manual.

Adapting it for local use provides an opportunity for local organizations to participate, creating a sense of ownership whereby they are more likely to use the manual.

Adaptation may need to take place at different levels. Countries and/or organizations may wish to develop the manual for national use or make further adaptations to meet regional and more local levels.

CHANGES NEEDED

The changes needed to adapt the manual to the requirements of a particular country or region will involve:

· Changes in foods and recipes to suit the local availability of food and community tastes and preferences in country, regional, urban or rural settings. This may mean omitting some foods from the manual and adding others of equivalent nutritional value.

· Inclusion of recipes for local dishes, including locally available foods, ensuring that the recipes are compatible with healthy eating guidelines. Suggestions may be made to combine foods with local dishes to ensure a balanced meal. Recipes or cooking methods may be adapted to suit specific HIV-related complications (see Annex 1 for recipes).

· Adaptation of recommendations to local realities, e.g. types of protected water systems, availability of refrigerators, local cooking procedures and measures of weight and volume.

· Selection of those parts of the manual that are relevant to the local situation, e.g. nutritional problems, the pattern of symptoms, availability of treatments used for HIV/AIDS management, drug treatments and local priorities for the care of people with HIV/AIDS.

· Modifications to include experiences gained locally in the nutritional support of people with HIV/AIDS.

· Adaptation to the educational level and cultural background of the users. The adapted manual can be tested on local users to ascertain whether the words and pictures are understood and acceptable. Any words and pictures that are poorly understood should be replaced and the final versions tested again.

SOME SUGGESTIONS ON HOW TO ADAPT THE MANUAL

The manual can be adapted in different ways depending on its intended use and the resources and people available. One approach would be to form a technical working group of people (“stakeholders”) from key government positions and non-governmental organizations (NGOs) to promote nutrition for people with HIV/AIDS. This working group could meet on a regular basis, review the manual, make suggestions for content and then produce the local version. Suggestions for the role of this working group are given in the box.

Another approach would be to start with a workshop at the national level that would seek to involve all the main stakeholders, such as health and extension workers and other service providers, experts on HIV/AIDS and nutrition, organizations working with people living with HIV/AIDS and people living with HIV/AIDS themselves. The objectives of the workshop would be to identify the kind of manual required and develop a workplan and a budget for producing a locally relevant version. From this participatory process would emerge a technical working group to carry out the detailed work of implementing the recommendations and producing the revised manual. A suggested checklist for a workshop is given below.

Role of a technical working group

Plan how to mobilize resources and initiate the necessary steps.
Identify and review existing nutrition education and home-based care materials/services. As nutritional advice for people living with HIV/AIDS is no different from general nutritional advice in principle, some existing material can be used for the development of the guidelines.
Identify information gaps in existing material and additional information needed; develop an information collection strategy and define responsibilities.
Identify what needs to be developed.
Identify resource materials, including existing generic guidelines and the parts that can be adapted.
Put together recipes for food, herbal drinks and home cures and test them on volunteers for acceptability.
Seek local experience on nutrition and AIDS, identify additional recipes and assess them for suitability for inclusion in the manual.
Draft the guidelines (by drafting committee).
Share the guidelines with all stakeholders for comments.
Incorporate the comments.
Pre-test guidelines on local field staff to check that they are easy to read, clear and acceptable.
Finalize nutritional guidelines.

Suggested checklist for a national workshop

Hold a workshop with all stakeholders to:

build a common vision on content of the guidelines, the kind of materials
required and target groups;
refine and agree on the process of the development of the guidelines;
form a technical working group to work on the guidelines;
develop a workplan and a budget for the production of national guidelines on nutritional care and support for people living with HIV/AIDS;
mobilize resources.

DISSEMINATION OF THE GUIDELINES

Once the guidelines have been finalized, a programme for dissemination at national, district and local levels needs to be developed. This programme would include:

· distribution of the guidelines to government, international and national organizations;

· training workshops for field staff on the use of the guidelines in nutrition work with people with HIV/AIDS;

· development of educational aids such as brochures, posters, leaflets, fact sheets, radio programmes, TV spots, training materials, issue briefs, music and theatre activities and nutrition ambassadors.

