August is a 48-year-old Zulu-speaking man who lives with his wife and two sons in an informal settlement near the Sefako Makgatho Health Sciences University Hospital (SMHSU) where you work as a clinical dietitian. August was diagnosed with human immunodeficiency virus (HIV) at the age of 28 (horizontal transmission) and is currently on a fixed-dose combination therapy (FDC) of tenofovir, lamivudine and dolutegravir (TLD). He reports to be compliant with treatment. He is admitted SMHSU hospital with a clinical picture of parapneumonic effusion with a possible etiology of streptococcus pneumonia.
(1 South African Rand (R) is the equivalent of 0.082 Australian Dollars (AUD)
August is unemployed and receives a disability grant of R2090 ($170 AUD) per month, from the South African Social Security Agency (SASSA). August’s wife is employed as a cleaner at the local school and earns a monthly salary of R6000 ($500 AUD). August’s children contribute R7500 ($600 AUD) to the household monthly income. Together, this income covers the living expenses of four people. Typically, 60% of this sum is spent on food, while the remainder goes towards transportation and household expenses.
Nutrition-focused Physical Findings
August presented to emergency three days ago with fever, shortness of breath and severe pain in the left upper quadrant. His chart notes mucositis, oral candidiasis, mouth ulcers, dysgeusia (a distortion of the sense of taste and no appetite. Your assessment August reports a persistent cough, weakness and a feeling of malaise which he has experienced for the past three weeks. He says he hasn't felt like participating in his usual activities and has been spending most of the day resting.
Anthropometry
August reports losing 7.5 kg in the past 6 months. He notes that he has been losing weight during the last month but is unsure how much. He currently weighs 59 kg with a height of 1.72 m. His mid-upper arm circumference (MUAC) is 19 cm. Upon admission, he was initially weighed at 58 kg, but has since regained 1 kg to reach his current weight of 59 kg. A physical examination reveals moderate wasting. Further examination of Me's muscle and fat stores shows the following.
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+ Introduction
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INTRODUCTION 0. Introduction to August
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+ 1. Food/Nutrition-related History (FH)
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Watch and Read Patient Story Dietitian's Information Home Diet
Nutrition Assessment Overview
TOOL KIT
— Australia: Ready Reckoner: Dietary Guidelines
— USA: Exchange List: Dietary Guidelines
— South Africa: Food Guide Servings1. Do you eat red meat and or fish?
2. Cannot eat prime meat very often.
3. Other meal choices.
Record Patient Dietary Preferences/Home Diet
The diet history you are undertaking with August is a retrospective structured interview at the hospital bedside. The interview consists of questions about Augusts habitual intake of foods with a focus on the food groups, that is protein foods, grains, dairy foods, fruits and vegetables, oils and fats, added sugars and beverages.
As you are working through August's diet history identify food items that require further clarification.
Protein Foods
- August states he not like red meat and later states he occassionally has prime meat.
Note - Enquire if this is because he does not like red meat or because it is not within his budget or if he has trouble chewing/swallowing meat - August states he eats fish, incluing haik, however he does like tinned fish.
Note - Ask patient to expand on fish allergy.
Depending on the patient's characteristics and an aim of dietary assessment, the interview may put weight on specific dietary items or behaviours. For example, if a target population is pregnant women, diet history should capture use of dietary supplements and an experience of ‘pica’ (food craving). If the research aim is to identify a common dietary habit of people admitted to a hospital during a heatwave or an infectious outbreak, specific food consumption in a specific period may be assessed retrospectively.
- (Note - Reduced saturated fat intake. This is positive given saturated fat intake among HIV-infected patients is observed to exacerbate hypertriglyceridaemia in patients who have developed metabolic abnormalities (source).
- Enjoys beans - consumption of FOS and GOS (Note - Ongoing research is assessing the impact of increasing gut microbial diversity on immune recovery i.e., the effect on CDT4 cell count (source).
- Consider August's physical activity level.
Hospital Diet
4. Appetite getting better - **doubled up**
5. What did you have for breakfast this morning?
6. Never misses medicine
7. If you keep up with your medication/treatment, there is no need to communicate HIV status.
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8. What are healthy foods for you pt1
9. What are healthy foods for you pt2
10. What are healthy foods for you pt3
11. How does nutrition help your health?
written format Knowledge, Beliefs and Attitudes
12. Nutrition intake & health
Eligibility for Government Programs
13. Are you part of any community HIV support groups?
Physical Activity
14. Energy Levels
- August states he not like red meat and later states he occassionally has prime meat.
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+ 2. Anthropometric Measurements (AD)
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Watch and Read Patient Story Dietitian's Information Weight
Anthropometry Video (rename)
15. Have you been losing weight?
16. Tell Me About Your Weight?
17. Effect of sickness on weight
Mid-upper Arm Circumference
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Watch and Read Patient Story Dietitian's Information XXXX
Biochem Video (Rename)
Refer to the medical chart
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+ Check-in
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Check-in 18. Are you feeling tired?
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+ 4. Nutrition-Focused Physical Findings (PD)
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Watch and Read Patient Story Dietitian's Information Appetite
Nutrition-focused video (rename)
19. How has your appetite been?
20. Appetite getting better - **duplicated**
21. Previous dietetic intervention: do you get any supplements?
22. Do you think it will help you if you took supplements?
23. Watching the Patient Drinking Supplement
Oral Pain
24. Struggling and Painful to Eat
Symptoms
25. Symptoms Before Hospital
26. Do You have Any Symptoms Today?
27. Energy Levels (also under 1. Nutrition XXXX)
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+ 5. Client History (CH)
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Watch and Read Patient Story Dietitian's Information Patient Medical History
Client History Video (rename)
28. HIV diagnosis & testing procedures.
29. Maybe they can drain out the infection
Budget
30. Where do you cut on your budget?
31. My wife must take care of the kids.
32. Things are too expensive
33. Currently Unemployed
34. How much money do you spend on food in a month?
35. Do you feel like you are struggling to buy food?
36. 2000 Rand does not buy a lot of food.
37. Promised food that never arrives.
38. Not qualified to get food
The Stigma of HIV 39. Do people in your community know your HIV status?
40. Do people treat you different?
Community Support
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+ Comparative Standards
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Watch and Read Patient Story Dietitian's Information Comparative Standards Video (rename)
- Assessment, Monitoring and Evaluation Tools (AT)
- Etiology Category (EY)
- Comparative standards (CS)
- Progress Evaluation (EV)