MONITORING AND EVALUATION

It is important to monitor the implementation of the guidelines and review them in the light of local experience. This could involve:

· monitoring the number of people trained and the number of copies of guidelines distributed;

· a follow-up meeting with key persons in agencies involved in the development of the local guidelines to assess the experience within their agency of the use of the manual;

· follow-up and assessment of the use made of the manual, problems experienced and lessons learned by relevant field staff;

· interviews with people living with HIV/AIDS who have received nutrition education as part of the programme to assess the extent to which they have been able to follow the guidelines and suggest modifications.

The benefits of good nutrition for people and families living with HIV/AIDS

WE EAT FOR MANY REASONS

Food is important for everyone. Familiar foods make us feel safe and secure. Food reminds us of our childhood, home country and culture. We celebrate events by eating special foods in the company of people who are important to us. When we eat well we feel well.

When the body does not get enough food, it becomes weak and cannot develop or function properly. Healthy and balanced nutrition means eating the right type of foods in the right quantities to keep healthy, keep fit and enjoy ourselves. The basics of good nutrition are explained in the next chapter.

HIV/AIDS AND NUTRITION

The HIV virus attacks the immune system. In the early stages of infection a person shows no visible signs of illness but later many of the signs of AIDS will become apparent, including weight loss, fever, diarrhoea and opportunistic infections (such as sore throat and tuberculosis).

Good nutritional status is very important from the time a person is infected with HIV. Nutrition education at this early stage gives the person a chance to build up healthy eating habits and to take action to improve food security in the home, particularly as regards the cultivation, storage and cooking of food.

Good nutrition is also vital to help maintain the health and quality of life of the person suffering from AIDS. Infection with HIV damages the immune system, which leads to other infections such as fever and diarrhoea. These infections can lower food intake because they both reduce appetite and interfere with the body's ability to absorb food. As a result, the person becomes malnourished, loses weight and is weakened.

One of the possible signs of the onset of clinical AIDS is a weight loss of about 6-7 kg for an average adult. When a person is already underweight, a further weight loss can have serious effects. A healthy and balanced diet, early treatment of infection and proper nutritional recovery after infection can reduce this weight loss and reduce the impact of future infection.

A person may be receiving treatment for the opportunistic infections and also perhaps combination therapy for HIV; these treatments and medicines may influence eating and nutrition. Good nutrition will reinforce the effect of the drugs taken.

When nutritional needs are not met, recovery from an illness will take longer. During this period the family will have the burden of caring for the sick person, paying for health care and absorbing the loss of earnings while the ill person is unable to work. In addition, good nutrition can help to extend the period when the person with HIV/AIDS is well and working.

HEALTHY AND BALANCED NUTRITION IS IMPORTANT FOR PEOPLE LIVING WITH HIV/AIDS

Nutritional care and support promote well-being, self-esteem and a positive attitude to life for people and their families living with HIV/AIDS.

Healthy and balanced nutrition should be one of the goals of counselling and care for people at all stages of HIV infection. An effective programme of nutritional care and support will improve the quality of life of people living with HIV/AIDS, by:

· improving the function of the immune system and the body's ability to fight infection;

· improving response to treatment; reducing time and money spent on health care;

· keeping HIV-infected people active, allowing them to take care of themselves, their family and children; and

· keeping HIV-infected people productive, able to work, grow food and contribute to the income of their families.

Healthy and balanced nutrition is important for everyone

OUR BODIES NEED FOOD

Food is made up of nutrients. Micronutrients such as vitamins and minerals are needed only in small amounts. Macronutrients such as carbohydrates, protein and fat are needed in larger amounts. The body cannot function properly if one or more nutrients are missing. A healthy and balanced diet provides foods in the right amounts and combinations that are safe and free from disease and harmful substances.

Prevention is better than cure. The earlier a person starts to eat a healthy and balanced diet, the more he or she will stay healthy. Once weight has been lost it may be difficult to regain it because of tiredness and lack of appetite.

The section below contains some guidelines on healthy and balanced nutrition. These apply to everyone - whether they are infected with HIV or not.

HEALTHY AND BALANCED NUTRITION

Enjoy a variety of foods

Eating well means eating a variety of foods. No single food contains all the nutrients that our bodies need, except for breastmilk for babies up to the age of six months. Eating a variety of different foods will supply the nutrients that are essential for our bodies. By taking care to choose foods that are in season and locally available, eating can be enjoyable, healthy and affordable.

Eat staple foods with every meal

Staple foods should make up the largest part of a meal. These foods are relatively cheap and supply a good amount of energy and some protein. Staples include cereals (such as rice, maize, millet, sorghum, wheat and barley), starchy roots (such as potatoes, sweet potatoes, cassava and yams) and starchy fruit (such as plantains).

However, staple foods are not enough to provide all the nutrients the body needs. Other foods must be eaten to provide additional energy, proteins and micronutrients.

Eat legumes if possible every day

These foods provide a person with the proteins needed to develop and repair the body and also to build up strong muscles. They are good sources of vitamins, minerals and fibre and help to keep the immune system active.

Legumes include beans, peas, lentils, groundnuts (including peanut butter) and soybeans. When eaten with staple foods the quality of protein is increased. Legumes are a cheaper protein source than animal foods, such as beef and chicken, and should be eaten every day, if possible.

Eat animal and milk products regularly

Foods from animals and fish should also be eaten as often as you can afford them. They supply good-quality proteins, vitamins and minerals and extra energy. They will help to strengthen muscles and the immune system.

These foods include all forms of meat, poultry (birds), fish, eggs and dairy products such as milk, sour milk, buttermilk, yoghurt and cheese. If insects, such as caterpillars or grasshoppers, are part of your diet, they also provide good nutrients.

Eat vegetables and fruit every day

Vegetables and fruit are an important part of a healthy and balanced meal. They supply the vitamins and minerals that keep the body functioning and the immune system strong. These foods are especially important for people living with HIV/AIDS to fight infection. Eat a wide variety as each one provides different vitamins and minerals. A recommended list is provided below.

Yellow, orange, red or dark green	Other vegetables and fruit vegetables and fruit
Green leafy vegetables (spinach, pumpkin, cassava leaves), green peppers, squash, carrots, yellow peaches, apricots, papaya and mangoes	Tomatoes, cabbage, oranges, mandarins, grapefruit, lemons, guavas mangoes, passionfruit, pineapples, mulberries and baobab fruit
· Good sources of vitamin A	· Good sources of vitamin C; help to fight infection

Use fats and oils as well as sugar and sugary foods

Fats, oils and sugar are good sources of energy and can help one gain body weight, which can be particularly important for those living with HIV/AIDS. They also add flavour to food, thereby stimulating appetite.

Fats and oils play an important part in a healthy and balanced diet. Even small amounts can provide lots of energy. Fats and oils include butter, lard, margarine, cooking oil (vegetable, coconut and palm oil), cream, mayonnaise and coconut cream. They are also found in avocados, oilseeds (sunflower, groundnut and sesame), fatty meat and fish, curds and cheese.

Although fats and sugars are good sources of energy, they are not rich in other nutrients. They should therefore be eaten in addition to other foods, not in place of them.

Drink plenty of clean and safe water

Water is important for life and is necessary every day. A person needs about eight cups of fluid per day. When it is very hot, while working, sweating or suffering from diarrhoea, vomiting or fever, a person needs to drink even more to replace the water that has been lost. If drinking-water is collected from a protected well or borehole it is important to store it in a clean container. If the water is from an unprotected well or river the water should be boiled for at least ten minutes and stored in a clean container (see advice on food hygiene). In addition to drinking clean water, fluid can also come from juices, soups, vegetables and fruit as well as meals that have gravy or sauces. However, avoid drinking tea or coffee with a meal, as this can reduce the absorption of iron from the food.

Alcoholic drinks remove water from the body and should therefore be consumed only in limited amounts. They can also interfere with the action of medicines.

Special eating needs for people living with HIV/AIDS

A person who is infected with HIV/AIDS and is not showing signs of illness does not need a specific “HIV-diet”. However, those infected with HIV should make every effort to adopt healthy and balanced nutrition patterns (as explained in Chapter three) in order to meet their increased protein and energy requirements and maintain their nutritional status.

Once people with HIV/AIDS become ill they will have special needs, which are described below.

PEOPLE LIVING WITH HIV/AIDS HAVE INCREASED NUTRIENT NEEDS

When infected with the HIV virus the body's defence system - the immune system - works harder to fight infection. This increases energy and nutrient requirements. Further infection and fever also increase the body's demand for food. Once people are infected with HIV they have to eat more to meet these extra energy and nutrient needs. Such needs will increase even further as the HIV/AIDS symptoms develop.

HIV/AIDS reduces food intake

· the illness and the medicines taken for it may reduce the appetite, modify the taste of food and prevent the body from absorbing it;

· tiredness, isolation and depression reduce the appetite and the willingness to make an effort to prepare food and eat regularly;

HIV/AIDS reduces the absorption of food

Food, once eaten, is broken down by digestion into nutrients. These nutrients pass through the gut walls into the bloodstream and are transported to the organs and tissues in the body where they are needed. One of the consequences of HIV and other infections is that since the gut wall is damaged, food does not pass through properly and is consequently not absorbed.

Diarrhoea is a common occurrence in people with HIV/AIDS. When a person has diarrhoea the food passes through the gut so quickly that it is not properly digested and fewer nutrients are absorbed.

HIV/AIDS AFFECTS WEIGHT

When a person does not eat enough food, or the food eaten is poorly absorbed, the body draws on its reserve stores of energy from body fat and protein from muscle. As a result, the person loses weight because body weight and muscles are lost.

The weight loss may be so gradual that it is not obvious. There are two basic ways to discover whether weight is being lost.

· Weigh the person on the same day once a week and keep a record of the weight and date (see sample sheet in Annex 4). For an average adult, serious weight loss is indicated by a 10 percent loss of body weight or 6-7 kg in one month. If a person does not have scales at home it might be possible to make an arrangement with a chemist, clinic or local health unit to weigh him or her.

If a person loses weight he or she needs to take action to increase weight to the normal level.

GAINING WEIGHT

Weight is gained by eating more food, either by eating larger portions and/or eating meals more frequently, using a variety of foods as described in the previous chapter. Here are some suggestions for gaining weight:

· Eat more staple foods such as rice, maize, millet, sorghum, wheat, bread, potatoes, sweet potatoes, yams and bananas.

· Increase intake of beans, soy products, lentils, peas, groundnuts, peanut butter and seeds, such as sunflower and sesame.

· Include all forms of meat, poultry, fish and eggs as often as possible. Minced meat, chicken and fish are easier to digest. Offal (such as kidney and liver) can be the least expensive source.

· Eat snacks regularly between meals. Good snacks are nuts, seeds, fruit, yoghurt, carrots, cassava crisps, crab crisps and peanut butter sandwiches.

· Slowly increase the fat content of the food by using more fats and oils, as well as eating fatty foods - oilseeds such as groundnuts, soy and sesame, avocados and fatty meat. If problems with a high fat intake are experienced (especially diarrhoea), reduce the fat intake until the symptoms are over and then gradually increase it to a level that the body can tolerate.

· Introduce more dairy products such as full-cream milk, sour milk, buttermilk, yoghurt and cheese into the diet.

· Add dry milk powder to foods such as porridge, cereals, sauces and mashed potatoes. However, do not use coffee and tea whiteners, which do not have the same nutritional benefits as milk. Note that some people may find milk difficult to digest. It should be avoided if it causes cramps, a feeling of being full or skin rashes.

· Recipes following these recommendations for gaining weight are provided in Annex 1.

Increasing the number of meals and snacks in a day. If poor appetite persists or the person is ill, it is a good idea to spread the food intake throughout the day. Snacks should be included in the daily meal plan.

· A snack is any nutritious food that is readily available and can be eaten without much preparation. Good snacks are nuts, seeds, fruit, yoghurt, carrots, cassava chips, crab chips and peanut butter sandwiches. With at least three meals a day and snacks in between, there is less likelihood of malnutrition or weight loss.

· If a person needs to stay in bed, food and water should be kept within easy reach.

· Carers should ensure that sick members of the family are given preference, fed more frequently and receive extra servings to maintain their weight and strength. Food should be served in an attractive way. Carers need to be kind, while frequently encouraging people to eat.

Exercise improves well-being.Regular exercise makes a person feel more alert, helps to relieve stress and stimulates the appetite. Exercise is the only way to strengthen and build up muscles. The body uses muscles to store energy and protein that the immune system can draw upon when required. Exercise is therefore especially important for maintaining the health of people with HIV/AIDS.

It may be that everyday activities such as cleaning, working in the field and collecting firewood and water provide enough exercise. If a person's work does not involve much exercise, an enjoyable exercise programme should be found that can be part of his or her daily life. Exercise should not be tiring or stressful; gentle muscle-building exercise is recommended. Walking, running, swimming or dancing are all suitable. People living with HIV/AIDS need to make an effort to find the exercise that they enjoy and that suits their situation.

Preventing weight loss during and after illness. Infection increases the body's requirements for nutrients. Illness also reduces the appetite and the ill person will eat less food, causing weight loss. Recommendations for dealing with poor appetite, diarrhoea, vomiting, sore mouth and nausea are given in Chapter six.

Early treatment of infection is important to maintain body weight. If infection persists and cannot be cured by nutritional management within a couple of days, advice and treatment should be sought from a doctor, nutritionist, nurse or local health worker.

Once the infection is over and the person is feeling better, he or she should start eating normally again. It is important to regain the weight lost as soon as possible and to restore the body's nutritional reserves.

Try to eat three good meals daily with frequent snacks in between

INCREASE VITAMIN AND MINERAL INTAKE

Vitamins and minerals are essential to keep healthy. They protect against opportunistic infection by ensuring that the lining of skin, lungs and gut remain healthy and that the immune system functions properly. Of special importance are vitamin A, vitamin C, vitamin E, certain B-group vitamins and minerals such as selenium, zinc and iron. A mixed diet as recommended in Chapter three should provide enough of these vitamins and minerals. Some background information on micronutrients, their nutritional role and food sources is provided in Annex 3.

Vitamin A is important to keep the lining of skin, lungs and gut healthy. Vitamin A deficiency increases the severity of diseases such as diarrhoea while infection will increase the loss of vitamin A from the body. Good vitamin A sources are dark green, yellow, orange and red vegetables and fruit. These include spinach, pumpkin, cassava leaves, green peppers, squash, carrots, amaranth, yellow peaches, apricots, papaya and mangoes. Vitamin A is also contained in red palm oil, yellow maize, orange and yellow sweet potatoes, egg yolks and liver.

Vitamin C helps to protect the body from infection and aids in recovery. It is found particularly in citrus fruits such as oranges, grapefruit, lemons and mandarins. Guavas, mangoes, tomatoes and potatoes are also good sources of vitamin C.

Vitamin E protects cells and aids resistance to infection. Foods containing vitamin E are green leafy vegetables, vegetable oils, peanuts and egg yolks.

Vitamin B-group. This group is necessary to keep the immune and nervous system healthy. Vitamins, however, may be lost from the body through the use of certain medicines for the treatment of tuberculosis. Good food sources include white beans, potatoes, meat, fish, chicken, watermelon, maize, grains, nuts, avocados, broccoli and green leafy vegetables.

Iron. Iron-deficiency anaemia is a widespread problem in many countries, especially among women and children. Good iron sources are green leafy vegetables, seeds, whole-grain products, dried fruit, sorghum, millet, beans, alfalfa, red meat, chicken, liver, fish, seafood and eggs.

Selenium is an important mineral because it helps to activate the immune system. Good sources include whole grains such as wholemeal bread, maize and millet and dairy products such as milk, yoghurt and cheese. Meat, fish, poultry, eggs and other protein-rich foods are also good sources, as are peanut butter, dried beans and nuts.

Zinc is also important for the immune system. Zinc deficiency reduces the appetite. Sources include meat, fish, poultry, shellfish, whole-grain cereals, maize, beans, peanuts and milk and dairy products.

Further recommendations

Since the vitamin content of food can be damaged during cooking, it is better to boil, steam and fry vegetables for a short time only. Boil vegetables in a little water and use it afterwards for cooking as it contains considerable amounts of vitamins and minerals. Vegetables will lose some of their vitamins and minerals if soaked for a long time.

The skins and kernels of grains and legumes contain vitamins, in particular of the B-group. Processed refined grains have lost many of their vitamins, minerals and proteins so whole grains such as brown bread and unrefined cereals are better sources than white bread and refined cereals. Fortified cereals and bread are preferred because of their higher vitamin content. If a person has diarrhoea, however, whole unrefined grains and cereals should be avoided since these insoluble fibres make the diarrhoea worse. Soluble fibre foods such as bananas are recommended. Fibres are contained in many plant foods. Soluble fibres will bind water in the gut and therefore reduce diarrhoea.

MICRONUTRIENT SUPPLEMENTATION - WHICH, HOW MUCH AND WHEN?

When food intake is low, multivitamin and mineral supplements - often in the form of pills - can help to meet increased requirements. However, these supplements are often not available, they are expensive and leave less money for food. It would therefore be better to provide a good mixed diet whenever possible rather than buy supplements.

If supplements are considered necessary, the following guidelines should be adhered to:

· Discuss your intake of vitamin and mineral supplements with your health worker or nutritionist.

· Always take vitamin pills on a full stomach. Be consistent and take them regularly.